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LECTURES 
 
 DISEASES OF INFANCY 
 
 AND 
 
 CHILDHOOD. 
 
 BY 
 
 CHAKLES WEST, M. D., 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN. 
 
 FIFTH AMERICAN 
 
 FROM THE SIXTH REVISED AND ENLARGED ENGLISH EDITION 
 
 PHILADELPHIA: 
 
 HENKY C. LEA. 
 
 1874. 
 
A CT 
 
 
 
 SHERMAN & CO., PRINTERS, 
 PHILADELPHIA. 
 
ADVERTISEMENT 
 
 THE SIXTH EDITION. 
 
 Theee remains but little to add to the Preface to the former edition. 
 Seven years more of clinical observation, and the records of 743 more 
 cases, and of 181 more post-mortem examinations, making in all nearly 
 2000 cases, and nearly 600 post-mortem examinations, have, it may be 
 hoped, enabled me to add something to the value of the work. I 
 have striven not to increase its bulk, and have omitted much that 
 seemed to me less important, in order to obtain space for the introduc- 
 tion of additional matter which appeared to me of greater moment. In 
 spite, however, of all my pains, this volume is bigger than its prede- 
 cessor by more than thirty pages. 
 
 An Italian translation, accompanied with notes, was published by 
 Dr. Blasi of Rome in the year 1869 ; a second edition is now in prep- 
 aration. Causes which it is not worth while to mention having inter- 
 fered with the publication of the French translation of the former edi- 
 tion, the present is in the most competent hands of Dr. Archanibault, 
 Physician to the Hopital des Enfants Malades. 
 
 Any one in his fifty-eighth year must feel it very doubtful whether 
 his life will be so prolonged as to allow him to take part in the publi- 
 cation of another edition of a book which first appeared more than 
 twenty-five years ago ; or whether some better, completer work will 
 not before long occupy its place. 
 
 • But be this as it may, to me it is no small satisfaction to feel that 
 future laborers will have their tasks lightened by my endeavors ; that 
 
IV ADVERTISEMENT TO THE SIXTH EDITION. 
 
 while thirty years ago there was not a single hospital for children in 
 the whole British dominions or in America, the Hospital for Sick 
 Children in Great Ormond Street and its thirty daughters will now 
 tell, if my name should be at all remembered, that it was permitted 
 me to live not altogether to myself, but in some small degree at least 
 to serve my generation, and to help those little ones whom I so much 
 love. 
 
 Charles West. 
 
 61 Wimpole Street, 
 
 December 1, 1873. 
 
PREFACE 
 
 THE FIFTH EDITION. 
 
 Twenty-six yeaes ago the kindness of De. Eobeet Willis 
 threw open to me the field of observation afforded by the Children's 
 Dispensary in Lambeth, and in 1842, I succeeded him there in the 
 office of Physician. 
 
 In 1847 I gave a series of Lectures on the Diseases of Children, 
 based on observations made at the Children's Dispensary, to the Pupils 
 of the Middlesex Hospital ; and these Lectures appeared in the "Med- 
 ical Gazette" during the summer and autumn of the same year. 
 
 In 1848 these Lectures were published as a distinct book ; founded 
 on the notes of 600 cases, and 180 post-mortem examinations, which I 
 had observed at the dwellings of the poor in the district where I 
 labored. 
 
 The establishment of the Children's Hospital, in Great Ormond 
 Street, brought me readier means of more careful observation, and the 
 appointment within the past four years of different gentlemen to the 
 office of Registrar, has provided for the record of cases of which want 
 of leisure would have otherwise prevented me from preserving an 
 account. 
 
 I have thus been enabled in each successive edition to add to the 
 preceding one, and I trust to improve upon it. The present edition 
 embodies the result of 1200 recorded cases, and of nearly 400 post- 
 mortem examinations, collected from between 30,000 and 40,000 
 
Tl PREFACE TO THE FIFTH EDITION. 
 
 children who, during the past twenty-six years, have come under rny 
 care, either in public or private practice. 
 
 While improving, as far as I could, the substance of this book, I 
 have not attempted to alter its form ; for the fact that it has passed 
 through three editions in America, and through four in Germany, 
 while it has also been translated into Danish, Dutch, and Russian, 
 and that the French translation is now in the press, may be taken as 
 good proof that it has to a great extent met the wants of the Profession 
 both here and abroad. 
 
 A moment's satisfaction may be pardoned me in thankfully acknowl- 
 edging these evidences that my toil has not been fruitless. But it is 
 with no feeling of flattered vanity that I now lay down my pen. The 
 revision in mature age of the labors of one's youth must, with most 
 persons, minister to self-reproach rather than to self-satisfaction. The 
 same unsolved problems meet one's eye now as met it years ago ; one's 
 deficiencies are felt more deeply ; they seem graver and less excusable, 
 as the time for remedying them passes by ; one longs for the leisure 
 gone, for the energies of former years, which one fancies, coupled with 
 the soberness of advancing life, might help to add something more 
 and better to the common store of knowledge. 
 
 I can for my part say most honestly, that nothing will give me 
 greater pleasure than to see some younger man, better furnished for 
 the task than I was, devote himself to the cultivation of that field 
 where I have labored. No one would greet the skilled husbandman 
 more heartily than I, nor rejoice more sincerely to see him reap, as he 
 cannot fail to do, a most abundant harvest. 
 
 Charles West. 
 
 61 Wimpole Street, 
 
 June 1, 1865. 
 
CONTENTS. 
 
 LECTURE PAGE 
 
 I. Introductory : On the Study of Children's Diseases, ... 17 
 II. Introductory : On the Treatment of Children's Diseases, . . 27 
 
 III. Diseases of the Brain and Nervous System. General Remarks 
 
 upon them, and on their symptoms in Early Life, . . 38 
 
 IV. Congestion of the Brain : its Causes, Symptoms, and Treatment, 47 
 Y. Cerebral Hemorrhage and Cephalhematoma, or Hemorrhage 
 
 external to the Skull, 58 
 
 VI. Inflammatory Affections of the Brain. Tubercular Meningitis : 
 
 its morbid Appearances and Symptoms, .... 69 
 VII. Tubercular Meningitis concluded : its Symptoms and Treat- 
 ment, 82 
 
 VIII. Simple Inflammation of the Brain. Inflammation succeeding to 
 Disease of the Ear. Thrombosis of the Sinuses of the Dura 
 
 Mater, 100 
 
 IX. Chronic Hydrocephalus, 110 
 
 X. Hypertrophy and Atrophy of the Brain, 121 
 
 XI. Hydrocephaloid Disease. Tubercle of the Brain. Hydatids 
 
 and Cancer of the Brain, 131 
 
 XII. Diseases of the Spinal Cord. Irritation and Congestion. In- 
 flammation of its Membrane and Substance. Trismus, . 147 
 
 XIII. Convulsions, and Spasm of the Glottis, 161 
 
 XIV. Epilepsy and Chorea, 177 
 
 XV. Paralysis, 201 
 
 XVI. Night Terrors. Disorders of the Mind and Idiocy, . . . 215 
 XVII. Diseases of the Respiratory Organs. General Remarks on the 
 Respiratory Eunctions in Early Life. Imperfect Expansion 
 
 of the Lungs, 234 
 
 XVIII. Collapse of Lung after Birth. Induration of the Cellular 
 
 Tissue, 247 
 
 XIX. Inflammation of Respiratory Mucous Membrane. Catarrh. 
 
 Coryza. Post-mortem Appearances of Bronchitis, . . 259 
 XX. Inflammation of Substance of Lung ; its Port-mortem Ap- 
 pearances. Symptoms and Treatment of Bronchitis. In- 
 fluenza, 268 
 
 XXI. Pneumonia : its Symptoms and Treatment, .... 284 
 XXII. (Edema of the Lung. Gangrene of the Lung. Pleurisy, 
 
 Acute and Chronic, 298 
 
 XXIII. Croup : its Varieties, Causes, Post-mortem Appearances, and 
 
 Symptoms. Treatment of its Early Stages, . . . 320 
 
 XXIV. Croup: Treatment of its Advanced Stages — Tracheotomy, . 337 
 
V1U CONTENTS. 
 
 LECTURE PAGE 
 
 XXY. Diphtheria, or Angina Maligna. Laryngitis Stridula, or 
 Croup with Predominance of Spasmodic Symptoms. 
 XXYI. Hooping-cough : its Symptoms and Complications, . . 371 
 
 Varieties of Spasmodic Cough, 347 
 
 XXYII. Hooping-cough : its Complications, continued — Post-mor- 
 tem Appearances, and Treatment, .... 384 
 XXVIII. Pulmonary Phthisis: its Peculiarities, Anatomical Charac- 
 ters, and Symptoms in Childhood. General Symptoms 
 of Bronchial Phthisis, and of Phthisis in early Infancy, 401 
 XXIX. Phthisis, continued : its Auscultatory Signs, its different 
 
 Forms, Duration, and Treatment, .... 413 
 
 XXX. Diseases of the Heart, 427 
 
 XXXI. Diseases of Organs of Digestion and Assimilation. General 
 
 Remarks on the Diet of Infants, .... 444 
 XXXII. Infantile Atrophy. Thrush. Dentition, and the Manage- 
 ment of Children during it, 456 
 
 XXXIII. Stomatitis — Follicular, Ulcerative, and Gangrenous. Cy- 
 
 nanche Tonsillaris, Hypertrophy of the Tonsils. Re- 
 tro-Pharyngeal Abscess. Cynanche Parotidea, . . 468 
 
 XXXIV. Diseases of the Stomach. Indigestion. Softening of the 
 
 Stomach. Hsematemesis and Melama, . . . 487 
 
 XXXV. Jaundice. Constipation, and Mechanical Causes of it, as 
 
 imperforate Anus and Intussusception, . . . 501 
 XXXVI. Diarrhoea : its Symptoms and Morbid Appearances, . . 517 
 XXXVII. Diarrhoea, continued : its Treatment, and that of its Com- 
 plications, 528 
 
 XXXVIII. Peritonitis : its Acute and Chronic Forms. Tubercular 
 
 Peritonitis. Tabes Mesenterica, .... 540 
 XXXIX. Intestinal Worms. Diseases of the Urinary Organs : Al- 
 buminuria, Gravel, and Calculus. Diabetes. Inconti- 
 nence of Urine, 557 
 
 XL. Abdominal Tumors, 580 
 
 XLI. Infantile Cachexias : Syphilis, Scrofula, and Rickets, . . 598 
 XLII. Fevers : General Remarks on them. Typhoid Fever : its 
 Symptoms and Treatment. Intermittent Fever or 
 
 Ague, 617 
 
 XLIII. Small-pox. Modified Small-pox, 632 
 
 XLIV. Measles and Scarlatina, . 643 
 
 Index to the Subjects, 665 
 
 Index to the Formulae, . . 677 
 
LECTURES 
 
 DISEASES OF INFANCY AND CHILDHOOD. 
 
 INTEODUCTOEY. 
 
 On the Study of Children's Diseases. — Its difficulties, and how to overcome 
 them — Rules for the examination of sick children, and for taking notes of cases 
 — General plan and objects of the Course. 
 
 Gentlemen : It is not without hesitation that I have determined 
 on adding another to the already numerous courses of lectures that you 
 are called on to attend while engaged in the study of medicine. My 
 reasons — and I trust my justification — for so doing are furnished partly 
 by the frequency of the diseases of infancy and childhood, partly by 
 their fatality, but still more by their many peculiarities. 
 
 Children will form at least a third of all your patients; and so seri- 
 ous are their diseases, that one child in five dies within a year after 
 birth, and one in three before the completion of the fifth year. These 
 facts, indeed, afford conclusive arguments for enforcing on you the im- 
 portance of closely watching every attack of illness that may invade the 
 body while it is so frail ; but they alone would scarcely be adequate 
 reasons for ray bringing these diseases under your notice as objects for 
 special study. 
 
 The body, however, is not only more frail in infancy than it becomes 
 in after life, but the sympathies between its different parts are more 
 extensive and more delicate. One organ seldom suffers alone, but the 
 effects even of local diseases extend to the whole system, and so dis- 
 order its workings that it is often no easy matter to determine the seat 
 of the original mischief. Nor is this all ; but many important con- 
 sequences result from the period of childhood being one of unceasing 
 development. In the 'adult the structure of the body is complete, and 
 its functions are the same to-day as they were yesterday : but the child 
 learns successively to breathe, to feel, to think ; and its body is daily 
 undergoing modifications to fit it for new duties, as well as daily grow- 
 ing in size and strength. Disease, therefore, not merely disturbs the 
 
18 PECULIARITIES OF THE DISEASES OF CHILDREN. 
 
 present, but its influence reaches to the future ; it not only interrupts 
 the present function of the organ that is affected, but it puts a stop for 
 a time to the completion of the general machinery of the body, or dis- 
 arranges the due proportion of one part of that machinery to another. 
 Moreover, there are periods, namely, those of the first and second den- 
 tition, when very great changes take place in the organism of the child, 
 and when all these dangers are especially to be feared. Disease is 
 then frequent and serious beyond what it is at other times, and every 
 ailment then warrants a double measure of anxiety ; while, on the 
 other hand, if these epochs are safely passed, there succeeds a season of 
 comparative immunity from many affections that before were both 
 common and perilous. 
 
 But, if this be so, you will at once perceive that something more is 
 essential to the successful treatmennt of children's diseases than to 
 watch their advances carefully, and to adapt the strength and doses of 
 your remedies to the tender years of your patients. It is not mere 
 hyperbole to say that you have to study a new semeiology, to learn a 
 new pathology and new therapeutics. Matters of such importance 
 cannot be properly examined at the end of a course of lectures on 
 midwifery. I have therefore preferred making them the subjects of 
 separate consideration during the summer, when the comparative leisure 
 of the season will, I hope, enable you to devote some of your time to 
 the practical as well as the theoretical study of the diseases of children. 
 
 I must warn you, however, of one difficulty which you will encoun- 
 ter at the very outset — a difficulty that disheartens many, and makes 
 them abandon in despair the study of children's diseases. Your old 
 means of investigating disease will here to a great degree fail you, and 
 you will feel almost as if you had to learn your alphabet again, or as 
 if, entering a country whose inhabitants you expected to find speaking 
 the same language and having the same manners as the people in the 
 land you had lately left, you were to hear around you everywhere the 
 sounds of a foreign tongue, and to observe manners and customs such 
 as you had never seen before. You cannot question your patient ; or if 
 old enough to speak, still, through fear, or from comprehending you 
 but imperfectly, he will probably give you an incorrect reply. You 
 try to gather information from the expression of his countenance, but 
 the child is fretful, and will not bear to be looked at ; you endeavor 
 to feel his pulse, he struggles in alarm ; you try to auscultate his chest, 
 and he breaks out into a violent fit of crying. 
 
 Some practitioners never surmount these difficulties, and the dis- 
 eases of children are consequently a sealed book to them. After a 
 time they grow satisfied with their ignorance, and will then with the 
 greatest gravity assure you that the attempt to understand these affec- 
 tions is useless. They have fallen into this unfortunate error from not 
 taking the pains to start aright ; they have never learned how to inter- 
 rogate their little patients, and hence they have never received satis- 
 factory replies. I speak of interrogating them ; for though the infant 
 cannot talk, it has yet a language of its own, and this language it must 
 be your first object to learn, if you mean ever to acquire the character 
 of successful practitioners in the diseases of children. But, if you have 
 
EXAMINATION OF SICK CHILDREN. 19 
 
 not cultivated your faculties of observation, you cannot learn it, for it 
 is a language of signs, and these signs are such as will escape the notice 
 of the careless ; if you are not fond of little children, you cannot learn 
 it, for they soon make up their minds as to who loves them, and when 
 ill they will express their real feelings, whether by words or signs, to 
 no one else. 
 
 There is, moreover, a certain tact necessary for successfully investi- 
 gating the diseases of children. If, when summoned to a sick child, 
 you enter the room abruptly, and going at once to your patient, you 
 begin to look closely at it, while at the same time you question the 
 mother or nurse about its ailments in your ordinary pitch of voice, the 
 child, to whom you are a perfect stranger, will be frightened, and will 
 begin to cry ; its pulse and respiration will be hurried, its face will 
 grow flushed, and you will thus have lost the opportunity of acquaint- 
 ing yourself with its real condition in many respects. Besides this, 
 the child's alarm once excited, will not subside so long as you are pres- 
 ent ; if you want to see its tongue, or auscultate its chest, its terrors 
 will be renewed, and it will scream violently : you will leave the room 
 little wiser than you entered it, and, very likely, fully convinced that 
 it is impossible to make out children's diseases. 
 
 Very different would be the result if you conducted this examina- 
 tion properly ; and though, I believe, where there is real love for chil- 
 dren, the tact necessary for examining into their ailments will not be 
 long in being acquired, still a few hints on this subject may not be out 
 of place in an introductory lecture. 
 
 The quiet manner and the gentle voice which all who have been ill 
 know how to value in their attendants, are especially needed when the 
 patient is a child. Your first object must be not to alarm it ; if you 
 succeed in avoiding this clanger, it will not be long before you acquire 
 its confidence. Do not, therefore, on entering the room, go at once 
 close up to the child ; but, sitting down sufficiently near to watch it, 
 and yet so far off as not to attract its attention, put a few T questions to 
 its attendant. While doing this, you may, without seeming to notice 
 it, acquire a great deal of important information ; you may observe the 
 expression of the face, the nature of the respiration, whether slow or 
 frequent, regular or unequal ; and if the child utters any sound you 
 may attend to the character of its cry. All your observations must be 
 made without staring the child in the face ; little children, especially if 
 ill, seem always disturbed by this, and will be almost sure to cry. If 
 the child is asleep at the time of your visit, your observations may be 
 more minute : the kind of sleep should be noticed, whether quiet or 
 disturbed, whether the eyes are perfectly closed during it, or partly 
 open, as they are in many cases where the nervous system is disor- 
 dered : you may, too, if the sleep seems sound, venture to count the 
 frequency of the respiration and the beat of the pulse, but in doing 
 this you should be careful not to arouse the child. It should be 
 awakened gently by the nurse or mother, and a strange face should 
 not be the first to meet its eye on awaking. If it were awake when 
 you entered the room, it will probably in a few minutes have grown 
 accustomed to your presence, and will allow you to touch its hand and 
 
20 EXAMINATION OF SICK CHILDREN. 
 
 feel its pulse. This must always be done at as early a period in your 
 visit as possible, in order that you may count it while the child is 
 undisturbed, since the pulsations of the heart vary in young chil- 
 dren, as much as twenty in a minute under comparatively slight dis- 
 turbing causes ; and any inferences that you might draw from the 
 pulse of the child, when frightened or excited, would almost certainly 
 be erroneous. Here, as throughout when children are your patients, 
 your difficulties will be great or small exactly in proportion to your 
 tact. If you grasp the hand, however gently, and try to feel the pulse, 
 the little one will struggle to be free. If you place your hand as if 
 accidentally on its arm, and gradually move your fingers downward 
 to the wrist, you will often unobserved and unsuspected count the 
 pulse. Or if the nurse or mother takes the babe's hand in hers it will 
 leave it there with confidence, and will not heed the pressure of your 
 fingers. Besides the pulse, the frequency of the respiration should, if 
 possible, be noticed, since the results obtained by a comparison of the 
 two are always more valuable than those of either taken alone. But 
 if this is your first visit to the child, do not, for the sake of ascertain- 
 ing either of these points exactly, persevere in attempts which irritate 
 or frighten it: probably you would, after all, be unsuccessful ; and even 
 though you were to succeed, the knowledge would not repay you for 
 the loss of the child's confidence, which it must be your grand object 
 to acquire and to keep. 
 
 With management and gentleness, however, you will comparatively 
 seldom fail; and while you are feeling the pulse, or with the hand on 
 the abdomen are counting the frequency of the inspirations, you will 
 also learn the temperature of the body and the condition of the skin. 
 Supposing your examination has thus far been pretty well borne, you 
 may now probably, venture to talk to the child, or to show it some- 
 thing to amuse it — as your watch or stethoscope ; and while thus testing 
 the state of its mental powers, you may pass your hand over the head, 
 and note the state of the fontanelle, and the presence or absence of heat 
 of the scalp. 
 
 Often, though not always, it is important to ascertain the tempera- 
 ture with greater exactness than is possible without the aid of the ther- 
 mometer; and its neglect would then beat least as culpable as the 
 omission of auscultation, and would lead, to just as grave mistakes. 
 When practicable it is best to take the temperature in the axilla, but 
 where the restlessness of the patient, as is often the case with infants 
 and very young children, renders this impossible, the thermometer can 
 almost always be placed in the fold of the groin without exciting resist- 
 ance, and the results thus obtained are very little less accurate. 
 
 The examination of the state of the abdomen, though too important 
 to allow of its ever being omitted, will often lead to no satisfactory 
 result unless carefully managed. If you allow the nurse to change the 
 child's posture and to lay it back in her lap, in order that you may 
 pass your hand over its stomach, the child will often be alarmed, and 
 begin to cry. Its abdomen then becomes perfectly tense, and you cannot 
 tell whether pressure on it causes pain, or whether the cries are not 
 altogether the consequence of fear. It is therefore the best plan to pass 
 
EXAMINATION OF SICK CHILDREN. 21 
 
 your hand beneath the child's clothes, and to examine the abdomen 
 without altering its posture, while, at the same time, the nurse talks to 
 it to distract its attention, or holds it opposite the window, or a bright 
 light, which seldom fails to amuse an infant. If there is no tenderness 
 of the abdomen the child will not cry on pressure ; or if, during your 
 examination, the presence of flatus in the intestines should occasion 
 pain, gentle friction, instead of increasing suffering, will give relief. 
 
 You must next examine the chest: and for this purpose immediate 
 auscultation is always to be preferred, since the pressure of the stetho- 
 scope generally annoys the child. If the child is not in its bedgown, 
 it will usually be your best course to have the back of its dress undone, 
 and then, while it is seated in its mother's or nurse's lap, to kneel down 
 behind it, and apply your ear to its chest. In all acute diseases of the 
 lungs in infancy, the condition of their posterior part is a sure index 
 to the extent of the mischief from which they are suffering; for owing 
 to the infant passing so much of its time in the horizontal position, the 
 blood naturally gravitates towards the back of the lungs, and the 
 secretions are much more likely to accumulate in the bronchi in that 
 situation than elsewhere : hence, if air is heard permeating the lungs 
 throughout the whole posterior part of the chest, and unaccompanied 
 with any considerable amount of crepitation, it may fairly be inferred 
 that their front parts are free from serious disease, even though you 
 should be unable to ascertain the fact by actual observation. 
 
 When you have listened thoroughly to the back of the chest, you 
 may next percuss it. You must not percuss first and listen afterwards, 
 as you often do in the adult ; for, even when practiced with the greatest 
 gentleness, percussion sometimes frets the child, and makes it cry, 
 whereby any subsequent attempt to listen to the breathing will often 
 be rendered unsuccessful. But you must not neglect percussion : it is 
 of peculiar value in childhood, since auscultation is then unavoidably 
 incomplete in many instances, sometimes quite impracticable. In prac- 
 ticing it, however, there are some rules without attention to which you 
 will very likely fail of acquiring any information. You must never, 
 in the child, attempt to percuss the walls of the chest immediately, but 
 should strike on your finger, and even then very gently. The chest of 
 tjie child is so resonant, that, if you percuss smartly, you will fail to 
 perceive the finer variations of sonority which would be readily appre- 
 ciable on gentle percussion. Always compare the results obtained by 
 percussing opposite sides of the chest, since otherwise you may overlook 
 a very considerable degree of dulness. It often happens, too, that the 
 lower lobes of both lungs are involved nearly equally ; you must there- 
 fore notice the resonance of the lower as compared with that of the 
 upper part of the chest. Sometimes you are compelled, by the fretful- 
 ness of the child, or by the tenderness of the walls of its chest, to percuss 
 so gently as scarcely to elicit any sound. It is of importance, therefore, 
 to attend to the sensation of solidity communicated to the finger, as 
 well as to the sound of dulness that falls upon the ear, since if your 
 sense of touch is delicate, it will correct or confirm the evidence of 
 hearing:. 
 
 Having thus examined the back of the chest, you may, if the child 
 
22 EXAMINATION OF SICK CHILDREN. 
 
 is likely to tolerate it, try to listen at its sides, and then in front. You 
 can, however, scarcely auscultate the front of the chest in infancy with- 
 out a stethoscope, and this you will often be unable to use ; for, if the 
 child is not frightened, it will probably be so exceedingly amused at 
 what it regards as specially intended for its own diversion, that it will 
 join in the game, and disconcert you by playing with the instrument. 
 You will encounter this difficulty in cases of phthisis in early child- 
 hood, and will sometimes find it no easy matter to ascertain the charac- 
 ter of the respiration in the front of the chest. In such cases you will 
 learn all the value of percussion, which may be practiced over the front 
 of the chest as well as the back, while the state of the breathing in the 
 upper and back part of the chest will generally afford a tolerably ac- 
 curate clue to its condition in front; though, except in instances of 
 great tubercular enlargement of the bronchial glands, the signs of pul- 
 monary consumption are perceived earlier, and in a more marked de- 
 gree, under the clavicle than in any other situation. 
 
 Your examination of the chest will not be complete until you have 
 noticed the character of the breathing, whether the whole of the chest 
 is expanded by it, or whether the respiration is merely abdominal — 
 whether the child breathes as deeply as it should, or whether it makes 
 frequent short inspirations which cannot fill the smaller bronchi. The 
 time for ascertaining these points must vary in each case ; but the ear- 
 lier they are observed the better, since otherwise you run the risk of 
 drawing your inferences, not from the child's ordinary condition, but 
 from its state when excited and alarmed. Some of these points may 
 be noticed though the child be so fretful that you cannot auscultate 
 even the back of its chest satisfactorily. An imperfect auscultation, 
 however, is better than none ; for at the very worst, during the deep 
 inspirations that are made at intervals in a fit of crying, you may as- 
 certain how far the lungs are permeable to air, and whether the bron- 
 chi are much loaded with mucus. Independently of auscultation, too, 
 much may be learned from the cry. If its two periods are clearly 
 marked — the long loud cry of expiration, and the shorter, less loud, 
 but perfectly distinct sound that attends inspiration — you may feel 
 convinced that there exists no. important ailment of the respiratory 
 organs. 
 
 It will still remain for you to examine the tongue, and to ascertain 
 the condition of the gums ; and it is wise to defer this to the last, since 
 it is usually the most grievous part of your visit to the child. If dur- 
 ing any part of your previous examination it had cried, you might seize 
 that opportunity to look at its tongue, and, if necessary , to pass your finger 
 over the gums ; thus sparing it any further distress about the matter. 
 If you had not this opportunity, you will generally get a good view of 
 the mouth and throat in young infants by gently touching the lips with 
 your finger ; the child opens its mouth instinctively, and then you can 
 run your finger quickly over its tongue, and down towards the pharynx, 
 and thus secure a perfect view of the mouth and throat. With older 
 children a good deal of coaxing is sometimes necessary to persuade 
 them to open their mouth ; but, if once you get your finger on the 
 gum, you can usually keep the patient quiet by rubbing it, and, by a 
 
CASE-TAKING. 23 
 
 little address, will then seldom fail in opening the mouth wide enough 
 to get a view of the tongue. 
 
 If little children are very ill, all this minute care in the order of 
 your examination is not so much needed, because they will not notice 
 so quickly; but gentleness of tone and manner will be even more 
 necessary to soothe the pettish ness and quiet the alarm of the little 
 sufferer. 
 
 Many of the directions that I have just given you refer to the ex- 
 amination of infants, and become less applicable in proportion to the 
 greater age of the patient. Minute rules for your examination of 
 children from three years old and upwards are not needed : but pa- 
 tience the most untiring, and good temper the most unruffled, are in- 
 dispensable. 
 
 The previous history of a patient, the circumstances in which his 
 present illness came on, and the symptoms that at first attended it, 
 often help to remove our doubts with reference to the nature of a dis- 
 ease, and sometimes greatly modify our diagnosis, and influence our 
 plan of treatment. Really trustworthy information on these points, 
 however, is often difficult to be obtained, and the attempt to elicit it is 
 almost sure to be unsuccessful, if the questions put to the patient are 
 proposed at random, and without some previously well-digested plan 
 on the part of the physician. One great object of clinical instruction 
 is to teach the student so to conduct this as well as other parts of his 
 examination of the sick, as to throw from every source the greatest 
 possible amount of light upon the nature of the disease, and thus to 
 fit himself to decide with some approach to certainty on the means 
 most likely to effect its cure. Such instruction has been amply afforded 
 you in the wards of the hospital ; but you must allow me to detain 
 you while I point out the subjects towards which your inquiries must 
 be especially directed in the case of children, since they differ in many 
 respects from the questions that you would propose if your patient 
 were an adult. 
 
 We will suppose, if you please, that a child is brought to you of 
 whose case you wish to preserve a record. Its name, age, sex, and 
 residence will form of course the first entry in your note-book ; but 
 your next inquiries should be as to the number of living children that 
 the parents have had, whether any of those children have died, and, if 
 so, at what age, and of what diseases, and as to the health of both 
 parents, and of their immediate relatives. The object of these questions 
 is to ascertain whether there exists any hereditary tendency to disease 
 in the family, since that plays a most important part in many of the 
 affections of childhood, and symptoms that in the child of healthy 
 parents would cause you but little uneasiness, would at once excite 
 serious alarm if you knew that some members of the family had died 
 of hydrocephalus, or of consumption, or had been the subjects of scrofula. 
 
 Many of the most serious affections of childhood occur within the 
 period of a few years, and after a certain age are comparatively rare in 
 their occurrence, and generally mild in their character. It is therefore 
 very desirable when any ailment is coming on, the nature of which is 
 not yet quite apparent, to know which of the diseases incidental to 
 
24 CASE-TAKING. 
 
 childhood have already affected your patient. With this view you 
 would ask whether the child has been vaccinated, or has had the small- 
 pox, and whether it has passed through any other of those affections — 
 such as chicken-pox, hooping-cough, measles, or scarlatina — which 
 generally come on in early life. If the child had suffered from any 
 other disease, you should learn its nature, the age at which it occurred, 
 and any other point of importance connected with it. 
 
 In writing out your history of the case, these preliminary matters 
 would naturally be mentioned at the beginning ; and, though you 
 would not follow any very strict order in proposing your questions, 
 yet it is always desirable to obtain information on these points at an 
 early stage of your examination, since it may guide you in some of the 
 questions that you afterwards propose, or may lead you to pay par- 
 ticular attention to symptoms which otherwise would not seem to be of 
 much moment. Besides, if you postpone these inquiries till you have 
 nearly completed your examination of the patient, the parents will 
 probably apprehend that they are suggested by some doubt and appre- 
 hension in your mind as to the nature of the case, and will distress 
 themselves by causeless fears, or perhaps disconcert you by questions 
 to which you are not prepared to return a positive answer. 
 
 There are two other points which bear on the general condition of 
 the child, to one or both of which your inquiries must in many instances 
 be directed. If your patient is an infant at the breast, you must learn 
 whether it lives entirely on its mother's milk, or has other food besides. 
 If it has been weaned, you must ask its age at weaning ; whether it 
 was taken from the breast on account of any failure in its own health 
 or its mother's, and on what diet it has since been fed. The process of 
 dentition is the other subject for examination ; and in reference to it 
 you must ascertain how many teeth the child has, and which they are; 
 whether they were cut easily or with difficulty, the age at which teeth- 
 ing commenced, and the time that has elapsed since any fresh teeth 
 appeared. 
 
 You may now endeavor to obtain a clear and connected history of 
 the present illness ; and for this purpose it is well to begin with asking, 
 When did the child last seem quite well? since you thus get a fixed 
 starting-point from which you can make the mother or nurse set out 
 in her detail of symptoms. The date thus assigned, indeed, will often 
 be a wrong one, the disease having begun before with some symptom 
 that was not noticed, or its real origin having been considerably subse- 
 quent to its supposed commencement. But notwithstanding this pos- 
 sible error, you derive much advantage from thus making sure of the 
 symptoms being told you in something like their chronological order, 
 since otherwise it is very likely that those only would be mentioned 
 which had chanced to strike the mind of the mother or of the nurse, 
 while the others would be passed over in silence. Your object in the 
 examination must not be to curtail the garrulity of the nurse, or to 
 suppress the mother's expression of her sometimes imaginary fears, but 
 to get as clear an account as possible of everything that has been 
 observed. You must be careful not to underrate the value of the infor- 
 mation they communicate, or even of the opinions they express. Both 
 
CASE-TAKING. 25 
 
 are much more likely to be correct when your patients are children, 
 than when they are adults. A mother hanging over her sick infant, 
 or a nurse watching the child she has helped to rear from babyhood, 
 may sometimes see dangers that have no existence, but will generally 
 be the first to perceive the approach of such as are real. You see the 
 child but for a few minutes and at distant intervals, and the excitement 
 or alarm which your presence is so likely to occasion may greatly 
 modify its condition 'during your visit. They tend the little one by 
 day and night, notice each movement, and seize the most transient 
 variations in its expression. 
 
 I need not say much concerning the necessity of inquiring about 
 the appetite and thirst, the state of the bowels, and the appearance of 
 the evacuations ; for these are points which you would investigate in 
 patients of every age. I will just mention, however, that the degree 
 of appetite and thirst cannot be so readily determined in the infant as 
 they may be in the adult, or even in the weaned child • for an infant 
 may suck, not because it is hungry, but in order to quench its thirst. 
 That extreme craving for the breast, which is appeased only so long 
 as the child is sucking, while the milk swallowed is speedily vomited, 
 may be taken as a sign of thirst ; but it is always better to record the 
 fact than the inference. It is likewise often desirable to let the infant 
 be put to the breast in your presence, not only for the sake of observ- 
 ing the above-mentioned facts, but also in order to notice the vigor 
 with which it sucks, the ease or difficulty with which it swallows, and 
 other similar points, from which very important conclusions may often 
 be drawn. 
 
 Before you venture on drawing any inferences from the state of the 
 child at the time of your visit, you should ascertain whether it has 
 just before been taking food, or has been recently excited or fatigued by 
 being washed or dressed ; since comparatively trivial causes are suffi- 
 cient to accelerate the pulse and respiration, and to give rise to changes 
 which might, if unexplained, lead you to very erroneous conclusions. 
 Any such circumstances ought of course to be mentioned in your notes, 
 as should also the fact of the child being asleep at the time of your 
 visit, since that would explain even a very considerable diminution in 
 the frequency of the pulse and respiration. 
 
 But if you are carefully to observe all the points which I have 
 mentioned, and to make yourselves thoroughly masters of a case, you 
 must be most lavish of your time ; you must be content to turn aside 
 from the direct course of investigation, which you would pursue unin- 
 terruptedly in the adult, in order to soothe the waywardness of the 
 child, to quiet its fears, or even to cheat it into good humor by joining 
 in its play ; and you must be ready to do this, not the first time only, 
 but every time that you visit the child, and must try to win its affections 
 in order to cure its disease. If you fail in the former, you will often 
 be foiled in your attempts at the latter. Nor is this all : you must visit 
 your patient very often, if the disease is serious in its nature and rapid 
 in its course. New symptoms succeed each other in infancy and child- 
 hood with great rapidity ; complications occur that call for some change 
 in your treatment, or the vital powers falter suddenly, when you least 
 
26 PROPOSED PLAN OF THE LECTURES. 
 
 expect it. The issues of life and death often hang on the immediate 
 adoption of a certain plan of treatment, or on its timely discontinu- 
 ance. Do not wait, therefore, for symptoms of great urgency before 
 you visit a child three or four times a day ; but if the disease is one in 
 which changes are likely to take place rapidly, be frequent in your 
 visits as well as watchful in your observation. 
 
 You will naturally think, that before I finish this lecture I should 
 tell you something definite about the subjects that I mean to bring 
 before your notice, and the manner in which I propose to treat them. 
 The title of these lectures can, I should think, scarcely need any ex- 
 planation, for by the diseases of infancy and childhood you will natur- 
 ally understand all those affections which are either limited in the 
 time of their occurrence to early life, or which, though incidental to all 
 ages, yet in the child present many peculiarities in their symptoms, and 
 require many important modifications in their treatment. Some of 
 these diseases, indeed, are usually allotted to the care of the surgeon, 
 and on their examination I will not enter, since I could tell you noth- 
 ing more than has already been better said by others. For the same 
 reason, too, I leave untouched the very important class of cutaneous 
 affections, well worth your study indeed ; but that study should be 
 carried on under a more skilful guide than I could prove myself. 
 
 In the description of the diseases of children, no practically useful 
 end would be attained by following any elaborate nosological system. 
 I shall therefore adopt the most simple classification possible, and shall 
 treat in succession of the diseases of the nervous system, of the respira- 
 tory and circulatory, and of the digestive systems and their appendages. 
 There will still remain one very important class of affections, namely, 
 fevers; and these I propose to consider last of all, because much of their 
 danger arises from their complications, and to treat them judiciously yon 
 must be familiar with the diseases of the brain, the lungs, and the bowels. 
 In this plan it will be easy to detect a want, perhaps too great a want, 
 of scientific arrangement ; but the one object of my endeavors will be to 
 communicate to you, as clearly as I can, such information as may be 
 most useful to you in the discharge of your daily duties. 
 
 With this view I have, while composing these lectures, tried to think 
 over the doubts I felt, the difficulties I met with, and the errors I fell 
 into, when, now many years ago, I entered on the office of physician to 
 a large institution for the treatment of children's diseases. I have pre- 
 sumed that where I had encountered difficulties, there you might meet 
 them too ; that where I had made mistakes, there you would need a 
 guide ; and, remembering the many anxious hours I passed when I 
 hesitatingly adopted some course which I feared might after all be a 
 mistaken one, it has been my aim to lay down, not only the rules for 
 the diagnosis, but also the indications for the treatment of each disease 
 as minutely as possible. 
 
 To the task before me I now apply myself, with a deep conviction of 
 the narrow limits of my own knowledge, but still feeling that I have 
 contracted an obligation to impart to others what I trust experience has 
 taught me. My end will be answered, if you learn it at an easier rate 
 
RULES FOR DEPLETION IN CHILDREN. 27 
 
 than I did, and if I can be the means of saving you from some of those 
 errors in diagnosis, and some of those mistakes in treatment, which, for 
 want of some one to guide me aright, I committed. 
 
 LECTUEE II. 
 
 INTRODUCTORY. 
 
 Ok the Treatment of Children's Diseases. — influence of remedies modified by 
 the age of the patient — Rules for the practice of depletion, for the use of mer- 
 cury, antimony, opium, and other sedatives, and for the employment of blisters 
 — Suggestions as to the mode of prescribing for infants and children. 
 
 In the introductory lecture, I tried to point out the main peculiarities 
 which distinguish the diseases of early life, and to furnish you with some 
 general rules for their investigation. It may not be time misspent, if, 
 before we begin the examination of any special class of ailments, I en- 
 deavor to give you a few general directions for their treatment, though in 
 so doing I must of necessity anticipate some things which will require 
 notice hereafter, and must occasionally presuppose the possession of that 
 knowledge which it is the main object of these lectures to impart. 
 
 The importance of great exactness in prescribing for infants and chil- 
 dren, and the necessity for regulating the doses of our remedies accord- 
 ing to the tender years of our patients, are self-evident. Posological 
 tables, as they are termed, are, however, of very little value for our 
 guidance, since the susceptibility of the young to the action of different 
 remedies varies greatly according to their nature, so that the rule which 
 safely defines the dose of an opiate, would be altogether inapplicable as 
 determining the strength of a purgative or of an emetic. 
 
 The abstraction of blood, the use of emetics and purgatives, the em- 
 ployment of antiphlogistics, and the administration of sedatives, are the 
 great weapons with which we endeavor to combat the advances of acute 
 disease. The safe use of each of these in early life implies the obser- 
 vance of certain precautions which I will now attempt to explain, and 
 will then try to furnish you with a few general directions that may be 
 of service in prescribing for infants and children. 
 
 The early age of our patients imposes of necessity some restriction 
 on the mode in which depletion can be practiced ; for venesection in the 
 arm is hardly ever possible before the age of three years, often not till 
 later, in consequence both of the small size of the veins, and of the 
 quantity of fat in which they are imbedded. In cases of extreme ur- 
 gency the jugular vein may be opened, and I have never found any 
 difficulty in the operation, though I believe the necessity for the pro- 
 
28 RULES FOR DEPLETION 
 
 ceeding very seldom arises, and the only cases in which I have had 
 recourse to it were either instances of violent convulsions succeeded by 
 profound coma, or else of very acute inflammatory croup. 
 
 For almost all purposes of depletion in early life we are dependent 
 on the use of leeches, and by this means, if rightly managed, w T e may 
 attain nearly all the ends of general bleeding. The great objection to 
 the employment of leeches rests on the difficulty of estimating and of 
 controlling the quantity of blood abstracted by them. This objection, 
 however, applies almost entirely to the common practice of putting on 
 a comparatively small number of leeches, and trusting to the applica- 
 tion of a poultice, or the employment of fomentations, for obtaining a 
 sufficient quantity of blood. Instead of adopting this plan, than which 
 nothing can be more uncertain, it is far better to apply a larger number 
 of leeches, and to allow of no subsequent bleeding. It may be calcu- 
 lated that each leech takes about two drachms of blood, and we are 
 thus enabled to estimate the quantity removed with a certainty little 
 less than we are possessed of if we employ venesection, while, further, 
 the blood is removed in the course of fifteen or twenty minutes, instead 
 of draining away, as in the other case, for six or eight hours, weaken- 
 ing the patient, and yet exercising comparatively small influence on 
 the disease. 
 
 To insure certainty and safety, however, in the employment of 
 leeches, there are several precautions which must not be neglected. 
 Of these the most important is, that their application should not be 
 left to a nurse, but that, wherever it is at all practicable, the medical 
 attendant should himself superintend it. This is of special moment 
 in all acute diseases in which it is desired to obtain by local bleeding 
 the constitutional effects of general depletion ; since, according to the 
 result produced, it may, on the one hand, be desirable to put on a larger 
 number, or, on the other, to remove some before they have completely 
 filled themselves. The effects produced by the loss of blood often in- 
 fluence the character of the subsequent treatment. On this account, 
 therefore, as well as with the view of lessening the risk of hemorrhage 
 going on from the leech-bites unperceived, it is desirable to apply 
 leeches by day, not towards evening, or at bedtime, as is commonly 
 the practice. Attention should further always be paid to apply leeches 
 in situations where they will not alarm the child by being within his 
 sight, and where, also, there is a firm surface beneath against which 
 pressure can be made, so as readily to control the bleeding. Behind 
 the ears, therefore, or on the vertex, are the best situations for applying 
 leeches to the head, and under the scapula? when it is necessary to de- 
 plete from the chest ; while, in many abdominal affections, all the ad- 
 vantages of local bleeding may be most safely obtained by the appli- 
 cation of leeches to the anus. 
 
 The above rules apply to the mode of practicing depletion in early 
 life; but, independently of the mere manner of drawing blood, there 
 are some still more important cautions which have reference to the 
 general principles that should govern us in resorting to depletion at all. 
 
 1st. It should be remembered that large losses of blood are worse 
 borne by the child than by the adult; that if syncope is produced, its 
 
AND EMPLOYMENT OF MERCURY. 29 
 
 effects do not pass away so speedily, but leave a much more abiding 
 depression. 
 
 2d. That the shock consequent on large losses of blood, shows itself, 
 not merely by causing syncope, but also, not very seldom, by producing 
 convulsions; and such convulsions are specially apt to be excited in 
 cases where the previous disorder of the nervous system was consider- 
 able, even though that disorder depended on congestion of the brain 
 which called for depletion to relieve it. It seems as if in these cases, 
 just as in some of comparatively slight disease of the heart, if the 
 equilibrium of the circulation is suddenly disturbed it altogether fails 
 to recover itself. A child of ten months old was brought to me many 
 years ago with symptoms of cerebral congestion — a hot head, a raised 
 fontanelle, a burning skin, and twitching of the tendons of the arms 
 and legs. I ordered leeches to the head, which drew freely : but the 
 convulsions which it was hoped they would ward off, occurred while 
 the bleeding was still going on, and the child sank at once into a state 
 of coma, from which it never rallied completely, and died in the course 
 of forty-eight hours. Now, in this case, the abstraction of blood was 
 indicated, and the appearances discovered after death showed that the 
 depletion had not been excessive. It had, however, been too sudden ; 
 and probably, had I been present w T hen the leeches were applied, I 
 should have noticed some change in the child's condition which would 
 have warned me to put a stop to further bleeding, and might thus have 
 led to an entirely different result. In proportion, therefore, to the youth 
 of our patient, must be our caution in ordering free depletion, and our 
 care in watching its effects; and these must both be greater when marked 
 disorder of the nervous system forms the indication for our treatment. 
 
 3d. Not only are very large losses of blood hazardous, and great 
 shock by its too sudden abstraction also attended with danger in 
 early infancy, but repeated bleedings are also inexpedient. The system 
 rallies from them with proportionately far greater difficulty than in 
 the adult, and that peculiar class of symptoms, by which exhaustion is 
 apt to simulate congestion of the brain, is specially likely to be in- 
 duced. It may be added that, to a considerable degree, the same cau- 
 tion holds good with reference to all other antiphlogistic remedies ; that 
 free purgation, spare diet, and depressing measures of all kinds, though 
 often requisite, yet require most heedful watching, and generally need 
 to be soon discontinued. 
 
 Changes in medical opinion, such as have taken place within the 
 past twenty years, influence one's conduct by slow and almost imper- 
 ceptible degrees, and I find that my practice now differs much from 
 what it was a quarter of a century ago ; that I deplete less than I did, 
 that I have less faith in mercury, that I employ antimony more rarely, 
 that I have more confidence in nature's powers, less reliance on my 
 own resources. And yet I am unwilling to believe that all my former 
 observations were erroneous and that my old faith was entirely mis- 
 placed ; but unhappily Lhave no longer the leisure to test the value of 
 these changes as I could wish ; while the peculiarities of consultation 
 practice in a large city, though they may sharpen one's perception, and 
 
30 RULES FOR EMPLOYMENT 
 
 increase one's promptness in action, are anything but favorable to 
 scientific investigation or to accurate reasoning. 
 
 With this explanation, and if need be, apology for my still enter- 
 taining views on some subjects opposed to, or as may be said, behind 
 the opinions of the day, I will now proceed to tell you what I think 
 about other great remedies that one employs in the diseases of child- 
 hood. 
 
 And first, with reference to mercury. I still believe that it possesses 
 a peculiar and specific power in controlling acute inflammation of the 
 serous membranes of the chest and abdomen; and that both acute 
 pleurisy and acute peritonitis (the latter, by the by, as rare* as the for- 
 mer is frequent in early life), yield to a combination of calomel and 
 opium more speedily than to opium alone. I feel also persuaded that 
 in severe inflammation of the mucous membrane of the large intestines 
 — in other words, in dysentery in childhood — the part borne by mer- 
 cury in its cure is at least of as much moment as that of the opium with 
 which it is right to combine it ; but the latter alone will fail when the 
 two together will save the patient. 
 
 In laryngeal inflammation, or true croup, after the first active symp- 
 toms have been subdued, mercury often plays an important part in its 
 more chronic stages ; and I still hold to the belief that in some forms 
 of chronic non-tuberculous consolidation of the lung, recovery is ex- 
 pedited by the careful employment of mercurials. I do not regard it as 
 of any service in acute affections of the pulmonary tissue, nor in any 
 form of bronchitis, but I still regard mercury as of service in acute 
 pericarditis ; and I say this with full consciousness of the sources of 
 fallacy which in this case may readily interfere with the formation of 
 a correct judgment. 
 
 In cachectic diseases its utility is far more limited. The earlier 
 symptoms of congenital syphilis yield rapidly to the employment of 
 small doses of mercury ; but the tertiary results of the disease are often 
 aggravated, very seldom indeed benefited, by that medicine. In the 
 majority of disorders connected with the tubercular diathesis, mer- 
 curials are not beneficial, and in tubercular meningitis in particular, in 
 which they are so often given, I never saw even momentary improve- 
 ment from them, apart from their occasional action as purgatives. It 
 must, however, be confessed that in their powerlessness to control this 
 disease, they do but stand on the same footing with all other medicines. 
 There is one class of ailments, too, connected with tuberculosis, in 
 which the action of mercury is almost uniformly beneficial, and that is 
 tubercular peritonitis, and those vague disorders of the functions of 
 nutrition so commonly, though so often erroneously, referred to disease 
 of the mesenteric glands. 
 
 In administering mercury to infants and young children, it must be 
 borne in mind that evidence of the system being affected by it is 
 seldom afforded, as in the adult, by the occurrence of salivation. So 
 rare, indeed, is mercurial stomatitis in early life, that I have seen but 
 one instance in which it proved fatal, and have very seldom met with 
 it in such a degree as to be troublesome. I should therefore regard 
 the production of gangrene of the mouth by the administration of mer- 
 
OF MERCURY AND ANTIMONY. 31 
 
 cury, as an evidence of some rare idiosyncrasy on the part of the pa- 
 tient rather than of want of due care on that of the doctor. In early 
 life, mercury, instead of affecting the mouth, usually acts very speedily 
 as an irritant on the intestinal canal ; and the green stools, which are 
 often looked on with satisfaction as a proof of the system being brought 
 under the influence of the medicine, are far from always having that 
 meaning. They prove its action as a local irritant — a result which 
 may be most undesirable, and which often compels us to diminish its 
 dose, sometimes even completely to suspend its administration. Some- 
 times, too, calomel acts as an irritant on the mucous membrane of the 
 stomach, producing nausea and vomiting, and giving rise to so great a 
 degree of depression as to necessitate its discontinuance. 
 
 Besides its use in those more formidable diseases to which reference 
 has hitherto been made, mercury is also often employed as a purgative 
 and alterative. There is no doubt but that used with either of these 
 objects it is a remedy of great value, and the objection to its employ- 
 ment is, not that it fails to accomplish these ends, but that it answers 
 them at a greater expense of constitutional power than is necessary. 
 Rhubarb, soda, the mineral acids, aloetic preparations, taraxacum, and 
 other remedies, exert an alterative power over the secretions, without 
 any of that depressing influence which attends the use of mercurials. 
 In the same manner, there are many purgatives no less certain, and no 
 less speedy in exciting the action of the bowels ; so that, before pre- 
 scribing calomel or gray powder, both of which ought to be absolutely 
 banished from nursery use, the practitioner ought to be satisfied that 
 there is some special end, in producing an increased secretion of bile, 
 in controlling an excited state of the circulation, or in rapidly modify- 
 ing the condition of the intestinal mucous membrane, which no other 
 remedy would attain, or at any rate would not attain so certainly or so 
 quickly. 
 
 A second remedy of great value in early life is antimony, though one 
 which also is not infrequently misapplied. It is not as a simple emetic 
 that antimony ought to be employed, for, unlike ipecacuanha, its influ- 
 ence is not confined to inducing vomiting, but it also exerts a most 
 powerful depressing action on the circulation, and is therefore especially 
 indicated in acute inflammation of the lungs and air-tubes. When the 
 object is merely to empty the stomach, to produce that revulsion which 
 follows the operation of an emetic, and which leads us often to prescribe 
 it at the onset of a febrile attack for the sake of the moist skin and 
 tranquil pulse which seldom fail to succeed its operation ; or when we 
 seek simply to free the bronchi from the secretions poured into them 
 in too great abundance, as in catarrh or in simple hooping-cough ; 
 every end is answered by the use of ipecacuanha. On the other hand, 
 in the onset of croup, in the early stage of acute pneumonia or of capil- 
 lary bronchitis, when disease is advancing every hour and when its 
 advance directly threatens life, antimony is the only medicine suffi- 
 ciently speedy and sufficiently powerful in its action to keep pace with 
 the advances of the disease, and to hold it in check. Even in these 
 cases, however, the administration of antimony needs care, and after 
 tolerance of it has been established we cannot, so safely as in the adult, 
 
32 RULES FOB USE OF OPIUM. 
 
 continue its use. I shall hereafter have to explain to you the liability 
 to collapse of the lung in early life, when feeble inspiratory power is 
 associated with the presence of secretion in the air- tubes. In this state 
 the pulmonary tissue tends by its own elasticity to exclude the air 
 from the air-vesicles ; and if the muscular power is reduced below a 
 certain point, the patient's efforts fail to dilate them, and by degrees 
 more and more of the lung becomes dense, unaerated, and as useless 
 for the time, for all purposes of respiration, as if it had been solidified 
 by inflammation or compressed by fluid. This danger is always to be 
 borne in mind in the pulmonary affections of early life, and the vigor 
 of the patient's powers must be the measure of our treatment, as much 
 as the urgency of the disease. 
 
 As a mere diaphoretic, antimony, when administered in small doses, 
 is as useful in the case of the child as in that of the adult. I am not 
 fond of its use, however, as an antiphlogistic in ordinary febrile affec- 
 tions ; for the nausea which it is apt to produce may obscure the 
 approach of cerebral mischief, or lead to an erroneous interpretation of 
 the symptoms. 
 
 A third great remedy in the diseases of early life is opium in its 
 various preparations ; and with it may be classed, though separated by 
 a wide interval, other sedatives, such as hemlock, henbane, hop, and 
 lettuce. Perhaps no remedies are so often needed in the diseases of 
 early life as sedatives, for at no other age is the nervous system so easily 
 disturbed. At the same time, the susceptibility to the action of narcotics 
 and sedatives is so remarkable, and the evils which result from their 
 unnecessary employment or from their administration in excessive doses 
 are so serious, that some practitioners altogether abstain from their use. 
 To do so, however, is to deprive ourselves of one of the most impor- 
 tant classes of remedies, and of one for which no substitute can be 
 devised. 
 
 The danger which especially attends the use of opium arises partly 
 from the employment of uncertain preparations, such as the syrup of 
 poppies ; partly from the administration of overdoses, or from their 
 too frequent repetition : of which two errors, the latter is more fre- 
 quently committed. In prescribing for children, preparations of definite 
 strength should always be used, as the compound tincture of camphor, 
 tincture of opium, or Dover's powder. The weaker preparation, the 
 compound tincture of camphor, is often preferable to laudanum, since 
 a slight error in dispensing is of so much less moment. Sometimes the 
 comparative tastelessness of laudanum renders it the more suitable ; but 
 if so, even though only a single dose is needed, it is wiser in the case 
 of infants to order a mixture containing two or three doses, in order to 
 lessen the risks of error. But mischief is more frequently done by the 
 frequent repetition of opium, than by the improper prescription of over- 
 doses ; and I am always averse to the common practice of giving small 
 quantities of opium at short intervals, for the purpose of checking 
 diarrhoea or of soothing restlessness in young infants; and prefer, 
 unless there be some strong reason to the contrary, to give a larger dose 
 of the remedy once or twice in the twenty-four hours. 
 
 In addition to these general precautions with reference to the mode 
 
RULES FOR USE OF SEDATIVES. 33 
 
 of administering opium, special care is needed in its employment in 
 some conditions. It must be given charily in all cases where the 
 system has been exhausted by the previous disease, or by the previous 
 treatment ; and this caution must be particularly borne in mind during 
 convalescence from fever, where yet the patient's restlessness not seldom 
 requires its employment. In all cases of cerebral excitement the use 
 of opium calls for great watchfulness ; sometimes it must be given rather 
 as an experiment whereby the real nature of the disease is tested, and 
 when so employed its results must be scrutinized with the most anxious 
 care. In severe diarrhoea, too, the transition from a state of excita- 
 bility of the nervous system to a condition of coma is often very rapid 
 in its occurrence; an overdose of opium may hasten or induce this 
 catastrophe, or, even though it should not have this result, yet without 
 great care we shall be at a loss to determine how far the disease, and 
 how far the medicine, has induced the symptoms. 
 
 The subcutaneous injection of morphia is an exceptional means for 
 obtaining relief from intense pain which once or twice I have had 
 recourse to. It is, however, hazardous in early childhood, and the few 
 instances in which it is likely to be needed will be met with in surgical 
 rather than in medical practice. 
 
 In mere restlessness, unattended by severe pain, other sedatives are 
 often preferable to opium : thus, for instance, the feverish disquietude 
 of a child during teething is often soothed by henbane, w T hile that which 
 manifests itself by a disposition to carpopedal contraction and to spasm 
 of the glottis is mitigated by small doses of hydrocyanic acid and chloric 
 ether as effectually as by opiates, and with far greater safety. 
 
 Two additional sedatives have of late years been introduced into 
 practice, both of them of great value, and both free from the special 
 risks of opium. The bromide of potass and the hydrate of chloral, 
 either alone or in combination, seem to exercise special influence in 
 producing sleep in various disorders of the nervous system, such as 
 spasm of the glottis in infancy, or chorea in subsequent childhood. 
 They are of equal service in overcoming the persistent sleeplessness for 
 which in delicate children it sometimes happens that no definite cause 
 can be discovered. In cases where cerebral disease is suspected they 
 may be given with advantage, and without obscuring the symptoms, 
 and also in the restlessness of fever, provided the stimulating power of 
 opium is not indicated. They do not, however, annul pain as opium 
 does, even though they may produce sleep ; the sleep is not refreshing 
 if the actual suffering is severe when the patient awakes ; and as they 
 both tend to depress the circulation, they must not be given in cases of 
 great exhaustion, nor, I think, when there is serious organic disease of 
 the heart. 
 
 The difficulties in the administration of internal remedies in early 
 life have had no small share in leading practitioners to the employment 
 of outward applications with much greater frequency than in the adult. 
 Fomentations, poultices, and liniments of various kinds relieve pain, 
 abate spasm, or serve as useful counter-irritants, in very many cases 
 which I need not now occupy your time in specifying. But, besides 
 these, blisters are also much used in different inflammatory affections, 
 
 3 
 
34 APPLICATION OF BLISTERS. 
 
 more particularly in those of the lungs and air- tubes, though I think 
 their application is more restricted and is resorted to with greater 
 caution now than formerly ; and I see far fewer instances of unhealthy 
 ulceration of blistered surfaces among the children of the poor now, 
 than came under my notice twenty years ago. 
 
 In applying blisters to infants and young children, it must be borne 
 in mind, not only that they vesicate more speedily that in the adult, 
 but that the vesicated surface is apt, especially in some diseases, to pass 
 into a state of ulceration ; and, further, that the amount of constitutional 
 disturbance produced by blisters is considerable in proportion to the 
 youth of the patient. 
 
 The ordinary rule, which prescribes four hours as the longest time 
 during which a blister should be allowed to remain on the skin in 
 infancy, is on the whole a good one, but it must be remembered that 
 some parts of the surface are far more sensitive than others. Thus, for 
 instance, the skin on the front of the chest is peculiarly delicate, and a 
 blister applied there for two hours would almost certainly vesicate, 
 while it might not produce the same effect in double the time if applied 
 beneath the scapulae. On the other hand, the scalp is remarkably 
 deficient in sensitiveness, and a blister may be allowed to remain on it 
 for eight hours without any risk of mischief ensuing. Tnere are, 
 moreover, some diseases which increase the susceptibility of the skin to 
 the action of irritants : thus, for instance, in all the ailments which 
 accompany or succeed to measles, and especially in the pneumonia 
 which often complicates it, a vesicated surface is apt to pass into a state 
 of dangerous ulceration. Nor is this the only hazard that attends 
 their use ; but the constitutional disturbance which they produce, the 
 pain while they are drawing, the soreness of the surface while they are 
 being dressed, and the itching and irritation which accompany their 
 healing, often keep up an amount of restlessness, and a state of feverish 
 irritation, that are in every way prejudicial to the child's recovery. 
 
 On these accounts, therefore, I have almost entirely abandoned the 
 use of blisters in infancy and early childhood, and am always most 
 careful that no extensively abraded surface shall be left by their appli- 
 cation. Partly with this object, and partly in order to avoid the in- 
 convenience of the blister being dislodged by the movements of the 
 child, I make use almost exclusively of the blistering fluid, which is 
 painted once or oftener over the surface, according as it is wished to 
 produce a more or less considerable degree of irritation. If vesication 
 takes place, the serum is let out by pricking with a needle, and a layer 
 of cotton-wool being applied over the surface is allowed to remain there 
 until, healing being completed, it drops off of its own accord. In 
 addition to the avoidance of danger and the lessening of constitutional 
 disturbance by these means, we have the great advantage of being 
 able, if it should be desirable, to repeat the same proceeding in the 
 course of three or four days, while, by the ordinary mode of employing 
 blisters, ten days almost invariably elapse before the sore left by their 
 application is healed. In other cases, such as those of chronic pleurisy, 
 where we are anxious to promote the absorption of the effused fluid, or 
 in cases of consolidation of the lung, associated with signs of tubercular 
 
RULES FOR PRESCRIBING FOR YOUNG CHILDREN. 35 
 
 mischief, the application of tincture of iodine once a day over the 
 surface takes the place most advantageously of the blisters which we 
 should employ in the adult. 
 
 The whole range of remedies might thus be gone through ; and with 
 reference to each it might be pointed out how its employment requires 
 to be more or less modified according to the age of the patient. But 
 to do this would be more tedious than profitable, and the majority of 
 details will find their fittest place when we notice the disease for the 
 cure of which this or the other medicine is specially indicated. 
 
 A few general hints may, however, be given with reference to the 
 art of prescribing for infants and children of tender age. But first of all 
 I must remind you of the twofold difficulty which you encounter in the 
 treatment of the diseases of children, owing partly to the waywardness 
 of the little patients themselves, partly to the prejudices of their pa- 
 rents, while your success as practitioners will depend on the amount of 
 tact with which you avoid coming into direct collision with either. To 
 prescribe nauseous medicine, when with a little care you could order it 
 in a palatable form ; to insist on a particular article of diet being given, 
 or on a particular remedy being employed, which the parents fancy will 
 not suit, unless you believe one or the other to be absolutely indispen- 
 sable to your patient's cure — is needlessly to weaken that authority 
 which in the graver maladies it is absolutely essential that you should 
 be able to exert. As has been truly said by MM. Rilliet and Barthez, 
 it is in the slighter much more than in the serious diseases of children 
 that waywardness, fretfulness, and obstinate refusal of medicine are 
 met with. In the majority of such cases nature alone suffices for the 
 patient's cure, and, while you watch carefully the approach of any 
 serious symptoms, you will lose nothing in the confidence of the pa- 
 rents, and gain much in the love of your patients, by sparing them the 
 nauseous draught, and the agony of tears and fright and temper which 
 they often undergo before they swallow it. The battle with a child to 
 compel it to take medicine, to force it into a bath, or to give it an 
 emetic, generally does far more harm than the remedy so administered 
 can do good ; and the many tears saved by it in the nursery are one of 
 the strongest practical recommendations of homoeopathy to the public. 
 
 But even the most expectant plan of treatment does not leave you 
 without the power of regulating to a great degree the diet of the child, 
 the temperature of its room, the nature of its amusements, and of ex- 
 cluding bright light and loud sounds from its apartment ; and nothing 
 beyond these simple measures is needed to remove many of the minor 
 ailments of the young child. Many medicines, too, can be given with- 
 out any trouble either to the child or to its attendants. A few drops of 
 ipecacuanha wine will be unperceived in its drink, a little James's pow- 
 der may be concealed in some arrowroot or on a bit of bread and but- 
 ter, or a dose of scammony may pass unnoticed in a little hot and sweet- 
 ened milk; while, if tonics are needed, the saccharine carbonate of iron 
 or the steel wine will seldom be refused by the most spoiled and most 
 wilful inhabitant of the nursery. Your own ingenuity will suggest 
 many other remedies which may be given without exciting suspicion, 
 or at any rate without causing disgust - T and,, believe me, the doctor 
 
36 RULES FOR PRESCRIBING # FOR YOUNG CHILDREN. 
 
 who brings smiles rather than tears into the nursery, he whom the 
 children love most, the parents will trust most, and that love and 
 trust will stand him much in stead when he has to combat serious 
 illness. 
 
 As far as may be, then, it is well to avoid formal prescriptions in 
 treating the ailments of early life. Often, however, this is not possi- 
 ble ; but something may still be done to make physic at any rate sup- 
 portable. Let its bulk be small : two teaspoonfuls will be swallowed 
 readily by many a child whom no persuasion could induce to take two 
 tablespoonfuls. For the same reason, powders, except when very 
 small, are often worse than useless ; and yet one sees powdered bark or 
 powdered calumba, or large doses of rhubarb and soda, prescribed for 
 little children of two or three years old : and they must have been 
 educated with far more than average wisdom, or be possessed of more 
 than average docility, who will be prevailed on to take the nauseous 
 compound. 
 
 In the heat and fretfulness of fever, when the child would gladly 
 drink any moderately palatable medicine, the solution of acetate of 
 ammonia is not seldom prescribed, and the return of the time for giv- 
 ing each dose of medicine is but the signal for a fresh combat between 
 the child and its attendant, in which, whoever gains the victory, the 
 patient is sure to suffer. A few moments' thoughtful ness would avoid 
 the trial both to the child and its parents, for nothing would be easier 
 than to prescribe a mixture such as it would take eagerly. A solution 
 of carbonate of potash saturated with citric acid and flavored with 
 syrup of mulberries, or a few grains of nitre dissolved in water and 
 rendered palatable with syrup of lemons, form a febrifuge mixture to 
 which very few children would object. If it is desirable to give anti- 
 mony, a watery solution of tartar emetic may be substituted for the 
 wine, the unaccustomed taste of which might be disagreeable. If a 
 stimulant is needed, milk well sweetened conceals to a great extent the 
 pungency of ammonia; while the chloric ether, on account of its sweet 
 taste, is almost always taken readily. 
 
 Of course it is not possible to make all medicines palatable, and then 
 you must confine yourselves to giving that which is unpleasant in as 
 small a bulk as possible. Still, if you keep this object in view, it is 
 remarkable to how large an extent it is attainable. The compound 
 jalap powder is almost the only aperient powder which children do not 
 very much object to, and the small bulk of jalapin enables us to dis- 
 pense even with that in the greater number of instances. Scammony, 
 and especially its extract, can be concealed in milk ; and even castor 
 oil shaken up in a bottle with hot sweetened milk, in which a piece of 
 cinnamon has been boiled, is so disguised as scarcely to be suspected. 
 The addition of a little chloric ether to the infusion of senna covers its 
 nauseous taste almost completely, and an extra quantity of licorice 
 makes even the decoction of aloes palatable, while powdered aloes, occu- 
 pying a small space, can often be given in brown sugar. Rhubarb is 
 the one medicine which nothing effectually disguises, though a little 
 spirit of nutmeg mitigates the nauseous flavor of the infusion. Even 
 .the difficulty ©£. administering rhubarb may often be surmounted, if we 
 
RULES FOR PRESCRIBING FOR YOUNG CHILDREN. 37 
 
 employ the extract, which is thrice as strong as the powder. Each 
 grain of the extract may be divided into four or six tiny pills, and 
 these, if silvered, may be given unsuspected, or at any rate quite un- 
 tasted, in a little arrowroot or currant jelly. We seldom, however, 
 need be at a loss in selecting some of the milder laxatives ; for the 
 senna electuary, the various syrups and essences of senna, the nursery 
 infusion of senna and prunes, fluid magnesia, the saccharine carbonate 
 of magnesia, or the very palatable Limonade Purgative of French 
 chemists, may each in turn be employed. 
 
 It is not in general difficult to prescribe a tonic which shall both be 
 suitable for a child, and at the same time not very unpalatable. The 
 ordinary bitter infusion, as gentian, cascarilla, and calumba, are out of 
 the question with young children; but the mineral acids can always be 
 made tolerable, and the infusions of roses, cloves, and orange-peel, 
 though perhaps of little value except as vehicles for some other remedy, 
 are by no means unpleasant. The decoction of logwood is very valu- 
 able as a tonic and astringent, and a little sugar and a teaspoonful of 
 port wine generally render the dose popular. In spite of its bitter 
 flavor, the small bulk of quinine often enables us to give it without 
 much difficulty ; while the Yin de Quinquina is rarely objected to by 
 any but very young children ; and the most rebellious little ones gen- 
 erally grow fond of the Yin de Bugeaud — a compound of bark, cacao, 
 and Burgundy. Cod-liver oil, disgusting as it seems to be, is com- 
 paratively seldom objected to, and orange syrup or orange wine usu- 
 ally conceals its taste very effectually. It happens frequently, indeed, 
 that children grow very fond of the oil ; and I have known quarrels 
 to take place in the nufsery over the spoon which had contained it. 
 The steel wine, the saccharine carbonate of iron, and the syrup of the 
 phosphates, which goes "by the name of Parrish's chemical food, are 
 the best and most digestible chalybeates for children ; but if iron is 
 needed in stronger forms, the syrup of orange-peel covers the taste of 
 the muriated tincture of iron, and even the compound iron mixture of 
 the London Pharmacopoeia is taken readily if sufficiently diluted with 
 almond emulsion. 
 
 But enough has probably been said on these preliminary subjects. 
 Your own experience will every iy ear deepen the conviction that in 
 dealing with the diseases of early life nothing can be considered trivial. 
 The object of my first lecture was to show you how it is only by atten- 
 tion to little things that you will learn rightly to discriminate their 
 nature ; the purpose of this has been to teach you how necessary the 
 same attention is to their successful treatment. 
 
38 DISEASES OF THE NERVOUS SYSTEM, 
 
 LECTURE III. 
 
 Diseases of the Brain and Nervous System. — Their extreme frequency in 
 early life favored by the rapid development of the brain, and the wide varia- 
 tions in the cerebral circulation during childhood — Peculiar difficulties of their 
 study — The Ophthalmoscope — Symptoms of cerebral disease in the child — Con- 
 vulsions, symptomatic value very various — Their frequency in great measure 
 due to the predominance of the spinal s}*stem in childhood — May be excited by 
 many causes — Hence attention should always be paid to the precursors of an 
 attack — Description of a fit of convulsions. 
 
 It can scarcely be necessary to assign many reasons for beginning 
 this course of lectures with the study of the diseases of the nervous system. 
 The subject, although beset with many difficulties, has always engaged 
 much attention ; partly, no doubt, from the natural tendency of the 
 human mind to inquire most curiously into those truths that seem most 
 hidden ; but still more from the alarming nature of many of the symp- 
 toms that betoken disturbance of the nervous system, and from the 
 frequently fatal issue of its diseases. But besides the general interest 
 and importance of these affections, at whatever age they may occur, 
 their extreme frequency in early life gives them an additional claim on 
 our notice. 
 
 It appears from the Reports of the Registrar-General, that 16,258 
 out of 91,225 persons who died in the metropolis during the years 1842 
 and 1845, of ascertained causes, were destroyed by the various diseases 
 of the nervous system. But 9350 of these 16,258 deaths took place 
 during the first five years of existence ; or, in other words, 57 per cent, 
 of the fatal disorders of the nervous system occurred within that period. 1 
 Even after making a very large allowance for the possible errors of 
 statistical data, this predominance of the diseases of the nervous system 
 in early life is far too remarkable to be overlooked ; though some per- 
 sons, not being able to account for the fact, have affected to doubt its 
 reality. ^ • 
 
 The fact <is one w 7 hich cannot be gainsaid ; and though we do not 
 pretend thoroughly to account for it, yet ttvo considerations may help 
 in some degree to explain it. 
 
 The first is derived from our knowledge of the fact, that in an organ 
 whose development is rapidly advancing, many diseased processes 
 also, if -once set up, will go on with proportionate activity. Now 
 there is no organ in the body, with the exception of the pregnant womb, 
 which undergoes such rapid development as the brain in early child- 
 
 1 These numbers, which yield results differing but very little from those given in 
 the first edition, are deduced from the returns furnished in the Fifth and Eighth 
 Reports. The returns for 1846, which are also given in the Eighth Report, are not 
 included, since, owing to the epidemic prevalence of diarrhoea in the autumn of 1846, 
 they would not yield average results. 
 
THEIR STUDY DIFFICULT. 39 
 
 hood. It doubles its weight during the first two years of life, and 
 though it does not absolutely cease to grow, even after adult age has 
 been attained, its growth is slow and comparatively inconsiderable 
 after the end of the seventh year. This same active state of the nu- 
 tritive or vegetative processes in the brain of the child renders the 
 organ liable to have disease set up in it by causes which would pro- 
 duce little or no injurious effect on the brain of the adult. 
 
 In the second place, the brain in infancy is much more exposed to 
 disorder than that of the adult, owing to the far wider variations of 
 which the cerebral circulation is susceptible in early life than subse- 
 quently. Nor is the cause of this difficult to discover. The cranium 
 of the adult is a complete bony case, and the firm substance of the 
 brain affords a comparatively unyielding support to the vessels by 
 which it is nourished. It has been proved, indeed, by Dr. Burrows, 1 
 that the quantity of blood which these vessels contain is not always 
 the same, as some have erroneously supposed ; still its variations must 
 needs be circumscribed within far narrower limits than in the child, 
 whose cranium, with its membranous fontanelles and unossified sutures, 
 opposes no such obstacle to the admission of an increased quantity of 
 blood, while the soft brain keeps up a much lighter counter-pressure 
 on the vessels than is exerted by the comparatively firm parenchyma 
 of the organ in the adult. If the circulation in the child is disturbed, 
 whether from difficulty in the return of venous blood as during a par- 
 oxysm of hooping-cough, or from increased arterial action as at the 
 onset of a fever, or during the acute inflammation of some important 
 organ, the brain becomes congested, and convulsions often announce 
 the severity of the consequent disturbance of its functions. The same 
 causes too, which expose the brain to be overfilled with blood, render 
 it possible for it to be drained of that fluid more completely than in 
 the adult. This fact, which you should always bear in mind when 
 treating the diseases of infants, is one reason why excessive depletion 
 induces a far more serious train of symptoms in young children than 
 succeed to it in the grown person. 
 
 It happens, unfortunately, that while there are special reasons for 
 studying the diseases of the nervous system in childhood, their study 
 is beset with special difficulties which w r e do not meet with in the 
 adult. Disordered intellect, altered sensation, impaired motion, are 
 the three great classes to which the symptoms of disease of the nervous 
 system may be referred. If our patient is an adult, he tells us of his 
 altered feelings ; he perhaps experiences some disorder of his intellec- 
 tual powers even before it has become observable to others, and, thus 
 timely warned, we can often take measures to prevent the advance of 
 
 1 In his Lumleian Lectures, published in the Medical Gazette, April 28 and May 
 6, 1842, and subsequently in his work on Disorders of the Cerebral Circulation, &c, 
 8vo., Lond., 1846 The general accuracy of Dr. Burrows's conclusions, though called 
 in question by the late Dr. John Keid,in the London and Edinburgh Monthly Jour- 
 nal for August, 1846, and more recently by Dr. Hamernjk, of Prague, in the Yier- 
 teljahrschrift fur die praktisrhe Heilkunde, vol. xvi, p. 38, seems to be placed be- 
 yond doubt by the very careful experiments of Dr. Berlin, published in the Neder- 
 landsche Lancet, February, 1850, and in Schmidt's Jahrbiicher for 1851, No. l,p. 
 14-16. 
 
40 USE OF THE OPHTHALMOSCOPE. 
 
 disease, and to ward off that impairment of the motor powers, which, 
 in his case, we know usually indicates the occurrence of some grave 
 organic lesion. In the child, things follow a very different course. 
 At first it cannot express its sensations at all, while, long after it has 
 acquired the power of speech, it knows too little how to shape its 
 ideas into words to give a correct account of what it feels ; and we can- 
 not expect to learn much from the disturbance of an intellect which as 
 yet has scarcely asserted its claim to be anything higher than the 
 instinct of the animal. The value of the symptoms, too, is different; 
 for disturbance of the motor power, which is comparatively rare in the 
 adult, except as the consequence of some serious disease of the brain, 
 takes place in the child in cases of the mildest as well as of the most 
 serious ailments; and we may even observe convulsions recurring sev- 
 eral times a day for many days together, apparently without adequate 
 cause, and not leading to any serious impairment of the child's health. 
 
 How, then, are we to attain in the child to anything beyond the 
 merest guesswork in our diagnosis of diseases of the nervous system, 
 when we are deprived to so great an extent of that information which 
 the state of his intellect and the description of his sensations afford us 
 in the adult? What meaning are we to attach to that symptom, the 
 impairment of the motor power, which in the adult we look on as of 
 such grave import, but which we meet with in the child under such 
 varying conditions and in by far the greater number of cases? The 
 task, indeed, is attended with difficulty, and the solution of these in- 
 quiries will need that you should devote to it some time and some care- 
 ful observation ; but if you do this, you need not despair of learning 
 much about an infant's sensations and the state of its mind, and will 
 at length become able rightly to interpret the meaning even of a fit of 
 convulsions. 
 
 And here will, perhaps, be the fittest place for saying a few words 
 about the Ophthalmoscope — an instrument by which we may be said 
 to see into the brain, and to gain that kind of knowledge of its state 
 with which the stethoscope furnishes us in the case of the heart and the 
 respiratory organs. 
 
 Unfortunately I have no skill in its use ; but I do not, therefore, 
 underestimate its value. On the contrary, I counsel you most earnestly 
 to make yourselves familiar with its employment/in order that you 
 may start in practice furnished with the amplest resources possible for 
 the solution of the difficult problems which we have to encounter. I 
 shall, hereafter, try to give you some account of the special information 
 which, in different circumstances, it conveys to the instructed observer; 
 but must beg leave now to give you in better words than my own an 
 estimate of its value, and a caution as to its use. The words are those 
 of M. Roger, 1 physician to the Hopital des Enfans Malades at Paris, 
 my much -valued friend, and one of the ablest physicians of our time ; 
 whose only fault is that he plans his works as though he reckoned on 
 
 1 Recherches cliniques sur les Maladies de l'Enfance, 8vo., Paris, 1872, vol. i, pp. 
 156, 157. 
 
SYMPTOMS OF CEREBRAL DISEASE. 41 
 
 an antediluvian length of days, and that he forgets the "vita brevis " 
 for whose span all our undertakings should be calculated. 
 
 "The use of the ophthalmoscope," says he, "is by no means as easy 
 in the child as in the adult, especially when Ave have to do with any 
 acute affection of the brain, as, for instance, with meningitis in its early 
 stages. It often happens either that the indications which it yields are 
 scarcely marked, and have no definite value ; or that if they are more 
 distinct, they have become so only at a time when the disease is already 
 advanced, and has declared itself by unmistakable symptoms. Be this 
 as it may, however, to be furnished in doubtful cases with even one 
 new sign to guide us is well worth having ; and if the ophthalmoscope 
 did no more than confirm a diagnosis already arrived at on other 
 grounds, its importance would be very real, and skill in its use well 
 worth acquiring. 
 
 " Do not imagine, however, that by this instrument you can read as 
 it were in the eye the diseases of the brain ; and can even, with much 
 practice in its use, read them readily. Our diagnosis of these affections 
 must be based on a complete view of all their signs and symptoms, and 
 not upon one solitary sign, whether it be the tache meningitique which 
 Trousseau made so much of, or the souffle cerebral to which I myself 
 paid so much attention, or whether it be the changes in the optic disk. 
 It is not the corporeal eye, it is the eye of the mind which alone can 
 see and recognize the different diseases of the brain ; whose diagnosis 
 will always continue most obscure in spite of the ophthalmoscope, as 
 it used to be before its invention." 
 
 I need then make no apology for asking you to study well now, 
 with just as much attention as I should have bespoken twenty years 
 ago, the symptoms by which disease of the nervous centres, and especially 
 of the brain, manifests itself in infancy and early childhood. 
 
 The painful sensations which the infant experiences soon show them- 
 selves in the haggard, anxious, or oppressed look, which takes the place 
 of the naturally tranquil expression of its countenance. It often puts 
 its hand to its head, or beats or rubs it, or, while lying in its cot, bores 
 with its occiput in the pillow ; owing to which, in children who have 
 suffered for any time from uneasy sensations in the head, you will often 
 find the hair worn quite off the occiput. It turns its head away from 
 the light, and lies much with its eyes half closed, in a state of apparent 
 drowsiness, from w T hich it often arouses with a start, and cries. The 
 cry, especially in inflammatory disease, is peculiar ; it is generally a 
 low, almost constant moan, very sad to hear — interrupted occasionally 
 by a sharp, piercing, lamentable cry, almost a shriek. If the child is 
 young, it w T ill often seem relieved by being carried about in its nurse's 
 arms, and while she is moving will cease its wail for a time, but begin 
 it .again the moment she stands still. You will sometimes observe, 
 too, that if moved from one person's arms to those of another, or even 
 if its position is but slightly altered, a sudden expression of alarm will 
 pass across its features • the child is dizzy, and afraid of falling. 
 
 You see, then, that even in the infant there is a language of signs 
 by which we learn w r ith certainty the existence of pain in the head, 
 and the connection of this pain with dizziness and intolerance of light. 
 
42 SYMPTOMS OF CEREBRAL DISEASE. 
 
 You must beware, however, of concluding from any one set of symp- 
 toms that the head is the seat of real disease. The child, as well as 
 the adult, may have sick headache; and the degree of febrile disturb- 
 ance, of heat of surface, and of heat of head, together with the state 
 of the digestive organs, are all to be taken into account in forming your 
 diagnosis. 
 
 Something may be learned of the state of the mental powers and of 
 the feelings even in early infancy. Have you never watched an infant 
 on its mother's lap, and noticed the look of happy recognition with 
 which its eye meets that of its mother ? An early result of cerebral 
 disease is to interrupt this intercourse : the child now never seems to 
 catch its mother's eye, but lies sad and listless, as if all persons were 
 alike indifferent to it; or at other times even familiar faces cause alarm, 
 the child apparently not recognizing those who yet have always tended 
 it. This disturbance, however, is but momentary, and the child sub- 
 sides into its former condition, and allows itself to be taken by those 
 at whom a minute before it seemed frightened. 
 
 But these symptoms are to be interpreted by the light thrown on 
 them from other sources, and by the information, both positive and 
 negative, thus obtained. You fear that disease is going on in the 
 brain ; but is the skin hot ? — is there heat of head ? — are there fre- 
 quent flushings of the face, and does the accession of each flush seem 
 connected with an increase of agitation and distress, or followed by a 
 deepening of the drowsiness ? Is the fontanelle prominent and tense, 
 or are the pulsations of the brain to be felt with unusual force through 
 it? — are the veins of the scalp full, or do the carotids beat with unu- 
 sual force ? What is the character of the pulse ? — is it not merely 
 increased in rapidity ; but even when examined under exactly similar 
 conditions, does it afford a different result each time? Do you find it 
 irregular in frequency, or unequal in the force of its beats, or even dis- 
 tinctly intermittent? Again, what is the state of the pupil? — is it gen- 
 erally contracted, as if to exclude light as much as possible from the 
 oversensitive retina? or is it usually dilated, and does it act slowly, as 
 though disease had deadened the sensibility of the nervous system ? or 
 do the pupils of the two eyes not act simultaneously, but one more 
 readily than the other? Do the pupils oscillate under the light, at 
 first contracting, then dilating, and either remaining dilated or con- 
 tinuing to oscillate, though within narrower limits, and with a ten- 
 dency to remain more dilated than at first? Or, lastly, do you find, 
 when the child is roused, this oscillation of the pupil going on under 
 the ordinary amount of light that enters the chamber? Now all of 
 these are indications of disordered function of the brain, and many of 
 them point to disorder of a very serious kind. 
 
 But there are yet other sources from which we must not neglect .to 
 seek for information. Much may be learned from the state of the 
 digestive functions. The bowels are almost always disturbed; usually, 
 though not invariably, constipated; while nausea and vomiting are 
 seldom absent. I am not acquainted with any one symptom which 
 should so immediately direct your attention to the brain, as the occur- 
 rence of causeless vomiting, and especially its continuance. At first^ 
 
PRECURSORS OF AN ATTACK OF CONVULSIONS. 43 
 
 perhaps, the child vomits only when it has taken food ; but before long 
 the stomach will reject even the blandest fluid, and then the efforts at 
 vomiting will come on when the stomach is empty, a little greenish 
 mucus being rejected with no relief, the retching and vomiting soon 
 returning. I shall have occasion to dwell again upon the importance 
 of this symptom, which I have known continue for several days before 
 any other indication of cerebral disease could be discovered. In chil- 
 dren of three or four years old this occurrence would scarcely be over- 
 looked ; but the case is different with infants, who so often vomit the 
 milk when ill, that the mother or nurse might fail to mention it to you, 
 if you did not make special inquiries with reference to that point. 
 
 The manner in which the functions of the respiratory organs are 
 performed is also not to be overlooked. That peculiar, unequal, irreg- 
 ular breathing, to which the name of cerebral respiration has been 
 applied, though of considerable value when present, is sometimes not 
 observed, or not until the disease of the brain is already so far advanced 
 that all questions of diagnosis have long been set at rest. There is, 
 moreover, a short, hard, hacking cough, which you may sometimes 
 hear, and the import of which you ought to be acquainted with, since 
 it betokens disease of the brain, not of the lungs. There are peculiar 
 sounds, too, which sometimes attend respiration 1 , and are known as 
 indicating disturbance of the nervous system. To these, however, I 
 shall have to return hereafter, since they betoken a disease of a serious 
 nature, known by the name of spasmodic croup, and which I must in 
 the course of these lectures describe in full. 
 
 I have purposely delayed till now speaking of the indications ot 
 cerebral disease afforded by the occurrence of com-ulsic»is. The symp- 
 tom is one undoubtedly of great importance, since it is observed in 
 almost every case of serious disease of the brain, at some stage or other 
 of its progress. The very frequency of the phenomenon, however, and 
 the great variety of the circumstances in which it occurs, render it diffi- 
 cult for us rightly to interpret its meaning. Perhaps it will help us 
 to understand it, if we bear in mind that in a large proportion of cases 
 convulsions in the infant answer to delirium in the adult. In early 
 life the superintendence of the motor power is the chief function of the 
 brain, which has not yet attained to its highest office as the organ of 
 the intellect. Hence the convulsions which you may observe to come 
 on in infancy in the course of some acute diseases, such as inflamma- 
 tion of the lungs, do not import that any new malady has invaded the 
 brain, but simply that the disease is so serious as to disturb the due 
 performance of all the functions of the organism, and of those of the 
 brain in common with the rest. Convulsions at other times take place 
 in infancy not as the result of any abiding disease of the brain, but 
 simply in consequence of those anatomical peculiarities which allow of 
 a much more sudden and more considerable congestion of the cerebral 
 vessels than can occur in the adult. Of this kind are frequently the 
 convulsions that come on during a paroxysm of hooping-cough, which 
 are induced by the impediment to the return of blood from the head, 
 and which often cease so soon as that impediment is removed by the 
 child taking a deep inspiration. But these two considerations are, it 
 
44 
 
 CONVULSIONS — THEIR EXCITING CAUSES VARIOUS. 
 
 must be owned, by no means adequate to explain the very great fre- 
 quency of convulsions in children, though they account for much that 
 otherwise would be inexplicable. 
 
 The grand reason of their frequency is no doubt to be found in the 
 predominance of the spinal over the cerebral system in early life. In the 
 adult, the controlling power of the brain checks the display of those 
 reflex movements which become at once evident if disease high ten the 
 excitability of the spinal cord, or cut oif the influence of the brain from 
 the paralyzed limb, or even if sleep suspend that influence for a season'. 
 When the child is born the brain is but imperfectly developed, its 
 functions are most humble, and convulsions are then so frequent, that 
 they are computed to occasion 73.3 per cent, of all deaths which take 
 place during the first year of existence from diseases of the nervous 
 system. In the next two years the brain more than doubles its weight, 
 and deaths from convulsions sink to just a third of their former fre- 
 quency. In proportion as the brain increases in size, and its structure 
 acquires perfection, and its higher functions become displayed, con- 
 vulsions grow less and less frequent, until from the 10th to the 15th 
 year they cause less than 3 per cent., and above 15 less than 1 per 
 cent., of the deaths from diseases of the nervous system. 1 
 
 But a little observation will show you, that though convulsions are 
 often the immediate cause of death, yet this fatal event is rare during 
 childhood in comparison with those instances in which they pass off 
 without any serious result ; and that in proportion to their frequency 
 they less often betoken grave disease of the brain in the child than in 
 the adult, while any cause which greatly excites the spinal system may be 
 attended by them. The disturbance of the spinal system which ushers 
 in fever in the adult, shows itself by shivering ; while in the child the 
 same disturbance often manifests itself, not by shivering but by con- 
 vulsions. Convulsions may be induced in early life by a constipated 
 state of the bowels, by the presence of worms in the intestinal canal, or 
 of a calculus in the kidney, or by the pressure of a tooth upon the 
 swollen gum, — causes wholly inadequate to occasion so serious an 
 occurrence in the grown person * Hence your first duty is, in every 
 case, to ascertain where is the seat of the irritation which excited the 
 nervous system to this tumultuous reaction. If the fits come on in an 
 advanced stage of some serious disease, they are probably only the 
 
 1 The first line in the accompanying table shows the proportion per cent, of deaths 
 from diseases of the nervous system at different ag^s, to the deaths from all causes 
 at the same ages, in the metropolis ; and the second line, the proportion borne by 
 deaths from convulsions to deaths from diseases of the nervous system in general. 
 
 Under 1 year. 
 
 From 1 to 3 
 
 years. 
 
 From 3 to 5 
 years. 
 
 Total under 
 5 years. 
 
 From 5 to 
 10 years. 
 
 From 10 to 
 15 years. 
 
 Total above 
 15 years. 
 
 30.5 
 73.3 
 
 18.5 
 24.9 
 
 17.6 
 
 17.8 
 
 24.3 
 54.3 
 
 15.1 
 9.9 
 
 10.6 
 2.4 
 
 10.4 
 .8 
 
 Deduced from the Fifth and Eighth Reports of the Registrar -General. 
 
PRECURSORS OF AN ATTACK. 45 
 
 indications that dcatli is busy at the centres of vitality ; if they occur 
 during hooping-cough, they point to a congested state of the brain, the 
 consequence of the impeded circulation through the lungs ; if they at- 
 tack a child apparently in perfect health, they probably indicate that 
 the stomach has been overloaded, or that some indigestible article of 
 food has been taken ; or, if this be certainly not the case, one of the 
 eruptive fevers is perhaps about to come on; most likely either small- 
 pox or scarlatina. 
 
 To determine the cause of convulsions, you must acquaint yourself 
 with the history of the child's health for some time before any threat- 
 ening of them had appeared ; you must learn whether the child has 
 ever suffered from worms, whether its digestive functions have long 
 been out of order, or whether the process of dentition, which is now 
 perhaps going on, has been attended with much constitutional disturb- 
 ance. But, besides all these points, your inquiries must be still more 
 carefully directed to ascertain whether any cerebral symptoms preceded 
 the attack, and if so, what was their nature, since it is seldom that acute 
 disease of the brain sets in with convulsions. You will sometimes, 
 indeed, be told that the child was well until a convulsive seizure sud- 
 denly came on ; but on inquiring minutely it will usually be found that 
 some indications of cerebral disease had been present for days, though 
 not sufficiently severe to attract much attention. In cases of apoplexy, 
 of intense cerebral congestion, and of phrenitis, convulsions occur at a 
 very early period ; but even then, extreme drowsiness, great pain in 
 the head, and vomiting, usually precede for a few hours the convulsive 
 seizure. When the brain is thus seriously involved, the recovery from 
 the convulsions is very imperfect; coma perhaps succeeds to them, or 
 other evidences of cerebral disease are so marked as to leave no doubt 
 of the brain being affected. Tubercle sometimes remains for a long 
 time after its deposition in the brain, without giving rise to any well- 
 marked symptoms, till its presence is at length announced by a fit of 
 convulsions. These convulsions are seldom at first very severe, but 
 you will learn to dread them more than those which assume a more 
 formidable appearance, from noticing either that one side of the body 
 is exclusively affected, or, at least, that there is a marked preponderance 
 of the affection on one side. It is well to bear in mind, too, that con- 
 vulsions may occur from a want of blood in the brain as well as from 
 its excess, and that the convulsions which come on in some ill-nourished 
 infants may indicate a state of atrophy of the brain. 
 
 I must, however, have said enough already to impress upon you the 
 importance of narrowly scrutinizing the meaning of every attack of 
 convulsions. But though so important, there are few tasks more diffi- 
 cult. You have to maintain your own self-composure at a time when 
 all around you have lost theirs ; to extract truth as you best may from 
 the imperfect, often exaggerated, accounts of anxious relatives ; to observe 
 not only minutely but quickly, and to come to a speedy decision : since 
 while in those cases which require active treatment delay is almost 
 synonymous with death, there is at least as great danger of destroying 
 your patient by that " nimia diligentia" to which the prejudices of the 
 nurse and the fears of the friends will often conspire to urge you. 
 
46 DESCRIPTION OF A FIT. 
 
 It is well to watch closely the first indications of that disturbance of 
 the nervous system which will be likely to issue in convulsions. And 
 here let me recommend you not to listen with too incredulous an ear 
 to old nurses, who may tell you that a child has been much convulsed, 
 while you find upon inquiry that it has not had any fit. When they 
 say that a child has been much convulsed, they mean usually that it 
 has shown many of the symptoms which forebode an attack of general 
 convulsions. These forebodings are often induced by dyspepsia or by 
 disorder of the bowels in young infants, and have been described by 
 writers under the name of " inward fits." A child thus affected lies as 
 though asleep, winks its imperfectly closed eyes, and gently twitches 
 the muscles of its face — a movement especially observable about the 
 lips, which are drawn as though into a smile. Sometimes, too, this 
 movement of the mouth is seen during sleep, and poets have told us 
 that it is the " angePs whisper " which makes the babe to smile — a 
 pretty conceit of which we can scarcely forgive science for robbing us. 
 If this condition increase, the child breathes with difficulty, its respira- 
 tion sometimes seems for a moment almost stopped, and a livid ring 
 surrounds the mouth. At every little noise the child wakes up; it 
 makes a gentle moaning, brings up the milk while sleeping, or often 
 passes a great quantity of wind, especially if the abdomen be gently 
 rubbed. When the intestinal disorder is relieved, these symptoms 
 speedily subside ; nor have we much reason to fear general convulsions 
 so long as no more serious forebodings show themselves. There is 
 more cause for apprehension, however, when we see the thumbs drawn 
 into the palm either habitually, or during sleep ; when the eyes are 
 never more than half-closed during sleep ; when the twitching of the 
 muscles is no longer confined to the angles of the mouth, but affects 
 the face and extremities ; when the child awakes with a sudden start, 
 its face growing flushed or livid, its eyes turning up under the upper 
 eyelid, or the pupils suddenly dilating, while the countenance wears an 
 expression of great anxiety or alarm, and the child either utters a shriek 
 or sometimes begins to cry. 
 
 When a fit comes on, the muscles of the face twitch, the body is stiff, 
 immovable, and then in a short time, in a state of twitching motion, the 
 head and neck are drawn backwards, and the limbs violently flexed and 
 extended. Sometimes these movements are confined to certain muscles, 
 or are limited to one side. At the same time neither consciousness nor 
 sensation is present. The eye is fixed and does not see ; the finger may 
 be passed over it without winking ; the pupil is immovably contracted 
 or dilated ; the ear is insensible even to loud sounds; the pulse is small, 
 very frequent, often too small and too frequent to be counted; the 
 breathing hurried, labored, and irregular ; the skin bathed in abundant 
 perspiration. 
 
 After this condition has lasted for a minute, or ten minutes, or an 
 hour or more, the convulsions cease; and the child either falls asleep, 
 or lies for a short time as if it were bewildered, or bursts into crying, 
 and then returns to its senses, or sinks into a state of coma in which it 
 may either be perfectly motionless, or twitching of some muscles may 
 still continue ; or, lastly, it may die in the fit. This, however, is not 
 
CONGESTION OF THE BRAIN. 47 
 
 usual except when the convulsions have come on in subjects exhausted 
 by previous disease, or when they are the result of apoplexy or of intense 
 cerebral congestion, such as takes place occasionally in hooping-cough, 
 or when they are associated with that closed state of the larynx which 
 occurs sometimes in spasmodic croup. 
 
 This preliminary examination of the symptoms of disturbance of the 
 nervous system has placed us in a position to commence our investiga- 
 tion of the different forms of cerebral disease ; on which we will enter 
 at the next lecture. 
 
 LECTUEE IV. 
 
 Congestion of the Brain. — Often supposed to be present when the symptoms are" 
 not really due to it — Active congestion — Its causes, symptoms, and treatment — 
 Notice of conditions once supposed to be due to congestion, as sunstroke, and 
 head symptoms preceding eruptive fevers — Passive congestion, its causes, symp- 
 toms, and treatment. 
 
 In my last lecture I endeavored to point out to you some of the 
 reasons for the greater frequency of affections of the nervous system in 
 infancy and childhood than at other periods of life. I dwelt especially 
 upon certain structural peculiarities of the brain, and of its bony case, 
 which render the cerebral vessels liable to become overloaded with 
 blood, under the influence of causes that would be wholly inadequate 
 to produce such an effect in the adult. With the advance of the ossi- 
 fication of the skull, and the closure of its fontanelles and sutures, these 
 peculiarities are rendered fewer and less important ; but still a remark- 
 able liability to congestion of its vessels continues to characterize the 
 brain through all the years of early childhood. A late distinguished 
 German physician, Dr. Mauthner, of Vienna, 1 on examining the bodies 
 of 229 children who had died at different ages and of various diseases, 
 found a congested state of the vessels of the brain in 186 of the number. 
 In some of these cases it is probable that this condition had come on 
 only a short time before the patient's death, since in them no symptoms 
 of cerebral disturbance had appeared during the progress of their ill- 
 ness ; but in many it was not so ; and I shall have occasion to warn 
 you over and over again to be on the watch against congestion of the 
 brain, as a condition which is very likely to come on in the course of 
 affections even of distant organs. Nor is it merely as a serious com- 
 plication of many other diseases that this cerebral congestion deserves 
 
 1 DieKrankhei en des Gehirns unci Btickenmarks bei Kindern. 8vo., Wien, 1844, 
 p. 12. See, however, the cautions given by JMiemeyer as to the sources of error with 
 reference to this very point in post-mortem examinations of the brain, in his Lehr,- 
 buch der speciellen Pathologic 8th ed., Berlin, 1871, vol. ii, p. 163. 
 
48 ACTIVE CONGESTION OF THE BRAIN. 
 
 your notice ; its importance depends still more on its constituting the 
 first and curable stage of many diseases of the brain, which, unless 
 arrested at the outset, soon pass beyond the resources of our art. 
 Neither, indeed, must it be forgotten, that although inflammation, 
 hemorrhage, and the effusion of serum are the three results to one or 
 other of which congestion of the cerebral vessels tends, yet the excep- 
 tions to their occurrence are by no means few, even when that conges- 
 tion has been very considerable or of long continuance ; and that not 
 only may the functions of the brain be seriously disordered, but the 
 life of the patient may be destroyed, without the anatomist being able 
 to discover any one of these results, or indeed anything more than a 
 general repletion of the vessels of the organ. 1 
 
 Any cause which greatly increases the flow of blood to the head, or 
 which greatly impedes its reflux, may give rise to a congested state of 
 the brain ; and according as this state is induced by the one or the 
 other cause, it is said to be active or passive. The active form of cere- 
 bral congestion is associated with and in measure dependent on ex- 
 citement of the heart's action, and is therefore observed in connection 
 with various forms of febrile disturbance ; while the passive form re- 
 ceives its best illustrations in cases of hooping-cough, and of spasm of 
 the glottis, in which violent and fruitless expiratory efforts are made. 
 The brain may become actively congested at the time of teething, or 
 from a blow on the head, or the state may come on independently of 
 any definite exciting cause ; or a state of passive congestion may be 
 induced by some mechanical impediment to the return of blood from 
 the organ — such as the pressure of a hypertrophied thymus, or of en- 
 larged and tuberculated bronchial glands upon the jugular veins ; or 
 it may be merely the result of a languid circulation from the want of 
 pure air, or of nourishing and sufficient food. 
 
 I have been used, in common with other physicians, to believe and 
 to teach that the symptoms of violent cerebral disturbance which 
 sometimes usher in the eruptive fevers, and even prove fatal before the 
 rash has had time to show itself, were among the most striking illus- 
 trations of active cerebral congestion. 2 It seems, however, more than 
 doubtful whether this opinion is correct, and some of the best authori- 
 ties assure us that they are positively erroneous. These symptoms, it is 
 said, do not in any sense depend on an increased flow of blood towards 
 the brain produced by the excited action of the heart, but partly on 
 the high temperature of the blood circulating in the cerebral vessels, 
 partly on its altered composition due to the greatly intensified meta- 
 morphosis of tissues which the fever produces. The so-called asthenic 
 fevers are a remarkable example of the truth of this opinion, since in 
 
 1 Dietl's Anatomische Klinik der G-ehirnkrankkeiten, 8vo., Wien, 1846, contains, 
 at pp. 53-73, a very able exposition and defence of views concerning cerebral con- 
 gestion in many respects similar to those expressed in this lecture. 
 
 2 See Armstrong's notice of these suddenly fatal accidents at the outset of scarla- 
 tina, at p. 30 of his work on Searlet Fever, &c, 2d edit , London, 1817; and Von 
 Amnion's mention of it in his description of the epidemic of malignant scarlatina 
 at Dresden in 1831-2, in the Analekten liber Kinderkrankheiten, lltes Heft, p. 42. 
 Stuttgart, 1836. 
 
ACTIVE CONGESTION OF THE BRAIN. 49 
 
 them we have an extremely high temperature associated with enfeebled 
 though accelerated action of the heart, but with no determination of 
 the blood to the brain, while yet we meet in them with most marked 
 delirium, and with the gravest disturbance of the brain functions. 1 
 
 The same explanation is given of the nature and cause of the symp- 
 toms of sunstroke, which the late unhappy Franco-German war af- 
 forded so many opportunities of observing. A remarkable support is 
 given to this view by the fact that in the infant and young child all 
 the symptoms of sunstroke may result from lengthened exposure to 
 a very high temperature even though the day is cloudy, or the child 
 sheltered completely from direct action of the sun's rays. 
 
 But, even though we separate these two classes of cases from their 
 supposed connection with cerebral congestion, there yet remain many 
 others in which the symptoms may still with propriety be referred to 
 that cause. Such, for instance, are many of the disorders of the nerv- 
 ous system, and especially of the cerebral functions, which occur during 
 teething. Febrile disturbance almost always attends upon the process 
 of dentition, and it is *iot difficult to understand how, when the circu- 
 lation is in a state of permanent excitement, a very slight cause may 
 suffice to overturn its equilibrium, and occasion a greater flow of blood 
 to the brain than the organ is able to bear. Sometimes too, and that 
 by no means rarely, symptoms of cerebral congestion come on for 
 which it is not possible to assign a distinct exciting cause, and for the 
 explanation of which we have to fall back on the well-known fact that 
 all periods of development such as childhood, are periods during which 
 the growing organs are most apt to become disordered. 
 
 Let us now then pass to an examination of its symptoms. In the 
 great majority of cases they come on slowly ; and for the most part, 
 general uneasiness, a disordered state of the bowels, which are usually 
 though not invariably constipated, and feverishness, precede for a few 
 days the more serious attack. The head by degrees becomes hot, the 
 child grows restless and fretful, and seems distressed by light or by 
 noise or by sudden motion, and children who are old enough sometimes 
 complain of their head. One little boy, nearly three years old, who 
 died of congestion of the brain, had seemed to suffer for some days 
 before any alarming symptom came on, from severe pain in the head. 
 He sometimes awoke crying from his sleep, or when awake would sud- 
 denly put his hands to his ears, exclaiming, "Oh, hurt! hurt!" 
 Usually, too, vomiting occurs repeatedly ; a symptom on the impor- 
 tance of which I have already insisted, since it is not only confirma- 
 tory of others, but also may exist before there is any well-marked in- 
 dication of the head being affected, and when, though the child seems 
 ailing, there is nothing definite about its illness. The degree of fever 
 which attends this condition varies much, and its accessions are irregu- 
 lar; but the pulse is usually much and permanently quickened; and 
 if the skull is unossified, the anterior fontanelle is either tense and 
 prominent, or the brain is felt and seen to pulsate forcibly through it. 
 The sleep is disturbed, the child often waking w T ith a start, while there 
 
 1 Niemeyer, Op. cit., vol. ii, p. 165-6. 
 4 
 
50 SYMPTOMS OF CEREBRAL CONGESTION. 
 
 is occasional twitching of the muscles of its face or of the tendons of 
 its wrist. 
 
 The child may continue in this condition for many days, and then 
 recover its health without any medical interference ; but a slight cause 
 will generally suffice to bring back the former indisposition. You will 
 sometimes see striking instances of this in children while teething; the 
 fever subsiding, the head growing cool, and the little patient appearing 
 quite well, so soon as the tooth has cut through the gum, but the ap- 
 proach of each tooth to the surface being attended by the recurrence of 
 the same symptoms. 
 
 But though the disturbance of the brain may pass away of its own 
 accord, yet we cannot reckon on such a favorable result occurring, for 
 symptoms such as I have mentioned are often the indications of the 
 organism generally having begun to suffer from mischief which has 
 been going on for months unnoticed, and which is now about to break 
 out with all the formidable characters of acute hydrocephalus. Or 
 should they have no such grave import, yet congestion of the brain 
 is itself a serious, sometimes a fatal malady. Even though no treat- 
 ment should be adopted indeed, the heat of head may diminish, and 
 the flush of the face grow slighter and less constant; but the counte- 
 nance becomes very heavy and anxious, the indifference to surrounding 
 objects increases, and the child lies in a state of torpor or drowsiness, 
 from which, however, it can at first be roused to complete consciousness. 
 The manner on being roused is always fretful, but if old enough to talk 
 the child's answers are rational, though generally very short ; and mur- 
 muring, " I am so sleepy, so sleepy," it subsides into its former drow- 
 siness. The bowels generally continue constipated and the vomiting 
 seldom ceases, though it is sometimes less frequent than before. The 
 pulse is usually smaller than in the other stage and it is often irregular 
 in its frequency, though not actually intermittent. An attack of con- 
 vulsions sometimes marks the transition from the first to the second 
 stage ; or the child passes without any apparent cause from its previous 
 torpor into a state of convulsion, which subsiding, leaves the torpor 
 deeper than before. The fits return and death may take place in one 
 of them, or the torpor growing more profound after each convulsive 
 seizure, the child at length dies comatose. 
 
 This second stage, if so it may be called, is usually of short dura- 
 tion ; and if relief is not afforded by appropriate treatment, death is 
 seldom delayed beyond forty-eight hours from the first fit, though no 
 graver lesion may be discovered afterwards than a gorged state of the 
 large vessels of the membranes of the brain, and perhaps a little clear, 
 fluid in the ventricles and beneath the arachnoid ; together with a gen- 
 erally white color of the cerebral substance, due to an oedema of its 
 tissue which has succeeded to the previous congestion of its capillaries. 
 
 Occasionally, indeed, death does not so speedily follow these symp- 
 toms ; but they continue slightly modified for days, or even w r eeks, and 
 contrary to all expectation recovery now and then takes place. This 
 protracted course of the affection is I believe met with only in the case 
 of very young children, in whom, the congestion having relieved itself 
 by a copious effusion of serum into the ventricles, the yielding skull 
 
SYMPTOMS AND TREATMENT OF CEREBRAL CONGESTION. 51 
 
 accommodates itself to its increased contents. The symptoms, though 
 to a great extent the same as before, are now due to the presence of 
 water in the brain — a disease which, though dangerous and often fatal, 
 is yet chronic in its course, and may even admit of cure. 
 
 In the treatment of congestion of the brain, whatever may be the 
 circumstances in which it has come on, our first and best attention 
 ought always to be paid to just those things which in far too many 
 cases receive it least. The temperature of the room, the amount of 
 light admitted into it, the number of persons present, the position of 
 the child's cot, the material of its pillow (which ought to be horsehair, 
 and not down), and the nature of its food, are matters of the greatest 
 importance. All these things, however, are so simple that their value 
 is frequently underrated; and it is so often said, almost as a matter of 
 course, "Keep the child quiet and the room cool, and apply cold to the 
 head," that it does not strike the parents how much depends upon 
 those directions on which the doctor seems to lay so little weight. You 
 must learn, however, that in the treatment of children's diseases none of 
 these things are trivial, but that on their due performance often hangs 
 the life of your patient. Do not content yourselves then with merely 
 giving directions, but stay to see them attended to ; and do not leave 
 the house till the chamber is darkened, the cool air freely admitted, the 
 cold application to the head properly adjusted, nor till all persons who 
 are not actually waiting on the child have left the apartment. 
 
 Next in importance in these cases are the arrangements for keeping 
 the head cool. For this purpose it is necessary that the infant should 
 be removed from its nurse's lap: where lying with its head resting on 
 her arm and pressed against her bosom, all attempts to keep it cool are 
 idle. The child should be placed in bed, its head resting on a horse- 
 hair pillow, and if it will not (and indeed it seldom will) allow a linen 
 rag soaked in some evaporating lotion to be kept on its head, the fol- 
 lowing simple plan will usually be found very efficient, and will be 
 readily submitted to in most instances. Let two bladders be half filled 
 with pounded ice, or cold water, and be placed, each wrapped in a nap- 
 kin, the one under and the other upon the child's head. By pinning 
 the corners of the napkin to the pillow, you can secure them from being 
 displaced, and can also prevent the weight of the upper bladder from 
 resting too heavily on the child's head. 
 
 At the outset of the affection the bowels are usually constipated, so 
 that an active purgative is in most cases called for. You may give a 
 dose of calomel and jalap, or the calomel may be administered alone, 
 «md followed by the infusion of senna, which may be repeated every 
 three or four hours till the bowels act. Should the stomach be very 
 irritable, a larger dose of calomel may be given, and after the lapse of 
 a couple of hours an attempt may be made to quicken its action by ad- 
 ministering a purgative enema, or by dissolving some sulphate of mag- 
 nesia or the less nauseous phosphate of soda in the child's drink, and 
 giving it at short intervals. In many cases the disorder will be speedily 
 removed by this treatment, and the child, whose life had seemed to be 
 hanging by a thread, will, in the course of twentv-four hours, be almost 
 well. 
 
52 TREATMENT OF SYMPTOMS 
 
 Next in order comes the question of depletion, and I purposely say 
 next, because the simple measures already pointed out not infrequently 
 so relieve the urgency of the symptoms that one passes within twelve 
 hours from a state of great anxiety about the patient to one of compara- 
 tive tranquillity. If, however, these means are not succeeded by a 
 speedy and marked improvement, if the heat of the head has not sunk> 
 down to the same temperature as that of the body, if the fontanelle is 
 tense or strongly pulsating, or the carotids are beating visibly, if the 
 pupils are very contracted and light is ill borne, if the hands twitch, or 
 if sickness continues and there is much distress and fretfulness, with 
 frequent cries and moaning, the abstraction of blood is then plainly 
 indicated, and will give relief which no other measures can procure. 
 This depletion may be accomplished by means of leeches, and should 
 when indicated be effectually done, and once for all. It may be calcu- 
 lated that a good leech will draw 5ij of blood ; and the application of 
 one leech for every three months of a child's life, assuming that no 
 bleeding is allowed to take place after the leech falls off, may, I think, 
 be adopted as a fairly safe rule for your guidance in the case of infants 
 and young children. It is truer economy of the child's strength to de- 
 plete once sufficiently to produce a decided influence, than by acting 
 with too timorous a hand to be compelled to repeat the abstraction of 
 blood again and again. 
 
 Supposing now, that by the employment of these means you have 
 removed the imminent danger and that your patient is going on favor- 
 ably, still it will be generally desirable to continue treatment for a few 
 days. Free action of the bowels must be maintained, for which pur- 
 pose small doses of calomel may be given two or three times a day, and 
 it may be desirable to accompany each powder with a dose of a mix- 
 ture containing nitre and sulphate of magnesia. 1 Or, if there is no indi- 
 cation for acting on the bowels, but yet a good deal of heat of skin, a 
 rapid pulse, and much cerebral excitement are present, you may employ 
 with advantage the bromide of potass with small doses of aconite. 2 
 You must, however, bear in mind that you will do less harm by allow- 
 ing a child to go without medicine than by forcing on it remedies which 
 it dislikes and resists taking. Calomel, indeed, can almost always be 
 given ; and even sulphate of magnesia will very often be taken if mixed 
 with the drink, or dissolved in a little veal broth. But how much 
 
 1 (No. 1.) 
 5t. Potassse Nitratis, gr. xij. 
 
 Magnesia? Sulph., ^j. 
 Syr. Limonum, giij. 
 
 Aquae destill., gix. M. ^ij three times a day. 
 For a child a year old. 
 
 2 (No. 2.) 
 R. Potassse Citratis, gr. xx. 
 
 Potassii Bromidi, gr; xv. 
 Tinct. Aconiti, n^iij . 
 Tinct. Chloroformico, i^xv. 
 Syrupi Mori, giv. 
 
 Aquae destill., ^j. M. gij every four hours. 
 For a child a year old. 
 
OF CEREBRAL CONGESTION. 53 
 
 soever a child may resist medicine, the abstraction of blood, a spare diet, 
 a cool and dark and quiet chamber, are remedies always at command, 
 the value of which you must not underrate. 
 
 I need not tell you that all cases do not admit of this treatment. 
 When the disease creeps on with febrile symptoms, occasional vomit- 
 ing, constipation, loss of appetite, and restless nights, with complaints 
 if the child is old enough to speak, of pain in the head or limbs, or 
 vertigo, and with a quick and variable pulse, you must treat it very 
 gently, and must trust much to quiet and the careful regulation of the 
 diet. In such cases you will often find a tepid bath night and morn- 
 ing soothe the child and tranquillize the circulation far more than you 
 might have expected from so simple a remedy. Drastic purgatives 
 must be avoided ; but small doses of mercury and chalk, or of calomel, 
 either alone or combined with rhubarb, may be given with advantage 
 once or twice a day. Half a grain of calomel, or two grains of the 
 Hydr. c. Greta, with three of rhubarb, or one of the powdered extract, 
 would be a proper dose for a child a year old. If there is much fever- 
 ishness and restlessness during the day, you may give a mixture of 
 bicarbonate of potash not quite saturated with citric acid, and contain- 
 ing small doses of ipecacuanha wine, if the stomach is not extremely 
 irritable, and of the tincture of hyoscyamus, the -value of which last 
 medicine as a sedative in the diseases of children can scarcely be too 
 highly estimated. The addition of a little syrup of mulberries will 
 render the above mixture extremely palatable. 1 
 
 I have already referred to various conditions, once assumed to be 
 due to intense cerebral congestion, by which the correcter pathological 
 knowledge of the present day has proved to depend on other causes. 
 It is hard to know where to classify them, for there are many points 
 still uncertain with reference to their mode of production ; and there- 
 fore, as a mere matter of convenience I notice them here, on the ground 
 of the similarity of their symptoms in many respects to those which 
 congestion of the brain occasions. It is true that pathological anatomy 
 lays the only ground on which we can securely tread; but when that 
 fails us, or is insufficient, we must be guided by symptoms in our 
 arrangement, not forgetting how lifelike are the portraitures of disease 
 which Hippocrates and AretaBus have drawn, although morbid anatomy 
 was a sealed book to them. 
 
 The great peculiarity of these cases, whether they occur as the result 
 of blood-poisoning in the incubation period of a fever, or from sun- 
 stroke, or from the irritation produced by unwholesome or undigested 
 food, is the suddenness of the onset of their symptoms, and their 
 violence. A child who went to bed well, is seized in the night with 
 
 1 (No. 3.) 
 R. Potassae Bicarbonatis, 
 Acidi Citrici, aa s;r. xx. 
 Vin. Ipecac, Trj^xij. 
 Trae. Hyosc, t^xviij. 
 Syr. Mori, giij. 
 
 Aquae destill., ^ix. M. gij every six hours. 
 For a child a year old. 
 
54 TREATMENT OF SYMPTOMS RESEMBLING CONGESTION. 
 
 vomiting, followed by convulsions of extreme severity, which leave it 
 comatose, with burning skin, rapid pulse, twitching of the limbs, and. 
 stertorous breathing — a state that may continue for some hours, and 
 then slowly pass away : or which may be interrupted by renewed con- 
 vulsions, to end in still more profound coma, and at last in death : or 
 the appearance of the rash of one of the eruptive fevers may indicate 
 the cause of the attack, and at the same time dissipate it : or abundant 
 action of the bowels may remove the cause of disorder, and leave the 
 child quite well; or the functions of the nervous system disordered by 
 intense heat may but slowly return to their regular performance ; and 
 heat of skin, and hurried pulse, and disturbed brain may continue for 
 days — really a brain fever; but the term must not be used, as it might 
 lead to misconstruction. 
 
 Whenever any symptoms such as these come on, you must endeavor 
 to make out what has been the antecedent of the attack. Inquire 
 whether your patient has had the eruptive fevers, especially scarlatina 
 or small-pox, or whether he has been recently exposed to their conta- 
 gion, and examine the arm to see whether there are good cicatrices as 
 evidences of successful vaccination. Learn what the child has eaten 
 during the previous twenty-four hours ; or if the attack comes on 
 during the summer, ascertain at what time of the day the child was 
 taken out, where it was taken, and what covering it had on its head. 
 Learn, too, whether the child appeared quite well, or whether it was 
 hot, and seemed languid or drowsy when it came home. 
 
 An emetic, followed by an active purge, will often remove the symp- 
 toms which were due to an overloaded stomach, but it must be remem- 
 bered that be their cause what it may, these attacks inflict a shock 
 upon the brain (I use popular language, for scientific terms are to be 
 avoided where our ideas are not definite), the effects of which may last 
 for weeks in disorder of its functions, and that sometimes such attacks 
 appear to be the exciting cause of organic disease, especially in children 
 who inherit a predisposition to tuberculosis. 
 
 In the case of the formidable symptoms which usher in the exan- 
 themata, one's first impulse is to deplete, and to deplete largely, and I 
 have certainly seen good results follow from this treatment. I have, 
 however, of late years tried the use of the wet sheet in these cases, and 
 with results all the more satisfactory, since they are obtained without 
 any of that depression of the vital powers inseparable from the free 
 abstraction of blood. I have seen the packing in the wet sheet fol- 
 lowed, in the course of one or two hours, by an abatement of tempera- 
 ture, a cessation of convulsions, and a return of consciousness, as re- 
 markable as I have ever observed follow from even a copious bleeding, 
 while the action of the skin has certainly been more speedily estab- 
 lished, and the appearance of the eruption has been brought about 
 sooner and more satisfactorily, than by any other means with which I 
 am acquainted. While, therefore, I would not say that depletion 
 ought never to be practiced, and while, if hydropathy failed, I should 
 still have recourse to it, I no longer employ, nor should I advise that 
 free depletion to which, in ignorance of these other means, I was ac- 
 customed to have recourse. 
 
PASSIVE CONGESTION ITS SYMPTOMS AND TREATMENT. 55 
 
 The effects of sunstroke in our climate are, in general, less formid- 
 able than those which are sometimes produced by the fever-poison. 
 Alarm, restlessness, and fretfulness, alternating with drowsiness, hur- 
 ried irregular breathing, intense heat of skin, violent pulsation of the 
 anterior fontanelle if still unossified, a pulse almost too rapid to be 
 counted, twitching of the limbs, and starting of the tendons of the 
 wrists, such are the usual symptoms of its severer forms. Sickness is 
 generally present, the stomach rejecting immediately even the simplest 
 fluid, the bowels are usually relaxed, while sometimes there is severe 
 diarrhoea ; and occasionally, though not I think usually, the disorder 
 of the nervous system is so severe as to give rise to convulsions. Oc- 
 casionally as the signs of cerebral disturbance abate, the diarrhoea in- 
 creases, and in young infants I have even known fatal dysentery suc- 
 ceed to the other symptoms of sunstroke. In other instances, while 
 the first urgent symptoms abate, the general feverish condition con- 
 tinues, accompanied with signs very similar to those I have already 
 enumerated as characterizing cerebral congestion, while the bowels are 
 irregular, though acting with undue frequency, and the evacuations are 
 almost always destitute of bile. My experience of these cases is that, 
 unless the first shock proves fatal, or the dysenteric symptoms carry off 
 the patient, recovery is tolerably certain to take place. 
 
 These cases require very gentle treatment, and especially the observ- 
 ance of all those minor precautions which I dwelt on as of so much 
 moment in the treatment of cerebral congestion. The tepid bath often 
 soothes remarkably, and may be repeated two or three times in the 
 twenty-four hours. The diarrhoea which is so often present is not to 
 be checked by astringents; but ^ grain of calomel and 1 grain of 
 Dover's powder, given every 8 hours to an infant of a year old for one 
 or two days, w T ill generally improve the state of the secretions, and 
 check the irritability of the bowels ; while the simple soothing febri- 
 fuge medicines which have already been suggested, will favor the action 
 of the skin, and abate the excitement of the circulation. The difficulty 
 in these cases is to read them aright, to discover the nature of the pos- 
 sible clanger, and to avoid in treatment the too little or too much, each 
 of which has its own danger. 
 
 Thus much may suffice for these conditions; but we must now briefly 
 notice those cases in which congestion of the brain exists in what may 
 be called the passive state. In the paroxysms of hooping-cough the 
 brain becomes congested by the impediment to the return of the blood 
 from the head ; and cerebral congestion is induced in a similar manner 
 when the larynx becomes spasmodically closed in the disease known by 
 the name of Laryngismus Stridulus. But we likewise meet with cases 
 where the passive succeeds to the active form of cerebral congestion, or 
 becomes more or less gradually developed out of some disorder of the 
 abdominal viscera ; or, lastly, where it supervenes towards the close of 
 life in weakly children, whose vital powers have at length become too 
 feeble to propel the blood. 
 
 In children who have suffered long and severely from hooping- 
 cough, you often notice a general lividity of the face and lips, a puffed 
 and anxious countenance, and the child makes grievous complaints 
 
56 PASSIVE CONGESTION. 
 
 about its head, while the skin is moist and cool, and the pulse soft, 
 though frequent. Many of these symptoms indicate an overloaded 
 state of the cerebral vessels ; and if a paroxysm of coughing occurs, 
 and the circulation is thus further disturbed, the child may die in a fit, 
 or may sink after some convulsive seizure into a state of coma, which 
 sooner or later proves fatal. In such a case you will find the vessels 
 of the brain and its membranes universally gorged with black blood, 
 the choroid plexuses of a deep purple color, and more bloody points 
 than natural will present themselves on a section of the brain being 
 made. 1 Both the symptoms during life, and the appearances after 
 death, are only a rather exaggerated illustration of what occurs in all 
 cases of passive congestion of the brain. It is not, however, always 
 easy to explain why this condition comes on. Among the poor you 
 often find it connected with general disorder of the digestive organs, 
 and occurring as one of a long train of ills induced by destitution and 
 neglect. It was so in the case of a little boy four months old, whom I 
 saw some years ago. His parents were young and healthy people, but 
 they had already lost three children, apparently in consequence of their 
 inhabiting one of those narrow courts so numerous in London, into 
 which the sun never shines, and where young children pine and fade 
 like tender plants shut up in a cellar. When ten weeks old, this little 
 boy was taken with pain in his bowels and diarrhoea, and at three 
 months old he began to suffer from fits, which came on daily, some- 
 times several times a day. No efficient treatment had been adopted 
 when he was brought to me. He was then as large as most children 
 of his age, and by no means emaciated ; but his flesh was flabby, his 
 face unintelligent, puffed, and livid, his head hot, the veins of the scalp 
 and eyelids were turgid, the eyes prominent, lustreless, covered by 
 mucus, and the pupils scarcely acted under light. He lay on his 
 mother's lap, uttering a constant hoarse moan ; his head thrown rather 
 back, and in incessant rotatory motion; his mouth was open, his tongue 
 red and parched, and the papillae on its surface were very prominent ; 
 his abdomen was rather full, and his legs were constantly drawn up 
 towards it. He vomited much ; his bowels were open three or four 
 times a day, the motions being green and offensive ; his pulse was fre- 
 quent, but without power. In this, as in many instances of passive 
 congestion of the brain, local depletion was resorted to at first, and, ben- 
 efit resulting from it, was repeated more than once. It is not, how- 
 ever, every case that will admit even of local depletion, which whenever 
 employed, must be practiced only with the view of affording relief to 
 the gorged cerebral vessels, not with the idea of curing the patient by 
 bleeding ; for repeated congestion is often associated with atrophy of 
 the brain-substance, as well as with marked dilatation of its vessels. 
 The greatest attention must in every case be paid to diet and to the 
 state of the bowels, and you will find no means of inducing their 
 healthy action better than the employment of small doses of mercury 
 
 1 Niemeyer's caution must not be forgotten as to the dependence of the number 
 of bloody points apparent on a section of the brain, on the degree of fluidity of the 
 blood rather than on the distension of the vessels. Op. cit., Vol. ii, p. 164. 
 
PASSIVE CONGESTION. 57 
 
 and chalk two or three times daily for a couple of days. If the child 
 is not weaned, you may find it desirable, if there is constant sickness, 
 to take it almost or entirely from the breast for a day or two, and to 
 substitute barley-water, sugar and water, or a weak solution of isin- 
 glass, with the addition of one-third of milk, which should be given in 
 quantities of one or two tablespoonfuls at a time till the stomach be- 
 comes more settled. A stimulating bath, as a hot salt-water bath, or a 
 bath into which a handful of mustard has been put, and in which the 
 child is to be kept for four or five minutes, night and morning, will 
 often be found a valuable auxiliary to the general treatment, as well as 
 very useful, if combined with the application' of cold to the head, in 
 cutting short the convulsive seizures. 
 
 If the case is associated with much diarrhoea and general impairment 
 of nutrition, the extract of bark with a few drops of sal volatile, or of 
 the compound tincture of bark, should be given two or three times a 
 day, and you should not let the head symptoms lead you to keep the 
 child on a low diet. 1 Eemember, too, that when nutrition is much im- 
 paired, farinaceous food is not usually well digested ; you must, there- 
 fore, be sparing of arrowroot, and give milk and water, or milk and 
 water with isinglass, or with the white of egg beaten up with it; or 
 veal tea ; or some concentrated meat essence, as Brand's or Gillon's, in 
 very small quantities. If all animal broths or meat essences should 
 purge, as they sometimes do, the white decoction of Sydenham 2 will for 
 a time be a useful substitute for them. As the child improves, the 
 ferrocitrate of quinine will be one of the best remedies you can give, 3 
 and throughout the wdiole progress of the case you will remember the 
 tonic influence of pure air; and may even find the removal to a health- 
 ier spot and a purer atmosphere absolutely necessary to the recovery of 
 your patient. 
 
 Lastly, I will just allude to the head symptoms that sometimes for 
 a few days precede death in children who have been long ill. You 
 may in such cases find the vessels of the brain -turgid, and be disposed 
 to reproach yourselves for not having adopted active treatment. Such 
 self-reproach would be unmerited; the streams have stagnated, because 
 the vital powers were all too feeble to keep them in motion. 
 
 1 (No. 4.) 
 R. Extr. Cinchonse, gj. * 
 
 Trse. Cinch. Co., gij. 
 Aquse Carui, ^ij. gvj. M. £ij three times a day in milk. 
 
 For a child a year old. The taste of the above mixture is best concealed by sweet- 
 ening it, and mixing it with twice the quantity of milk. 
 
 2 This, the Decoction Blanche of the French Pharmacopoeia, is made by boiling 
 half an ounce of hartshorn shavings, and the inside of one French roll, in three 
 pints of water, till reduced to two; when it may be sweetened, and given either 
 alone or with the addition of one pint of milk. 
 
 3 (No. 5.) 
 R. Syrupi Quinse et Ferri Citratis, ^iss. 
 Syrupi Aurantii, spjss. 
 
 Aquse Flor. Aurantii, gj.'M. gj three times a day. 
 For a child a year old. 
 
58 CEREBRAL HEMORRHAGE 
 
 LECTUKE V. 
 
 Cerebral Hemorrhage. — The rupture of any large vessel in childhood very rare, 
 but effusion of blood into arachnoid frequent — Keasons for its especial frequency 
 in new-born infants — Its association with infantile asphyxia — Blood sometimes 
 effused external to the skull in new-born infants — Cephalhematoma, its char- 
 acters, changes in the effused blood, and process of cure — Its treatment — 
 Hemorrhage into arachnoid in childhood — Changes in the effused blood— Ob- 
 scurity of the symptoms — Occurs sometimes in very feeble children, or in con- 
 nection with changes in the blood — Illustrative cases — Hemorrhage into cere- 
 bral substance in childhood extremel}' rare— Cases in illustration of its causes 
 and symptoms — Capillary hemorrhage in connection with tubercle in the Drain. 
 
 When we last met, I called your attention to the very important 
 consequences that ma}' result from the vessels of the brain becoming 
 overloaded with blood. I pointed out to you a train of symptoms, 
 rising in severity, from mere pain or heaviness»of the head, to convul- 
 sions or coma, according to the degree of the cerebral congestion ; and 
 told you that death itself might take place, without any mischief being 
 discoverable afterwards, more serious than a general turgescence of the 
 vessels of the brain and its membranes. Simple apoplexy, indeed, is 
 by no means rare in childhood, and the knowledge of this fact may 
 furnish encouragement to us in cases where the symptoms of present 
 danger are most alarming. We may hope, that if the instant peril 
 can be averted, the blood, which has not burst its vessels, will flow 
 again tranquilly through them, and the functions of life once more go 
 on in their wonted course. In the adult we could scarcely indulge 
 such an expectation, for the import of apoplectic symptoms is generally 
 far more serious. If the patient die, we look for, and seldom fail to 
 find, blood poured out into the brain, compressing its substance, and 
 lacerating the delicate fibres along which the nervous influence travels. 
 Or, even should he survive, it often is to pass through a tedious con- 
 valescence, with palsy, and weakened senses, and impaired mental 
 powers — the sad and standing evidence of the grievous injury which 
 the brain has sustained. 
 
 You may naturally inquire how it happens that in the child, the 
 very structure of whose skull favors the occurrence of cerebral conges- 
 tion, hemorrhage into the brain is comparatively so rare ; while in the 
 adult, whose unyielding cranium and firmer brain tend to check con- 
 gestion, the extravasation of blood into its substance takes place so 
 often ? The changes which advancing age induces in the structure of 
 the cerebral vessels are probably the chief cause of this difference. In 
 early life, the arteries are yielding, and admit of being greatly dis- 
 tended without giving way ; but in the course of years they lose their 
 elasticity, their calibre becomes diminished and unequal, and their 
 coats grow brittle by the deposit of fatty or earthy matter in their 
 tissue. 
 
 But though the larger arterial trunks withstand the constantly re- 
 
ONE CAUSE OF INFANTILE ASPHYXIA. 59 
 
 curring variations in the cerebral circulation during infancy and child- 
 hood, the smaller and more delicate vessels of the brain are very liable 
 to give way, and capillary hemorrhage, or hemorrhage by exhalation, 
 as it has been often though incorrectly termed, takes place with greater 
 frequency than in adult age. 
 
 All periods of childhood are not equally exposed to this accident, 
 but it is oftenest met with immediately after birth ; and no circum- 
 stances can be imagined more favorable to its occurrence than those 
 which then concur to produce it. The head of the infant has been 
 subjected to severe and long-continued pressure during its progress 
 through the mother's pelvis ; immediately on its birth, the course of 
 the circulation is altogether changed, and, should any difficulty occur 
 in the establishment of the new function of respiration, a long time 
 will elapse before the blood flows freely through its unaccustomed 
 channels. No one will wonder that death should frequently take place 
 during this transition to a new kind of existence. The tumid scalp 
 and livid face of some stillborn children point to one of its most im- 
 portant causes, since they are but the measure of that extreme con- 
 gestion of the vessels within the skull that has at length ended in the 
 effusion of blood upon the surface or at the base of the brain. 
 
 There would be reason to fear that this occurrence had taken place, 
 if an infant, when born, were to present great lividity of the surface, 
 and especially of the face ; and if the heart were to beat feebly, and at 
 long intervals, although the pulsations of the cord were slow and 
 faint, or had altogether ceased. In these circumstances, death some- 
 times takes place without any effort at respiration being made, the 
 beatings of the heart growing feebler and fewer till they entirely cease; 
 but at other times the child breathes irregularly, imperfectly, and at 
 long intervals. The hands are generally clenched, and spasmodic 
 twitchings are of frequent occurrence about the face, or these twitchings 
 are more general and more severe, and amount almost to an attack of 
 convulsions. The symptoms, however, are by no means uniform, for it 
 sometimes happens that the breathing is not much disturbed, and that 
 after living for a few hours in a state of weakness and torpor, with 
 chilliness of the whole surface, the child dies without any signs of 
 convulsion. 
 
 In these cases it must not be supposed that the stillbirth of the 
 infant is due solely or directly to the congestion of the brain, or to the 
 effusion of blood interfering with respiration, as cerebral apoplexy does 
 in the adult. The violent uterine action which has compressed the 
 head has at the same time interfered with the placental circulation, 
 and the child is born asphyxiated from the hindrance to foetal respira- 
 tion before the influence of the medulla oblongata is called into play, 
 as it is after birth in the establishment and continuance of pulmonary 
 respiration. Cerebral congestion, or actual effusion of blood, may 
 complicate the asphyxia, or render the carrying on of breathing dif- 
 ficult or even impossible, but apncea is the cause of stillbirth ; and the 
 establishment of respiration as speedily as possible is its great remedy. 1 
 
 1 Schultze, Der Scheintod ISTeugeborner, 8vo., Jena, 1871, pp. 97-150. 
 
60 CEPHALHEMATOMA. 
 
 I shall hereafter return to this subject when we come to speak of 
 affections of the respiratory organs. At present, however, it may 
 suffice to say that we do sometimes meet with instances in which, not- 
 withstanding most persevering attempts at inducing respiration, these 
 attempts fail owing to the injuries received in birth, either from in- 
 struments or from the mother's passages, having issued in such an 
 extravasation of blood as to paralyze the functions of the medulla 
 oblongata. In such cases the extravasation is sometimes limited to 
 the neighborhood of the cerebellum, but at other times it covers a 
 considerable part of the convex surface of the brain, and even occupies 
 the spinal canal ; as you see in this by no means exaggerated repre- 
 sentation of a case of infantile apoplexy in Cruveilhier's great w T ork on 
 Morbid Anatomy. 1 
 
 It fortunately happens that the overcharged vessels of the head in 
 the new-born infant do not always relieve themselves by pouring out 
 blood within the skull, but sometimes the capillaries of the scalp give 
 way, and blood is extravasated into its tissue; or, at other times, the 
 effusion of blood takes place between the bone and pericranium. 
 When this last accident occurs, it often gives rise to the formation of a 
 tumor upon the head, that presents peculiarities sufficient to call for 
 some notice. 
 
 This tumor (cephalhematoma, as it has been called, from z^a/^, 
 head, and ai/iarcufxa, from al,ua,. blood) makes its appearance within forty- 
 eight hours after birth — often much sooner — on one or other parietal 
 bone, most frequently on the right, as a circumscribed, soft, elastic, 
 slightly fluctuating, painless swelling, beneath the unchanged integu- 
 ment. On a careful examination, it is generally felt to be bounded by 
 a firm, apparently osseous ridge, which usually encircles it completely, 
 though more distinct at one part than another. On passing the finger 
 over the summit of this ridge, and down towards the base of the 
 tumor, the impression is at once conveyed of the parietes of the skull 
 being deficient at this point, and of the ridge being the edge of a hole 
 in the bone. When first discovered, the tumor is usually small, but 
 increases in the course of two or three days, from the size of a marble 
 to that of a chestnut, or of half a hen's egg. As it grows larger, it 
 generally becomes tenser, but still seems to cause no pain, and the 
 child's health continues good. After it has attained its full size, it 
 often remains stationary for a few days, and during this time a gradual 
 increase in the distinctness of the ring which surrounds it is the only 
 change that it undergoes. A slight diminution in the size of the 
 tumor at length becomes perceptible, and then it slowly disappears, 
 though its removal occupies a month, six weeks, or more ; and a slight 
 elevation of the skull at the point where it was situated sometimes re- 
 mains even longer. The centre of the tumor generally retains its soft 
 and fluctuating character nearly to the last, but occasionally it loses 
 this, and communicates to the finger a sensation of crackling, such as 
 we should experience if we pressed on a piece of tinsel. 
 
 Although once the subject of much difference of opinion, the mode 
 
 1 Anatomie Pathologique, liv. xv, pi. 1. 
 
CEPHALHEMATOMA. 61 
 
 of formation of these tumors, and the nature of the changes they 
 undergo, are now tolerably well understood. The edges of the os 
 uteri, compressing the foetal skull during labor, just as in this engrav- 
 ing 1 the hands are represented compressing it, often produce an effect 
 similar to that which you see depicted here, and occasion an oozing of 
 blood from its surface ; or the same result may follow from undue 
 pressure of the foetal head against the pelvic walls. The quantity of 
 blood thus poured out is usually small, and is then speedily absorbed, 
 without having at any time produced a perceptible swelling. If, how- 
 ever, it is more considerable, a tumor is formed on the exterior of the 
 skull, and this tumor may continue to enlarge for some time after 
 birth, owing, possibly, to the influence of causes calculated to keep up 
 a congested state of the brain, and to favor the effusion of blood. 2 
 
 The blood thus effused coagulates after very various intervals (often, 
 however, remaining fluid for a considerable time), and the edge of the 
 coagulum sometimes conveys to the finger an indistinct sensation of a 
 raised border surrounding the tumor. The elevated ring that is after- 
 wards plainly felt circumscribing it, is however the result of a repara- 
 tive process, in the course of which new bone material is poured out 
 from the inner surface of the detached pericranium, and is heaped up 
 in especial abundance just where the bone and its investing membrane 
 come into apposition. This is proved to be its real source, by the fact 
 that the ring becomes much more evident after the absorption of the 
 blood has commenced than it is at first ; while in those cases Avhere 
 the effusion of blood has been very considerable, no ring is perceptible 
 during life, and it is found after death that scarcely any attempt at 
 reparation has been made, and that the fibrinous exudation is very 
 scanty, or altogether absent. 
 
 This exudation is generally absorbed in course of time, but some- 
 times a process of ossification is set up in it ; the fibrinous ring becomes 
 converted into an osseous ridge, and that part of the cranium over 
 which the blood had been poured out is roughened by the formation 
 of new bone upon its surface. The meaning of the appearances thus 
 produced was long misunderstood, and they were thought to be owing 
 to a process of destruction, not to one of cure. The roughened surface 
 
 1 In Yalleix's Clinique des Maladies des Enfants Nouveaux-n.es, Paris, 1839, 
 planche i, fig. 2. 
 
 2 The various questions relating to the mode of formation of these tumors are 
 fully discussed by Feist, Ueber die Kopfblutgeschwulst der Neugebornen, 4to., 
 Mainz, 1839; and by Burchard, De Tumore Cranii recens natorum sanguineo, 4to., 
 Yratislavite, 1837; where are likewise mentioned various exceptional cases in which 
 the swelling formed on the parietal bone that had been directed towards the sacrum, 
 and not. as is usual, on the bone which had presented during labor. The investiga- 
 tions of Professor Levi, of Copenhagen, published in the Journal fur Kinderkrank- 
 heiten, March, 1802, show fresh exceptions to this, which had been supposed to be 
 the general rule, and prove that sudden pressure, however exerted, is quite adequate 
 to occasion this accident. M. Seux's laborious essay on the subject, which forms 
 the second number of his Becherches sur les Maladies des Enfants Nouveaux-nes, 
 8vo., Paris, 1863, and the remarks of Virchow in his great work (Die Krankhaften 
 Geschwiilste, vol. i, p. 128-135, Berlin, 1863), in which, however, he states the fact 
 of the blood remaining fluid for a long time, much more absolutely than either my 
 own experience or the statements of other observers bear out, do but confirm in all 
 other points the results arrived at by previous observers. 
 
62 CEPHALHEMATOMA. 
 
 of the skull was looked on as the result of ulceration by which its 
 outer table had at one part been destroyed, and the bony ridge around 
 it was supposed to be the edge of that part of the outer table to which 
 the disease had not yet extended. The real nature of these changes 
 was extremely well exemplified in a very remarkable case that came 
 under my notice, in which blood was effused between the skull and 
 dura mater, as well as between it and the pericranium. 1 This drawing 
 shows the processes of cure in progress. First, however, you may 
 notice the perfect smoothness of the inner surface of the bone, in order 
 to display which the edge of the clot is raised. Its outer as well as 
 its inner investment had been detached from this portion of the skull 
 by the effusion of blood beneath them, and the bone continues un- 
 roughened, because an attempt at reparation was impossible here. At 
 the edge of the clot, the dura mater and the bone come again into con- 
 tact, and nature has here begun the cure. New bone has been de- 
 posited, and an osseous ridge has been formed precisely similar to that 
 which in so many instances surrounds the external effusion. Nor is 
 this all ; but bony plates are beginning to be deposited between the 
 layers of the dura mater, exemplifying the manner in which, when 
 blood has been poured out beneath the pericranium, that membrane 
 sometimes becomes ossified, and accounting for the crackling sensation 
 that in these cases is felt on pressing the tumor. 
 
 The characteristics of these tumors are so well marked, that they are 
 not likely to be confounded with swellings of the scalp produced by 
 any other cause. A hernia of the brain, indeed, may present some 
 resemblance to them, since it forms a soft painless tumor, unattended 
 by discoloration of the integuments, and the edges of the aperture in 
 the bone through which the brain protrudes may easily be taken for 
 the ring surrounding an effusion of blood beneath the pericranium. 
 Independently, however, of the pulsating character of the swelling 
 formed by hernia of the brain, its situation at one of the fontanelles, 
 probably the posterior, or in the course of one of the sutures, will gen- 
 erally distinguish it sufficiently from these sanguineous tumors, which 
 are almost always seated on the parietal bone, and near to* its protu- 
 berance. 
 
 While the nature of this affection was ill understood, many practi- 
 tioners regarded it as of very serious import, and thought that its cure 
 could be effected only by making a free incision into the tumor, and 
 emptying it of the effused blood, or else by applying caustic to its 
 surface, with the view of exciting suppuration within it. There is, 
 however, no real necessity for these severe measures, which appear in 
 not a few instances to have caused the death of the child ; for the blood 
 will in the course of a few weeks be absorbed, and the tumor diminish 
 and disappear of its own accord. I have even seen a tumor,of larger 
 size than my fist, w T hich Was seated on the right parietal bone, but 
 extended considerably beyond the mesial line, disappear completely of 
 its own accord in the course of four months. The great difficulty, indeed, 
 
 1 A description of this case will be found at p. 397 of vol. xxviii of the Medico- 
 Chirurgical Transactions. 
 
HEMORRHAGE INTO THE ARACHNOID. 63 
 
 that you will encounter will consist in persuading the parents to let the 
 swelling alone, and to wait till time effects its removal. While, how- 
 ever, the affection requires no treatment, and is generally not attended 
 by any danger, it is yet right to bear in mind the possibility of internal 
 as well as external effusion having taken place. In this case, as hap- 
 pened in an instance that came under my notice, the sudden increase 
 of the internal effusion may be followed by apoplectic symptoms, and 
 death ; or, as in the other instance which I have just mentioned of the 
 very large effusion, the injury inflicted on the brain may be so con- 
 siderable, that the child may survive only to present every sign of 
 hopeless idiocy. 
 
 Perhaps I may be pardoned if I digress for a moment to notice the 
 occasional pouring out of blood beneath the occipito-frontalis or temporal 
 muscle in children as the result of a blow on the head. Unlike a 
 bruise, this effusion does not always take place at the precise spot where 
 the injury w T as inflicted, but the greater size of the vessels that traverse 
 the skull at the side seems to be the reason why a shock, such as a fall 
 on the occiput, is sometimes succeeded by the formation of a tumor of 
 this kind at the side of the head, and not at the part which received 
 the blow. It has twice come under my notice in these circumstances. 
 The tumor thus formed is soft, painless, and fluctuating, and its size at 
 first increases very rapidly, but the integuments covering it are neither 
 hot nor discolored. It is not surrounded by so w^ell-defined a ring as 
 circumscribes the swelling formed by the effusion of blood beneath the 
 pericranium ; the ridge is imperfect, its edge is much less sharp, and 
 it is often to be felt nowhere except near to the insertion of the temporal 
 muscle. 
 
 In this as- in the other case nature herself is usually fully equal to the 
 removal of the blood, and the consequent dispersion of the swelling. 
 
 Cerebral hemorrhage, though at no other time so frequent as imme- 
 diately after birth, may occur at any period of subsequent childhood, 
 under the influence of causes that favor congestion of the brain, or even 
 independently of any cause that we can discover. The hemorrhage 
 still takes place almost invariably into the arachnoid cavity, and blood is 
 sometimes poured out there in very large quantity; but the accident is 
 neither so invariably nor so speedily fatal as in the new-born infant. 
 
 If death should follow very soon after the occurrence of the effusion, 
 the blood is found unchanged, forming a more or less extensive layer 
 upon the convex surface of the brain, and extending downwards and 
 backwards towards the base of the organ, but seldom situated at its 
 anterior part unless the hemorrhage have been unusually profuse. If 
 life is prolonged, the clot speedily separates into serum and crassamen- 
 tum, and a series of changes commences in the latter, the effect of which 
 is to deprive it of its coloring matter, and to convert it, in course of 
 time, into a delicate false membrane, which lies in close apposition with 
 the parietal arachnoid. This transformation may sometimes be ob- 
 served while in course of progress, and a central clot may then be seen 
 gradually losing itself in a membrane that grows more and more deli- 
 cate towards its periphery. If, as occasionally happens, successive 
 effusions of blood take place at somewhat distant intervals, this mem- 
 
64 OBSCURITY OF SYMPTOMS OF 
 
 brane may become thick and firm, and may even present a pearly lustre; 
 changes which have led some observers into the error of attributing the 
 appearance to alteration and thickening of the dura mater. The amount 
 of the original effusion has much to do with the rapidity of the changes 
 in the clot. If the effusion were but inconsiderable, the serum of the 
 blood soon becomes absorbed, and no other trace of the occurrence re- 
 mains than the false membrane lining a portion of the arachnoid. If 
 the hemorrhage were at all abundant, the reddish serum will, even after 
 the lapse of a considerable time, be very evident on opening the sac of 
 the arachnoid, and some of it will probably be found entangled in the 
 substance of the clot. By degrees the serum loses its color, but its 
 quantity may still continue for a long time undiminished, or the efforts 
 of nature may even entirely fail to accomplish its absorption. The 
 fluid in such cases is either simply contained within the arachnoid 
 cavity, or, having remained inclosed within the clot during the changes 
 which it underwent, appears at length to be situated within a delicate 
 cyst or shut sac. If the hemorrhage, in the first instance, were very 
 considerable, or if it were to recur two or three times, the yielding cra- 
 nium of the child will enlarge, the head will alter in form, and the 
 case will assume many of the characters of chronic hydrocephalus. 1 
 
 All writers, even those who, like MM. Rilliet and Barthez, have 
 thrown the most light on the anatomy and pathology of cerebral hemor- 
 rhage in the child, concur in representing its symptoms as extremely ob- 
 scure. Paralysis, which, in the grown person, is one of the most fre- 
 quent results of the escape of blood from the cerebral vessels, is so rare 
 in the child that it was observed by M. Legendre 2 only in one out of 
 nine cases, and by MM. Rilliet and Barthez 3 in one out of seventeen 
 cases. This peculiarity is doubtless in great measure accounted for by 
 the circumstance of the blood being almost always poured out into the 
 cavity of the arachnoid, so that the pressure which it exerts on the brain 
 is generally diffused over the surface of the organ, and is nowhere very 
 considerable. 
 
 The absence of paralytic symptoms, however, is not the sole cause 
 of the obscurity of these cases, but the indications of cerebral dis- 
 
 1 Not having had the opportunity of observing the whole series of changes said to 
 take place in blood effused into the sac of the arachnoid, I have chiefly followed the 
 account given by MM. Rilliet and Barthez, in their Traite des Maladies des Enfans, 
 2 e ed., Paris, 1853, vol. ii, pp. 247-255. I am not, however, prepared to say how far 
 this, which was the generally received opinion as to the source of the hemorrhage 
 and the mode of formation of the false membrane associated with it, is still to be re- 
 garded as correct. The observations of recent writers, as, for instance, Virchow, in 
 his work Die Krankhaften G-eschwiilste, 8vo., Berlin, 1863, p. 140 ; and Lancereaux, 
 in the Archives de Medecine, 1862, vol. ii, p. 526-679, and 1.863, vol. i, p. 38, tend 
 to prove the formation of inflammatory false membranes to be the first step in the 
 morbid process, the occurrence of hemorrhage the second. I can, however, scarcely 
 imagine that accidents which seem so sudden as hemorrhages into the arachnoid in 
 children can really be due to a long train of previous morbid phenomena. The ob- 
 servations which have led to this conclusion were all made in the adult and in the 
 aged. The subject seems to me to require further investigation in infancy and early 
 childhood. 
 
 2 Kecherches Anatomo-Pathologiques sur quelques Maladies de l'Enfance, 8vo., 
 Paris, 1846, p. 130. 
 
 s Lib. cit., p. 257. 
 
HEMORRHAGE INTO THE ARACHNOID. 65 
 
 turbance by which they are attended vary greatly in kind as well as in 
 degree. The sudden occurrence of violent convulsions, and their fre- 
 quent return, alternating with spasmodic contraction of the fingers and 
 toes in the intervals, appear to be the most frequent indications of the 
 effusion of blood upon the surface of the brain. I need not say, how- 
 ever, that such symptoms taken alone would by no means justify you in 
 inferring that effusion of blood had taken place. Many circumstances 
 having reference to the previous history of the child, as well as to 
 its present condition, must be taken into account in forming a diagnosis. 
 Hemorrhage into the arachnoid cavity is most frequent in early child- 
 hood — symptoms such as have been enumerated would therefore ac- 
 quire additional diagnostic importance in proportion to the tender age 
 of the child in whom they occurred. The probability of their beto- 
 kening this accident would be still further strengthened if the child 
 who experienced them had previously suffered from frequent attacks 
 of cerebral congestion, or had been recently exposed to the sun with- 
 out proper covering for the head ; or had been placed in other circum- 
 stances calculated to favor determination of blood to the head. 
 
 The popular notion that associates the idea of rude health and general 
 plethora with the occurrence of apoplexy in the adult, is in many in- 
 stances altogether fallacious. In the case of the child. it has still less 
 foundation, since the effusion of blood upon the brain occurs much 
 more frequently in weakly children than in such as are robust. There 
 seems to be reason, indeed, for supposing that the hemorrhage is some- 
 times of a purely passive character, and dependent on an altered state 
 of the blood. I will relate to you a case or two as illustrations of this 
 cachectic form of cerebral hemorrhage. 
 
 Some years ago, I saw a little boy, five weeks old, the child of 
 healthy parents, and who had been perfectly well for the first fortnight 
 after his birth : he then, without any evident cause, grew drowsy, and 
 vomited often, and his skin became quite jaundiced. His abdomen at 
 this time was large and hard, and he cried when pressure was made on 
 the right hypochondrium :» these symptoms still continued when he 
 was brought to me. A leech now applied on the right side drew a 
 good deal of blood, and the hemorrhage was stopped with difficulty ; 
 the bowels, previously constipated, were acted on by small doses of 
 calomel and castor oil, and in three days the child lost the yellow tinge 
 of his skin, became cheerful, and seemed much better. He was now, 
 however, on July 18, suddenly seized with hurried respiration and 
 great depression, soon followed by violent convulsions, during which 
 he screamed aloud. At the same time it was observed that his left 
 hand had begun to swell, and to put on a livid hue, and on the 20th, 
 the right hand also became cedematous. His whole surface grew quite 
 sallow, and, on the day before he died, the oedema of the left hand had 
 much increased ; the liver had become considerably deeper, and there 
 were small spots of extravasated blood over each knuckle. The right 
 elbow was slightly livid ; the right hand much swollen, but of its 
 natural color ; and a small black spot had appeared under the chin 
 corresponding to the knot of the cap-string. The fits recurred very 
 frequently, the child in the intervals lying quite still ; the pupils were 
 
 5 
 
66 HEMORRHAGE INTO THE ARACHNOID. 
 
 contracted, and the condition seemed to be one of extreme exhaustion 
 rather than of coma. On the 20th, the power of deglutition was lost, 
 and after several returns of less violent convulsions the child died at 
 9 a.m., on July 21 ; about sixty hours after the occurrence of the 
 first fit. 
 
 The sinuses of the brain were full of fluid blood ; a black coagulum, 
 three or four lines thick, covered the whole posterior part of both hem- 
 ispheres, extending from the posterior third of the parietal bones, occu- 
 pying the whole concha of the occipital bone, and reaching along the 
 base of the skull to the foramen magnum. A little blood was likewise 
 effused about the anterior part of the base of the brain, though the 
 quantity was very small in comparison with what was found at its 
 posterior part. The substance of the brain w T as very pale, and all the 
 organs of the body were ansemic, except the liver, which was gorged 
 with fluid blood, while the heart was quite empty. The ductus arte- 
 riosus was closed, the foramen ovale admitted a probe with ease, the 
 ductus venosus admitted one with difficulty. 
 
 Another instance has since then come under my notice, in which 
 passive hemorrhage took place into the arachnoid in a child exhausted 
 by long-continued illness, the effects of which were aggravated by pov- 
 erty and want. From the age of two to that of five months the child 
 had been under my care in consequence of frequent attacks of hsemat- 
 emesis and purging of blood, and though his health afterwards im- 
 proved, yet he never became strong, and his evacuations were almost 
 always white, and deficient in bile. After he was weaned, the coarse 
 food which his indigent parents gave him did not nourish him ; he lost 
 flesh and strength, and when almost three years old was puny and 
 emaciated. Three days before his death an attack of diarrhoea came 
 on, which induced great exhaustion; and while suffering from this 
 aifection, he suddenly grew comatose, cold, and almost pulseless, and 
 his breathing became so slow that he inspired only four or five times 
 in a minute. In this state he lay for twenty-four hours, and then died 
 quietly. Nearly six ounces of dark coagulated blood were found in 
 the sac of the arachnoid over the right hemisphere of the brain ; a little 
 blood was likewise eifused beneath the arachnoid, and there was a very 
 small clot in the lower and front part of the right middle lobe of the 
 brain, but no ruptured vessels could be perceived. Great anaemia of 
 every organ, and a state of extreme attenuation of the walls of the heart, 
 were the only other remarkable appearances. 
 
 Hemorrhage into the substance of the brain, though extremely rare in 
 infancy and childhood, does sometimes occur, and then gives rise to 
 appearances similar to those with which we are familiar in the adult. 
 Death, however, usually takes place too speedily in these cases for any 
 of those changes to occur in the apoplectic effusion which are often 
 observed in the adult, and which betoken the advance that nature has 
 made in her efforts to repair the injury of the brain. 
 
 I have only twice met with distinct extravasation of blood into the 
 substance of the brain in children. In the first case, that of a little 
 girl eleven months old, the occurrence was evidently due to the impedi- 
 ment to the circulation through the brain produced by the formation 
 
HEMORRHAGE INTO THE SUBSTANCE OF THE BRAIN. 67 
 
 of a thrombus in the longitudinal sinus, and consequent inflammation 
 of the sinuses of the dura mater. In addition to other appearances, 
 which I shall describe in a future lecture/ there was great venous 
 congestion of the membranes covering the middle lobe of the left hem- 
 isphere of the brain, the cerebral veins were distended with coagula, 
 and their coats were thickened. At the anterior part of the lower sur- 
 face of the left middle lobe of the brain there were four apoplectic 
 effusions, in all of which the blood still retained its natural color, and 
 each effusion was situated close to an obliterated and distended vein. 
 The largest clot extended for an inch into the substance of the Wain, 
 and the others were of smaller dimensions. Head symptoms, as might 
 be expected, had existed in this little child for a long time before her 
 death. The occurrence of the effusion was probably synchronous with 
 a sudden attack of extreme faintness that came on forty-eight hours 
 before she died, and from which she never completely rallied. 
 
 The other instance of hemorrhage into the substance of the brain 
 occurred in a girl eleven years old, the child of healthy parents, and 
 whose own health had been quite good until she was six years of age. 
 At that time the extraction of a molar tooth was followed by necrosis 
 of a large portion of the lower jaw, and by the formation of abscesses 
 in the face and head, from which bone escaped. An abscess, attended 
 with similar exfoliation of bone, formed likewise on the right foot, and 
 it was three years before the child had recovered completely. Though 
 much disfigured by the disease, her health ever after continued good 
 until April 12, 1846. She was then suddenly and causelessly at- 
 tacked by vomiting and pain in the head, for which no other treat- 
 ment was adopted during ten days than the occasional administration 
 of an aperient. During this time, however, a condition of stupor 
 gradually stole over the child, for which, on April 21, a blister was 
 applied to the back of her neck with great relief. On April 23 she 
 had two attacks of convulsions, with an interval of four hours between 
 each. She struggled much during their continuance, especially with 
 the right side ; when the convulsions subsided partial palsy of the left 
 side remained ; the child complained much of her head, and sank from 
 time to time into a state of stupor, from which, however, she could 
 always be roused. Very free purgation on April 24, and the applica- 
 tion of another blister to the back of the neck, were followed by some 
 amendment. On the evening of the 25th another fit occurred, with 
 symptoms similar to those that had been observed on the previous 
 occasions ; but it was not followed by any increase in the palsy of the 
 left side, nor was the degree of stupor so considerable as on the former 
 occasion. Mercurials, which had been employed from the commence- 
 ment of the attack, had now produced a decided influence on the mouth, 
 and the abundant action of the bowels was again succeeded by much 
 improvement in the child's condition. The pulse, which had varied 
 from 60 to 70, now continued about 70, and was natural in character, 
 and the child improved daily, though taking no other medicines than 
 occasional aperients. The headache returned occasionally, though 
 
 1 See Lecture VIII. 
 
68 CAPILLARY HEMORRHAGE. 
 
 each time it was less severe than the time before ; but on the evening 
 of May 15, this amendment was suddenly interrupted by an attack of 
 violent pain in the abdomen, which was soon followed by convulsions 
 and coma, and the child died convulsed in sixteen hours ; on the 36th 
 day from the first attack of pain in the head. 
 
 On making an examination of the head, blood was found to be 
 effused into the subarachnoid tissue over a great part of the right hemi- 
 sphere of the brain. The quantity of blood, however, was nowhere very 
 considerable, but merely occupied the sulci between the convolutions. 
 The. brain presented no remarkable appearance, except that, on a level 
 with and just exterior to the right lateral ventricle, there was a large 
 clot of blood, rather larger than a hen's egg, but of more irregular 
 shape, around which the brain was softened. This effusion was per- 
 fectly black throughout, the coloring particles of the blood being 
 equally diffused through it, and no appearance betokened that hemor- 
 rhage had previously taken place in this situation. The anterior cere- 
 bral artery ran for a considerable distance just outside the clot, but it 
 could not be ascertained that it had given way at any point. 
 
 Cerebral hemorrhage is one of the few affections of early life con- 
 cerning the treatment of which but little can be said ; for where the 
 symptoms of a disease are so obscure, it would be idle laying down 
 elaborate rules for its cure. The general principles, according to which 
 you would manage a case of congestion of the brain, would still guide 
 you if hemorrhage had taken place. It cannot, however, be necessary 
 for me to repeat to-day the observations on that point to which I yes- 
 terday directed your attention. 
 
 Before concluding, I must for a moment refer to a form of cerebral 
 hemorrhage, which, though of no great importance, yet forms an excep- 
 tion to what has been stated as to the rarity of the accident in early 
 life. In children who have been affected with tubercular disease of the 
 brain, it is by no means unusual to observe very small effusions of 
 blood in the midst of the softened cerebral matter that surrounds the 
 deposit This capillary apoplexy, produced by some of the minute 
 vessels of the brain giving way, is, however, seldom extensive, and 
 probably has but little share even in accelerating the fatal event. 
 
 When next we meet, we shall pass from this subject, which, it must 
 be owned, has more of a pathological than of a practical interest, and 
 shall enter on the study of the inflammatory affections of the brain in 
 childhood. 
 
INFLAMMATORY AFFECTIONS OF THE BRAIN. 69 
 
 LECTURE VI. 
 
 Inflammatory Affections of the Brain. — Frequent in childhood, hut over- 
 looked by early writers — First noticed about a century ago — Their most common 
 form described under the name of acute hydrocephalus by Dr. Whytt — Progress 
 of knowledge with reference to these diseases — Gradual recognition of impor- 
 tance of affection of the membranes — Its two varieties — The simple and the tu- 
 bercular — Reasons for rejecting old nomenclature, and treating of Simple and 
 Tubercular Meningitis — The latter name restricted in these lectures to scrofu- 
 lous inflammation of the brain, which is much more frequent than its simple 
 inflammation in childhood. 
 
 Tubercular Meningitis.— Morbid appearances in it — Due either to inflammation 
 or to tubercular deposit — Alterations more apparent in the membranes at the base 
 of the brain than in those of its convexity — Increase of fluid in the ventricles 
 almost invariable — Central softening of the brain not a post-mortem alteration 
 — Frequently connected with changes in the lining of the ventricles — Inferences 
 to which these facts lead. 
 
 Symptoms of the three stages of the disease. 
 
 Few of the diseases of childhood are more serious than those inflam- 
 matory affections of the brain on the examination of which we are now 
 about to enter. They occasion 9.8 per cent, of all deaths under five 
 years of age in this metropolis, while they are so especially the diseases 
 of early life, that 81.1 per cent, of all cases of fatal inflammation of the 
 brain occur in children under five years of age, 90.2 per cent, before 
 the age often, and 92.4 per cent, before the age of fifteen. 1 
 
 But though the frequency of these affections in the young is a matter 
 of such popular notoriety that most of you were familiar with the fact 
 long before you were engaged in your present profession, yet if you 
 turn to the writings of any of the old physicians, you will find in them 
 no mention of inflammation of the brain in childhood. At first this may 
 surprise you, but a few moments' consideration will explain the seeming 
 oversight. Convulsions, which form a prominent symptom in most 
 cases of inflammation of the brain, occur, as I need not remind you, 
 in the course of many other affections of the nervous system. An 
 accident so alarming as a fit of convulsions is sure to attract attention, 
 but much careful examination is often needed to distinguish those 
 minor differences between the symptoms that precede or accompany it, 
 which alone would indicate its cause. It cannot, then, be surprising, 
 that in the absence of this minute care, many diseases, though differing 
 in most important particulars, should have long been classed together 
 under the head of convulsions, and that inflammation of the brain 
 should not have been recognized as a distinct affection. The impor- 
 tance of some of those less obvious structural changes which we know 
 to be most significant of the nature of previous diseases, was not then 
 understood, so that an alteration in the consistence of the brain, or a 
 
 1 Deduced from 5th and 8th Keports of Eegistrar-General for 1842-5. 
 
70 INFLAMMATORY AFFECTIONS OF THE BRAIN. 
 
 diminution in the transparency of its membranes, often passed unno- 
 ticed ; and anatomical research was not exact enough to make up for 
 the deficiencies in clinical observation. 
 
 But just as the physician's attention was fixed on the convulsive 
 seizures which in so many cases affected his patients, so the eye of the 
 anatomist was often arrested by the discovery of a large quantity of 
 fluid in the interior of the brain. Sometimes this fluid had been 
 secreted in such quantity, as not only to distend the ventricles of the 
 brain, but to occasion a manifest enlargement of the skull. In such 
 cases the disease was essentially chronic in its course, and was called, 
 from its most striking characters, dropsy of the brain, or chronic hydro- 
 cephalus. 
 
 Speculation, however, was set afloat by the occasional notice of cases 
 in which, though fluid was found in large quantity within the brain, 
 yet the previous disease had been of short duration, its symptoms had 
 been acute, and the fever, drowsiness, and cerebral disturbance which 
 attend it had run a very rapid course to their fatal termination. Dr. 
 Whytt was the first 1 who, in the year 1768, clearly pointed out the 
 connection between these symptoms and the accumulation of fluid in 
 the ventricles. His attention, like that of previous observers, was 
 mainly fixed on this point, to the exclusion of other morbid appear- 
 ances, and he was thus led to regard the 'disease as an acute dropsy of 
 the brain. Little can even now be added to his description of the 
 malady ; but further, observation has shown that the presence of an 
 increased quantity of fluid in the brain, on which he laid so much 
 stress, is not of invariable occurrence ; that there is no certain relation 
 between the amount of the fluid and the intensity of the symptoms, or 
 the rapidity of their course ; and that it is always associated with other 
 very important lesions, some of which are the evident results of inflam- 
 mation. Many years were occupied in the investigations which led to 
 this conclusion ; so that long before Whytt's theory had been ascer- 
 tained to be erroneous, people had grown familiar with the name of 
 acute hydrocephalus which he proposed for the disease, and continued 
 to employ it as a convenient term long after it was known that it ex- 
 pressed a part only, and that not the most important part, of the truth 
 with reference to its nature. 
 
 The first great step towards a knowledge of the true pathology of 
 the affection, was the discovery that the fluid poured out into the ven- 
 tricles is not a mere dropsical effusion, but that it is the result of pre- 
 vious inflammatory action. Next came the observation, that the effects 
 of inflammation are as remarkable in the membranes of the brain as 
 in its substance ; or in other words, that the meningitis is as important 
 as the cerebritis. A further advance was made when it was ascertained 
 that the occurrence of Whytt's disease was associated during life with 
 more or less marked evidences of the tubercular diathesis, and that 
 deposits of tubercle were invariably found after death in various organs 
 of the body of patients who had died from it ; and last of all came the 
 discovery, which we owe to the acuteness of French anatomists, that 
 
 1 In his Observations on the Dropsy in the Brain, 8vo., Edin., 1768. 
 
TUBERCULAR MENINGITIS. 71 
 
 in these eases the inflamed membranes of the brain themselves have 
 been the previous seat of inflamed deposit — that the disease is not a 
 simple but a tubercular meningitis. 
 
 One difficulty still remained in the occasional occurrence of cases 
 similar to, but yet not altogether identical with Whytt's disease, either 
 in their symptoms or their course, the former being usually more violent, 
 the latter more rapid, in which meningitis was discovered, after death, 
 associated with more or less fluid in the ventricles, and more or less 
 softening of the brain-substance ; but in which no trace of tubercle is 
 to be found, either in the membranes of the brain or in any organ of 
 the body. 
 
 Careful observation brought to light the curious fact, with reference 
 to the two classes of cases, that the membranes covering the upper sur- 
 face of the brain were mainly affected in simple meningitis, those of 
 the base in the tubercular form. So constantly, indeed, does this rule 
 hold good, that some writers of great authority employ the terms 
 ■meningitis of the convexity and basilar meningitis as synonymous with 
 simple and tubercular meningitis respectively. 
 
 To one or the other of these classes may be referred almost all cases 
 of what used to be called acute hydrocephalus on the one hand, and 
 encephalitis, or simple inflammation of the brain, on the other. I pro- 
 pose therefore to discard phraseology which no longer represents the 
 state of pathological knowledge, and to speak first of Tubercular Men- 
 ingitis, which is vastly the more frequent form, then of Simple Menin- 
 gitis, and afterwards to notice the rare instances of inflammation of the 
 brain-substance — Encephalitis, or still more properly Cerebritis. 
 
 We will commence this investigation with an inquiry into the 
 nature of the appearances found after death in cases of Tubercular 
 Meningitis. These may be divided into two classes, according as they 
 are the result of inflammation or of the deposit of tubercle ; and changes 
 due to both of these causes are often found in the membranes of the 
 brain as well as in its substance. 
 
 The appearances which present themselves on the skull being opened 
 are seldom very striking, for the dura mater is usually healthy, and 
 the changes in the arachnoid are not in general of a kind at once to 
 attract attention. Sometimes, indeed, the eye is struck by an excessive 
 vascularity of the membranes, but this appearance often depends on 
 the overfilling of the large vessels, as the result of position. Atten- 
 tive examination will enable us to distinguish between this, and that 
 increase of vascularity which is produced by a uniform injection of the 
 minuter vessels; and moderate pressure, while it causes the disappear- 
 ance of the apparent vascularity in the former case, will produce no 
 effect on the true congestion in the latter. 
 
 The secretion that naturally moistens the sac of the arachnoid is 
 altered, increased, or suppressed ; but the last of these changes is the 
 most frequent, while the first is seldom observed. The preternatural 
 dryness of the membrane is usually connected with some diminution 
 of its natural transparency ; it looks dull and lustreless, and feels 
 sticky — a state to which the French have applied the term " poisseux." 
 The dulness of the arachnoid is sometimes more considerable, and it 
 
72 MORBID APPEARANCES 
 
 then presents an opaline appearance, which is very evident at those 
 parts where the membrane passes from one convolution to another. 
 This opalescence is not often general, but is usually most marked about 
 the upper part of the hemispheres, and in the neighborhood of the 
 longitudinal fissure. 
 
 When any considerable degree of vascularity of the membranes is 
 evident, this is, of course, chiefly due to the injection of the minute 
 vessels of the pia mater. Such intense injection of the pia mater is, 
 however, far less frequent than the effusion of fluid between it and the 
 arachnoid, and it is still less common to find the two appearances in 
 the same subject. The effused fluid is for the most part colorless and 
 transparent, and if present in any considerable quantity, the surface of 
 the convolutions appears as if covered by a layer of transparent jelly, 
 though on puncturing the membrane a drop of clear serum will exude. 
 The effusion of lymph or pus into the pia mater covering any consider- 
 able extent of the convexity of the brain is very seldom met with, but 
 deposits of a yellow puriform lymph are not [infrequently seen occu- 
 pying the depressions between the convolutions, or following the course 
 of the vessels along the sides, or at the upper surface of the hemi- 
 spheres. 
 
 But though the alterations presented by the membranes at the con- 
 vexity of the brain are usually comparatively trivial, the membranes 
 at the base of the organ almost always show unequivocal traces of in- 
 flammatory action. The predominance of the affection of the mem- 
 branes at the base of the brain may indeed, as I have already stated, 
 be regarded as pathognomonic of scrofulous inflammation of the organ j 1 
 for even if the rule is not absolutely without exception, it yet holds 
 good in the vast majority of cases. In 75 out of 80 cases under my 
 care, in which the symptoms during life were those of acute hydro- 
 cephalus, the membranes at the base of the brain were found to be the 
 seat of disease more or less extensive, and always more considerable 
 than that which existed at the vertex. I hesitate to draw any conclu- 
 sion from the five remaining cases, since they were recorded many 
 years ago, and I am more disposed to believe that my observation was 
 inaccurate than that a pathological law which seems so well established 
 should have so many exceptions. 
 
 The least considerable of the morbid changes in the membranes at 
 the base of the brain consists in a milky or opaline condition of the 
 arachnoid and pia mater, but chiefly of the former, sometimes extend- 
 ing over the whole lower surface of the cerebrum, but seldom being 
 equally apparent in that part of the membrane which invests the cere- 
 bellum. But, besides this opacity, we usually observe much more dis- 
 tinct evidences of inflammatory action in the effusion of yellow lymph 
 beneath the arachnoid. This is generally found about the olfactory 
 nerves, which- are often completely imbedded in it, while a similar 
 effusion extending across the longitudinal fissure unites the two hemi- 
 
 1 On which subject, the valuable essay of M. Eilliet, De l'Inflammation tranche 
 des Meninges chez les Enfants, in the Archives de Medecine for December, Janu- 
 ary, and February, 184(3-7, may be consulted with advantage. 
 
IN TUBERCULAR MENINGITIS. 73 
 
 spheres of the brain together. A deposit of the same kind likewise 
 reaches up the fissure of Sylvius in many cases, and connects the an- 
 terior and middle lobes of the brain with each other ; or if poured out 
 in less abundance, it may be seen running up in narrow yellow lines 
 by the side of the vessels as they pass from the base of the brain 
 towards its convexity. It is in the neighborhood of the pons Varolii, 
 however, and about the optic nerves, that the most remarkable altera- 
 tions are met with. The opacity of the arachnoid is here particularly 
 evident, while the subjacent pia mater is opaque, much thickened, and 
 often infiltrated with a peculiar semi-transparent gelatinous matter, 
 sometimes of a dirty yellowish-green color. This matter is occasion- 
 ally so abundant as perfectly to conceal the third and fourth nerves, 
 and at the same time to invest the optic nerves with a coating two or 
 three lines in thickness; though, on being dissected off, the substance 
 of the nerves beneath appears quite healthy. When this morbid con- 
 dition exists in any very considerable degree it extends beyond the 
 pons, and involves the membranes covering the medulla oblongata, 
 especially at its anterior surface. 
 
 It is little more than forty years since- attention was first drawn to 
 the importance of another element, besides mere inflammation, in the 
 production of tubercular meningitis. The peculiar granular appear- 
 ances which various parts of the membranes of the brain almost invari- 
 ably present in this disease, though noticed many years before, began 
 then to engage the special attention of several French physicians. 1 
 The conclusion to which we are led by trheir careful investigation of 
 the subject is, that this appearance is not due to inflammation, as was 
 once supposed, but that it is occasioned by the presence of tubercular 
 deposits. These deposits often assume the form of minute, flattened, 
 spherical bodies of the size of a small pin's head, or smaller, and either 
 of a yellowish color, and rather friable under pressure, or grayish, semi- 
 transparent, and resistant, almost exactly resembling the gray granula- 
 tions which are sometimes seen in the lungs or pleurae of phthisical 
 subjects, and, whatever appearance they ultimately assume, they all 
 originally begin in the form of gray granulations. They are likewise 
 sometimes met with in what would seem to be an earlier stage, when 
 they appear like small opaque spots of a dead white color, much smaller 
 than a pin's head, and communicating no perceptible roughness to the 
 membrane. This appearance is often observed in the arachnoid cover- 
 ing the cerebellum, and those parts of the base of the brain where the 
 arachnoid is stretched across from one part of the organ to another. 
 The flattened yellowish bodies are most frequently seen at the con- 
 vexity of the brain, and on either side of the hemispheres. They gen- 
 erally follow the course of the vessels that ramify in the pia mater, and 
 accordingly occupy the sulci between the convolutions much oftener 
 than their summit. The firm gray bodies are mostly seen about the 
 pons, or imbedded in the pia mater in the neighborhood of the optic 
 
 1 M. Papavoine appears to have been the first who, in the Journal Hebdomadaire 
 for 1830, vol. vi, p. 113, clearly established the tubercular nature of these granula- 
 tions of the membranes of the brain. 
 
74 MORBID APPEARANCES 
 
 nerves, or projecting from the surface of the membranes that cover the 
 medulla oblongata. They are also often deposited in the arachnoid 
 lining the occipital bone, and are then sometimes collected in consider- 
 able numbers around the foramen magnum. These bodies, sometimes 
 of a gray, at other times of a yellow color, are likewise met with, 
 though less frequently, in the substance of the velum interpositum, or 
 imbedded in the choroid plexuses, and in both of these situations they 
 are sometimes very abundant. 
 
 These bodies, however, do not always retain the appearance of dis- 
 tinct granules, but sometimes on separating two folds of the arachnoid 
 which had seemed to be glued together by an effusion of yellow lymph 
 or concrete pus, w r e find that the matter which forms these adhesions is 
 not homogeneous, but that it consists of an aggregation of minute 
 granular bodies connected together by the lymph or pus in which they 
 are imbedded. This appearance is often met with at the convexity of 
 the brain, and close to the longitudinal fissure, and rather more towards 
 its posterior than its anterior part : a strip of this yellow matter, half 
 an inch long by two or three lines broad, connecting together the two 
 hemispheres of the brain or the two surfaces of the arachnoid. Some- 
 times two or three deposits of this kind are observed at the convex 
 surface of the brain, but they are generally more extensive at the base 
 of the organ, where they occupy the longitudinal fissure and the fissure 
 of Sylvius, and frequently connect opposite surfaces of the brain so 
 closely together as to render their separation impossible without injury 
 to its substance. 
 
 The nature of these granular bodies was for a long time much de- 
 bated, and I was accustomed once to state fully the reasons which led 
 to the conclusion that they are really tubercular deposits, and not the 
 products of inflammation. It would, however, be needless to do so 
 now, for on this point all morbid anatomists without exception are 
 agreed; and all too are agreed in regarding their presence as essentially 
 characteristic of this form of cerebral disease. We may now, therefore, 
 with great propriety discard the long-used but incorrect term of Acute 
 Hydrocephalus, and speak as I have already done only of Tubercular 
 Meningitis. 1 
 
 1 It is perhaps scarcely necessary to give a caution against confounding with 
 these tubercular granulations those small corpuscles, the Pacchionian bodies as they 
 are termed, which are met with either singly or in groups upon the upper surface 
 of the hemispheres near the falx cerebri in the early years of childhood. They are 
 minute round excrescences of the arachnoid, either semi-transparent or of a white 
 color, made up of dense fibrous tissue like that of lowly organized cellular tissue. 
 The arachnoid around them is not infrequently somewhat thickened ; but they are 
 in no other respect to be regarded as pathological conditions, than that there ap- 
 pears to be some connection between their development and the previous frequent 
 occurrence of cerebral congestion. In the course of time they sometimes perforate 
 the dura mater, and form little depressions in the bone, in which they become im- 
 bedded. They not seldom undergo conversion into the carbonate and phosphate of 
 lime, and yield also slight traces of silex ; and are in all respects different from the 
 bodies referred to in the text. See Luschka, in Miiller's Archiv, 1852, p. 101 ; a 
 review of a thesis by M. Faivre, in Arch. G6n. de Med , Avril, 1854; and Koki- 
 tansky, Pathol. Anat., Wien, 1856, vol. ii, p. 407. The laborious investigations of 
 Dr. Meyer, of Hamburg, published in Virchow's Archiv, 1860, vol. xix, pp. 171— 
 288, support the view that the development of these bodies is associated with fre- 
 
IN TUBERCULAR MENINGITIS. 75 
 
 Notwithstanding the important nature of the changes presented by 
 the membranes of the brain, it was long before they attracted as much 
 attention as the alterations in the substance of the brain itself, and espe- 
 cially as that distension of its cavities with fluid from which the malady 
 derived its name of acute hydrocephalus. The surface of the brain, 
 indeed, generally presents but few traces of disease, though sometimes 
 the convolutions are greatly flattened, and the sulci between them 
 almost obliterated by the pressure of the fluid from within. The cere- 
 bral substance is often healthy as low down as the centre of Vieussens, 
 or, presents no change more important than the presence of an unusual 
 number of bloody points, the divided cerebral vessels. But, though 
 unaltered to the eye, a diminution of consistence is often perceptible 
 as the ventricles are approached. Sometimes the whole brain seems 
 softer than natural, while at other times, though not actually softened, 
 it is infiltrated with fluid, as though it had soaked up the serum from 
 the ventricles. 
 
 The presence of a larger quantity of fluid than natural in the lateral 
 ventricles is of almost constant occurrence. In 78 out of 80 cases in 
 which death had taken place under the symptoms of tubercular menin- 
 gitis, I found an appreciable quantity of fluid in the ventricles ; and in 
 65 of these cases the quantity was considerable, amounting to several 
 ounces. The fluid is in general a perfectly transparent serum, resem- 
 bling passive effusions poured out from other serous membranes ; and 
 such it doubtless is in many cases in which it is found distending the 
 lateral ventricles. But, in a large proportion of instances, the increased 
 secretion in the ventricles is associated with a very notable change in 
 the surrounding cerebral substance. This change consists in a loss of 
 the natural firmness of the central parts of the brain ; varying in degree 
 from a slight diminution of consistence to a state of perfect diffluence, 
 in which the cerebral substance forms a pulpy mass that is easily 
 washed away by a stream of water ; or the softening may be even more 
 considerable, and the cerebral matter may beco'me semifluid, and closely 
 resemble thick cream. The parts thus affected are perfectly pale and 
 bloodless, and the adjacent substance of the brain is usually rather 
 anaemic. The fornix, septum lucidum, corpus callosum, and posterior 
 horn of the lateral ventricles, are the parts most frequently affected ; 
 the optic thalami, corpora striata, and lower parts of the middle and 
 posterior lobes of the brain, rank next in this respect, while the an- 
 terior lobes are but seldom softened. In a few instances the cerebel- 
 lum is involved in the softening, and now and then the whole brain is 
 found to have lost much of its natural firmness — a change, however, 
 which is usually much more marked on one side than the other. 
 Closely allied to this softening is the state to which I have already 
 referred, wherein the whole brain appears perfectly infiltrated with 
 
 quent and long-standing variations in the cerebral circulation ; and my own im- 
 pression is that they are discovered in children who have died of hydrocephalus 
 with much greater frequency than Meyer's statement of their extreme rarity before 
 the sixth year would lead one to anticipate, though I do not know that I could 
 state the fact numerically. It gives, however, to these appearances that position on 
 the border land between physiological and pathological products which is, I appre- 
 hend, their proper place. 
 
76 MORBID APPEARANCES 
 
 serum, as though it had been long soaked in it, and had imbibed it 
 like a sponge. 
 
 A mechanical explanation has been frequently suggested to account 
 both for this appearance and for the central softening of the brain, 
 which you will observe is most marked in those very parts to which 
 the fluid in the ventricles would naturally gravitate after death. 
 Many facts, however, are opposed to this view of the cause of softening 
 of the brain. If it were a change induced by the imbibition of fluid 
 after death, we should expect to find it as constant as is hypostatic 
 congestion of the lungs ; but instead of this being the case, fluid is 
 found in many instances in the ventricles without the consistence of 
 the brain being in the least diminished. In a German work on 
 Acute Hydrocephalus, which embodies the results of a very large num- 
 ber of dissections, it is stated that central softening of the brain existed 
 only in 47 out of 71 instances, in which the ventricles contained a 
 quantity of serum varying from 3 to 11 ounces. 1 In my records of 
 the examination of the brain in hydrocephalus, I have preserved an 
 accurate account of the condition of the cerebral substance in 78 cases, 
 and find that in 35 instances there was not the least central softening, 
 although the ventricles contained fluid in every case but one, and the 
 quantity amounted on 21 occasions to several ounces. M. Louis, too, 
 mentions in his work on Phthisis, 2 that in 75 out of 101 tubercular 
 subjects, each ventricle contained a quantity of fluid varying from half 
 an ounce to two or three ounces, but yet in only 6 of these 101 cases 
 were the central parts of the brain at all softened. And not to dwell 
 on any other arguments which might be adduced, it may be added 
 that M. Rokitansky has subjected the supposed hygroscopic property of 
 the brain to the test of experiment, and found that no change whatever 
 was produced in slices of cerebral matter by soaking them for hours 
 in serum. 
 
 But if we reject the theory of this change in the brain being a mere 
 post-mortem occurrence, the question still remains, to what is it due ? 
 M. Rokitansky regards it as a condition of acute oedema of the brain, 
 often, though not invariably, associated with inflammation, since its 
 products, pus and exudation corpuscles, are usually found in the broken- 
 down or infiltrated nervous matter. 
 
 One very strong proof of the close connection that subsists between 
 softening of the brain and an inflammatory process going on in the organ, 
 is furnished by the changes which in many of these cases may be ob- 
 served in the lining membrane of the ventricles. 
 
 My own observation would lead me to believe that in at least two- 
 thirds of the cases these changes exist to such a degree as to be readily 
 appreciable by the naked eye, and the microscope would, I have no 
 doubt, ascertain their almost invariable existence. The first alteration 
 that takes place in the membrane is the loss of its transparency, which 
 is often, though not always, associated with a turgid state of its vessels. 
 
 1 Beobachtungen und Bemerkungen iiber den rasch verlaufenden Wasserkopf. 
 von K. Herrieh. 8vo., Kegensburg, 1847, p. 161, § 126. 
 
 2 Recherehes sur la Phthisie ; 2d ed., 8vo., Paris, 1843, p. 160, \ 161. 
 
IN TUBERCULAR MENINGITIS. 77 
 
 At the same time it loses its polish, and next acquires an unnatural 
 toughness, so that it can be raised by the point of the scalpel ; and 
 sometimes it is not merely opaque and tough, but greatly thickened, 
 forming a dense firm membrane ; and sometimes it presents a granular 
 appearance, which is usually most marked over the optic thalami and 
 corpora striata. This granular condition is sometimes so slight as to 
 be perceptible only when the membrane is looked at in certain lights ; 
 sometimes so extreme as to present a distinct roughness to the finger. 
 It is due to the presence 1 of small new-formed papillary outgrowths, 
 consisting of an accumulation of roundish cells with transparent nucle- 
 oli, which spring from an unevenly deposited layer of cells superim- 
 posed on the lining of the ventricle itself. 
 
 These changes, though observed in cases of tubercular meningitis, 
 are present in their most characteristic degrees in chronic internal 
 hydrocephalus, and are the evidence of inflammatory action which dates 
 back in some instances even to the time of foetal life. Now and then, 
 indeed, the lining of the ventricles, instead of presenting the above 
 described changes, is thickened, pulpy, and softened, so as to fray with 
 the slightest touch ; or participates in the general diffluence of the 
 central parts of the brain. This, however, is a decidedly exceptional 
 occurrence, and opacity, loss of polish, thickening, toughening, and 
 granular deposit on its surface, are the changes almost invariably pre- 
 sented by the lining membrane of the ventricles. I have not been able 
 to satisfy myself that these changes bear any certain relation to the 
 quantity of fluid, or to the degree of central softening, though it is rare 
 to find an extreme degree of change in the lining of the ventricles with- 
 out a considerable quantity of fluid in their cavity, and great softening 
 of the brain around them. 
 
 It is clear that in cases of tubercular meningitis there are two distinct 
 elements, which have no constant relation to each other, which even 
 are not invariably associated. The one of them manifests itself in the 
 affection of the membranes at the base of the brain, and is characterized 
 by the deposit of tubercle there, as well as of the exudation-products of 
 inflammation. The other displays itself in the affection of the lining 
 of the ventricles, in the changes which that undergoes, and in the 
 alteration of the adjacent brain-substance. 
 
 It were well worth the inquiry to. determine the exact connection of 
 the two; to make out which is the earlier occurrence, which predis- 
 poses to the other, which contributes most to bring about the fatal 
 event, to ascertain what symptoms betoken the one order of changes, 
 what the other ; and so to arrive, if possible, at some means of distin- 
 guishing cases which admit of remedy from those in which treatment 
 is vain and hope has no place. 
 
 One sometimes hears the complaint that the field of science has been 
 reaped so thoroughly by previous laborers as to leave but scanty glean- 
 ing for those who come after. But surely this is an idle lamentation 
 while problems such as these remain unsolved, to which it so much 
 
 1 See the minute researches of Dr. Loschner on this subject in his Aus dem Franz 
 Joseph-Kinder-Spitale, I Theil, 8vo., Prag, 1860, pp. 48-85. 
 
78 TUBERCULAR MENINGITIS. 
 
 imports the practical physician as well as the pathologist to be able to 
 return a correct answer. 
 
 It happens sometimes that we find large patches of tubercular matter 
 deposited beneath the membranes on the convex surface of the brain, 
 and extending to the depth of about a line into its tissue, in children 
 who have died of tubercular meningitis. Now and then, also, masses 
 of tubercle, of a spheroidal shape, and of various sizes, are found im- 
 bedded in the cerebral substance. This latter appearance, however, is 
 not frequent : it existed only in 8 out of the 80 cases on which I have 
 founded my remarks on the morbid anatomy of the disease, and even 
 in these cases peculiar symptoms existed which during the lifetime of 
 the patient led to the suspicion of the disease being something else than 
 an ordinary attack of water on the brain. 
 
 The complications of tubercular meningitis consist almost entirely in 
 the deposit of tubercle in many organs of the body, and in the various 
 results to which that tubercular deposit may have given rise. The 
 lungs and the bronchial glands are the parts most frequently and most 
 seriously invaded by the tubercular deposit ; the spleen, liver, mesen- 
 teric glands, and intestines, rank next in frequency as the seat of tuber- 
 cle. The association of meningitis with tuberculous ulceration of the 
 intestines is an accident which, though not very frequent, must not be 
 lost sight of, since its existence may give rise to diarrhoea, and thus 
 lead to an error of diagnosis on your part, if you look for constipation 
 of the bowels as an invariable symptom of water on the brain. 
 
 But let us now pass to the examination of the symptoms of tubercular 
 meningitis. We cannot, however, do more to-day than familiarize our- 
 selves with the main features of the disease, and must leave all attempts 
 at filling up the outline to our next meeting. 
 
 The first or premonitory stage of the affection is attended by many 
 indications of cerebral congestion, coupled with general febrile disturb- 
 ance, and presenting exacerbations and remissions at irregular periods. 
 The child becomes gloomy, pettish, and slow in its movements, and is 
 little pleased by its usual amusements. Or, at other times, its spirits 
 are very variable ; it will sometimes cease suddenly in the midst of its 
 play, and run to hide its head in its mother's lap, putting its hand to 
 its head, and complaining of headache, or saying merely that it is tired 
 and sleepy, and wants to go to bed. Sometimes, too, it turns giddy, 
 as you will know, not so much from its complaint of dizziness, as from 
 its suddenly standing still, gazing around for a moment as if lost, and 
 then either beginning to cry at the strange sensation, or seeming to 
 awake from a reverie, and at once returning to its play. The infant 
 in its nurse's arms betrays the same sensation by a sudden look of 
 alarm, a momentary cry, and a hasty clinging to its nurse. If the 
 child can walk, it may be observed to drag one leg, halting in its gait, 
 though but slightly, and seldom as much at one time as at another, so 
 that both the parents and the medical attendant may be disposed to 
 attribute it to an ungainly habit which the child has contracted. The 
 appetite is usually bad, though sometimes very variable; and the child, 
 when apparently busy at play, may all at once throw down its toys 
 and beg for food ; then refuse what is offered, -or taking a hasty bite, 
 
SYMPTOMS OF ITS THREE STAGES. 79 
 
 may seem to nauseate the half-tasted morsel, may open its mouth, 
 streteh out its tongue, and heave as if about to vomit. The thirst is 
 seldom considerable, and sometimes there is an actual aversion to drink 
 as well as to food, apparently from its exciting or increasing the sick- 
 ness. The stomach, however, seldom rejects everything ; but the 
 same food as occasions sickness at one time is retained at another. 
 Sometimes the child vomits only after taking food; at other times,. even 
 when the stomach is empty, it brings up some greenish phlegm without 
 much effort and with no relief. These attacks of vomiting seldom 
 occur oftener than two or three times a day; but they may return for 
 several days together, the child's head probably growing heavier, and 
 its headache more severe. The bowels during this time are disordered, 
 generally constipated from the very first, though their condition in this 
 respect sometimes varies at the commencement of the disease. The 
 evacuations are usually scanty, sometimes pale, often of different colors, 
 almost always deficient in bile, frequently mud-colored, and very offen- . 
 sive. The tongue is not dry, generally rather red at the tip and edges, 
 coated with white fur in the centre, which becomes yellowish towards 
 the root. Occasionally I have seen it very moist, and uniformly coated 
 with a thin white fur. The skin is harsh, but there is no great heat 
 of surface ; the nares are dry, the eyes lustreless, the pulse accelerated, 
 but seldom exceeding 120 in children of four years old and upw l arcls ; 
 not full nor strong, but often unequal in the force and duration of its 
 beats. The child is drowsy, and will sometimes want to be put to bed 
 two or three times in the day; but it is restless, sleeps ill, grinds its 
 teeth in sleep, lies with its eyes partially open, awakes with the slightest 
 noise, or even starts up in alarm without any apparent cause. At night, 
 too, the existence of intolerance of light is often first noticed in conse- 
 quence of the child's complaints about the presence of the candle in the 
 room. 
 
 I need scarcely say that you must not expect to find all these symp- 
 toms in every case, neither, indeed, when present, are they persistent, 
 but the child's condition varies greatly in the course of a few minutes; 
 cheerfulness alternating with depression, and sound sleep being now 
 and then enjoyed in the midst of the unrefreshing dozes of the night. 
 It will not be by a hurried visit of a few minutes that you will learn 
 these things ; you must not grudge your time if you hope ever to attain 
 to excellence in the management of children's diseases. 
 
 This precursory stage is of very variable duration, but on the aver- 
 age does not exceed four or five days. If the disease is not recognized, 
 or if the treatment adopted is unsuccessful, it will pass into the second 
 stage, in which the nature of the affection is very apparent, though 
 unhappily the prospect of its cure is almost lost. The child no longer 
 has intervals of cheerfulness, nor attempts to sit up, but wishes to be 
 left quiet in bed, and the face assumes a permanent expression of 
 anxiety and suffering. The eyes are often kept closed, and the eye- 
 brows are knit, the child endeavoring to shut out the light from its 
 morbidly sensitive retina. The skin continues dry, the face is some- 
 times flushed, and the head often hot ; and though these two symptoms 
 vary much in their duration, coming and going without any evident 
 
80 TUBERCULAR MENINGITIS. 
 
 cause, yet there is a permanently increased pulsation of the carotids, 
 and if the skull is not ossified the brain may be felt and seen forcibly 
 beating through the anterior fontanelle. The child is now very averse 
 to being disturbed, and often lies in a drowsy condition, unless spoken 
 to, when, if old enough to answer, it usually complains of its head, or 
 of weariness or sleepiness. Its replies are generally rational, but very 
 short; and if it needs anything, it asks in as few words as possible, in 
 a quick pettish manner, and shows much irritability if not at once at- 
 tended to. At other times it lies with its face turned from the light, 
 either quite quiet, or moaning in a low tone of voice, and now and 
 then uttering a short, sharp, lamentable cry, which M. Coindet, of 
 Geneva, regarded as characteristic of the disease, and hence termed it 
 cri hydrencephalique ; but making no other complaint than the low 
 moan and the occasional plaintive cry. To this, however, there are' 
 exceptions, and children sometimes scream with the intensity of the 
 pain, or cry out, " My head ! my head !" most piteously. As night 
 comes on there is almost always a distinct exacerbation of the symp- 
 toms, and the quiet of the day is frequently succeeded by a noisy and 
 excited state, in which vociferous cries about the head alternate with 
 delirium. This, however, is not by any means a constant occurrence; 
 an increase of restlessness being often the only difference from the state 
 of stupor in which the child lay during the day. At the commence- 
 ment of this stage the pulse is quickened, sometimes very much so, and 
 is in many cases unequal in the force and quickness of the beats. Ir- 
 regularity of its rhythm, or distinct intermission in its beat, is the next 
 change, and is usually perceived at the same time with a great dimi- 
 nution in its frequency, which often falls in a few hours from 120 to 
 90 or 80. At the same time that these changes take place in the 
 general characters of the pulse, its power becomes manifestly dimin- 
 ished, while the slightest exertion, such as attends any alteration in the 
 child's position in the bed, will often suffice to increase its frequency 
 twenty beats or more in the minute. The child sometimes keeps its 
 eyes so firmly closed that we can scarcely see the state of its pupils. 
 Usually they are not much affected, but sometimes one is more dilated 
 and acts more sluggishly than the other, or, in other cases, strabismus 
 exists, though perhaps in a very slight degree, or confined to one eye. 
 It is seldom that vomiting continues beyond the commencement of this 
 stage, bat its cessation is not followed by any desire either for food or 
 drink. The bowels usually become even more constipated than they 
 were before, and the evacuations continue quite as unnatural, while all 
 flatus -disappears from the intestines, and the abdomen thus acquires 
 that shrunken form on which much stress has been laid by some writers 
 as characteristic of the disease. 
 
 The transition from this to the third stage is sometimes effected very 
 gradually by the deepening of the state of drowsiness, till it amounts 
 to a stupor, from which it is impossible to arouse the child. At other 
 times, however, this stupor comes on very suddenly, succeeding imme- 
 diately to an attack of convulsions. The convulsions usually affect 
 one side much more than the other, and after the fit has passed off, 
 one side is generally found partially or completely paralyzed, while 
 
SYMPTOMS OF ITS THREE STAGES. 81 
 
 the child makes constant automatic movements with the other, carry- 
 ing the hand to the head, and alternately flexing and extending the 
 leg. The side which is the most affected during the fit is generally, 
 though not invariably, the most palsied afterwards. When the third 
 stage is fully established, the child lies upon its back in a state of 
 complete insensibility, with one leg stretched out, the other drawn up 
 towards the abdomen. The tremulous hands are either employed in 
 picking the lips or nose till the blood comes, or one hand is kept on 
 the genitals while the other is rubbing the face or head. The head is 
 at one moment hot, and the face flushed, and then the heat disappears 
 and the flush fades, though usually there is a permanent increase in 
 temperature about the occiput. Sometimes the skin is dry, and then, 
 though the extremities are cold, a profuse sweat breaks out on some 
 parts of the body or on the head. The pulse often loses its irregularity, 
 but at the same time it grow T s smaller and more rapid, till at length it 
 can be counted only at the heart. The eyelids now close only very 
 partially, and in most cases there is some degree of strabismus. Light 
 is no longer unpleasant, for the dilated pupils are either altogether 
 motionless, or they act very sluggishly, frequently oscillating under 
 the stimulus of a bright light, alternately contracting and dilating, till 
 at length they subside into their former dilated condition. The child 
 now often makes automatic movements with its mouth, as though chew- 
 ing, or as though endeavoring to swallow something. It generally 
 happens that, although sensibility is quite extinguished, the child will 
 still swallow anything that is put into its mouth, and the power of 
 deglutition is in most cases one of the very last to be abolished. 
 
 An attack of convulsions now sometimes puts an end to the painful 
 scene ; but often the child lives on for days, though wasted to a skel- 
 eton, and its features so changed by suffering, that those persons who 
 had seen it but a short time before would now scarcely recognize it. 
 The head often becomes somewhat retracted, and the child bores with 
 the occiput in the pillow : the eyelids are wide open, and the eyes 
 turned upwards so as to conceal three-fourths of the iris beneath the 
 upper lid, while the countenance is still further disfigured by a horrible 
 squint, or by a constant rolling of the eyes. The pupils are now fixed 
 and glassy, the white of the eyes is extremely bloodshot, and their surface 
 is besmeared with a copious secretion from the Meibomian glands, which 
 collects in their corners. One leg and arm are stiff and motionless, 
 the other in constant spasmodic movement, while the hands are often 
 clenched and the wrists bent upon the forearm. At the same time 
 there is frequently so much subsultus as to render it impossible to 
 count the pulse, and the muscles of the face are thrown from time to 
 time into a state of spasmodic twitching. Cold clammy sweats break 
 out abundantly about the head, the breathing is labored, deglutition 
 becomes difficult, and the child almost chokes with the effort to swal- 
 low, or lets the fluid run out at the corners of its mouth. It is uncer- 
 tain how long this condition may endure : the recurrence of convul- 
 sions usually hastens the end, but sometimes many days will pass, 
 during which death is hourly expected, and earnestly prayed for, to 
 put an end to the patient's sufferings. 
 
 6 
 
82 DIAGNOSIS OF TUBERCULAR MENINGITIS: 
 
 LECTURE VII. 
 
 Tuberculak Mentngitis, continued. — Diversities in its course and in its modes of 
 attack— Insidious approach in phthisical subjects — Resemblance of its symptoms 
 to those of typhoid fever — of simple gastric disorder — Serious import of con- 
 tinued sickness in cases of gastric disorder. 
 
 Prognosis. — Disease almost always fatal — Appearances of improvement often delu- 
 sive — Cautions against being misled by them. 
 
 Duration of the disease. 
 
 Treatment. — Prophylaxis. — Treatment of the disease — Rules for depletion, for use 
 of purgatives, mercurials, application of cold — Diet of patients — Circumstances 
 in which opiates may be useful — When blisters are to be applied — Alleged 
 efficacy of tartar-emetic ointment as a counter-irritant — Conclusions about 
 treatment. 
 
 It can scarcely be necessary to observe that tubercular meningitis 
 does not always run precisely that course which I described to you at 
 our last meeting. Almost every case, indeed, presents some slight 
 peculiarity, either in the comparative severity of the different symptoms, 
 in the date of their occurrence, or in the order in which they succeed 
 each other. Convulsions, for instance, though hardly ever absent, 
 occur earlier in one case than in another — affect in one the whole 
 body, in another are limited to one side — are succeeded in one instance 
 by paralysis, in another by a stiff and contracted state of the limbs. 
 Again, coma sometimes comes on gradually, at other times takes place 
 suddenly ; in one instance it continues long, in another is speedily 
 followed by death. The pupils sometimes become early insensible to 
 light ; at other times they continue to act, though slowly, almost to the 
 time of death ; and in like manner strabismus may exist in various 
 forms, or there may be constant rotation of the eyeball, or neither of 
 these symptoms may be present ; and yet we cannot couple these 
 diversities in the signs of the disease with any certain differences in the 
 morbid appearances. But, how much soever one case of tubercular 
 meningitis may differ from another in these respects, such differences 
 are of comparatively but little moment, since, whether these symptoms 
 occur early or late — whether they are slight or severe — short in their 
 duration, or of long continuance — the appearance of any one of them 
 stamps the character of the disease too plainly for it to be mistaken, 
 and indicates not the incipient but the fully developed evil. The 
 deviations from the ordinary mode of its attack are far more important, 
 since they may lead you to mistake the nature of the disease during 
 the only time when treatment is likely to be of much avail. 
 
 The healthy and robust are comparatively seldom attacked by tuber- 
 cular meningitis, and in many instances the indications of declining 
 health precede for weeks or months the real premonitory symptoms of 
 the disease. You may, however, be so much taken up with watching 
 the former as to overlook the latter, or to misinterpret their meaning. 
 Your solicitude is excited by the gradual decacy of a child's strength, 
 
ITS SYMPTOMS OBSCURE IN PHTHISICAL SUBJECTS. 83 
 
 and the wasting of his flesh. You observe that he becomes subject to 
 irregular febrile attacks — that he coughs a little — that he loses his 
 appetite — that his bowels are almost always disordered, and generally 
 constipated — and that he makes frequent vague complaints of pains 
 in his limbs, or of weariness or headache. These symptoms, which 
 depend upon that general deposit of tubercle in the different organs of 
 the body which almost every dissection of fatal cases of the disease 
 reveals, make you apprehensive lest phthisis should be about to come 
 on, and you often auscultate the chest in the expectation of discovering 
 some signs of disease in the lungs. At length, the child seems worse 
 — he coughs more, and is more feverish — grows heavier and more dull, 
 but does not complain more about his head — or, at most, says that the 
 cough makes his head ache. The parents think the child must have 
 caught cold, and you do not see the indication of any new disorder ; 
 for, though listless and moody, he still moves about the house, and 
 sometimes plays, though in a spiritless manner. Simple treatment 
 seems to do a little good, and you not unnaturally hope that the 
 aggravation of the symptoms will prove only temporary ; but, after an 
 unusually restless night, a fit of convulsions comes on, or the listless- 
 ness deepens in the course of a few hours, and without any evident 
 cause, into profound coma, and a very few days terminate the patient's 
 life. 
 
 A little girl, nearly eight years old, was brought to the Children's 
 Hospital one December. She was very pale, very languid, and so ema- 
 ciated that she looked as if far advanced in consumption. Her mother 
 stated that from birth the child's health had been delicate, but that she 
 had had no disease until the previous July, when hooping-cough came 
 on, which in a few days was complicated by the occurrence of measles, 
 attended with diarrhoea. She recovered from these ailments, though 
 they left her very thin and very weak, and the hooping-cough did not 
 completely cease until late in the antumn. 
 
 From the time of the hooping-cough ceasing, the child's health im- 
 proved, but her appetite was never very good, and she seemed by 
 degrees to become more and more unable to eat the coarse food of 
 poverty. She next was sick sometimes after taking food, and then 
 complained occasionally of headache ; and after these fresh symptoms 
 had continued for a few days, her mother brought her to the hospital. 
 She attended as an out-patient for nearly a fortnight, during which 
 time no new symptom appeared ; but the child grew daily weaker, and, 
 accordingly, was received into the house on December 16. The fact 
 that the auscultatory signs of phthisis which were present, consisted 
 merely in slight impairment of resonance on the left side posteriorly, 
 with coarse breathing and loud expiratory sounds, led to the hope that 
 the mischief in the lungs was not very considerable. She was ordered 
 beef tea, with a little wine, and a mixture containing the nitro-muriatic 
 and hydrocyanic acids. 
 
 For a few hours, the comforts of the hospital made a change in her 
 for the better ; but, on the night of the 17th, she slept badly, complained 
 of headache on the following morning, and was sick after her break- 
 fast. A single dose of calomel freely relieved her bowels, blisters 
 
84 DIAGNOSIS OP TUBERCULAR MENINGITIS 
 
 behind the ears removed the headache, and the sickness was quite 
 stopped by the prussic acid given in an effervescing mixture. This 
 improvement, however, lasted only for twenty-four hours. On Decem- 
 ber 20, after a restless night, she became very drowsy, refused her beef 
 tea, asked for nothing, complained of nothing, but, if much pressed, 
 said that her head ached. A blister was put on the shaven scalp ; the 
 wine, which flushed her, was discontinued, while an attempt was made 
 to nourish her with beef tea enemata. The drowsiness, in spite of the 
 blister, deepened on the next- day into coma; and thus she lay, in a 
 state of unconsciousness, with occasional convulsive twitchings of the 
 muscles of the face for the last two days of her life, till she died quietly 
 on the morning of December 25. 
 
 On examining the body after death, there was found advanced tuber- 
 culous disease of the bronchial glands at the left side of the trachea, 
 but the lungs were quite free from tubercle. The ventricles of the 
 brain contained some fluid • the arachnoid at the base was less trans- 
 parent than natural ; while a thin layer of toughish yellow lymph ex- 
 tended over the pons Varolii, being rather more considerable at the 
 right than the left side. The two hemispheres of the brain were 
 united by old adhesions along the longitudinal fissure, and the ante- 
 rior and middle lobes were connected along the fissure of Sylvius ; but 
 there was scarcely any effusion of hyaline matter or any granular ap- 
 pearance between the pons and the optic commissure, where usually it 
 is so marked. 
 
 There were but few symptoms of the coming disease ; for the same 
 reason, I imagine, as that which will account for the comparatively 
 slight appearances after death : namely, that it takes but little to ex- 
 tinguish life, when long standing ailments have so enfeebled all the 
 vital powers. 
 
 In cases such as this, you will, it is true, most likely be able to do 
 little or nothing, even if you recognize the approach of the disease from 
 the earliest indication of its coming. But you will save your patient's 
 friends some sorrow, and yourself some reproach, if you discover the 
 danger at a distance. Now, whenever any child, especially if it is of a 
 consumptive family, has been failing in health for some weeks or 
 months, without evident cause, I advise you to look with much suspi- 
 cion on the supervention of unusual drowsiness or listlessness, or on any 
 aggravation of the cough, for which you cannot find adequate reason in 
 the information afforded by auscultation. A frequent, short, dry cough 
 is not infrequent at the commencement of tubercular meningitis : but 
 in cases where cough has existed for some time, you are very likely to 
 refer its aggravation to mischief in the chest, and to lose sight of its 
 possible connection with affection of the brain. Inquire, therefore, in 
 every doubtful case, whether there has been any vomiting — for some- 
 times it is but slight, and occurs only after food has been taken, and 
 then only occasionally, so that it may seem to the parents to be a symp- 
 tom of little importance. Ascertain the condition of the bowels ; watch 
 the pulse most carefully ; it may not be irregular nor intermittent, but 
 you will probably find a little inequality in the force and duration of 
 its beats : if so, you may be sure that the head is suffering, and if the 
 
FROM TYPHOID FEVER. 85 
 
 head suffers in such a patient, it is in ninety-nine cases out of a hundred 
 from the approach of tubercular meningitis. Do not content yourselves 
 with seeing your patient once a day ; visit him at least morning and 
 evening — stay some time with him, watch him closely, and see how 
 far he is capable of being amused : but if you are still strangers to that 
 freemasonry which assures a little child that you love it, you will very 
 likely fail of arriving at the truth. 
 
 But it may happen that a child, though not robust, had yet been 
 tolerably well till a week or two before you visited it, and that it was 
 then attacked by febrile symptoms, with a little headache, and perhaps 
 wkh vomiting and constipation. You learn that these two symptoms 
 were but of short duration, but that the fever has continued ever since, 
 and that the child has been very taciturn, rather drowsy, and averse 
 to being disturbed, though giving rational answers when spoken to. 
 You regard the case as one of what you call remittent fever, and treat 
 it without either improvement or deterioration, till the appearance of 
 convulsions or of coma corrects your diagnosis, though unfortunately 
 too late. 
 
 This error would indeed be avoided three times out of four if you 
 would once for all recognize the fact that apart from ague and from the 
 eruptive fevers, 1 typhoid is the only essential fever with which we have 
 to do; that all other fevers are but indications of the constitution 
 sympathizing with local mischief somewhere. But still it must be 
 confessed that it is not always easy to distinguish between the milder 
 forms of typhoid fever and the early symptoms of tubercular menin- 
 gitis. It may help you, however, to bear in mind that typhoid fever 
 is very rare before five years of age, and is hardly ever met with in 
 children under three ; while at least half of all cases of tubercular 
 meningitis occur in children who have not completed their fifth year. 
 Still this is not the kind of evidence on which you can place much re- 
 liance in a doubtful case, but there are differences in the symptoms, 
 which will generally enable you to discriminate between them, if you 
 have acquired the habit of minute and careful observation. The vom- 
 iting, on which I have laid so much stress as a symptom of approach- 
 ing tubercular meningitis, is generally absent even at the onset of ty- 
 phoid fever ; it soon ceases, and is not followed by that abiding nausea 
 which is frequent in meningitis. In typhoid fever the bowels are often 
 relaxed from the very outset, or speedily become so, and the evacua- 
 tions present no resemblance to the scanty, dark, or mud-colored mo- 
 tions which are voided in tubercular meningitis ; but are usually watery, 
 fecal, and of a lightish yellow color. Tenderness of the abdomen is 
 nearly constant in typhoid fever, and .is greater in the iliac regions 
 than elsewhere, and wind can always be felt in the intestines. The 
 tongue is not moist as in meningitis, and is seldom much loaded, but 
 has in general only a thin coating of yellow fur at the centre and to- 
 wards the root, while it is very red at the tip and edges, and becomes 
 dry at an early stage of the disease. In tubercular meningitis there is 
 
 1 Typhus fever, in London, at least, is of such rare occurrence in childhood, that 
 I have not thought I am wrong in passing it over here without notice. 
 
86 DIAGNOSIS OF TUBERCULAR MENINGITIS 
 
 frequently a great distaste for drink as well as for food, while although 
 the appetite is lost in cases of typhoid fever, yet the patients have 
 great desire for drink, especially for cold drink, to quench the urgent 
 thirst. The heat of the skin in typhoid fever is extremely pungent, it 
 is usually greater than in tubercular meningitis, and more abiding, in 
 which, although there is great dryness of the surface, yet the tempera- 
 ture is either not much increased, or else fluctuates independently of 
 corresponding changes in the disease. It is in such doubtful cases that 
 the full value of the thermometer as an aid to diagnosis becomes ap- 
 parent. Not only is the temperature in typhoid fever higher as a rule 
 than in tubercular meningitis, but it follows laws with reference to its 
 increase and diminution, a knowledge of which ought to save us from 
 error. It increases slowly day by day during the first stage of the 
 disease, and this independently of corresponding acceleration of the 
 pulse, the evening temperature being constantly from half a degree to 
 a degree and a half higher than that of the preceding morning. So 
 invariably is this the case that Wunderlich and Griesinger 1 on the one 
 hand deny that any acute disease on the second evening of which the 
 temperature is 104° Fahr. can be typhoid, and on the other hand they 
 equally deny its being typhoid if the evening temperature on the fourth 
 day does not reach 103.1°; or if between the eighth and eleventh day 
 it remains permanently below this point. On the other hand, in tu- 
 bercular meningitis the variations of temperature seem to obey no law, 
 to bear no relation to the frequency of the pulse, but to vary much, 
 being sometimes very high quite early in the disease, at other times 
 continuing low long after the temperature of typhoid would have 
 reached its maximum, while of all the fluctuations which it presents, 
 the most remarkable is the sudden decline of heat for a few hours or a 
 day, and its equally sudden subsequent rise without any corresponding 
 change in the symptoms or course of the disease. 
 
 The pulse in typhoid fever is much quicker than in tubercular 
 meningitis; it continues quick throughout, and never becomes unequal 
 or irregular, while its frequency is in direct proportion to the elevation 
 of the temperature of the surface. In typhoid fever the child makes 
 few complaints about its head, but delirium is of early occurrence, es- 
 pecially at night ; in tubercular meningitis, on the contrary, true de- 
 lirium hardly ever occurs till an advanced period of the disease, and 
 is sometimes absent altogether. In typhoid fever, there are distinct 
 remissions and exacerbations of the symptoms, the patient getting 
 better towards morning when the temperature falls, and worse again 
 as night approaches and the temperature rises ; while, though there 
 are many fluctuations in the course of tubercular meningitis, yet we 
 observe no definite periods at which the symptoms invariably remit or 
 are increased in severity. 
 
 With due caution you will scarcely take a case of incipient tuber- 
 cular meningitis for one of simple gastric disorder, though there are 
 many points of resemblance between the two. Vomiting and consti- 
 
 1 Eoger, Op. cit., pp. 275 and 320-328. 
 
FROM GASTRIC DISORDER. 87 
 
 pation occur in both, and there is usually some degree of headache in 
 the latter affection, though seldom severe or lasting. Mere gastric 
 disorder is not attended with much febrile disturbance ; the face, 
 though heavy, is not distressed nor anxious, while the tongue is 
 usually much more coated than at the onset of an attack of tubercular 
 meningitis. The relief that follows the use of remedies in the less 
 dangerous affiection is complete as well as speedy ; the sickness will 
 cease after the operation of an emetic, the bowels will act copiously 
 after the administration of a brisk purgative, and in a day or two 
 vour patient will be quite well. The persistence of vomiting, how- 
 ever, in any case, which you had thought to be one merely of gastric 
 disorder, must be looked upon by you with great suspicion, and this, 
 even though the bowels have acted freely from medicine, and though 
 there should be no obvious indication of mischief in the head. I once 
 saw a case in which the continuance of intractable vomiting for more 
 than six weeks after the cessation of a short but severe attack of diar- 
 rhoea, was the only symptom of illness in a boy five years of age. At 
 length he became a little drowsy, and once or twice when closely 
 questioned, said that his head ached. Not quite two days after the 
 first complaint of headache, the child had a violent fit of convulsions, 
 and in the course of the succeeding week he died, having suffered 
 during that time from all the symptoms of tubercular meningitis, and 
 his body presenting after death its characteristic lesions. 
 
 Before taking leave of the diagnosis of tubercular meningitis, we must 
 consider for a moment the question of how far the ophthalmoscope may 
 serve our purpose. At present I believe the ophthalmoscope occupies 
 somewhat the position as an aid to diagnosis which auscultation did 
 some fifty years ago, and I anticipate that in the course of time it will 
 yield us much more help than it does at present; so I beg that my 
 opinion may be taken as referring to the present, and to the present 
 only ; and further as being the opinion of one unskilled in its em- 
 ployment. My impression is that in the acute disorders of the brain 
 in childhood it adds but little to the knowledge which w T e derive from 
 other sources. Its use, never very easy in the case of children, is 
 rendered still more difficult by the fretfulness, restlessness, and intoler- 
 ance of light which characterize all cases either of meningitis or of 
 disorders resembling it ; while next, the signs of optic neuritis, which 
 in some cases it discloses to us, are neither sufficiently constant in their 
 presence, nor uniform in their import to justify us in drawing any very 
 definite conclusion either from the discovery of them in one case, or 
 from our inability to detect them in another. I do not think, there- 
 fore, that at present we can afford to neglect any of the ordinary 
 means for arriving at a diagnosis, since all that at present we can 
 safely expect from the ophthalmoscope is the confirmation of an opinion 
 arrived at on other grounds than those with which it can furnish us. 1 
 
 1 With the sincerest respect for the researches of Dr. Clifford Allbutt, I am not 
 at present prepared to subscribe to his opinion as to the not infrequent recovery 
 from tubercular meningitis ; and the cases of assumed meningitis in the appendix 
 
00 PROGNOSIS IN TUBERCULAR MENINGITIS. 
 
 An inquiry of little less importance than that concerning the means 
 of distinguishing between one disease and another, respects the prog- 
 nosis that we are to form, the inferences that we may draw, from the 
 course of the malady, either to encourage hope or to excite anxiety. 
 Unfortunately the prognosis in tubercular meningitis is so unfavorable 
 that we can scarcely speak of the circumstances which regulate it : for 
 under almost every variety of condition, of symptoms, and of treat- 
 ment, the patients die. The cases are but very few in which I have 
 seen any other than a fatal issue follow on even the premonitory symp- 
 toms of water on the brain. Once I saw recovery take place after 
 the second stage of tubercular meningitis had commenced, and once I 
 watched with surprise the gradual subsidence of the disease, though 
 convulsions had already taken place, and had been followed by coma. 
 In that instance the child, three and a half years old, was a member 
 of a phthisical family, and her younger brother had died a year before 
 of hydrocephalus. The disease in her case ran its ordinary course, 
 unchecked by the customary treatment. Convulsions took place, 
 coma succeeded them, deglutition was very difficult, the pupils were 
 dilated and almost motionless, the pulse was very feeble and very 
 frequent, and everything portended the speedy death which one looks 
 for as the usual termination of such symptoms. Food was still given, 
 as . the power of swallowing was not entirely lost, and ammonia and 
 ether were administered, which after a time were exchanged for 
 quinine. For days unconsciousness continued, and the first return of 
 voluntary effort was shown by the child raising her hand to steady 
 the cup that was put to her lips. She next recovered the power of 
 vision, but still could not move her legs, nor utter any articulate 
 sound. The power of speech was not regained for some weeks, nor 
 that of walking for many months ; the gait long continued tottering 
 and uncertain,' and the child's manner half-idiotic. When last I saw 
 her three years had elapsed, and recovery was then as perfect as 
 probably it ever will be ; but the child, though not deficient in intelli- 
 gence, had never regained flesh, nor recovered the look of health, nor 
 the manners of a child, but walked about unsteadily, with a weird 
 cast of countenance, and a vacant smile, and I felt surprise that the 
 disease, evidently still latent, had not yet returned. I do not know . 
 what eventually became of her. 
 
 I am aware that other practitioners have arrived at results far more 
 favorable than those to which my own experience has led me ; but 
 while I would gladly, if it were possible, modify my statements, I feel 
 sure that a careful perusual of the cases of alleged recovery recorded by 
 different writers must satisfy every one that the disease in almost every 
 instance was not tubercular meningitis at all ; and that often it was some 
 ailment bearing to it but a very slight resemblance. It is remarka- 
 
 to his work appear to me to be most inconclusive, and as far as I can judge from 
 the brief account of .symptoms were not meningitis at all. 
 
 His treatise on the " Use of the Ophthalmoscope," London, 8vo., 1871, is, however, 
 deserving of the highest praise for careful and patient research, and lucid state- 
 ment. It is by far the most valuable contribution to our knowledge of this new 
 means of diagnosis of which we are at present possessed. 
 
DELUSIVE APPEARANCES OF IMPROVEMENT. »y 
 
 ble, indeed, as M. Rilliet 1 well observed in a very valuable paper on 
 this subject, that almost all the instances in which recovery is stated to 
 have taken place, occurred before the real nature of the disease was 
 understood, while, since its tubercular nature has been recognized, not 
 a single authenticated case of the kind has been published by any 
 French physician. 
 
 M. Guersant, of Paris, who probably had seen more than any man 
 now living of children's diseases, gives the following statement as the 
 result of his experience : 
 
 " Tubercular meningitis," says he, " may sometimes terminate by 
 recovery in the first stage, though the nature of such cases is always 
 more or less doubtful ; in the second stage I have not seen one child 
 recover out of a hundred, and even those who seem to have recovered 
 have either sunk afterwards under a return of the same disease in its 
 acute form, or have died of phthisis. As to patients in whom the dis- 
 ease has reached the third stage, I have never seen them improve even 
 for a moment." 2 
 
 The minuteness with which M. Rilliet records the history of his 
 patient's recovery, leaves little room for doubt that the case was one of 
 tubercular hydrocephalus in the third stage ; and the bare possibility 
 of error is removed by the circumstance that the child died five years 
 afterwards under a recurrence of the former symptoms ; and that on a 
 post-mortem examination the old mischief at the base of the brain was 
 clearly distinguishable from the effects of the recent disease under 
 which the child had sunk. This case, however, and the few others 
 which are scattered through the annals of medicine, can be regarded 
 only as the exceptions which prove the rule that hydrocephalus follow- 
 ing the law of tubercular disease in general is almost incurable, while 
 it proves mortal all the more frequently owing to the importance of the 
 organ which is its seat. 
 
 Since, then, the fatality of the disease is almost invariable, it may 
 seem to you superfluous for me to say anything more with reference to 
 the prognosis ; but I am desirous of guarding you against being de- 
 ceived by certain delusive appearances of improvement which are by no 
 means unusual even in cases where the real nature of the disease has 
 for some two or three days been clearly manifest. Many years ago, a 
 little girl, three years old, was brought to me in a state of profound 
 coma, and presenting the symptoms of the third stage of acute hydro- 
 cephalus, of which she died forty-eight hours afterwards, without hav- 
 ing had any return of consciousness. I learned from her mother, that, 
 fourteen days previously, the child had been attacked by vomiting, 
 attended by fever and great drowsiness ; but that these symptoms 
 abated in three days, and that the child improved and was regaining 
 her cheerfulness until the morning of the day before she was brought 
 to me, when her mother found her comatose, and in just the condition 
 in which she was w T hen I saw her. A more acute observer than this 
 
 1 Archives G-en. de Medecine, Dec. 1853. 
 
 2 Diet. Me"d., t. xix, p. 403; quoted by MM. Eilliet and Barthez, op. cit., 1st edi- 
 tion, t. iii, p. 531. 
 
90 DELUSIVE APPEARANCES OF IMPROVEMENT. 
 
 child's mother would probably have seen something to make her dis- 
 trust the apparent improvement ; but it is evident that the change was 
 great from fever and drowsiness, and frequent vomiting, to a cessation 
 of the sickness, diminution of the fever, and a return of cheerfulness; 
 and yet during all this time disease was going on, and producing the 
 very extensive softening of the central and posterior parts of the brain 
 which was discovered after death. The cases in which you are likely 
 to fall into error are for the most part such as have come on insidiously, 
 unattended by very violent symptoms, and about which you perhaps 
 hesitated some little time before you became convinced that so grave a 
 malady could wear so mild a form. Treatment for some days pro- 
 duces no effect, the disease remaining stationary ; but at length your 
 hopes are raised by finding that the vomiting has ceased, and that the 
 constipated condition of the bowels has been overcome. The heat of 
 head has disappeared, the pulse presents much less irregularity than 
 before, or may even have lost it altogether ; the child's restlessness has 
 subsided, and its manner is almost natural. Perhaps the child seems 
 rather drowsy, or it may be sleeping at the time of your visit; but the 
 account you hear of it seems satisfactory ; its repose is quiet, and the 
 mother rejoices : her little one has had no sound sleep for many days, 
 and will, she thinks — and you may think so too — be much better when 
 it wakes. It does not wake up, but it swallows well when some drink 
 is given in a spoon, and the mother is still content. Presently slight 
 twitchings of the face and hands are seen, but the child does not wake 
 — you cannot rouse it ; the sleep has passed into coma, and the coma 
 will end in death. Always suspect the sleep which follows continued 
 restlessness in a case of affection of the brain. 
 
 In other instances, although the disease did not come on so insidi- 
 ously, and although it has reached a stage at which all its characters 
 are well marked, you may yet be led for a few hours to entertain, and 
 perhaps to express, ill-founded hopes, in consequence of the symptoms 
 having somewhat abated, of the child having had some hours of quiet 
 sleep, or having ceased to vomit, or no longer complaining of its head, 
 or being visited by a short gleam of cheerfulness. You must not for- 
 get, however, that it is characteristic of tubercular meningitis to present 
 irregular remissions, that they last but for a few hours, and that at your 
 next visit you may find every bad symptom returned, and, possibly, 
 some fresh one superadded. Usually, too, you may be guarded from 
 error by observing the suddenness of the change, and that the condition 
 which .has now come on is the very opposite of that which before ex- 
 isted, preternatural excitement having been succeeded by an equally 
 unnatural apathy, or great talkativeness having taken the place of 
 obstinate silence, or the pulse, which before was above 130, having 
 sunk all at once to 90 in the minute. At other times, though there is 
 a general abatement in all the previous symptoms," yet some new one 
 may have appeared ; not more formidable, perhaps, than the occurrence 
 of a slight degree of strabismus, which had not existed before, but still 
 enough to indicate that the mischief is still going on, and that you 
 must not dare to hope. 
 
 A still more remarkable temporary improvement is sometimes ob- 
 
DURATION OF TUBERCULAR MENINGITIS. 91 
 
 served, that "lightening before death," which seems, contrary to all 
 expectation, to warrant a hope of recovery even when dissolution is 
 impending. The only instance of it which has come under my notice 
 occurred in a girl, aged seven years, who died on the fifteenth day of 
 an attack of acute hydrocephalus. She had been in a state of stupor 
 for six days, and profoundly comatose for two days, when she became 
 conscious, swallowed some drink, spoke sensibly, and said she knew 
 her father. She became worse again, however, in the course of an 
 hour and a half, though she did not sink into the same deep coma as 
 before, and in another hour she died. 
 
 A few points still remain on which I must touch before passing to 
 the consideration of the treatment of hydrocephalus. One of these is 
 the question of its duration. The exact determination of this is not 
 always easy, owing to the insidious manner in which the disease comes 
 on ; but, on the whole, there is less discrepancy than might have been 
 expected between the statements of different writers. Of 117 cases 
 observed or collected by Dr. Hennis Green, 80 terminated within 14 
 days, and 31 more within 20 days. Of 28 cases recorded by Golis, 1 
 18 terminated within 14 days, and only 2 exceeded 20 days. MM. 
 Rilliet and Barthez 2 state the average duration of 28 cases that came 
 under their observation to have been 22 days; and the average dura- 
 tion of 73 fatal cases of which I have a complete record, was about 20 
 days. Of these 73 cases, that which ran the most rapid course termi- 
 nated fatally in 48 hours, and 3 in five. days; death took place in 24 
 more before the fourteenth clay ; in 25 others during the third week, 
 and in 18 during the fourth week. In the remaining 8 cases indica- 
 tions of cerebral disturbance had existed for four, six, or eight weeks ; 
 but death took place in every instance but two in less than 21 days 
 after the appearance of well-marked symptoms of hydrocephalus, and 
 in one on the eighth day from their becoming clearly manifest. We 
 are, then, warranted in stating that the disease usually runs its course 
 in from two to three weeks. 
 
 In describing this disease I divided it into three stages, but did so 
 simply for convenience. Many physicians, however, have attached 
 much greater importance to this division, regarding the first as the 
 stage of turgescence ; the second as that of inflammation; the third, 
 that of effusion. Again, the first has been characterized as the stage of 
 increased sensibility ; the second, of diminished sensibility ; the third, 
 of palsy. Lastly, Dr. Whytt proposed a division that has been much 
 followed, based on the variations of the pulse, which is usually quick 
 and regular in the first stage, slow and irregular in the second, and 
 quick in the third. There are too many exceptions, however, to the 
 order of these changes, for it to be right to make them the foundation 
 of any division of the disease into different stages ; and the same remark 
 may be made with reference to any arrangement founded on the varia- 
 tions in the sensibility of the patient. 
 
 I have said that the phenomena of the pulse are not constant ; I need 
 
 1 Praktische Abhandlungen, &c. 8vo., Wien, 1820, vol. i. 
 
 2 Op. cit., vol. iii, p. 497. 
 
92 PROPHYLACTIC TREATMENT 
 
 scarcely add, that the slow irregular pulse is no proof of the occurrence 
 of effusion ; neither is the dilated pupil a proof of it: it is a proof of 
 great mischief having been inflicted on the brain ; so are the strabismus 
 and the rolling of the eyes which frequently accompany it ; but you 
 cannot connect these symptoms with injuries of a special kind, or in- 
 volving particular parts of the brain. 
 
 Although a disease of childhood, tubercular meningitis is by no 
 means most frequent in early infancy. In only 5 of 79 fatal cases in 
 which the diagnosis was confirmed by a post-mortem examination, were 
 my patients under a year old ; 19 were between 1 and 3 years of age; 
 38 between 3 and 6; 13 between 6 and 9; 2 between 9 and 10; 1 
 between 10 and 11 ; and 1 between 12 and 13 years old. 1 
 
 From all that I have told you about this disease, you have, I doubt 
 not, already deduced the practical inference, that tjie only treatment 
 likely to avail much is the prophylactic ; and that, if you would hope 
 ever to save a patient, you must treat the mere threateuings of his 
 malady, and not remain inactive until you see it fully developed be- 
 fore you. 
 
 The prophylactic treatment of tubercular meningitis must be in the 
 main the prophylactic treatment of consumption, since not only is tuber- 
 cle invariably present in the various organs of children who have died 
 of tubercular meningitis, but the disease itself often supervenes on more 
 or less definite phthisical symptoms, as is shown by the fact that the 
 previous health of the children was indifferent in. more than two-thirds 
 of the cases that came under my notice. The influence of hereditary 
 predisposition to phthisis, in favoring its development, on which almost 
 all writers have insisted, is illustrated by the fact, that in 27 out of 42 
 instances, 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. 
 
 In any case where several children of the same family have already 
 died of tubercular meningitis, or have shown a marked tendency to 
 the disease, the mother should for the future abstain from suckling her 
 infants, and they should be brought up by a healthy wet-nurse. In 
 such circumstances, too, it is desirable that a child should always live 
 in the country ; should be warmly clad, and should wear flannel next 
 its skin. Its diet should be simple and any change in it should be 
 made with the greatest caution, while milk should for a longtime form 
 one of its chief aliments ; and it would be desirable not to wean it until 
 after it had cut four molar teeth, as well as all the incisiors. As it 
 grows up, overexertion, either of mind or body, must be most carefully 
 avoided : and on this account, though free exercise in the air is highly 
 
 1 This statement as to the time of life at which hydrocephalus is most frequent is 
 fully home out by the Fifth and Eighth Keports of the Kegistrar-G-eneral, from 
 which it appears that while only 7 per cent, of the total deaths under one year old 
 in this metropolis resulted from cephalitis and hydrocephalus, these diseases caused 
 12.5 per cent, of the deaths between 1 and 3 ; 12.5 per cent, of those between 3 and 
 5; 11.1 per cent of those between 5 and 10; and 5.9 per cent, of those between 10 
 and 15. I must, however, add that, since at the Children's Hospital only few and 
 exceptional cases are admitted under two years of age, the figures given above under- 
 state the frequency of hydrocephalus in early infancy. 
 
OF TUBERCULAR MENINGITIS. 93 
 
 beneficial, gymnastic exercises are by no means to be recommended. 
 The child must be watched carefully during the whole period of den- 
 tition, and every precaution must be taken to shield it from the conta- 
 gion of measles, hooping-cough, or scarlatina ; since these diseases, which 
 tend to excite the tuberculous cachexy, would be likely greatly to ag- 
 gravate the disposition to hydrocephalus, or even to bring on an attack 
 of the disease. The condition of the bowels must be most carefully 
 watched ; constipation must not be allowed to exist even for a day, and 
 the least indication of gastric disorder must be regarded as a serious 
 matter. It is not desirable that calomel should be used as a domestic 
 remedy ; but if the simplest aperients do not act, the child should be 
 immediately placed under proper medical care. If at any time there 
 should be heat of head, and the child appear squeamish, you must be 
 at hand with your remedies, and those well chosen. Any bulky 
 remedy would probably be rejected ; but the stomach is almost sure to 
 bear a grain or two of calomel with sugar, and you may follow this up 
 with small quantities of the sulphate of magnesia 1 every hour until the 
 bowels act freely. A small dose of mercury and chalk, or of calomel, 
 may be continued every night for two or three times ; and if any fever- 
 ishness remains, or if the bowels are disposed to be constipated, the sul- 
 phate of magnesia may still be given twice or thrice a day. Leeches 
 should n'ot be applied to the head without very obvious necessity, nor 
 then in large numbers, for strumous children do not bear the loss of 
 blood well ; and your endeavor should therefore always be, not simply 
 to cure, but to cure at the smallest possible expense to the constitution. 
 After attacks of this kind, children sometimes recover their health very 
 slowly, and much good may then be effected by a judicious use of tonics. 
 The infusion of calumba, 2 with small doses of rhubarb, is a very suita- 
 ble medicine, and one which children generally take tolerably well. 
 Or you may give the ferro-citrate of quinine in orange-flower water, 
 and sweetened with the syrup of orange-peel, 3 while you secure the 
 healthy action of the bowels by a grain or two of Hyd. c. Greta, com- 
 bined with five or six of rhubarb, administered every night, or every 
 other night. 
 
 If threatenings of head affection have frequently occurred, it has 
 been recommended that an issue should be inserted in the back of the 
 neck. I have no personal experience of its utility, but I can readily 
 believe that it may be of service ; though one's natural repugnance to 
 
 1 (No. 6.) 
 R. Magnes. Sulphat., ^ij. 
 
 Syr. Aurantii, gij. 
 Aquae Carui, gvj. M. gij every hour till the bowels act. 
 For a child three years old. 
 
 2 (No. 7.) 
 R. Inf. Calumbse, %\]. ^ij. 
 
 Inf. Rhei, ^ivss. 
 
 Trse. Aurantii, giss. M. giij twice a day. 
 For a child three years old. 
 
 3 See Formula No. 5, p. 57; or the Vin de Quinquina, or the Vin de Bugeaud of 
 French pharmaceutists, which both have the recommendation of being nice. 
 
94 TREATMENT OF TUBERCULAR MENINGITIS. 
 
 cause constant annoyance to children has prevented my giving it a 
 trial. A most remarkable instance of its value is recorded by Dr. 
 Cheyne, who mentions that all the children in a numerous family 
 were carried off by water on the brain, with the exception of one, in 
 whose case the precaution was adopted of putting a seton in the back 
 of his neck. 
 
 But the opportunity may not be afforded you of adopting any pro- 
 phylactic treatment ; and when you first see your patient, the existence 
 of headache, vomiting, constipation, and a quickened pulse, with per- 
 haps a very slight inequality in its beat, may leave you but little doubt 
 as to the formidable nature of the disease with which you have to con- 
 tend. In doing this, there are three remedies on which practitioners 
 commonly rely, namely depletion, purging, and the administration of 
 mercury. 
 
 With reference to depletion, you must not forget that the disease in 
 wmich'you are about to employ it, although of inflammatory nature, is 
 inflammation in a scrofulous subject, and is in many cases grafted on 
 previous organic disease ; such as those tubercular deposits in the 
 membranes of the brain which I have already described to you. You 
 cannot, therefore, hope to cut short the affection by a large bleeding, 
 but your object must be to take blood enough to relieve the congested 
 brain, and no more than is necessary for that purpose. Avoid pre- 
 cipitancy in what you do, and do not let your apprehensions betray 
 you into that overactivity which is sometimes more fatal to a patient 
 than his disease. If you feel any doubt as to the necessity of depletion, 
 visit your patient again before determining on it, but do not delay that 
 visit long. Order a dose of calomel, to be followed by some sulphate 
 of magnesia, if, as is most probable, the bowels are confined, and re- 
 turn again in three or four hours. You may then find that the bowels 
 have acted, and the sickness has ceased ; that the head is cooler, and 
 aches less ; and that depletion is, for the present at any rate, unneces- 
 sary. Or the child's state may be the same, and you may still feel 
 uncertain as to the right course. In vthat case, at once obtain the as- 
 sistance of some other practitioner. This is the season when advice 
 may be really useful, for it is only at the outset of the disease that its 
 cure is possible ; when convulsions have occurred, or coma is coming 
 on, your treatment matters but comparatively little, for the season for 
 hope and the opportunity for action have then fled. 
 
 Though you may have determined on the propriety of depletion, it 
 will seldom be found, even at the outset of the disease, that the char- 
 acter of the pulse is such as to warrant venesection. Local bleeding 
 will generally answer every purpose, and, indeed, the application of 
 leeches may, as I have already mentioned to you, 1 be so managed in 
 the case of infants or young children, as to answer every purpose of 
 general depletion. One caution may not be out of place with reference 
 to the part of the head on which leeches should be put; since, though 
 the reasons for it are obvious, it nevertheless is often forgotten. They 
 should be applied to the vertex, because, if put on the temples, they 
 
 1 See Lecture II, p. 28. 
 
TllEATMENT OF TUBERCULAR MENINGITIS. 95 
 
 hang down over the eyes and terrify the child ; if behind the ears, they 
 are very likely to be rubbed off as it rolls its head from side to side. I will 
 not say that this depletion is never to be repeated, but I believe that 
 in by far the greater number of cases you will do no good whatever by 
 its repetition, and the exceptional cases will generally be those in 
 which, very marked relief having followed the first bleeding, the same 
 symptoms appear to be returning twenty-four or thirty -six hours after- 
 wards. If you do not see the child until the second stage of the dis- 
 ease is far advanced — till general convulsions have occurred, or till 
 twitchings of the limbs, or of the muscles of the face, an appearance 
 of extreme alarm, or a state of alternate contraction and dilatation of 
 the pupils, show them to be impending — you must be exceedingly 
 careful in abstracting blood. In such circumstances, I have seen con- 
 vulsions, to all appearances induced, and the fatal course of the disease 
 accelerated, by a rather free, though by no means immoderate loss of 
 blood. 
 
 The value of 'purgatives in the treatment of tubercular meningitis 
 can scarcely be overrated ; but they must be given so as not merely to 
 obtain free action of the bowels, but to maintain it for some days. 
 After having once overcome the constipation, you will secure this end 
 best by giving small closes of a purgative every four or six hours. 
 The administration of a strong cathartic every morning will not 
 answer this end nearly so well; for, independently of the chance of its 
 being rejected by thestomach, you will find that the dose which sufficed 
 the first time will not be large enough the second, and that there will 
 be a constantly increasing difficulty in obtaining an evacuation. The 
 nausea and vomiting which at first stood in the way of your adminis- 
 tering any medicine, are often so much relieved by depletion, that the 
 stomach will almost immediately afterwards bear a dose of calomel and 
 jalap, or calomel and scammony, which may be repeated every three 
 hours, until it acts, wdiile you at the same time endeavor to quicken its 
 operation by the administration of a purgative enema. There is no 
 use, however, in persevering with these medicines if they excite sick- 
 ness, and it is then better to give a single large dose of calomel in some 
 loaf sugar, and to follow it up by a solution of sulphate of magnesia, 
 which should be repeated at short intervals. When a free evacuation 
 has been obtained, the same salt, in combination with the nitrate of 
 potash, will often keep up a free action of the bowels as well as stimu- 
 late the kidneys to increased activity. These remedies may be either 
 mixed with the child's drink, or be dissolved in water flavored with 
 syrup of lemon or of orange-peel. 1 
 
 Mercurial preparations, and especially calomel, have long had a high 
 reputation in all the cerebral diseases of early life. Unhappily my own 
 experience does not bear out the common practice, and I put no faith 
 in calomel, nor in the production of salivation, as a means of curing 
 tubercular meningitis. I have seen children die whose mouths had 
 been made sore by mercury, without any influence appearing to have 
 been thereby exerted on the disease; and I recollect two who, at the 
 
 1 See Formula No. 1, p. 52. 
 
96 TREATMENT OF TUBERCULAR MENINGITIS. 
 
 time of their death, were in a state of most profuse salivation. What- 
 ever good I have seen in these cases from calomel has been when it 
 was given in combination with purgatives, or when it produced a pur- 
 gative effect. 
 
 Let me, however, again remind you that you may have meningitis 
 combined with tubercular ulceration of the intestines, and that in such 
 a case diarrhoea may exist from the outset, or may come on after a 
 mild dose of some aperient. Xow and then, too, without such a cause, 
 constipation is absent, while diarrhcea comes on occasionally in the 
 advanced disease. You must not, therefore, draw inferences as to the 
 state of the patient too exclusively from the condition of the bowels. 
 
 There is still one remedy, the iodide of potassium, to which some 
 practitioners cling with a sort of half faith in its specific virtues ; and 
 its proved utility in various forms of scrofulous disease furnishes 
 without doubt an argument in its favor. I myself give it likewise, 
 and think that I have seen good from its employment, while in one 
 instance of what seemed to be advanced tubercular meningitis under 
 the care of my former colleague, Sir W. Jenner, recovery took place 
 under its employment. No other case of equal success has come under 
 my own notice, and I can therefore by no means indorse all that has 
 been said in its favor, though I have seen symptoms of a very threat- 
 ening kind subside under its continued use ; and this especially in 
 those cases which were the least active in their character. After the 
 bowels have been freely relieved, and with due care still to keep them 
 daily acting, I give about two grains of the iodide of potass every 
 four hours to a child three years old ; either alone, or if the child seems 
 feeble, and the case is one whose symptoms seem to occupy the bound- 
 ary line between true and spurious hydrocephalus, in combination with 
 a third of a grain of the sulphate of quinine ; and I can recommend 
 this practice as yielding results, on the whole, more encouraging than 
 any other with which I am acquainted. 
 
 I insisted much on the local employment of cold when speaking about 
 the management of cases of cerebral congestion. It is likewise a very 
 valuable agent in the treatment of tubercular meningitis, but its appli- 
 cation requires to be judiciously regulated. You will generally find 
 it of service after depletion, for you have abstracted blood on account 
 of the febrile disturbance, and heat of head, and other indications of 
 congestion of the brain, all of which cold will be a powerful auxiliary 
 in subduing. So long as the signs of active congestion of the brain 
 are present, cold will be of service ; but it should not be employed in- 
 dependently of the symptoms which betoken the existence of that con- 
 dition ; nor can you hope to see any benefit result from cold applica- 
 tions to the head in the advanced stages of the disease. I need scarcely 
 say that the application of cold with a shock, or the pouring cold water 
 from a height upon the head, though a very valuable means of arous- 
 ing the child from the state of coma into which it sinks in some cases 
 of intense cerebral congestion, is wholly inapplicable in the coma of 
 tubercular meningitis. The functions of the brain are here not merely 
 interrupted by the excess of blood in the organ, but they are abolished 
 
TREATMENT OF TUBERCULAR MENINGITIS. 97 
 
 bv the disorganization of its tissue, or the compression of its substance 
 by the effusion of fluid. 
 
 In the management of children attacked bv tubercular meningitis 
 vou must not forget that for the most part they are of feeble constitu- 
 tion, and that they will not bear too rigorous a diet. Just at first, in- 
 deed, while the febrile symptoms run high, and the bowels are unre- 
 lieved, or the sickness is urgent, the less the patient takes the better. 
 Afterwards, however, it is desirable that he should be supplied with as 
 much light and unstimulating nutriment as he will take; such, for 
 instance, as arrowroot, or veal or beef tea, either of which will often 
 remain on the stomach when most other articles of food or drink would 
 be rejected. 
 
 In the treatment of many diseases you see physicians destroy the 
 sense of pain by narcotics, and the question naturally suggests itself to 
 you whether you may not sometimes venture, in the management of 
 hydrocephalus, to mitigate by their means your patient's sufferings. 
 The inquiry is one not very easy to reply to satisfactorily. I think, 
 however, that there are two conditions in which you will be justified 
 in trying the experiment of giving them. Sometimes the disease sets 
 in with great excitement, and a condition closely resembling mania in 
 the adult, symptoms which may have been ushered in by convulsions. 
 In such a case, although the heat of head and the flush of the face may 
 have disappeared after free depletion and the copious action of purga- 
 tive medicine, and though the pulse is feeble as well as frequent, yet 
 ^the excitement may be scarcely if at all diminished. Here an opiate 
 will sometimes give the relief which nothing else will procure; your 
 patient will fall asleep, and wake tranquillized in the course of two or 
 three hours. In other cases, which did not set in thus violently, rest- 
 lessness, talkativeness, and a kind of half-delirious consciousness of 
 pain in the head, become very distressing as the disease advances, 
 being always aggravated at night, so that the patient's condition seems 
 one of constant suffering. But he is not able to bear any more active 
 treatment, and, indeed, you have already emptied your quiver of such 
 weapons. In these circumstances I have sometimes given a full dose 
 of morphia, and have continued it every night for several nights to- 
 gether with manifest relief. 
 
 There are two or three remedies comparatively recently introduced 
 into practice, from whose employment I have seen relief in cases of 
 cerebral excitement, whether dependent on tubercular meningitis, or on 
 some less grave cause. One of these is the aconite, from which in 
 cases of general febrile disturbance accompanied with excitement of the 
 brain from whatever cause, I have seen much good result. I have 
 never given it in any large dose ; but half a minim every four hours 
 to an infant of a year old, in conjunction with any simple febrifuge 
 medicine, and to older children in proportionately increased doses. 
 
 The hydrate of chloral is another remedy of comparatively recent 
 introduction, and one which in these cases appears usually to act as a 
 sedative, better even than any preparation of opium, obtaining sleep 
 especially in those cases where wakefulness is due to restlessness rather 
 than to pain. The bromide of potass, while powerless to retard the 
 
 7 
 
98 TREATMENT OF TUBERCULAR MENINGITIS. 
 
 progress of the disease, still sometimes does much to mitigate distress, 
 especially by restraining those convulsions which are, perhaps, more 
 grievous to the bystanders than to the patient. For this purpose, 
 however, it must be given in large and frequently repeated doses, such 
 as 10 grains to a child of 3 years old, every two or three hours till the 
 convulsions cease ; but when this end has been attained, I have seen 
 no further influence exercised by it on the progress of the disease. It 
 still, however, given in a single large dose at night, sometimes procures 
 quiet, and even sleep, especially if combined for this purpose with the 
 hydrate of chloral. 
 
 Another inquiry that you may put is, when are you to employ blis- 
 ters f Certainly not at the beginning of the disease, when they would 
 increase the general irritation, and do more harm than good. At a 
 later period they may be of service, when the excitement is about to 
 yield to that stupor which usually precedes the state of complete coma. 
 They should then be applied to the nape of the neck or to the vertex ; 
 and I am disposed to think the latter the better place, since, when applied 
 to the nape of the neck, they often become displaced by that boring 
 movement of the head which the child in many instances keeps up un- 
 consciously. It is well, too, to remember that the skin in this disease 
 is very inapt to vesicate, so that a blister will require to be kept on for 
 ten or twelve hours; contrary to what ought to be your usual practice 
 with children. Cases enough are on record proving the utility of 
 blisters thus applied, to render it your duty not to neglect this means. 
 
 I have made a few trials of a very energetic counter-irritant which 
 has been strongly recommended by a German physician, 1 but my ex- 
 perience does not induce me to recommend its adoption. Dr. Hahn 
 employs an ointment composed of one part of tartar emetic and two 
 parts of lard ; of which a portion, the size of a hazelnut, is to be rubbed 
 on the shaven scalp over a surface some two and a half inches in cir- 
 cumference, every two hours, till an abundant pustular eruption is pro- 
 duced. The sores which follow this inunction are remarkably intract- 
 able, requiring sometimes many months for their cure; but Dr. Hahn 
 asserts, and gives some cases in proof of the assertion, that even in an 
 advanced stage, and after the supervention of coma, recovery has often 
 taken place under the use of this remedy. Many of the cases that he 
 relates, however, are clearly not instances of tubercular meningitis at 
 all, while the theory which he propounds of the existence of a>6ort of 
 antagonism between it and certain pustular eruptions of the skin, and 
 on which he founds the assumption of a sort of specific virtue in the 
 tartar-emetic ointment, is a mere hypothesis, of the correctness of which, 
 as a general law, we have no sort of evidence. In the cases in which 
 I tried it, it produced most formidable ulcerations of the scalp : it did 
 what a very energetic counter-irritant might be expected to do, but 
 nothing more, and it was difficult to convince bystanders that a large 
 black-looking wound did not increase the suffering of patients whose 
 disease it certainly failed to arrest. 
 
 .Need I say that you must not think of treating a case of tubercular 
 
 1 De la Meningite Tuberculeuse, &c, par H. Hahn. 8vo., Paris, 1835. 
 
TREATMENT OF TUBERCULAR MENINGITIS. 99 
 
 meningitis throughout just in the same way as you did at its com- 
 mencement ? There is, if the disease does not run a very rapid course, 
 a stage of weakness and exhaustion, often associated with a half-coma- 
 tose condition, though sometimes attended with a considerable degree 
 of suffering, which frequently precedes the signs of approaching death. 
 The bowels are now sometimes relaxed, though oftener they continue 
 constipated, because the nervous energy which kept up the peristaltic 
 movements of the intestines is worn out. The powers of organic as 
 well as those of animal life are palsied. This is the time for the ad- 
 ministration of quinine, for the employment of nutritious broths and 
 jellies, and even of wine. 
 
 You may perhaps be disposed to ask me what I think of this remedy 
 or the other, which has at different times been boasted of, as having 
 done good when other means had failed. Now you must not infer 
 from my silence that I do not believe that other medicines besides those 
 which I have spoken of have been of service; but to attempt to canvass 
 the respective merits of each would, I tear, be a tedious task, and one 
 from which you would derive but little profit. 
 
 Besides, let me remind yon of what Sydenham says : ..." In eo 
 prsecipuS stat Medicina Practica, ut genuinas Indicationes expiscari 
 valeamus, non ut remedia excogitemus quibus illis satisfieri possit ; 
 quod qui minus observabant, Empericos armis instruxere, quibus 
 Medicorum opera imitari queant." 
 
 Looking over, at the end of nearly thirty years, what I wrote, and have 
 but little altered, as to the treatment of tubercular meningitis, I cannot 
 but ask myself what more I have learned since then, whether I have 
 gained the use of new weapons, or whether I wield the old ones with 
 greater skill than heretofore ? I fear that I cannot profess to do either. 
 With the advance of life, one's private practice becomes more and more 
 • that of a consultant, and one sees less of slight ailments, and of the 
 beginning of disease ; while further, one loses much when one no longer 
 has the leisure to attend the out-patients of a Children's Hospital. One 
 gains in diagnostic skill, one sees the danger further off, and foretells 
 the inevitable sorrow earlier and more surely than in former years, but 
 that is all. 
 
 I leave what I wrote but little changed, because I believe that on 
 the whole the rules laid down procure by their observance the greatest 
 relief to the symptoms ; because, in that large class of cases which 
 occupy, as it were, the border land between the curable and the irre- 
 mediable, they hold out the best prospect of doing good, and because, 
 if the ophthalmoscope should confirm the, I fear too sanguine, views of 
 some as to the curability, of tubercular meningitis, it is by such and 
 such like means that I believe its cure will be most probably effected. 
 
100 SIMPLE MENINGITIS. 
 
 LECTUEE VIII. 
 
 Simple Meningitis. — Its differences from tubercular meningitis — Occasional ex- 
 treme rapidity of its course — Cases in illustration — Morbid appearances— Fre- 
 quent connection with meningitis of the cord — Extreme rarity as an idiopathic 
 affection — Treatment. 
 
 Inflammation of the Bratx-Substance succeeding to Disease of the Ear. 
 — Digression concerning otitis — Its symptoms — Distinctions between it and 
 inflammation of the brain — Treatment — Chronic otorrhcea with disease of the 
 temporal bone — Case. 
 
 Thrombosis of the Sinuses of the Dura Mater. — Circumstances in which it 
 occurs — It sometimes succeeds to large collections of pus in distant organs — Case 
 in illustration. 
 
 We have been engaged at our last two meetings with the study of 
 one form of inflammation of the brain in the young subject. We found 
 tubercular meningitis to be an affection almost exclusively confined to 
 children whose previous health had been indifferent, who had shown 
 some indications of phthisis, or in whose family phthisical disease ex- 
 isted. "We observed its development to be gradual, its progress often 
 tardy and attended with irregular remissions, but its issue almost 
 always fatal. The alterations of structure discovered after death were 
 seen to be slight at the convexity of the brain, but very obvious at its 
 base, where, in addition to the effects of inflammation, the membranes 
 often present a peculiar granular appearance, due to the deposit of tuber- 
 cle. The fluid contained in the ventricles of the brain is almost always 
 transparent, and tubercle is discovered in some, often in many, of the 
 viscera. 
 
 But we sometimes meet with cases in which inflammation of the mem- 
 branes of the brain has given rise to changes that contrast remarkably 
 with those which true hydrocephalus produces. We find the cerebral 
 membranes intensely injected, the effusion of lymph or pus abundant, 
 especially about the convex surface of the brain, where it sometimes 
 forms a layer concealing the convolutions from view. Moreover, the 
 fluid that occupies the cavity of the arachnoid, as well as that within 
 the ventricles, is turbid and mixed with lymph, while the membranes 
 present no trace of that granular appearance so remarkable in tuber- 
 cular meningitis, and the various organs of the body are usually free 
 from tubercle ; or if not, its deposit is comparatively small and unim- 
 portant. 
 
 If we inquire as to the symptoms by which this disease was attended 
 during the lifetime of the patient, we shall most likely find that they 
 present fresh reasons for distinguishing between it and tubercular 
 hydrocephalus. We shall learn that the attack came on in a previ- 
 ously healthy child, that it was either ushered in by convulsions, or 
 that they soon occurred ; that they returned often, and probably that 
 they continued with but little intermission until death took place. We 
 
SIMPLE MENINGITIS. 101 
 
 shall be told, moreover, that the disease set in with violent vomit- 
 ing and intense febrile excitement; and that having commenced thus 
 severely, it advanced rapidly, and without remission, to its fatal termi- 
 nation, which may have arrived in the course of a few hours, and is 
 seldom delayed beyond the first week. 
 
 Some cases of this simple encephalitis, or more correctly of simple 
 meningitis, are recorded by Golis, 1 under the name of Water-stroke : I 
 will select one of them, as affording a good specimen of the most acute 
 form of the disease. 
 
 "A little girl, 14 months old, who was healthy and strong and fat, 
 was suddenly seized at 5 o'clock in the morning, after a restless night, 
 with violent fever and frightful general convulsions. Medical assist- 
 ance was at once obtained, and in less than thirty minutes from the 
 commencement of the attack four leeches were applied behind the ears, 
 which drew three ounces of blood : calomel and other remedies were 
 administered internally, and mustard poultices were applied to the 
 soles of the feet. These measures soon alleviated the symptoms, but 
 the relief lasted for but a very short time ; the fever returned as in- 
 tensely as before, convulsions came on again, attended with opisthoto- 
 nos, and the child became comatose. Hemiplegia succeeded; the 
 pupils became extremely contracted ; complete loss of vision, and 
 spasmodic twitch ings of the muscles of the face soon followed, and, 
 thirteen hours after the first convulsive seizure, in spite of most appro- 
 priate and energetic treatment, the little child died. 
 
 "The vessels of the scalp were loaded with blood, and the skull was 
 so intensely congested as to appear of a deep blue color. The sinuses 
 were full of coagulated blood mixed with lymph, and all the vessels of 
 the brain and its membranes were enlarged and turgid with blood. 
 
 "A large quantity of coagulated lymph covered the convolutions of 
 the brain and the corpus callosum like a false membrane, and furnished 
 a delicate lining to the lateral ventricles, whose Avails were softened 
 and in part broken down. The ventricles contained about three ounces 
 of turbid serum, and there was a considerable quantity of lymph at 
 the base of the brain." 
 
 As I have never seen an instance of this most rapid form of menin- 
 gitis, I will draw for another illustration of it upon that valuable 
 storehouse of facts, Dr. Abercrombie's work on Diseases of the Brain. 2 
 
 "A child, aged two years, 21st May, 1826, was suddenly seized in 
 the morning with severe and long-continued convulsion. It left her 
 in a dull and torpid state, in which she did not seem to recognize the 
 persons about her. She had lain in this state for several hours, when 
 the convulsion returned, and during the following night it recurred a 
 third time, and was very severe and of long continuance. I saw her 
 on the morning of the 23d, and while I was sitting by her she was 
 again attacked with severe and long-continued convulsion, which 
 affected every part of the body, the face and the eyes in particular 
 being frightfully distorted. The countenance was pale, and expressive 
 of exhaustion ; the pulse frequent. Her bowels had been freely opened 
 
 1 Praktische Abhandlungen, &c, vol. i, Case 2. 2 Case 10, p. 52. 
 
102 SIMPLE MENINGITIS. 
 
 by medicine previously prescribed by Dr. Beilby, and the motions 
 were dark and unhealthy. Farther purging was employed, with top- 
 ical bleeding, cold applications to the head, and blistering. After this 
 attack she continued free from convulsion till the afternoon of the 
 23d ; in the interval she had remained in a partially comatose state, 
 with frequent starting ; pulse frequent but feeble ; pupils rather dila- 
 ted ; she took some food. In the afternoon of the 23d the convul- 
 sion returned with greater severity ; and on the 24th there was a con- 
 stant succession of paroxysms during the whole day, with sinking of 
 the vital powers ; and she died early in the evening. 
 
 "On removing the dura mater, the. surface of the brain appeared in 
 many places covered by a deposition of adventitious membrane betwixt 
 the arachnoid and pia mater. It was chiefly found above the openings 
 between the convolutions, and in some places appeared to dip a little 
 way between them. The arachnoid membrane when detached ap- 
 peared to be healthy, but the pia mater was throughout in the highest 
 state of vascularity, especially between the convolutions : and when 
 the brain was cut vertically, the spaces between the convolutions were 
 most strikingly marked by a bright line of vivid redness, produced by 
 the inflamed membrane. There was no effusion in the ventricles, and 
 no other morbid appearance/' 
 
 It would not answer any useful purpose to multiply the recital of 
 cases, since though there are great varieties in the duration of the 
 disease, yet its general features are the same in almost every instance, 
 and will, I think, readily be recognized by you as betokening an affec- 
 tion very different from tubercular meningitis. 
 
 The morbid appearances are sometimes found to vary both in their 
 degree and in their extent, without any corresponding difference being 
 observed in the symptoms. With the exception of its course being 
 more rapid, Golis's case differed but little from that recorded by Dr. 
 Abercrombie. I believe that in the majority of instances the lining of 
 the ventricles is affected ; and it is certainly more common for the 
 membranes at the base of the brain to be involved in the disease, than 
 for it to be entirely limited to those at the convexity. My own ex- 
 perience, which, however, unfortunately extends only to six complete 
 post-mortem examinations, would lead me to believe that the inflam- 
 matory mischief extends in general to the membranes of the spinal 
 cord ; and the symptoms observed during life, even when no oppor- 
 tunity was afforded for a post-mortem examination, confirm this 
 opinion. 
 
 Acute inflammation of the membranes of the brain is fortunately of 
 very rare occurrence except as the result of fracture of the skull, or of 
 injury to the head or neck, and hence comes more frequently under the 
 observation of the surgeon than of the physician. In the nine cases 
 which came under my own notice, I was unable to discover any ade- 
 quate exciting cause for the attack, though I was not in all as alive to 
 the probable extension of inflammation from the cavity of the tym- 
 panum as I ought to have been ; for there can be no doubt but that long- 
 continued otorrhcea, and extension of disease to the temporal bone, are 
 by no means essential to the production of serious disease of the brain 
 
INFLAMMATION OF BR AIN - SUBSTANCE. 103 
 
 or its membranes. This fact serves to give increased importance to 
 every attack of earache in childhood ; and will keep you from looking 
 on it as a trivial ailment, painful indeed, but calling for no remedies 
 beyond what the nursery furnishes. 
 
 Exposure to the heat of the sun, cold, damp, and overfatigue, are 
 all alleged causes of meningitis probable enough, though I can say 
 nothing concerning them, while as a secondary occurrence and in a 
 somewhat masked form it occasionally complicates the eruptive fevers, 
 especially scarlatina and typhoid fever. 
 
 In the treatment of this affection in its idiopathic form, our remedies 
 must be, in the main, the same as we should employ to combat the 
 acute inflammation of any other vital organ. Bleeding, purgatives, 
 mercurials, and the application of cold, are the grand means on which 
 we must rely ; and these must be used with an unsparing hand if we 
 would have any chance of saving our patient. Our prospect of success, 
 however, depends almost entirely upon our seeing the patient at the 
 very outset. The case which I quoted from Golis showed you what 
 extensive mischief may occur in thirteen hours, and instances are on 
 record in which a greater amount of injury has been discovered after a 
 still shorter train of symptoms. Even in those cases which do not run 
 this extremely rapid course, and in which the mischief found after 
 death is not so considerable, there is little less need for speedy as well 
 as active interference, for if life be prolonged for a day or two without 
 the disease being overcome, the patient often sinks into an exhausted 
 condition, in which active treatment can no longer be ventured on. 
 
 But besides these cases in which the membranes of the brain are 
 alone affected, others are occasionally met with in which the gradual 
 extension of disease beginning without the skull involves not the mem- 
 branes only but also in many instances the substance of the brain, 
 producing extensive softening, or even giving rise to the formation of 
 a distinct abscess. Instances of this are occasionally furnished by 
 children who have suffered from scrofulous disease of the cervical ver- 
 tebra?, when a life of suffering is terminated by a most painful death ; 
 or inflammation of the brain, proving very quickly fatal, may come on 
 in a child who has long had discharge from the ear, with occasional 
 attacks of earache. Vague threatenings of mischief in the head may 
 perhaps have existed for some time, just sufficient to excite your appre- 
 hension, but not so serious nor so definite as to call for decided inter- 
 ference; and yet, when death takes place, you will find it almost 
 impossible to reconcile the existence of lesions so extensive and of such 
 long standing as a post-mortem examination discovers, with the long- 
 continued absence of definite cerebral symptoms. 
 
 In Dr. Abercrombie's work on Diseases of the Brain, 1 an account is 
 given of a boy, aged 14 years, who had been affected for two months 
 with headache and discharge of matter from the right ear. A week 
 before his death the pain increased, and was accompanied by great de- 
 bility, giddiness, and some vomiting. He continued in this state, 
 without stupor or any other remarkable symptom, until the day of his 
 
 1 Page 37; quoted from Mr. Parkinson, in London Med. Kepositoiy, March, 1817. 
 
104 INFLAMMATION OF BR AIN -SUBSTANCE FROM OTITIS. 
 
 death, when he was suddenly seized with convulsions, and died. An 
 abscess was found in the middle lobe of £he right hemisphere of the 
 brain, and another in the cerebellum, and there was extensive caries of 
 the pars petrosa, with effusion of three ounces of fluid in the ventricles. 
 
 I have quoted this case in order to impress upon your minds that 
 every, even the slightest, indication of cerebral disturbance is to be 
 looked on with the greatest anxiety in children who have suffered from 
 chronic otorrhoea. Your solicitude must be redoubled if the discharge 
 from the meatus had ever been attended with the formation of abscesses 
 at the back of the ear, or burrowing between the cartilage and the bone, 
 since they would render it extremely probable that caries of the bone 
 had existed, and that the membranes of the brain had been reached by 
 the advance of the disease. 
 
 Nor indeed is this the only caution which you will do well to bear 
 in mind. Another scarcely less important is, that even very great im- 
 provement must not lead you to look upon the danger as really at an 
 end in any case where head symptoms have succeeded to disease of the 
 internal ear. A boy between 8 and 9 years old had suffered for 2 
 years from attacks of earache, which had been followed about a month 
 before his admission into the Children's Hospital by the formation of 
 an abscess behind the right ear. For four days he had been sick, and 
 had had much frontal headache ; and when admitted there w T as ptosis 
 of the right eyelid, the pulse was irregular, the pupils were dilated, 
 and the boy was so drowsy as to be almost unconscious. From August 
 14 to September 15, his condition may be said to have seemed hopeless, 
 but then improvement began ; and in a month he seemed almost well. 
 He had gained much flesh, was cheerful, his appetite was good, and 
 his pulse was regular. The grasp of his hands was good and there was 
 no difference between the power of the two, and the only remarkable 
 thing about him was that he walked with effort, his body erect, his 
 elbows out as though like a rope-dancer trying to balance himself. He 
 was sent to the seaside, and there for six weeks he improved ; he then 
 for a day or tw r o complained of his head ; and next violent convulsions 
 came on, in which at the end of 36 hours he died. 
 
 In addition to a large quantity of fluid in the lateral ventricles there 
 were two abscesses in the right lobe of the cerebellum. The larger of 
 these was egg-shaped • of about the size of a bantam's egg, perfectly en- 
 cysted, with cretaceous substance covering the whole of its inner sur- 
 face,«and containing very thick pus. Behind this was another smaller 
 more recent abscess, containing similar pus, but not furnished with a 
 lining. There was no affection of the membranes of the brain except 
 slight thickening on the inner surface of the carious mastoid process of 
 the right temporal bone. 
 
 The possibility of inflammation either of the brain or of its mem- 
 branes following upon attacks of Otitis gives as you have seen its chief 
 importance to that affection. But even independently of that grave 
 consequence, the ailment deserves attention on account of the severe 
 suffering by which it is accompanied. In many instances, too, need- 
 less alarm is "excited by the symptoms of inflammation of the ear being 
 supposed to betoken that the brain is the seat of mischief. The one 
 
INFLAMMATION OF INTERNAL EAR. 105 
 
 indeed may follow on the other, but on this account it is all the more 
 necessary to become familiar with the diagnostic marks that distinguish 
 the less from the more dangerous affection. 
 
 The name of Otitis has been applied to inflammation of very differ- 
 ent parts of the organ of hearing, and in common speaking no adequate 
 distinction has been drawn between the affection of the external audi- 
 tory canal, and that of the more deeply seated parts of the ear, posterior 
 to the membrana tympani. The earache of infants and children is 
 sometimes due to inflammation of one, sometimes of all of these struc- 
 tures. It is more frequent in all its forms in early life than in adult 
 age, and it is the more deserving of mention since the amount of suffer- 
 ing by which it is attended is by no means a certain criterion by which 
 to judge of its importance. When limited to the external auditory 
 canal, the inflammation, though apt to recur from slight causes, and 
 though very painful, seldom leads either to permanent discharge from 
 the ear, or to permanent impairment of hearing. Inflammation of the 
 mucous membrane lining the cavity of the tympanum, when occurring 
 as an acute idiopathic affection, is usually associated with affection of 
 the external auditory canal, and then often greatly aggravates the 
 child's sufferings. It does, however, often run a comparatively chronic 
 course attended with uneasiness rather than with severe pain, but which 
 betokens the progress of mischief within the ear such as is likely to 
 lead to abiding: dullness of hearing. The deafness that follows measles 
 and scarlatina is due to inflammation, which terminates in secretion of 
 pus within the cavity of the tympanum, whence it escapes through the 
 membrana tympani; a mischief either repaired as the inflammation 
 declines by the closure of the opening, or rendered altogether incurable 
 by the detachment of the bones of the ear. In strumous subjects, too, 
 the evil which thus originated may become chronic, may involve the 
 petrous portion of the temporal bone, and may thence eventually ex- 
 tend to the brain. The same result may also follow on long-standing 
 purulent discharge from the ear dependent on chronic inflammation of 
 the external meatus ; and it is this circumstance which gives to otorrhoea 
 in childhood its most grave significance. 
 
 The full detail of the symptoms and management of these various 
 affections comes rather within the province of the aural surgeon 1 than 
 within mine. I must not, however, pass them entirely without men- 
 tion. Attacks of earache are most frequent before the completion of 
 the first dentition, and are by no means rare in young children who 
 are perfectly unable to point out the seat of their sufferings. The 
 attack sometimes comes on quite suddenly, but usually the child is 
 fretful and languid for a period varying from a few hours to one or 
 two days before acute pain is experienced. In this premonitory stage, 
 however, it will often cry, if tossed or moved briskly, noise seems un- 
 
 1 Two papers by Mr. Toynbee may be consulted with advantage : the one a pam- 
 phlet on Otorrhcea and Otitis, the other in vol. xxxiv of Med.-Chir. Transactions, 
 on "Those Affections of the Ear which produce Disease in the Brain;" and also 
 chap, xiv of his work on "The Diseases of the Ear," 8vo., London, 1860. There 
 are also some good practical remarks on internal Otitis in a paper by Dr. Schwartze, 
 J. f. Kinderkr., vol. xl, p. 305. 
 
106 INFLAMMATION OF INTERNAL EAR. 
 
 pleasant to it, and it does not care to be played with ; while children 
 who are still at the breast show a disinclination to suck, though vthey 
 will take food from a spoon. The infant seeks to rest its head on its 
 mother's shoulder, or, if lying in its cot, moves its head uneasily from 
 side to side, and then buries its face in the pillow. If you watch 
 closely, you will see that it is always the same side of the head which 
 it seeks to bury in the pillow, or to rest on its nurse's arm, and that no 
 othe» position seems to give any ease except this one, which, after much 
 restlessness, the child will take up, and to which, if disturbed, it will 
 always return. The gentle support to the ear seems to soothe the little 
 patient; it cries itself to sleep, but after a short doze some fresh twinge 
 of pain arouses it, or some accidental movement disturbs it, and it 
 awakes crying aloud, and refusing to be pacified, and may continue so 
 for hours together. Sometimes the external ear is red, and the hand is 
 often applied to the affected side of the head, but neither of these symp- 
 toms is constant. The intensity of the pain seldom lasts for more than 
 a few hours, when in many instances a copious discharge of offensive 
 pus takes place from the ear, and the child is well. In some instances, 
 indeed, the subsidence of the disease on one side is followed by a similar 
 attack on the opposite side, and the same acute suffering is once more 
 gone through, and terminates in the same manner. Sometimes, too, 
 this complete cure does not take place, but the earache abates, or alto- 
 gether ceases, for a day or two, and then returns ; no discharge, or but 
 a very scanty discharge, taking place, while for weeks together the child 
 has but few intervals of perfect ease. In infants earache seldom follows 
 this chronic course, though I have occasionally seen it do so in older 
 children ; and the disease is in these cases seated within the cavity of 
 the tympanum. 
 
 In children who are too young to express their sufferings by w^ords, 
 the violence of their cries, coupled with the absence of all indications of 
 disease in the chest or abdomen, naturally lead to the suspicion of some- 
 thing being wrong in the head. There are three circumstances, how- 
 ever, which may satisfy you that the case is not one of ordinary hydro- 
 cephalus : the child does not vomit, the bowels are not constipated, and 
 there is but little febrile disturbance. The loud and passionate cry, the 
 dread of movement, and the evident relief afforded by resting one side 
 of the head, are evidences of the ear being affected ; while in many in- 
 stances the movement of the hand to the head, and the redness of the 
 •external ear, with the swelling of the meatus, concur to make the diag- 
 nosis easy. Sometimes, when in doubt, you will be able to satisfy your- 
 selves that the cause of suffering is in the ear, by pressing the cartilage 
 of the organ slightly inwards, which will produce very evident pain on 
 the affected side, w r hile if practiced on the other side, it will not occasion 
 any suffering. 
 
 The treatment of this painful affection is very simple. In many in- 
 stances the suffering is greatly relieved by warm fomentations, or by 
 applying to the ear a poultice of hot bran or camomile-flowers. A little 
 oil, to which some laudanum has been added, may be dropped into the 
 ear, and repeated from time to time, while if the pain is extremely 
 severe, or has continued for several hours, it may be wise to apply a 
 
THROMBOSIS OF THE CEREBRAL SINUSES. 107 
 
 few leeches to the mastoid process. If the earache returns frequently, 
 a small blister should be applied behind the ear, or slight vesication 
 may be produced by means of the acetum cantharidis. After the cau- 
 tions I have already given it is scarcely necessary for me to add, that 
 the possible supervention of inflammation of the brain must of course 
 be borne in mind, and any indication of its approach must be immedi- 
 ately combated. 
 
 In those cases where offensive puriform discharge from the ear has 
 been of long continuance, and the matter is sometimes tinged or streaked 
 with blood, astringent injections must be used only with the greatest 
 care, while their employment is not at all advisable if exfoliation of 
 bone has taken place, since in such a case not only is the internal ear 
 disorganized, but the dura mater has very probably become exposed. 
 Attention to cleanliness, by frequently syringing out the ear with warm 
 water, or with a solution of gr. j or gr. ij of the acetate of lead in an 
 ounce of water, constitutes all the topical treatment on which it would 
 be safe to venture, while the most sedulous attention must be paid to 
 the general health of the patient. 
 
 It still remains for me to notice one singular form of cerebral disease, 
 which, though not confined to children, is seen much oftener among 
 them than among adults ; namely, thrombosis of the sinuses of the dura 
 mater. In grown persons it usually succeeds to some injury of the 
 head, but in the child it has generally been observed as a consequence 
 of long-continued purulent otorrhoea, combined with disease of the 
 temporal bone, or it has been connected with disease of the frontal 
 sinuses, or has followed an abscess of the scalp. In some instances, 
 also, it has seemed to be excited by the presence of large collections of 
 pus in distant parts of the body. M. Tonnele, who has written a very 
 valuable paper on inflammation of the sinuses of the dura mater in 
 children, 1 records one instance in which it coincided with a pleuritic 
 effusion ; and a somewhat similar case has come under my own notice, 
 which I will relate, partly on account of its rarity, partly because it 
 illustrates exceedingly well the morbid appearances observed in cases 
 of this description. 
 
 A healthy little girl was attacked by scarlatina when eight months 
 old. The attack was not severe, but, after it had passed away, she did 
 not regain her previous health, but continued restless and feverish; she 
 was sometimes sick, and her eyelids were often slightly swollen. A 
 fortnight after the rash appeared, she had one or two violent convulsive 
 seizures, but they ceased after her gums were lanced, and did not appear 
 to be in any way connected with her subsequent illness. She continued 
 out of health until she was 10J months old, when her mother noticed, 
 in addition to the puffiness of the eyelids, a swelling of the legs and 
 abdomen, for Avhich she came under my care when eleven months old. 
 The legs were then very cedematous, and fluctuation was distinctly felt 
 through the parietes of the abdomen, the urine being scanty and high- 
 colored. In the course of about three weeks her condition had im- 
 proved considerably, the urine having increased much, the anasarca 
 
 1 Journal Hebdomadaire, vol. v, p. 337. 1825. 
 
108 THROMBOSIS OF THE CEREBRAL SINUSES. 
 
 having greatly diminished, and the abdomen being 1J inch less in 
 circumference. A fit of convulsions now came on without any apparent 
 cause, but no other symptoms of cerebral mischief followed it, and the 
 convulsions did not return. After the lapse of another week, a dis- 
 charge of sero-purulent fluid took place from the umbilicus, and con- 
 tinued for several days in quantities of from a quarter to half a pint 
 daily. This discharge was attended with an improvement rather than 
 a deterioration in the child's health; but after it had continued for 
 eleven days, fever and dyspnoea suddenly came on, with dulness on 
 percussion over the right side of the chest, and absence of respiratory 
 murmur in that situation. The discharge ceased for a week during 
 the urgency of the thoracic symptoms, but then reappeared, though 
 scantily. The child now grew thinner and weaker, and sank into a 
 state of hectic. No new symptom came on till she was suddenly seized 
 with extreme faintness, amounting to almost perfect syncope. She 
 rallied, however, under the use of stimulants, but forty-eight hours 
 afterwards the faintness returned, and terminated in death, without any 
 convulsion having preceded it, just five months and a half after the 
 attack of scarlatina, and two months after she came under my care. 
 
 On an examination of the body after death, pleurisy of the right side 
 was discovered, with about gvj of pus in the right pleura, and peri- 
 tonitis, with Oiij of pus in the abdomen ; the passage being still trace- 
 able through which the fluid had escaped at the umbilicus. 
 
 The dura mater adhered firmly to the skull along the posterior half 
 of the longitudinal sinus, at the torcular Herophili, and along the left 
 lateral sinus ; but elsewhere it was easily detached from the cranium. 
 
 The sinuses on the right side were healthy, but the blood within 
 them was almost entirely coagulated. The posterior half of the longi- 
 tudinal sinus, the torcular, the left lateral and left occipital sinuses, 
 were blocked up with fibrinous coagulum, precisely such as one sees in 
 inflamed veins, and the clot extended into the internal jugular vein. 
 The coats of the longitudinal and of the inner half of the lateral sinus 
 were much thickened, and their lining membrane had lost its polish, 
 was uneven, and presented a dirty appearance. 
 
 There was some congestion of the arachnoid, a considerable quantity of 
 fluid in the ventricles, and sections of the brain presented more bloody 
 points than natural, especially on the left side. The base of the brain 
 was perfectly healthy on the right side, but there was great venous 
 congestion beneath the middle lobe of the left hemisphere; the cerebral 
 veins in that situation were distended with coagulum, and their coats 
 were thickened. Towards the anterior part of the left middle lobe 
 were four apoplectic effusions, in all of which the blood retained its 
 natural color. Each of these effusions was connected with an obstructed 
 and distended vein. The largest clot extended an inch into the sub- 
 stance of the brain ; the others were of smaller extent. 
 
 I cannot speak to you of any symptom as pathognomonic of this 
 occurrence: it usually comes on, as in this instance, in much debilitated 
 children, and though it generally follows some injury or disease in the 
 neighborhood of the brain, you will bear in mind the possibility of its 
 occurrence whenever large collections of pus exist in any part, and will 
 
THROMBOSIS OF THE CEREBRAL SINUSES. 109 
 
 draw a very unfavorable prognosis in the event of head symptoms 
 coming on in such circumstances. 
 
 It is now many years since I observed this case, and made with 
 reference to it the above remarks. No other instance has come under 
 my notice in which the thrombosis was so extensive, or in which its 
 results were so characteristic, and I therefore retain mention of it here, 
 though the subject has lost its novelty since the condition has been 
 described by several recent writers, who have brought to bear on it the 
 light which the researches of Yirchow have thrown on clot formation 
 in the bloodvessels. 
 
 The most elaborate essay on the subject is that of Von Dusch; 1 who 
 divides all cases of "Thrombosis of the Cerebral Sinuses" into two 
 classes, according as they are the result of inflammation in the neigh- 
 borhood, or as they depend on the indirect influence of general debil- 
 itating causes. The effects of local injuries to the skull, and the 
 extension of disease of the internal ear illustrate the former mode of 
 its production ; but the latter would seem to be much the more frequent 
 in early life, and in many instances of it, in addition to the influence of 
 general debilitating causes in its production, there was superadded 
 some condition or other obstructing the respiration, and thus prevent- 
 ing the right side of the heart from emptying itself properly, thereby 
 retarding the current of the blood. 
 
 Neither the researches of Von Dusch, nor the observations of other 
 writers indicate any symptoms as pathognomonic of this affection, and 
 the only conclusion at which we can arrive with reference to it is, that 
 when head symptoms set in suddenly in previously debilitated subjects, 
 and do not run the course of any ordinary form of cerebral disease, 
 such symptoms will probably be found to be due to the formation of 
 thrombus in the sinuses. 
 
 One additional suggestion, which we owe to the acuteness of Dr. 
 Gehrhardt, of Jena, is, that the occurrence of thrombosis may probably 
 explain the sudden tension of the fontanelle and enlargement of the 
 skull, and the hydrocephalic symptoms that sometimes succeed to the 
 depressed fontanelle and sunken sutures which one may observe in the 
 course of the diarrhoea, and some other exhausting diseases of early 
 infancy. 
 
 1 The essay of Von Dusch, on Thrombosis of the Cerebral Sinuses, is translated 
 in vol. xi of the publications of the New Sydenham Society, 8vo , London, 1861. 
 Several interesting cases have been contributed by Dr. Loschner, of Prague, in the 
 Prague Vierteljahrsschrift, and in the Jahrbuch fur Kinderheilkunde, vol. iv ; 
 Analeeten, p. 49, who dwells especially on the absence of any characteristic symp- 
 toms during life; and a case with remarks by Dr. Langenbeck, of Gottingen, will 
 also be found in the Journal fur Kindcrkrankheiten, vol. xxxvi, 1861, p. 75. In 
 Gehrhardt's Lehrbuch der Kinderkrankheiten, Tubingen, 1871, p. 500, there is also 
 a very able chapter on this affection. 
 
110 CHKONIC HYDROCEPHALUS: 
 
 LECTURE IX. 
 
 Chroxic Hydrocephalus. — Various conditions under which fluid collects in the 
 skull — Divided into the external and the internal — Symptoms of both nearly- 
 identical — Changes in form and size of the head— And their mode of production — 
 Course of the disease — Termination almost always fatal. 
 
 Internal Hydrocephalus. — Important questions involved in its pathology — Fre- 
 quent connection with malformation of brain — But also follows inflammation of 
 lining of ventricles — Description of post-mortem appearances — Case illustrative 
 of its connection with inflammation — Process of cure usually mere arrest of dis- 
 ease — Effusion occasionally passive — Alleged share of rickets in its production. 
 
 External Hydrocephalus. — Circumstances in which it exists — Its relation to 
 hemorrhage into the arachnoid — Treatment of both forms of the disease — Im- 
 portance, but difficulty, of distinguishing curable and incurable cases — Com- 
 pression — Puncture — Cases suited for each mode of treatment. 
 
 We have now completed our examipation of the acute inflammatory 
 affections of the brain, and with them we may consider that we have 
 dismissed the most important class of diseases of that organ. Before we 
 pass, however, to those in the production of which inflammation bears 
 no part, we must study one malady, which forms a kind of connecting 
 link between the two. 
 
 Chronic Hydrocephalus, or dropsy of the brain, is a morbid condition 
 met with in children at various ages, and coming on in a great variety 
 of circumstances. Sometimes it is congenital, and is then often, though 
 by no means invariably, associated with malformation of the brain. 
 In subsequent childhood, an excess of blood in the brain, or its defici- 
 ency, or the existence of some impediment to the circulation through 
 the organ, are conditions all of which have been found to give rise to 
 the effusion of fluid into the cavities of the brain, or upon its surface. 
 Instances of chronic hydrocephalus are on record, which have succeeded 
 to hemorrhage into the sac of the arachnoid ; others that have been con- 
 nected with wasting of the brain, in consequence of the supply of blood 
 being inadequate to its due nutrition, or in Avhich obliteration of the 
 sinuses by disease, or the pressure of a morbid growth upon some of 
 the vessels of the brain, has interfered with the due performance of the 
 cerebral circulation. In many cases, however, I believe, as do MM. 
 Rokitansky and Vrolik, 1 that the disease is not merely a passive dropsy, 
 nor simply a consequence of arrested cerebral development, but that it 
 is the result of a slow kind of inflammation of the arachnoid, especially 
 of that lining the ventricles, which may have existed during foetal life, 
 or may not have attacked the child until after its birth. I may fur- 
 ther add that each year leads me to estimate more highly the share of 
 inflammation of the lining of the ventricles in the production of chronic 
 hydrocephalus. 
 
 1 Kokitansky, Pathologische Anatomie, vol. ii, p. 754; Vrolik, Handboek der 
 Ziektedundige Ontleedkunde, Amsterdam, 1840, 8vo., pp. 514-537. 
 
ITS SYMPTOMS. Ill 
 
 According to the situation in which the fluid collects, a division has 
 been made of chronic hydrocephalus into the external and the internal; 
 the former term being applied to cases in which the fluid collects in 
 the sac of the arachnoid ; the latter to those in which it accumulates in 
 the ventricles of the brain. The two conditions sometimes coexist, but 
 generally they are independent of each other ; the internal hydrocepha- 
 lus being the more frequent and the more important; and to it we will 
 therefore first direct our attention. 
 
 The early symptoms of the disease vary. When it is congenital, in- 
 dications of cerebral disturbance are generally apparent from the in- 
 fant's birth. These are sometimes serious — such, for instance, as con- 
 vulsions recurring almost daily ; at other times they are comparatively 
 slight, and consist in nothing more than strabismus, or a strange rolling 
 of the eyes, unattended by any very definite sign of affection of the 
 brain. The size of the head generally attracts attention before long, 
 and causes importance to be attached to symptoms which otherwise 
 might have given rise to but little anxiety. In some instances, how- 
 ever, the increased size of the head is not very obvious until the child 
 is a few weeks old, although well-marked symptoms of mischief in the 
 brain existed from its birth. Enlargement of the head, indeed, is by 
 no means invariably the first indication of chronic hydrocephalus. In 
 1 2 out of 45 cases, fits, returning frequently, had existed for some weeks 
 before the head was observed to increase in size ; in 6, the enlargement 
 of the head succeeded to an attack resembling acute hydrocephalus ; and 
 in four other instances it had been preceded by some w r ell-marked in- 
 dication of cerebral disturbance. In the remaining 23 cases no distinct 
 cerebral symptom preceded the enlargement of the head ; but in almost 
 every instance the child's health had been noticed to be failing for some 
 time, although the cause of its illness was not apparent. 
 
 In whatever way the disease begins, impairment of the process of 
 nutrition is sure to be one among its earliest symptoms. The child may 
 suck well, and, indeed, may seem eager for food, but it loses both flesh 
 and strength ; and often, although the head has not yet attained any 
 disproportionate size, the child is unable to support it, either losing the 
 power it had once possessed, or never attaining that which, with its in- 
 creasing age, it ought to acquire. The bowels are usually, though not 
 invariably constipated. Sometimes diarrhoea comes on for a day or two ; 
 but, under either condition, the evacuations are almost always of an un- 
 healthy character. Thus far, indeed, there is but little to distinguish 
 the case from any other in which a young infant is imperfectly nour- 
 ished ; but, even though no well-marked cerebral symptom should be 
 present, occasional attacks of heat of head will be observed, attended 
 with pulsation or tension of the anterior fontanelle, while crying and 
 restlessness often alternate with a drowsy condition, though the child 
 almost always sleeps ill at night. In many instances, too, the open 
 condition of the fontanelles and sutures excites attention long before 
 any enlargement of the head becomes perceptible. 
 
 By and by, however, the increased size of the head grow r s very mani- 
 fest, and the child's physiognomy soon assumes the distinguishing fea- 
 tures of chronic hydrocephalus. As the disease advances, the unossi- 
 
112 CHRONIC HYDROCEPHALUS: 
 
 fied sutures become wider, the fontanel les increase in size, their angles 
 extend far into the sutures in which they terminate, while the fluid, 
 pressing equally in all directions, tends to impart a globular shape to 
 the receptacle in which it is- contained. Some of the casts upon the 
 table afford striking illustrations of this change in the form of the cra- 
 nium, which would be still more remarkable were it not for the very 
 unequal resistance of different parts of its walls. The bones at the 
 vertex of the skull are much less firmly fixed than the others, and ossi- 
 fication is nowhere so tardy as at the anterior fontanelle, and along the 
 inner edges of the parietal bones. Hence it results that the great in- 
 crease in the size of the head is effected by enlargement of the anterior 
 fontanelle, and by widening of the saggital suture. The os frontis con- 
 sequently becomes pushed forwards, the parietal bones are driven back- 
 wards and outwards, and the occipital booes downwards and back- 
 wards. The displacement of the bones is very obvious in this hydro- 
 cephalic skull, but it is still more striking in the two engravings which 
 I here show you. 1 You notice the great prominence of the forehead, 
 and the alteration in the position of the parietal bones, which are driven 
 backwards as well as outwards, so that the natural relations of their 
 protuberances are altogether changed ; while in this remarkable case of 
 a man named Cardinal, who though hydrocephalic from his infancy, 
 lived to the age of 29 years, the occipital bone lies almost completely 
 in a horizontal position. You will observe, too, another remarkable 
 alteration produced by the yielding of the orbitar plates of the frontal 
 bone, which are driven by the accumulating fluid from a horizontal into 
 an oblique direction. Sometimes, indeed, they become nearly perpen- 
 dicular, when, by contracting the orbits, they give to the eyeballs that 
 unnatural prominence, and that peculiar downward direction, which 
 constitute one of the most remarkable features in cases of chronic hy- 
 drocephalus. 
 
 Few objects are more pitiable than a little child who is the subject of 
 far-advanced chronic hydrocephalus. While the skin hangs in wrin- 
 kles on its attenuated limbs, the enlarged head appears full, almost to 
 bursting, owing to the stretching of the scalp ; and the scanty growth 
 of hair does not at all conceal the distended veins that run over its 
 whole surface. The size of the skull, too, appears greater than it really 
 is, since the face not only does not partake of the enlargement but re- 
 tains its infantile dimensions much longer than natural. The eyes are 
 so displaced by the altered direction of the orbitar plates that the white 
 sclerotica projects below the upper lid, and the iris is more than half 
 hidden beneath the lower. Often, too, there is a considerable degree of 
 convergent strabismus, or a constant rolling movement of the eyeballs 
 which the child is unable to control ; or the pupils are dilated, and quite 
 insensible to light. 
 
 The symptoms of cerebral disturbance that attend the advance of 
 the disease differ much in severity. Sometimes there is little besides a 
 state of uneasiness and restlessness, aggravated at intervals when the 
 
 1 Baillie's Morbid Anatomy, fasc. x, plate iii, fig. 1, and the drawing of Cardinal's 
 skull, in Bright's Keports, vol. ii, part 2, plate xxxv. 
 
ITS SYMPTOMS. 113 
 
 head grows hot and the fontanelle becomes tense. In other cases con- 
 vulsions occur very frequently, being induced by extremely slight 
 causes, or coming on without any. In several instances I have ob- 
 served spasmodic attacks of difficult breathing, attended with a crowing 
 sound in inspiration, and those symptoms which constitute spasmodic 
 croup, seizures of which sometimes come on even before there is much 
 enlargement of the head. But, whether the cerebral symptoms are 
 slight or severe, almost every case of chronic hydrocephalus has pauses 
 in its course, during which the child seems to enjoy a comparative im- 
 munity from suffering, and gains flesh, while its head ceases for a time 
 to enlarge. Nothing, however, can be more variable than the fre- 
 quency of these pauses, or their duration. 1 
 
 Though almost every case of chronic hydrocephalus is fatal, yet 
 death takes place in very different ways. Children who are the sub- 
 jects of the disease are almost always very weakly : hence, they fre- 
 quently give way under the first serious illness that attacks them, and 
 are carried off by maladies totally unconnected with their head affec- 
 tion ; while many others sink into that state of atrophy by which the 
 disease of the brain is often accompanied, and die exhausted. Others 
 are carried off suddenly by convulsions, or fall victims to some severe 
 paroxysm of spasmodic croup : and there are other instances in which 
 the disease seems lighted up again after a pause, by the irritation of 
 teething, or by some trivial accident, and death is preceded by the indi- 
 cations of acute cerebral mischief. 
 
 The pathology of chronic internal hydrocephalus involves questions 
 not merely of scientific interest, but of great practical moment ; for if 
 we come to the conclusion at which some observers of high authority 
 have arrived, that it is almost invariably the effect of arrest of the 
 development of the brain, all therapeutical proceedings must be worse 
 than useless. The early date of the occurrence of its symptoms in the 
 great majority of cases, lends support, indeed, to the opinion that the 
 causes to which it is due must generally have existed before birth ; for 
 I find, on examination of the history of 54 cases, 18 of which came 
 under my own observation, that some indications of it were observed 
 in 50 of tl^js number before the child was six months old ; that in 14 
 of these its symptoms existed from birth ; and that in 21 more they 
 appeared before the completion of the third month. The knife of the 
 anatomist, too, has discovered evidences of congenital malformation 
 of the brain, in some instances in which no sign of hydrocephalus 
 was apparent until several w T eeks after the child's birth ; a fact which 
 still further deepens the dark colors in which this malady has been 
 portrayed. 
 
 Still, large as is the proportion of cases in which symptoms of chronic 
 hydrocephalus have existed from birth, I am disposed to believe 
 
 1 I make no reference to the results of cerebral auscultation in this or other affec- 
 tions of the brain in early life. M. Roger's essay, Sur l'Auscultation de la Tete, in 
 vol. xxiv of the Memoires de l'Academie de Medecine, has completely settled the 
 imaginative character of MM. Fisher and Whitney's discovery. I have myself 
 listened, without success, for the cerebral souffle in several cases of chronic hydro- 
 cephalus. 
 
114 CHRONIC HYDROCEPHALUS. 
 
 that even in them the condition is by no means constantly cine to arrest 
 of development or to malformation of the brain, but rather to a process 
 of inflammation of the lining of the ventricles, such as we know may 
 produce effusion into the cavities of the brain after birth. To this 
 cause is doubtless due that occlusion of the cerebro-spinal opening, to 
 which Mr. Hilton was the first to draw attention as one very important 
 pathological element of chronic hydrocephalus. 1 
 
 In seven post-mortem examinations of children affected with chronic 
 internal hydrocephalus, who died at the respective ages of 16 months, 
 3 years, 8 months, 19 months, 2 years, 3 J and 3 J years, I found the 
 corpus callosum perfect in every instance. In all, also, the fornix was 
 present ; thrice it and the septum lucidum were thickened and tough : 
 twice they were found torn and softened ; acute hydrocephalus having 
 supervened on the chronic disease. Once the septum lucidum was 
 absent, and once both it and a large portion of the fornix also were 
 wanting. In one case the state of the membranes lining the ventricles 
 was not noted ; in the other six it was thickened, four times very re- 
 markably ; and twice it was roughened and granular, presenting an 
 exasperated degree of that condition which is also so often met with in 
 fatal cases of acute hydrocephalus, and to which I directed your atten- 
 tion when speaking of that disease. 
 
 In some cases — as, for instance, in this drawing by Professor Vrolik 2 
 of the brain of a young man who died of chronic hydrocephalus at the 
 age of 20 — a false membrane is found in the interior of one or other 
 ventricle, and may even occlude the foramen of Monro ; an accident 
 which, by interrupting the communication between the two sides of the 
 brain, may serve to account for the unequal distension of the two ven- 
 tricles, and the great want of symmetry occasionally observed in hydro- 
 cephalic skulls. The marks of inflammation of the membranes at the 
 base of the brain are, moreover, in many instances, very evident ; and 
 there is often an extremely abundant effusion of that hyaline matter in 
 the meshes of the pia mater, to which I called your attention when 
 speaking of acute hydrocephalus. 
 
 Lastly, I may remark, that the observation in a large number of 
 instances, that the cerebral substance has been simply unfokled by the 
 accumulation of the fluid in the ventricles, so that even wnen of ex- 
 treme tenuity the gray and white matter could still be distinguished, 
 proves not merely that the brain was not melted down by the action of 
 the fluid, but also that its accumulation could not, in these instances, 
 be due to the arrest of cerebral development. 
 
 Besides the evidence which post-mortem examinations often furnish 
 of the connection of chronic internal hydrocephalus with previous in- 
 flammatory action, the history of the patient's illness sometimes affords 
 distinct proof of its occurrence. A striking instance of this has been 
 
 1 See his Lectures on Rest and Pain, 8vo., London, 1803, pp. 34-44, and also " Some 
 Remarks on changes in the Ventricular Lining during Foetal Life," by Dr. Losch- 
 nnr of Prague, at p 54 of Part I of Aus dem Franz Josef Kinder-Spitale, &c. 
 8vo., Prague, 18'10. 
 
 2 Traite sur la Hydrocephalic Interne, 4to., plate iii. Amsterdam, 1839. 
 
MORBID APPEARANCES. 115 
 
 published by M. Rilliet, of Geneva/ in the ease of a little girl 10 J 
 vears old, in whom the symptoms of acute cerebral inflammation were 
 succeeded by those of chronic disease in the brain, which terminated 
 fatally at the end of four months. Ten ounces of transparent but 
 highly albuminous fluid were contained in. the lateral ventricles, the 
 lining membrane of which was nearly half a line thick, having a 
 gelatinous appearance, as if softened, but being in reality so tough that 
 it could be torn away from the cerebral substance in long strips. 
 
 Though in the following history the connection between the acute 
 and the chronic evil is far less striking than in M. Rilliet's case, yet I 
 think few will refuse to admit the injury to the head and the sub- 
 sequent cerebral symptoms as the first steps in the chain of morbid 
 processes which led to the distension of the ventricles of the brain with 
 fluid, and to the development of all the symptoms of chronic hydro- 
 cephalus. 
 
 A little girl, the child of healthy parents, was healthy when born, 
 and continued so until she was five months old, when she fell out of the 
 arms of the person who was nursing her, and on the same day was 
 taken in a fit, and lay stupid and senseless for some hours. She was 
 leeched and blistered for these and other head symptoms, which the 
 parents were unable to describe very accurately, and to all appearance 
 recovered. When a* year old, however, head symptoms returned, and 
 for several weeks convulsions were of extremely frequent occurrence ; 
 but at length ceased. About that time, the child being then 15 months 
 old, her mother first noticed that her head was beginning to enlarge, 
 since which time she had no return of fits but the head continued to 
 increase in size down to the time when I first saw her, she being then 
 just three years old. 
 
 Her countenance presented all the peculiarities of chronic hydroceph- 
 alus in a very marked degree : her head was large, measuring 20 inches 
 in circumference, and 13J from one meatus auditorius to the other ; 
 her forehead was prominent, and her eyes were directed downwards, 
 while her body was very ill nourished. Her bowels were regular, her 
 bodily functions generally natural, and she was very voracious. She 
 was by no means stupid, but on the contrary showed much shrewdness, 
 though she was noisy and almost constantly chattering. 
 
 I had not seen her above once or twice when she was attacked by 
 measles, on the second day of which convulsions came on, and she sank 
 into a comatose state, interrupted only by convulsive twitchings of the 
 limbs, and died in this condition on the fourth clay of her illness. 
 
 The head was examined 48 hours after death. 
 
 The bones of the head were quite firm and hard ; the posterior fon- 
 tanels was closed, but the anterior was open ; its diameter in either 
 direction being about 3 J inches. 
 
 There was no fluid in the sac of the arachnoid, nor morbid condition 
 of the membranes either at the vertex or base of the brain. 
 
 A very small quantity of fluid was in the subarachnoid tissue, and 
 a pint of perfectly transparent serum in the lateral ventricles. 
 
 1 Archives Gen. de Medecine, Dec. 1847. 
 
116 CHRONIC HYDROCEPHALUS. 
 
 The convolutions of the brain were quite flattened : its cortical sub- 
 stance was of natural thickness, the white substance very thin, and 
 expanded around the ventricles, which were dilated to four times their 
 natural size. 
 
 The white substance of the wall of the ventricles was quite firm, and 
 separable into a thin tough layer, leaving the substance of the brain 
 quite natural beneath. The septum lucidum was tough and mem- 
 branous and much thickened. The edges of the fornix were firmly ad- 
 herent to the upper surface of the optic thalamus, and included between 
 them a portion of the choroid plexus. 
 
 The membrane lining the ventricles was universally thickened; 
 where it covered the corpora striata, the optic thalami, the commissures, 
 and the floor of the fourth ventricle, it was not only peculiarly tough, 
 but granular, and presented an appearance just like shagreen. 
 
 The size of the head in this case had been increasing but slowly, and 
 probably, had the child not been cut off by the intercurrent attack of 
 measles, the effusion of fluid would at length have come to a standstill, 
 and the hydrocephalus would have been cured ; at least, as much as 
 hydrocephalus usually is. Strictly speaking, however, there is in gen- 
 eral no cure of the affection, but merely an arrest of its progress ; no 
 more fluid is poured out, but that already effused is unabsorbed ; the 
 sutures and fontanelles become ossified, and the enormous size of the 
 head attracts less attention, not because there is any diminution in its 
 dimensions, but because the disproportion between the cranium and 
 the face becomes less striking, owing to the development of the latter 
 as the child grows older. In some instances, indeed, Professor Otto 1 
 is of opinion that a real cure is effected by an increased activity of the 
 nutrition of the brain, producing hypertrophy of the organ ; the fluid 
 being absorbed, and nerve-matter deposited in its stead. This, how- 
 ever, is, in all probability, a purely exceptional occurrence; and the 
 majority of hydrocephalic patients who survive the advance of the dis- 
 ease still have their lateral ventricles distended with fluid. This w^as 
 all that occurred in the well-known case of Thomas Cardinal, whose 
 bust I here show you. Having been hydrocephalic from infancy, he 
 yet lived to the age of 29, in the possession of a tolerable amount of 
 bodily and mental activity. On examination of this body after death, 
 between seven and eight pints of .fluid were found in his cranium. In 
 the greater number of instances symptoms exist during life which show 
 clearly enough that the arrest of the disease differs widely from its cure, 
 or that the malady of the brain which its produces, or with which it 
 was associated, is irreparable ; for the intellectual powers are generally 
 feeble, and the temper very irritable, while the child is often unable to 
 walk, and its sight is very imperfect. 
 
 Although inflammation of the ventricular lining is, as I believe, by 
 far the most frequent cause of chronic hydrocephalus, there can be no 
 doubt but that the effusion of fluid is occasionally a purely passive 
 dropsy due to the accidental pressure of some morbid growth upon the 
 Vena? Galeni, or upon the lateral sinus. Such cases, however, are not 
 
 1 Rokitansky's Pathologische Anatomie, 1st ed , vol. ii, pp. 749-769. 
 
EXTERNAL HYDROCEPHALUS. H7 
 
 only of rare occurrence, but the effusion plays in them a very secondary 
 part, being merely an accidental consequence and complication of the 
 graver disease. 
 
 The frequent observation of evidence of rickets in children who are 
 hydrocephalic has also given rise to the suggestion 1 that the diminished 
 pressure of the cranial parietes in consequence of their tardy and im- 
 perfect ossification is in very many instances the exciting cause of the 
 effusion, the enlargement of the head being due to diminished resistance, 
 rather than to increased pressure. I cannot subscribe to this opinion, 
 for not only is hydrocephalus present in a very large proportion of cases 
 independent of any sign whatever of rickets, while the most extreme 
 degrees of rickets are not usually associated with hydrocephalus; but 
 the evidences of rickets when present are comparatively slight, and do 
 not precede but follow the enlargement of the skull. Further, the most 
 marked imperfection in the ossification of the skull, as in the so-called 
 craniotabes, is observed independent of effusion of fluid into the ventri- 
 cles, while lastly the shape of the head associated with rickets, is pecu- 
 liar, characteristic, and entirely different from that produced by chronic 
 hydrocephalus. 
 
 The presence of a large quantity of fluid in the sac of the arachnoid, 
 constituting what is called external hydrocephalus, may arise from sev- 
 eral causes. 
 
 1st. The commissures of the distended brain may yield, and a portion 
 or the whole of the fluid which it contains may escape into the cavity 
 of the cranium. This seems to have taken place in the case of Cardinal, 
 whose skull contained seven or eight pints of fluid, while "the brain 
 lav at its base, with its hemispheres opened outwards like tho leaves of 
 a book." 2 
 
 2d. An atrophied condition of the brain may exist, and fluid may be 
 poured out to fill up the vacuum thus produced in the skull; and such 
 eases are generally of a very hopeless kind, the defect of cerebral devel- 
 opment being almost always the result of congenital malformation or of 
 intra-uterine disease. 
 
 3d. A large quantity of fluid is sometimes found in the sac of the 
 arachnoid, as the result of hemorrhage into its cavity, and of the changes 
 subsequently undergone by the effused blood. MM. Rilliet and Barthez, 
 who have most ably investigated the subject of hemorrhage into the 
 arachnoid, believe that chronic hydrocephalus frequently has this origin. 
 I have seen a few and only a few cases which I suspect were of this 
 nature, but have never had the opportunity of confirming my suspicion 
 by a post-mortem examination; and doubt much whether this cause of 
 chronic hydrocephalus is not rare and exceptional. 
 
 In cases of this last kind, more may be expected both from nature's 
 own reparative powers, and from the resources of art, than in any other 
 form of chronic hydrocephalus. Unfortunately, their symptoms so 
 closely resemble those of the other less hopeful varieties of the disease, 
 that their diagnosis is attended by much difficulty and uncertainty, and 
 
 1 Dr. Dickinson, in his lectures on Chronic Hydrocephalus, published in the Lan- 
 cet for July and August, 1870. 
 
 2 Bright's Reports, vol. i, part 1, p. 433. 
 
118 CHRONIC HYDROCEPHALUS. 
 
 must be founded, in great measure, on the previous history of the 
 patient. " It is never congenital, but generally begins about the tenth 
 month ; that is to say, about the time when the teeth begin to appear. 
 The head, indeed, enlarges gradually, but does not acquire so large a 
 size as in internal hydrocephalus ; while, lastly, it is always preceded 
 by repeated convulsions, or by some other form of active cerebral dis- 
 turbance, which marks the date of the occurrence of hemorrhage. 7 ' 1 
 
 The observation has often been made, that the reputed means of cure 
 of any disease are generally numerous in a directly inverse proportion 
 to its curability ; and to this rule chronic hydrocephalus certainly forms 
 no exception : "its remedies have been derived," as Golis says, "from 
 all the kinodoms of nature, and include almost everv kind of surgical 
 contrivance and pharmaceutical compound." It would be an almost 
 endless task to attempt estimating the comparative value of them all ; 
 and I think it more useful to direct your attention to a few points of 
 real importance. 
 
 First of all, I would have you bear in mind that there are some 
 cases in which you can do no permanent good, but in which treatment 
 must fail, not because it is improper, but because the malady does not 
 admit of cure. Such cases are those in which the accumulation of fluid 
 within the brain is associated with extensive congenital disease, or mal- 
 formation of the organ. If aware of its existence, our treatment would, 
 of course, be simply palliative, and our efforts would be limited to 
 securing euthanasia, since we could not hope to avert death. We 
 should suspect the affection to be incurable, if, though the head were 
 large, and its ossification very imperfect, the forehead were low and 
 shelving; if a considerable degree of paralysis were present, if convul- 
 sions occurred daily and causelessly, and especially if these or other in- 
 dications of serious cerebral disorder had existed almost from birth. 
 Unfortunately, these hopeless cases are by no means invariably charac- 
 terized by peculiar symptoms, and the amount of functional disturbance 
 often affords but a very incorrect index to the extent of organic lesion: 
 your prognosis, therefore, must ahvays be most guarded, and even when 
 you see every reason to expect success, you must yet be prepared for 
 failure. 
 
 On the other hand, you must not regard a case as hopeless, and ab- 
 stain from remedial measures, merely on account of the head having 
 been larger than natural at birth, or its osssification having been less 
 advanced than usual, since we have evidence of perfect recovery from 
 chronic hydrocephalus in cases where many circumstances had appeared 
 to indicate that the disease was congenital. The state of the cerebral 
 functions must influence your prognosis as much as the size of the head, 
 or even more. 
 
 In either form of chronic hydrocephalus, the success of treatment 
 must depend, to a great degree, upon its being adopted early, but in no 
 stage of the disease can good be expected from violent remedies ; rough 
 measures would be likely to destroy the patient rather than the malady. 
 I tried for many years the plan of treatment suggested by Golis of 
 
 1 Legendre, Kecherches Anatomo-pathologiques, p. 135. See alsoKiiliet et Bar- 
 thez, op. cit.,*d ed., vol. ii, p. 259. 
 
ITS TREATMENT. 119 
 
 Vienna, consisting in the inunction of mercurial ointment into the head, 
 which was to be covered with a woollen cap, in the constant administra- 
 tion of small doses of calomel, and the occasional employment of counter- 
 irritation. The details of this plan were, however, irksome to carry 
 out and the results which I obtained, were not remarkable. I am now 
 therefore accustomed instead of following any specific course to employ 
 salines, with diuretics, 'and small doses of the bichloride of mercury; 
 with cold or tepid applications to the head whenever the symptoms 
 present any degree of activity, and to give small doses of the iodide of 
 potassium, and the syrup of iodide of iron with cod-liver oil when the 
 state is one of cachexia rather than of active cerebral disorder ; and I 
 think I have effected at least as much by these means as by any other. 
 The observation that in some cases where the spontaneous cure of 
 chronic hydrocephalus takes place, the ossification of the head, previously 
 so imperfect, makes rapid advances, and the bones become early united, 
 led Mr. Barnard, 1 of Bath, to imitate nature's processes, and to bandage 
 the head so as to prevent its yielding to the accumulating fluid. He 
 has related several cases of the successful adoption of this practice, 
 though, like many other persons, he rides his hobby rather too hard, 
 and advocates his mechanical method to the exclusion of all other 
 treatment. It is, however, a valuable adjunct to other treatment in 
 some cases. Unless you apply it well, it will be of little service, 
 and the plasters by which the compression is exerted will come off. 
 You cannot do better than follow M. Trousseau's rules for their appli- 
 cation. 2 He uses strips of diachylon plaster about one-third of an inch 
 broad ; and applies them — 1st, from each mastoid process to the outer 
 part of the orbit of the opposite side ; 2d, from the hair at the back of 
 the neck along the longitudinal suture to the root of the nose ; 3d, 
 across the w r hole head, in such a manner that the different strips shall 
 cross each other at the vertex ; 4th, a strip is cut long enough to go 
 thrice round the head. Its first turn passes over the eyebrows, above 
 the ears, and a little below the occipital protuberance, so that the ends 
 of all the other strips shall project about one-fourth of an inch below 
 the circular strip. These ends are next to be doubled up on the circu- 
 lar strip, and its remaining two turns are then to be passed over them 
 just in the same direction as the first turn. By these means you secure 
 a firm, and equal, and very powerful pressure on the head. You must 
 watch the results of this proceeding very carefully, and loosen the 
 plasters if symptoms of compression appear, since it once happened to 
 M. Trousseau, from neglect of this precaution, that the fluid acted on 
 the base of the skull, detaching the ethmoid bone from its connections, 
 and thus occasioned the infant's death. The pressure of a broad elastic 
 band around the head, as I have seen it applied by my colleague, Dr. 
 Dickinson, is a safer proceeding, and is more readily manageable than is 
 the use of plaster. Both act on the same principle as tight bandaging 
 in cases of ovarian dropsy. The pressure is in neither instance curative, 
 it merely retards the outpouring of the fluid, but with this special ad- 
 vantage in the case of chronic hydrocephalus, that time brings with 
 
 1 Cases of Chronic Hydrocephalus, &c, by J. H. Barnard, 8vo., London, 1839. 
 
 2 Journal de Medecine, April, 1843. 
 
120 CHRONIC HYDROCEPHALUS. 
 
 it increased ossification of the skull, and resistance to the effusion similar 
 to, but more efficient than, the temporary obstacle which the bandage 
 furnished. 
 
 You will naturally inquire whether pressure is applicable to every 
 case, and if not, when it should be employed ? I regret that I cannot 
 answer these inquiries so satisfactorily as I could wish. It is my be- 
 lief, however, that cases of external hydrocephalus, which have suc- 
 ceeded to previous hemorrhage into the arachnoid, will be found better 
 adapted than any others to treatment by mechanical means ; while I 
 am quite sure, from actual experience, that when there is any appear- 
 ance of active cerebral disease, pressure Avill not do good. 
 
 Puncture of the cranium, and the evacuation of the fluid, is another 
 proceeding which has been ocasionally resorted to from a very early 
 period in the history of medicine, and which is even at the present day 
 strongly advocated by some writers ; not merely as a palliative measure, 
 or as an adjunct to other remedies, but as a means of effecting the radi- 
 cal cure of the disease. Opinion, however, is much divided as to the 
 propriety of this practice, the statistics of which certainly do not yield 
 any very encouraging results. . Fifty-six cases, the particulars of which 
 I published many years ago, 1 as I found them recorded in various pub- 
 lications, yielded a proportion of fifteen alleged recoveries; but on sub- 
 jecting these cases to a rigid analysis, it appeared that in only four of 
 this number were the particulars recorded with sufficient accuracy, or 
 had the interval since the performance of the operation been long 
 enough to warrant our admitting them as permanent cures. The very 
 unfavorable conclusions which I then expressed with reference to this 
 operation were afterwards criticized by M. Durand-Fardel, 2 a gentle- 
 man whose opinion on any question connected with cerebral disease is 
 entitled to very great weight. He observed, that while it is admitted 
 that in a few cases puncture of the cranium has been followed by com- 
 plete and permanent cure, its failure on other occasions was often mani- 
 festly due to the existence of utterly incurable malformation of the 
 brain ; while in many instances, though the operation failed to effect a 
 cure, yet the very frequency with which it was repeated proved that in 
 itself it is not usually attended with any considerable danger. Since, 
 then, it may do good — since, if it should fail, its failure is often due to 
 causes which no remedy could remove — since, even if it should do no 
 good, yet in the majority of instances it will do no harm, while if left 
 to itself the course of the disease is almost invariably to a fatal result, 
 he advocates its performance in cases of chronic hydrocephalus. Though 
 I cannot but fear that this gentleman rather underrates the amount of 
 immediate risk attendant on the operation, yet I think that his author- 
 ity ought at least to have so much weight with you as to prevent your 
 looking upon its performance as altogether unjustifiable, and the rather 
 since there is good reason for believing that the accumulation of fluid 
 in the ventricles is frequently the result of previous inflammation of 
 their lining membrane, and that puncture of the cranium may therefore 
 
 1 In the Medical Gazette, April, 1842 
 
 2 In the Bulletin Generale de Therapeutique, vol. xxiii, p. 190. 
 
HYPERTROPHY OF THE BRAIN. 121 
 
 contribute to {he cure of dropsy of the brain, just as tapping the abdo- 
 men does to the cure of ascites. 1 
 
 I should regard any case as favorable for the operation, which, on the 
 whole, there was good ground for believing to be one of external hydro- 
 cephalus, or in which the enlargement of the head had not been attended 
 by indications of active cerebral disease. Though less promising, I 
 should not reject the operation simply because enlargement of the head 
 had been congenital ; while I should always be more ready to operate 
 if nutrition were well performed than if the child were emaciated. I 
 would not, however, have you operate simply because the head is large; 
 for it does not appear that diminution in its size has resulted from the 
 puncture, but only arrest of its enlargement: and if the disease is at a 
 standstill, and the cerebral functions are tolerably well performed, you 
 would risk much, with the chance of gaining but very little. The 
 proper situation for the puncture is the coronal suture, about an inch 
 or an inch and a half from the anterior fontanelle. A fine trocar and 
 canula are the best instruments; and care must be taken not merely to 
 withdraw only a very few ounces of fluid at a time, but to keep up 
 pressure both during the escape of the fluid as well as afterwards. 
 
 LECTURE X. 
 
 Hypertrophy of the Bratn. — Usually associated with general disorder of nutri- 
 tion — Symptoms and course — Seldom directly fatal — Nature of change in brain 
 — Alterations in form of skull, and difference from chronic hydrocephalus — 
 Treatment — Partial hypertrophy. 
 
 Atrophy or the Brain. — Case illustrative of its defective development — "Wasting 
 of the brain in protracted illness — Temporary retrocession of mental powers in 
 children after long illness — Case of partial atrophy. 
 
 The anxiety of parents is sometimes needlessly excited in consequence 
 of an infant's head being larger than common ; and even though the 
 child's health be good, the relations are apprehensive lest it should be 
 affected with water on the brain. Xow you must not be too ready to 
 take up this cry, which is one often raised by nurses and ignorant per- 
 sons, or to suppose that every large head is therefore unnatural; for 
 one child may have a bigger head than another, just as it may have a 
 bigger 'hand or foot. But it may be that the child's head is not only 
 larger than natural, but that well-marked symptoms of cerebral dis- 
 
 _ 
 
 1 See, moreover, some remarks on this operation, and cases of its successful per- 
 formance, in the Oesterr. Med. Jahrbiicher, vol. xxii. p. 27, by Dr. Schopf-Merei, 
 late of Manchester, and previously the distinguished director of the Children's Hos- 
 pital at Pesth. 
 
122 HYPERTROPHY OF THE BRAIN. 
 
 turbance are present, and yon may feel yourself compelled to adopt the 
 opinion that the case is one of incipient chronic hydrocephalus. The 
 subsequent history of the patient may in many respects confirm your 
 original diagnosis, so that great will be your surprise, on examining 
 the body after death, at not finding a drop of serum in the ventricles, 
 although, when you opened the skull, the cerebral convolutions had 
 appeared flattened, as if the brain were greatly distended with fluid. 
 
 Individual cases of this kind had been mentioned by medical writers 
 at different times, but Laennec 1 was the first who drew attention to 
 hypertrophy of the brain as a condition resembling chronic hydrocepha- 
 lus in many of its symptoms, and liable to be mistaken for it. It has 
 since then been frequently noticed, and I am not sure that an undue 
 importance has not sometimes been attached to it, as though it were of 
 much more common occurrence than you will really find it to be in 
 practice. 
 
 I have placed upon the table a cast taken from the head of a child 
 who was affected with hypertrophy of the brain, and whose very re- 
 markable case is related by Sir Thomas Watson. 2 He came under the 
 care of the late Dr. Sweatman when two years old, and his head, which 
 had been gradually increasing from the age of six m mths, was then so 
 large as by its weight to prevent the child from continuing long in the 
 upright posture. The boy was active and lively, though thin. He 
 had never any fit or convulsion, but occasionally seemed uneasy, and 
 would then relieve himself by laying his head upon a chair. He had 
 never squinted, nor was he subject to drowsiness or starting during his 
 sleep, and his pupils contracted naturally. His appetite Avas good, and 
 and all the animal functions were well performed. The case was 
 supposed to be one of chronic hydrocephalus ; but no urgent symptoms 
 being present, active remedies were not employed. About six months 
 afterwards the child died of inflammation of the chest, and Dr. Sweat- 
 man examined the head. It measured 1 2 inches from ear to ear over 
 the vertex, 13 inches from the superciliary ridges to the occipital, and 
 21 inches in circumference. The anterior fontanelle, which was quite 
 flat, measured 2 J inches by 1J across its opposite angles; the posterior 
 fontanelle was completely closed, as was the frontal suture. The skull 
 generally was increased in thickness ; the morbid appearances in the 
 membranes of the brain were quite trivial ; the ventricles were empty, 
 not dilated ; the convolutions were perfectly distinct, and retained their 
 proper rounded shape. The medullary matter, however, presented a 
 very unusual vascularity. 
 
 It is not merely on account of the great size which the head attained 
 that I have quoted this history, but because it affords an instance of 
 the overgrowth of the brain unconnected with any general disorder of 
 the processes of nutrition. Such an occurrence is very rare, for hyper- 
 trophy of the brain is usually only one manifestation of a deepseated 
 disorder of the nutritive process, and is met with, in connection with 
 rickets or scrofula, in the narrow lanes of a crowded city, or in the 
 
 1 Journal de Medecine, Chirurgie, et Pharmacie, 1806, t. xi, p. 669. 
 
 2 Lectures, 5th ed., vol. i, p. 384. 
 
ITS SYMPTOMS. ' 1.23 
 
 unhealthy valleys of mountainous districts, where goitre and cretinism 
 are endemic. 
 
 The majority of eases of hypertrophy of the brain that have come 
 under my notice in London have occurred in infants about six or eight 
 months old. Their history had usually been, that without any definite 
 illness, the children had lost their appetite, and grown by degrees dull 
 and apathetic, though restless and uneasy. Notwithstanding the gene- 
 ral apathy, this restlessness is often very considerable, though it does 
 not show itself in cries so much as in a state of general uneasiness, and 
 in frequent startings from sleep. Short gleams of cheerfulness occur 
 when the children are awake, but these are usually very transient. 
 The head seems too heavy to be borne, and even when its size is not 
 much greater than natural it hangs backwards, or to one side, as if the 
 muscles were too weak to support it. If placed in its cot, a child who 
 is thus affected bores with its occiput in the pillow, while its head is 
 almost constantly in a state of profuse perspiration. Convulsions 
 sometimes occur without any evident cause, but threatenings of their 
 attack are much more frequent than their actual occurrence, the child 
 awaking suddenly with a start and a peculiar cry, like that of spas- 
 modic croup, the surface turning livid, and the respiration becoming 
 difficult for a few moments, and the symptoms then subsiding of their 
 own accord. Such attacks may issue in general convulsions, which 
 may terminate fatally, but infants thus affected do not by any means 
 invariably die of the cerebral disorder ; but, being weakly, they are 
 often cut off by the first malady which attacks them. 
 
 If life be prolonged, it becomes more and more evident that the 
 process of nutrition is imperfectly performed : the child loses flesh and 
 looks out of health, and enlargement of the wrists and ankles shows 
 the connection between this disease and rickets — a connection which 
 becomes more evident in the second and third years of the child's 
 life. When the child survives infancy, or when, as occasionally 
 happens, the symptoms of hypertrophy of the brain do not come 
 on until dentition has been in a great measure accomplished, convul- 
 sions are of very rare occurrence. Complaints of headache, however, 
 are frequent and severe ; and, though drowsy in the daytime, the child 
 generally rests ill at night, and often awakes crying and alarmed. 
 Besides the symptoms, too, the child has occasional attacks of feverish - 
 ness, with great increase of the headache and giddiness, which last for 
 a few hours or a day, and then subside of their own accord, while it 
 grows by degrees more and more dull and listless, and its mental 
 powers become obviously impaired. 
 
 It happens, in some cases, that as the child grows older, these 
 symptoms become less and less severe ; the health improves, the 
 rickety deformity of the limbs gradually disappears, and the infant 
 who had excited so much solicitude, becomes at length a healthy child. 
 There is a termination in complete idiocy, which I have never seen in 
 this country, but some years ago I observed some instances of it in the 
 Hospital for Cretins, which then existed near Interlachen ; and I 
 believe that the association of cretinism and idiocy with hypertrophy 
 of the brain is by no means of unusual occurrence. Death is not often 
 
124 HYPERTROPHY OF THE BRAIN. 
 
 the direct result of the affection of the brain, but generally takes place 
 owing to the supervention of some other disease. The affections, how- 
 ever, which prove most fatal are those which favor cerebral conges- 
 tion — such as hooping-cough, or the eruptive fevers, especially scarlatina. 
 
 You must not infer that hypertrophy of the brain has existed in 
 every instance in which the organ may appear to be large, and its con- 
 volutions somewhat flattened, although the ventricles are free from 
 fluid. The weight and apparent size of the brain are much influenced 
 by the quantity of blood contained within it, and it may appear too 
 large for the skull simply because the vessels are over full. 1 In true 
 hypertrophy, on the contrary, the brain is generally pale and anaemic, 
 unless death should chance to have taken place as the result of an at- 
 tack of cerebral congestion. Neither, indeed, is the process one of mere 
 increased growth, but the nutrition of the organ is modified in charac- 
 ter as well as increased in activity. The gray matter of the brain is 
 but little involved in it, and, with the exception of its color being 
 somewhat paler than natural, it shows scarcely any alteration. The 
 white matter, on the contrary, is both paler and firmer than in a state 
 of health ; and Professor Rokitansky 2 states, as the result of many 
 microscopical 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 gran- 
 ular matter, most probably due to an albuminoid infiltration of that 
 structure. 3 These changes, too, do not affect indifferently all parts of 
 the brain, but are confined to the hemispheres, and do not implicate 
 either the base of the organ or the cerebellum. 
 
 Chronic hydrocephalus is the only affection with which hypertrophy 
 of the brain is liable to be confounded : the diagnosis between the two 
 affections is often by no means easy, though it is of much importance 
 with reference both to our prognosis and our treatment, for we should 
 have more hope of the recovery of a child whose brain is merely hy- 
 pertrophied than of one whose brain is distended with fluid, while the 
 means by which w^e should endeavor to effect a cure would differ widely 
 in the two cases. The history of the patient would afford some help 
 towards determining this question ; for the symptoms of chronic hydro- 
 cephalus generally come on earlier, and soon grow much more serious, 
 than those of hypertrophy of the brain, and the cerebral disturbance 
 is throughout much more marked in cases of the former than in those 
 of the latter kind. The form and size of the head, too, present pecu- 
 liarities by which you may often be enabled to distinguish between the 
 two conditions. Both diseases are attended by enlargement of the 
 head, and in both the ossification of the skull is very tardy, but the 
 head does not attain so large a size in hypertrophy of the brain as in 
 chronic hydrocephalus, neither are the fontanelles and sutures so widely 
 open. The skull, likewise, presents some peculiarities in form, which 
 are so remarkable as to have attracted the attention of several observ- 
 
 1 See Mauthner's elaborate tables of the weight of the brain in various circum- 
 stances, lib. cit., sect. v. 
 
 2 Lib cit , 3d ed., Vienna, 1856, vol. ii, p. 430. 
 
 3 See Jenner's valuable Lectures on Eickets, Lect. Ill, in Med. Times, April 28 T 
 i860, p. 415. 
 
ITS TREATMENT. 125 
 
 ers. The head not merely shows no tendency to assume the rounded 
 form characteristic of chronic hydrocephalus, but its enlargement is 
 first apparent at the occiput, and the bulging of the hind head contin- 
 ues throughout especially striking. The forehead may, in the course 
 of time, become prominent and overhanging, but the eye remains deep 
 sunk in its socket, for no change takes place in the direction of the 
 orbitar plates such as is produced by the pressure of fluid within the 
 brain, and. which gives to the eye that unnatural prominence, and that 
 peculiar downward direction, so striking in cases of chronic hydroceph- 
 alus. In hydrocephalus the anterior fontanelle is tense and prominent, 
 owing to the pressure of the fluid within, but when the brain is hyper- 
 trophied there is no prominence, but an actual depression in this situa- 
 tion. I have more than once observed this condition in a very remark- 
 able degree, the depression not being limited to the anterior fontanelle, 
 but being observable at all the sutures ; and you may notice something 
 of the kind in this cast. 
 
 When hypertrophy of the brain occurs in the adult, the symptoms 
 that arise are in great measure due to the compression which the organ 
 undergoes from its bony case being too small to contain it. These 
 symptoms are of course obscure, while, even if the nature of the affec- 
 tion could be recognized, its cure must be hopeless. In the infant, 
 however, and the child whose head is incompletely ossified, the imme- 
 diate consequences of the evil are far less serious, while some benefit 
 may be expected from the judicious employment of treatment, since 
 over-development of the brain in childhood is almost always associated 
 with general disorder of the processes of grow T th and nutrition. We 
 are not, indeed, acquainted with any means by which we can directly 
 check the morbid increase of the brain, but all our efforts should be 
 turned towards improving the general health, while we interfere di- 
 rectly with the cerebral symptoms only in so far as their urgency may 
 render it absolutely necessary. The child, therefore, must not be dosed 
 with calomel merely because its head is affected, though the deficient 
 secretion of bile may often render the employment of small doses of 
 mercurials necessary. Similar restrictions would apply to depletion, 
 for we have seen that the hypertrophied brain is characterized by a 
 want of blood rather than by its superabundance ; but, nevertheless, 
 occasional attacks of cerebral congestion may render local depletion 
 necessary, and the exacerbations of headache, with vertigo and fever, 
 will, if severe, be often benefited by its employment. At one time I 
 tried counter-irritation by means of the tartar-emetic ointment rubbed 
 into the back of the neck, with apparent relief to the head symptoms, 
 in the case of children who were suffering from the indications of hy- 
 pertrophy of the brain, but the ointment is by no means manageable, 
 and the sores which it produces are often very distressing. I have 
 therefore for some years entirely discontinued its use, and content my- 
 self in all cases with the application of blisters ; or with the employ- 
 ment of the blistering fluid, which from the rapidity of its action is far 
 preferable when one's patients are children. In young infants, one of 
 our first efforts must be to relieve the brain from the constant irritation 
 to which it is exposed when the child is in the recumbent posture, and 
 
126 TREATMENT OF HYPERTROPHY OF THE BRAIN. 
 
 the head rests on the yielding and imperfectly ossified occiput. For 
 this purpose we cannot do better than follow the suggestion of a German 
 physician, *Dr. Elsasser, 1 and have a small horsehair cushion prepared 
 for the child's head to rest on, a piece being cut out of it large enough 
 to receive the occiput. In^cases both of hypertrophy of the brain and 
 of chronic hydrocephalus, I have seen the adoption of this simple con- 
 trivance followed by almost immediate cessation of the rotatory move- 
 ment of the head, and by quiet sleep in its cot, to which perhaps for 
 weeks before the child had been a stranger. 
 
 It is not desirable that a child who suffers from this affection should 
 sleep entirely without covering to the head. The profuse perspiration 
 of the head is more effectually checked by a thin linen cap, which may 
 be changed once or twice in the night, while at the same time the child 
 is saved from the danger of catching cold. 
 
 While these hygienic proceedings, which have especial reference to 
 the head, are attended to, the child should be daily sponged with salt 
 and water, or with sea-water, if it be possible to remove it to some 
 place on the coast, such as Brighton ; or it would probably be bene- 
 fited by immersion in a tan-bath, in which it should remain for sev- 
 eral minutes. 2 
 
 The remedies under the continued use of which I have seen the 
 most good results are the extract of bark, from which you may pass to 
 the preparations of iron — such as Vinum Ferri, or the ferrocitrate of 
 quinine. 3 I have not made much trial of the iodide of potassium, 
 since in all the cases that I have seen some more decided tonic ap- 
 peared necessary. I have, however, given the syrup of the iodide of 
 iron sometimes with advantage ; and in cases where the tendency to 
 rickets was well marked, I have observed a most decided improve- 
 ment follow the use of cod-liver oil, in doses of a drachm twice a day 
 for a child of three years old. I ma}* just mention that, notwith- 
 standing its nauseous taste, this medicine is usually readily taken by 
 children, some of whom even become fond of it. 
 
 With reference to diet, it will probably be desirable, if the child is 
 not weaned, to obtain for it a healthy wet-nurse,; while, after weaning, 
 a diet of milk, with an e£g once or twice daily, will often agree better 
 than any other food. In cases of this kind, and, indeed, in all where 
 the digestive powers are feeble, a preponderance of farinaceous food is 
 not desirable, while the child may with safety be allowed a little veal 
 broth or beef tea daily, or even a little meat if it have cut some of its 
 molar teeth. 
 
 Cases of partial hypertrophy of the brain are on record, in which 
 one hemisphere alone was affected, or in which some one or more of the 
 central parts of the brain greatly exceeded the natural size, whilst the 
 
 1 Der weiehe Hinterkopf, 8vo., p. 205. Stuttgart, 1843. 
 
 2 The tan-bath, which I have employed with very marked benefit in the case of 
 weakly and rickety children among the poor, is prepared, as directed by Dr. 
 Elsasser, by boiling three handfuls of bruised oak bark, tied up in a linen bag, in 
 three quarts of water for half an hour, and adding the decoction to the water of 
 the child's bath. These baths should be applied tepid, and thpir use should be con- 
 tinued every day for several weeks 
 
 3 See Formulas Nos. 4 and 5, at p. 57. 
 
ATROPHY OF THE BRAIN. 127 
 
 rest of the organ deviated in no respect from its normal condition. An 
 instance of the kind yon see represented in this drawing of Dr. Manth- 
 ner's, 1 in which the right optic thalamus was as large as a hen's egg 
 in a girl of three years old. In cases of this sort sometimes no symp- 
 toms are present, and the anomaly is only accidentally discovered after 
 death ; whilst in others, although there are indications of cerebral dis- 
 turbance, yet they are not such as to enable us to determine the nature 
 of the evil of which they are the expression. 
 
 There is a condition of the brain the direct opposite of that which 
 we have been examining, in which the organ falls below the natural 
 size, or in which atrophy of the brain exists. I do not refer here to 
 those cases where the brain is imperfectly formed, the head exceedingly 
 small, and the child idiotic from birth ; but this state of microcephalus 
 appears sometimes to come on afterwards, owing probably, as has been 
 suggested^ to premature closure of the fontanelles and sutures. Such 
 a case I saw several years ago, when a woman brought to me her boy, 
 who was three years old, the elder of two children of perfectly healthy 
 parents, none of whose relatives had ever shown any sign of consump- 
 tion, idiocy, or mental derangement. When born, this boy was per- 
 fectly well formed, neither did he present any peculiarity till he was six 
 months old, when his mother began to observe that he did not look any 
 one in the face, and that he seemed to take but little notice of anything. 
 When eight months old, he began to have fits, which had since re- 
 turned about once a week, being preceded by extreme restlessness for a 
 day or two. The fits lasted for a quarter of an hour; they were at- 
 tended by convulsive movements of both sides, and followed by drow- 
 siness, which continued for some days. The child ate and drank, 
 though not heartily, and he never seemed anxious for food. He did 
 not distinguish between what was nice and what was nasty, swallowing 
 all things with the same readiness, though deglutition appeared to be 
 difficultly performed. He had cut all his teeth, he seemed tolerably 
 well nourished, and his body and limbs were well formed. He was, 
 however, quite unable to stand ; he passed his urine and faeces under 
 him without appearing to take the slightest notice of it, and he seemed 
 destitute of every glimmering of understanding. His mother said that 
 his head was smaller than that of her infant, which was only six months 
 old. It measured 17 inches in circumference around the parietal pro- 
 tuberances, and 11 inches across the head from the centre of the 
 meatus of one ear to the same point on the opposite side. The fore- 
 head was extremely narrow, and the head shelved upwards quite in a 
 sugar-loaf shape. All the sutures and fontanelles were firmly ossified, 
 but I have unfortunately omitted to record at what age they became so. 
 I never saw this boy again, but several similar cases have since come 
 under my notice. In all such cases the intellectual faculties are more 
 or less impaired; the condition being sometimes one of the lowest idiocy, 
 but I do not think that there is any invariable relation between the 
 degree of intellectual deficiency, and the degree of smallness of the skull. 
 The poor children who some twenty years ago were exhibited in Lon- 
 
 1 Lib. cit., plate i, and p. 189. 
 
128 ATROPHY OF THE BRAIN. 
 
 don as Aztecs, furnished a remarkable illustration of the effects of train- 
 ing in bringing out in the case of idiots who were at the same time re- 
 markable microcephali some of the lower forms of intelligence and that 
 imitative faculty with which idiots are often singularly endowed. I 
 have nothing more to say about such cases, for their cure is manifestly 
 quite hopeless, and, therefore, though they may interest us as patholo- 
 gists, they scarcely concern us as practical physicians. 
 
 Of much higher practical importance are those instances in which 
 the brain of children wastes during long-continued illness. The scalp in 
 such cases will usually be found bloodless, the fontanelles collapsed, 
 and the process of ossification will be seen to have been unusually 
 tardy. Fluid will be found within the sac of the arachnoid, and effused 
 into the subjacent pia mater. The brain will be far from filling up the 
 cavity of the skull, so that a knife may be passed in many places be- 
 tween it and the cranial walls. The sulci between the convolutions 
 appear unusually deep, and fluid will be found both at the base of the 
 brain and in the ventricles, as well as in the pia mater. The cerebral 
 substance is pale, and its texture firmer than usual. 
 
 The important point about such cases is, that cerebral symptoms and 
 frequently recurring convulsions may be observed in a child whose 
 brain is nevertheless not diseased, but too feeble and too wasted to per- 
 form its functions. If, then, you find indications of cerebral disturbance 
 come on in infants who have been exhausted and emaciated by previous 
 illness, you must not interpose too hastily with remedies directed 
 against a supposed disease of the brain, but bethink you whether these 
 symptoms may not be merely the signs of the brain having become un- 
 equal to its duties from its having been imperfectly nourished : and do 
 not, without consideration, abandon the tonic plan of treatment which 
 you had been previously pursuing. 
 
 It is only in infants that accidents of this grave nature are likely to 
 ensue from the imperfect nutrition of the brain consequent on protracted 
 illness: but symptoms arise in older children, in similar circumstances, 
 well calculated to excite the apprehension of parents. In children who 
 have but lately learned to talk, I have sometimes known loss of speech 
 follow a long illness, the child being too weak to talk, just for the same 
 reason as it is too weak to walk. Occasionally, however, the child ap- 
 parently regains its previous health, and yet makes no efforts to articu- 
 late, even for two or three months. In cases of this kind I have seen 
 parents thrown into great anxiety from the fear lest the child's con- 
 tinued silence should be the result of the intellect having become im- 
 paired during its illness. I imagine that in many of these cases the 
 child has forgotten during its illness much of its newly acquired knowl- 
 edge, and that it is some time before it again feels equal to the mental 
 effort of shaping its ideas into words. But usually, when it begins to 
 make the effort, it recovers its speech rapidly ; and you may therefore 
 console the parents with this prospect. 
 
 Even a manifest retrocession of the intellectual endowments should 
 not be regarded with too much anxiety, when it has followed some long- 
 continued disease, for it may be the result of mere weakness ; the vacant 
 look, the unmeaning laugh, and the silly manner, gradually disappear- 
 
PARTIAL ATROPHY OF THE BRAIN. 129 
 
 ing as the child gains strength. The brain seems to regain its lower 
 powers, and to perform its humbler functions, before it resumes its 
 nobler office as the organ of the mind. 
 
 Partial Atrophy, like partial hypertrophy of the brain, may occur, 
 we know not why, and may be discovered after death, where the exist- 
 ence of cerebral disease had never been suspected; or we may find the 
 explanation of a number of anomalous symptoms, which had existed 
 during life, in a wasted condition of some portion of the organ. This 
 state may be the result of original conformation, or it may come on as 
 the result of disease, in which latter case the substance of the wasted 
 portion of the brain is usually found to be much firmer than natural. 
 We are greatly in the dark as to the nature of the process by which 
 this 'change is effected ; but it is thought in some cases to be the remote 
 consequence of hemorrhage into the cerebral substance, and in others, 
 to be induced by a slow kind of inflammation. One case of this kind 
 has come under my own notice, which, for its rarity, I will relate to you. 
 
 The patient was a little girl, aged three years and ten months, the 
 child of phthisical parents, but w r hose health, though delicate, had 
 never been interrupted by any serious illness until she had an attack 
 of remittent fever in the early part of the spring of 1 845 : she recovered 
 from it without any bad symptom, and seemed doing pretty well for 
 about a month, when she became sleepy and heavy, and feverish, for 
 which symptoms she was brought to me on May 19th. After being 
 under a mild antiphlogistic treatment for a week, she got better, and 
 was beginning to walk about again, when she awoke one morning with 
 her face drawn to one side — a condition, however, which did not con- 
 tinue. When she attempted to walk, it was noticed that she halted 
 very much on her left leg, and that it sometimes gave way under her, 
 so that she fell down on that side, and then turned round upon her 
 back. She had, besides, but little power with her left hand and arm, 
 so that she could not grasp anything firmly, nor hold it steadily. The 
 child's bowels were at that time constipated : I purged her freely, and 
 sent her into the country, whence she returned in the beginning of 
 August much improved in every respect, though still limping a little 
 with the left leg, and using her right arm in preference to the left. At 
 the end of September I saw her again, she having then a bad impeti- 
 ginous eruption on the scalp, which was treated with warm poultices 
 and water-dressing ; when, on October 6th, she began to limp with her 
 right leg, just as she had previously done with her left; though in other 
 respects she continued pretty well. On October 17th, the affection of 
 the right leg was a good deal less marked ; but the child now became 
 unwilling to walk, often turning giddy, and always catching hold of 
 something by which to steady herself. When attempting to walk she 
 often fell down into a sitting posture ; and then would sit on the floor, 
 laughing loudly. Fits of uncontrollable laughter often came on with- 
 out any cause, and the face began to assume an idiotic expression. There 
 was occasionally slight inward strabismus of both eyes, but the pulse 
 was undisturbed ; the bowels were regular and the evacuations natural, 
 and the child rested well at night, though her head was often rather 
 hot. A week afterwards there w r as no new T symptom, except that the 
 
 9 
 
130 PARTIAL ATROPHY OF THE BRAIN. 
 
 child kept her neck quite stiff, as though she feared to move it. Her 
 head grew hotter, and she began to have a frequent teasing cough, while 
 her power of walking varied almost every day ; she now, too, grew more 
 restless at night. On the morning of the 27th, frequent convulsive 
 twitches of the muscles of the face and extremities came on, and the left- 
 eye became permanently turned inwards. She had no sleep in the 
 night ; general convulsions came on at 8 a.m. on the 28th and she died 
 convulsed two hours afterwards. 
 
 I found some deposit of tubercle in the bronchial glands, but none 
 in the brain, where I had expected to discover it. The left hemisphere 
 of the cerebellum, however, was fully a third smaller than the right ; 
 thus presenting an additional instance in confirmation of Schroder van 
 der Kolk ? s statement 1 as to the greater frequency of unilateral atrophy 
 on the left side of the brain ; it was of extremely firm consistence, 
 quite leathery, and on making a section of it, its surface presented a 
 rose tint. The halves of the pons and medulla oblongata were of equal 
 size, as were the two hemispheres of the cerebrum. It was evident, too, 
 that this condition was not congenital, since the two halves of the skull 
 were of equal size, and the elevations and depressions in the interior of 
 its base Avas precisely similar on both sides. There was a little fluid at 
 the base of the brain, but none in the ventricles ; a state of general con- 
 gestion of the brain and its membranes being the only other remark- 
 able appearances. 
 
 The spinal cord could not be examined. 
 
 There was no trace of any old effusion of blood in the substance of 
 the cerebellum, though the symptoms that occurred in May, and the 
 subsequent gradual improvement of the patient, are not easily explica- 
 ble on any other supposition than that hemorrhage had at that time 
 taken place into the substance of the brain. The history of the case 
 presents another difficulty, in the circumstance that the disease was 
 seated on the same side as that to which the symptoms had been chiefly 
 referred. Another problem which I cannot pretend to solve is, why 
 the paralysis should in the first instance have affected the left side, 
 while, on the occurrence of the relapse in October, the right leg was 
 palsied. I must therefore content myself with the bare relation of this 
 history. 
 
 1 In his essay on "Atrophy of the Brain," published in vol. xi of the new Syden- 
 ham Society's publications, he states that in 17 out of 29 cases, the affection was situa- 
 ted on the left side of the brain. In his case, however, while the left hemisphere of the 
 cerebrum was wasted, the right half of the cerebellum and the right half of the cord 
 were atrophied. In his case the right side of the body was atrophied ; in my case, 
 no wasting of any part of the trunk or extremities was observed, the child's inability 
 to regulate her movements being apparently the chief result of the affection of the 
 cerebellum. S. van der Kolk, in his elaborate essay, regards the affection not as the 
 result of congenital malformation, but a* the probable consequence of inflammatory 
 action, occurring sometimes before birth, at other times in early infancy ; and the 
 change of consistence of the brain-substance observed in my case bears out the same 
 opinion. 
 
HYDROCEPHALOID DISEASE. 131 
 
 LECTUEE XL 
 
 Hydrocephaloid Disease. — Often succeeds to sympathetic disturbance of brain 
 in course of various affections — Supervening on diarrhoea, pneumonia, and cere- 
 bral congestion — Diagnosis in each of these circumstances — Prophylaxis, and 
 treatment. 
 
 Tubercle of the Brain. — Its frequency in childhood — Its anatomical characters — 
 Symptoms — Occasionally absent — Generally very obscure — Symptoms of pre- 
 monitory stage, their great diversity — Symptoms of acute stage also various — 
 Diversities in these respects cannot be altogether explained by the morbid ap- 
 pearances — Occasional recovery where symptoms of cerebral tubercle have long 
 existed — Treatment. 
 
 Hydatids and Cancer of the brain. 
 
 Closely connected with the state of atrophy of the brain, which w T e 
 examined in the last lecture, is that condition which is induced if the 
 organ be somewhat suddenly deprived of its usual supply of blood. 
 Even in the adult a profuse loss of blood is followed, as you w r ell 
 know, by extremely severe headache, and by various other cerebral 
 symptoms. In the child, whose brain needs for the due performance 
 of its functions a proportionably larger quantity of blood, the symp- 
 toms that follow its excessive loss are of a corresponding gravity. 
 Often, indeed, they present a striking similarity to those which be- 
 token inflammation of the brain ; a fact implied in the name of hydro- 
 cephaloid disease, by which Dr. Marshall Hall, who was among the- 
 first to call the notice of the profession to this affection, has proposed 
 that it should be designated. 
 
 " This affection," says he, in his admirable essay on the subject, 1 
 " may be divided into two stages : the first, that of irritability : the 
 second, that of torpor. In the former there seems to be a feeble at- 
 tempt at reaction; in the latter, the 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 fever- 
 ish ; the face flushed, the surface hot, and the pulse frequent ; there is 
 an undue sensitiveness of the nerves of feeling, and the little patient 
 starts on being touched, or from any sudden noise ; there are sighing 
 and moaning during sleep, and screaming; the bowels are flatulent 
 and loose, and the evacuations are mucous and disordered. 
 
 " If, through an erroneous notion as to the nature of this affection, 
 nourishment and cordials be not given, or if the diarrhoea continue, 
 either spontaneously, or from the administration of medicine, the 
 exhaustion which ensues is apt to lead to a very different train of 
 
 1 Kepublished in his work On the Diseases and Derangements of the Nervous 
 System, 8vo., chap, v, sect, iii, London, 1841. It can scarcely be necessary to 
 refer to Dr. Gooch's paper On Symptoms in Children erroneously attributed to 
 Congestion of the Brain, for ano'ther most graphic account of this disorder. 
 
132 HYDROCEPHALOID DISEASE. 
 
 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 irregular, and ef- 
 fected by sighs : the voice becomes husky ; and there is sometimes a 
 husky teasing cough ; and eventually, if the strength of the little pa- 
 tient continue to decline, there is a crepitus or rattling in the breathing. 
 The evacuations are usually green ; the feet are apt to be cold." 
 
 In early infancy symptoms of this kind sometimes succeed to prema- 
 ture weaning, especially if that is followed by an unsuitable diet ; but 
 afterwards they are generally induced by some definite attack of illness, 
 either exhausting in itself, or for the cure of which active measures 
 had been necessary. It is important too to bear in mind that they are 
 not equally apt to come on in the course of all diseases, but that those 
 in the early stages of which considerable cerebral irritation has existed, 
 are much more likely to assume the characters of this spurious hydro- 
 cephalus when the bodily powers are exhausted. 
 
 There is no disorder in which the two conditions of considerable 
 sympathetic disturbance of the brain, coupled with rapid exhaustion of 
 the vital powers, are so completely fulfilled, as in infantile diarrhoea, 
 and in no other affection do we meet with such frequent or such well- 
 marked instances of the supervention of the hydrocephaloid disease. 
 
 Some time since a previously healthy boy, aged 18 months, was 
 brought to me suffering from vomiting and diarrhoea, which had ex- 
 isted for three days. After treatment had been continued for two days 
 the purging ceased, but the child seemed to have a distaste for all 
 nourishment, and refused both milk and arrowroot, and the mother 
 made but few attempts to overcome this repugnance; so that for 
 twenty-four hours the child took hardly anything except water and 
 barley- water, and those in small quantities. On the afternoon of the 
 sixth day the child became faint, and seemed so feeble during the night 
 that the mother became much alarmed, and came again to me on the 
 morning of the seventh day. The child's face was then sunken and 
 very anxious ; it lay as if dozing, with half-closed eyes, breathing 
 hurriedly ; suddenly waking up from time to time in a state of alarm 
 and restlessness, and then in a few moments subsiding into its former 
 condition. The skin was dry but cool, the extremities were almost 
 cold, the lips were dry and parched, and some sordes had collected 
 about the teeth ; the tongue was dry, red, and glazed, and coated in 
 the centre and towards the root with yellowish fur. The pulse was 
 extremely feeble. There was very great thirst. The bowels had not 
 acted for twelve hours. 
 
 I ordered the child a tablespoonful of equal parts of milk and 
 barley-water every half hour, with the addition of fifteen drops of 
 brandy every hour, and directed that some strong veal broth should be 
 prepared and given every two hours. At the same time, a draught 
 containing ten grains of aromatic confection, half a drachm of the com- 
 pound tincture of bark, and six drops of sal- volatile, was given every 
 three hours, and a grain of Dover's powder was directed to be taken at 
 bedtime. 
 
ITS SYMPTOMS. 133 
 
 Within six hours after the commencement of this treatment the 
 child began to improve ; it slept tolerably well in the night, and the 
 next day was lying tranquilly in bed, looking about and smiling 
 cheerfully ; the extremities were warmer, and the skin had lost its 
 harshness ; the tongue was no longer dry, and the pulse had increased 
 in power. The stimulants were gradually withdrawn; no further bad 
 symptoms came on, and the child was soon convalescent. 
 
 It is of great importance rightly to interpret the meaning of the 
 symptoms which attend the first stage of this affection, and to discrim- 
 inate between the cerebral disturbance of approaching exhaustion, 
 and that which implies the existence of real mischief in the brain. 
 
 A little girl was seized with diarrhoea on August 8, which at first 
 was severe, but soon yielded to treatment, and she was again convales- 
 cent; when, on the 15th, vomiting and purging returned with great 
 violence, and were attended with much febrile disturbance. On the 
 following day she was still worse in all respects, but was not brought 
 to me again until the 17th. Slie then looked exceedingly ill ; her face 
 was sallow, but with a flush on each cheek, and her eyes were deeply 
 sunk. She lay in a half-dozing state, with her eyelids half closed, and 
 the eyeballs turned upwards, so that nothing but the sclerotica was 
 visible ; but from this condition she awoke frequently and suddenly in 
 a state of great alarm, and looking as if she were about to have a fit of 
 convulsions. Her skki was hot and very dry ; her pulse very frequent, 
 but not strong ; and there was some subsultus of the tendons of the 
 wrist. The abdomen was rather tympanitic ; the tongue red, coated 
 with white mucus ; the thirst was great, the vomiting very frequent, 
 and the bowels acted two or three times in the course of an hour, the 
 evacuations having the appearance of dirty water. 
 
 The child was immediately placed in a tepid bath ; an enema con- 
 taining five drops of laudanum was next administered, and the abdomen 
 was covered with a large bran poultice. The extreme irritability was 
 almost immediately relieved by the warm bath, and still further soothed 
 by the enema. The bowels ceased to act so frequently, and the stomach 
 began to bear small quantities of barley-water and other drinks, which 
 were given cold. In a few hours the imminent danger had passed 
 away, and the child recovered in the course of a few days. 
 
 If, in a case of this kind, you fall into the error of regarding the 
 cerebral symptoms as the signs of active disease, and withhold the 
 Dover's powder, or the opiate enema that might have checked the 
 diarrhoea and soothed the irritability, while you apply cold lotions to 
 the head and give the child nothing more nutritious than barley-water 
 in small quantities, because the irritability of the stomach which re- 
 sults from weakness seems to you to be the indication of disease in the 
 brain, the restlessness will before long alternate with coma, and the child 
 will die either comatose or in convulsions. 
 
 But it is not only in the course of diarrhoea that errors of this sort 
 may be committed. The early stages of pneumonia are often attended 
 with so much sympathetic disturbance of the brain, as to throw the 
 other symptoms into the background. The child vomits, it refers all 
 its suffering to its head, and possibly has an attack of convulsions al- 
 
134 SPURIOUS HYDROCEPHALUS. 
 
 most at the outset. You not unnaturally assume the case to be one of 
 cerebral congestion, and treat it accordingly with free local depletion. 
 On the next da) r the indications of disordered respiration are more ap- 
 parent ; you think your former diagnosis was incorrect, and probably 
 apply more leeches to the chest to combat the pneumonia you had 
 overlooked. The urgency of the symptoms may be relieved by these 
 means, or, if that is not the case, still the reaction will diminish with 
 the diminished power, and the child for a short time seems to suffer 
 less. But soon the restlessness of exhaustion comes on, and then follow 
 the soporose condition and the apparent coma : you condemn yourself 
 for having overlooked the cerebral mischief, of which you fancy you 
 now have most convincing proof: you renew your antiphlogistic meas- 
 ures, to arrest, if it be not too late, this imaginary hydrocephalus, and 
 your patient dies. 
 
 Something of the same kind too may happen in cases where the 
 brain has really been congested, and where the depletion, which you 
 practiced somewhat too freely, was in reality indicated, though to a 
 smaller amount. The restlessness and heat of head may have been 
 diminished by your treatment, and the bowels may have been relieved 
 by the purgatives you administered. In a few hours, however, rest- 
 lessness returns, though not to so great a degree as before, the child 
 moans sadly when awake, and this suffering state alternates with a 
 drowsy condition, while the stomach, irritable before, now rejects every- 
 thing almost as soon as swallowed, though the child still seems eager 
 for drink. The previous arrest of very similar symptoms, though but 
 for a few hours, by active treatment, seems to you to indicate the pro- 
 priety of continuing the same plan, but, nevertheless, the drowsiness 
 deepens into coma, and the child dies, of hydrocephalus, as you sup- 
 pose — in reality of the nimia diligentia medici. 
 
 " Forewarned, forearmed," says the old proverb. When head-symp- 
 toms come on in the infant, do not judge of their import simply from 
 the present condition of the child, but ascertain its previous history. 
 Learn whether any other members of the family have had hydroceph- 
 alus or have been consumptive. Inquire whether this infant has 
 thriven at the breast, or whether it has for some time been drooping ; 
 if already weaned, ascertain on what it is now fed, whether signs of 
 declining health soon followed on the change of diet, while it throve 
 so long as it was suckled. Ask what signs of disorder of the bowels 
 there have been, and observe at what times the vomiting comes on ; 
 whether only after sucking or taking food, or whether efforts to vomit 
 occur when the stomach is quite empty. 
 
 In a case where the s}'mptoms of cerebral disturbance, and those of 
 disordered respiration, come on almost at the same time in a previously 
 healthy child, and so alternate with each other as to render your diag- 
 nosis difficult, you will do well to remember that pneumonia often sets 
 in with much sympathetic disorder of the nervous system, and that the 
 disease is much more likely to be seated in the lungs than in the brain. 
 In most cases auscultation will enable you to decide the question, and 
 if you once accustom yourselves to listen to a child's chest as invariably 
 as you would look at its tongue or count its pulse, you will but seldom 
 
ITS DIAGNOSIS. 135 
 
 have to reproach yourselves for the uncertain diagnosis and the vacil- 
 lating treatment into which, in eases of this description, you will other- 
 wise be too often betrayed. The use of the thermometer too ought to 
 keep you from much of the risk of error to which in former times you 
 would have been exposed. It may be laid down as a rule almost with- 
 out exception that when in any acute febrile affection of infancy or 
 childhood the thermometer rises within the first two days to 104° ; and 
 remains at that height, not for a few hours only but for twenty-four 
 hours or more, you have to do with inflammation of the lungs and not 
 with any form of cerebral inflammation. 
 
 In a child suffering from diarrhoea, you will be prepared to meet 
 with sympathetic disturbance of the brain, and will not allow the 
 occurrence of its symptoms to deter you from adopting the treatment 
 which the diarrhoea requires. If doubt cross your mind as to their 
 signification, and you fear lest mishief be really going on in the brain, 
 it will usually suffice to watch the symptoms closely, in order to detect 
 a want of correspondence between them, which would not exist if true 
 cerebral disease were present. Attention to this point will guard you 
 from error during the stage of excitement, as well as in that of exhaus- 
 tion and stupor, which simulates the last stage of hydrocephalus. 
 
 In no circumstances are mistakes more easily committed, and never 
 are their results more mischievous, than when real congestion of the 
 brain has been somewhat overtreated, and the consequent symptoms 
 of exhaustion are supposed to be those of advancing disease. In such 
 a case, however, it will usually be observed that great faintness had 
 been induced by the first depletion, and that the quiet which succeeded 
 it was that of exhaustion as much as of mitigated suffering. If so, the 
 returning restlessness will probably be the index of the feeble power of 
 the brain, no longer adequate to the performance of its wonted func- 
 tions, rather than .the evidence of active disease of the organ. Nor 
 will the history be the only safeguard from error, but the fontanelle 
 sunk below the level of the cranial bones, instead of being tense and 
 pulsating, the cool surface, and the pulse presenting no other characters 
 than those of frequency and feebleness, will all point to the real nature 
 of the case. You do not need to be told that to deplete in such cir- 
 cumstances would be to destroy your patient — that food is needed, not 
 physic. The sunken powers of life are to be rallied, and as their 
 strength returns, the functions of the brain will again go on harmoni- 
 ously. 
 
 Although the diagnosis of this affection is sometimes attended with 
 difficulty, the rules for its prevention and cure are happily very sim- 
 ple. Bearing in mind the possible supervention of the hydrocepha- 
 loid disease, you would never keep an infant from the breast, nor put 
 a young child on a spare diet for several days without most absolute 
 necessity ; you would pay especial attention to its food, if the disease 
 from which it suffers be, like diarrhoea, such as interferes directly with 
 its nutrition. Again, you would not trust depletion of a young child, 
 especially if suffering from head affection, to a nurse, but would your- 
 selves exercise the supervision of it. And, lastly, in the treatment of 
 every disease, you would at once suspend the antiphlogistic measures 
 
136 TUBERCLE OF THE BRAIN. 
 
 that you had previously been adopting, and resort to the use of stimu- 
 lants and tonics so soon as any of the symptoms that we have been 
 examining make their appearance. 
 
 The state of general restlessness and irritability that attends the 
 early stages of exhaustion is often greatly soothed by the tepid bath, 
 continued for not more than five minutes, for fear of still further de- 
 pressing the infant's powers. While you secure a free access of air too, 
 you must be extremely cautious to maintain the room at a sufficient 
 temperature ; for the power of generating heat is diminished in a very 
 remarkable degree in young animals who from any cause are insuffi- 
 ciently nourished. The irritability of the stomach is best overcome 
 by giving nourishment in extremely small quantities — as a dessert- 
 spoonful of asses' milk for an infant, or of veal tea for an older child, 
 given by little and little every half hour. If the symptoms have suc- 
 ceeded to weaning, a healthy wet-nurse should, if possible, be at once 
 obtained ; but as the effort to suck seems sometimes to exhaust the 
 child, and probably thereby to favor vomiting, it is sometimes better 
 at first to give the nurse's milk by a teaspoon. If the exhaustion is 
 very great, and a state analogous to coma is impending, a hot mustard 
 bath is sometimes serviceable in rousing the child ; while, at the same 
 time, a few drops of sal-volatile, or of brandy, may be given every few 
 hours. It is desirable, however, to suspend the use of the more power- 
 ful direct stimulants so soon as it can safely be done, though a nutri- 
 tious diet will be necessary for some time. Tonic medicines, likewise, 
 are often of much service, few of which are preferable to the extract of 
 bark, which, dissolved in carraway-water, mixed with a few drops of 
 the tincture, and well sweetened, will be taken very readily by most 
 children. The addition of a little milk to the medicine when taken 
 still further covers any unpleasant taste. 1 
 
 Those cases in which the brain becomes the seat of various morbid 
 growths still remain for us to consider, before we pass to the study of 
 affections of the spinal cord. 
 
 In the child, as in the adult, the brain may become the seat of hy- 
 datid cysts, or of cancerous tumors, or of tubercular deposits ; but I 
 should not detain you long with their study, if it were not that the last 
 of these three morbid conditions, though exceedingly rare in the adult, 
 is by no means unusual in the child. Thus, while M. Louis met with 
 only a single case in which the brain contained tubercle out of 1 1 7 
 examinations of adults who had died of phthisis ; MM. E-illiet and 
 Barthez discovered tubercle in the brain of 37 out of 312 children, 
 between the ages of 1 and 15, in some organ or other of whose body 
 this morbid deposit existed.- You will remember that I am not now 
 speaking of cases where tubercle is present merely in the membranes 
 of the brain, producing that granular appearance to which I called 
 your attention when treating of tubercular meningitis ; but my remarks 
 refer to separate deposits of tubercular matter in the substance of the 
 brain. These deposits are for the most part distincly circumscribed, of 
 a rounded form, and varying in dimensions from the size of a millet- 
 
 1 See Formula IsTo. 4, at p. 57. 
 

 ITS MORBID APPEARANCES. 137 
 
 seed to that of a split-pea, or of a bean, or even larger. The largest 
 mass that I ever met with in the brain of a child was almost as big as 
 a hen's egg, but they have been seen much larger. Sometimes there is 
 but a single deposit in the brain, but in the majority of cases there are 
 three or four small deposits, of the size of a millet-seed or rather larger, 
 as well as a single mass of greater magnitude. Sometimes, though not 
 often, the deposits of tubercle are limited to one hemisphere of the brain ; 
 but it generally happens that there is a marked preponderance of the 
 affection on one side. The situation of these deposits varies greatly, 
 and they have been found in all 'parts of the brain, both on its surface 
 and in its interior. The smaller deposits are, I think, most frequently 
 observed on the convexity of the brain, and they are then found closely 
 adherent to the pia mater, to which they remain attached if that mem- 
 brane is stripped off. They seem, however, to have some connection 
 with the cerebral substance besides mere juxtaposition, since a thin invest- 
 ment of it clings to them, and the place where they were situated may 
 be seen after their removal to be quite uneven. Even Avhen situated at 
 the base of the brain, or in the cerebellum, they often retain this relation 
 to the pia mater ; and those larger masses, which generally appear more 
 deeply seated, will often be found, if the convolutions are unfolded, to 
 have been in reality not far removed from the surface. Now and then 
 a distinct, firm, fibrous capsule may be found investing the deposit ; but 
 this is oftener absent, or at any rate so delicate as not to be clearly per- 
 ceptible. I have never seen these deposits presenting throughout the 
 characters of the gray semi-transparent tubercle frequently noticed in 
 the lungs, but once I found the exterior of a small deposit in this stage, 
 while its central part had undergone the transformation into the ordi- 
 nary friable yellow tuberculous matter — a condition which Kokitansky 
 has also occasionally met with. This appearance too points to the pro- 
 cess by which tubercular deposits in the brain increase in size. Fresh 
 deposits of miliary tubercle take place in the layer of connective tissue 
 which is usually found surrounding the mass, while at the same time 
 caseous degeneration takes place in its central or first-formed portion. 
 It is in accordance with this that when softening takes place in cejebral 
 tubercles it begins, just as in deposits of the same kind elsewhere, in 
 the centre, and gradually extends towards the periphery — a condition 
 which I have observed in 5 out of 24 cases. The brain around the 
 softened deposits is almost always of a rose tint and more or less softened, 
 though this alteration seldom extends for a distance of more than two 
 or three lines ; and once I observed the cerebral substance perfectly un- 
 changed around a small tubercle, in which the process of softening was 
 already considerably advanced. As a general rule, the brain around 
 deposits of crude tubercle still retains its natural characters ; but to this 
 I have seen one exception. 
 
 If death usually occurs before the process of softening has taken 
 place in the tubercular deposits, still rarer is it for life to be so pro- 
 longed as to give opportunity for the occurrence of that cretaceous 
 transformation by which the disease in other organs is sometimes 
 arrested. MM. Rilliet and Barthez have observed it only twice out of 
 37 cases of cerebral tubercle ; and but one instance of it has come 
 
138 TUBERCLE OF THE BRAIN. 
 
 under my notice, in a boy 3| years old, in whom but one deposit 
 existed, of the size of a large pea, situated in the left hemisphere of the 
 cerebellum. The change was in this instance incomplete, when death 
 took place from tubercular meningitis, succeeding to the sudden cessa- 
 tion of otorrhoea. Had the child lived, however, it is probable that 
 the disease would have been altogether cured, for no tubercles were 
 present in any other organ of the body, with the exception of the 
 bronchial glands ; and in them the same curative process was going on. 
 
 Cerebral tubercle does not invariably affect the rounded form, but it 
 occasionally extends as a patch, half an inch or more in length, by two 
 or three lines in breadth, immediately beneath the pi a mater, and not 
 reaching above one or two lines deep into the cerebral substance, which 
 is usually slightly softened beneath it. Now and then, too, the deposit 
 takes place not in distinct and isolated masses, but in the form of infil- 
 tration into the tissue of the brain, which, in this situation, is of a rose- 
 red color, and extremely soft. This condition has come twice under 
 my notice, and was associated on both occasions with abundant tuber- 
 cular deposits in almost all the viscera. 
 
 These tubercular deposits in the cerebral substance are very often, 
 but by no means invariably, associated with that granular state of the 
 membranes which I described to you as occurring in many cases of 
 tubercular meningitis. Thickening of the membranes, and effusion of 
 hyaline matter into the pia mater at the base of the brain — the evi- 
 dences, in short, of meningitis — are often present, as well as abundant 
 effusion of fluid into the ventricles, and softening of the central parts 
 of the brain. Sometimes, however, the signs of inflammation of the 
 membranes exist without any effusion into the ventricles ; and in a few 
 instances the ventricles contain an abundance of fluid, but no softening 
 of the central parts of the brain exists, nor any sign of inflammation of 
 the membranes. 
 
 I know but one instance in which tubercle was limited to the brain 
 in childhood, and in that case there was strumous disease of the right 
 ankle : when present in the brain it almost always exists in other vis- 
 cera, and is but one of the results of that general cachexia which may 
 show itself in any of the various forms of scrofulous or phthisical dis- 
 ease. At the same time there is no uniform connection between the 
 presence of tubercle in the brain, and the existence of advanced general 
 tuberculosis. This is a fact all the more to be borne in mind, since, 
 unless we remember that a condition of good general nutrition of the 
 body does not preclude the deposit of cerebral tubercle, we may run 
 some risk of misinterpreting the symptoms which otherwise would 
 excite our apprehension. 
 
 I am unacquainted with any special cause that renders the brain more 
 liable to this disease in childhood, than in adult age, or even in youth. 
 It certainly is not owing simply to the intensity of the tuberculous 
 cachexia, and the consequently greater abundance of the morbid de- 
 posit, for I have met with many instances of far more extensive tuber- 
 cular degeneration than existed in those cases where the brain had 
 become its seat. 
 
 Cases are not yet recorded in numbers sufficient for us to determine 
 
ITS SYMPTOMS. 139 
 
 accurately the time of the greatest liability to this affection : or whether 
 difference of sex exerts any real influence in predisposing to it. Of my 
 own 24 cases, 14 were male and 10 female; 5 were under 2 years of 
 age, 3 between 2 and 3 ; 5 between 3 and 4 ; 1 between 4 and 5; 4 be- 
 tween 5 and 6 ; and of the remaining 6, one was 6 J ; one, 8 ; one, 9 ; 
 and three, 10 years of age. 1 
 
 We come now to the examination of a very difficult question, — 
 namely, that of the symptoms of this affection. The difficulty arises 
 from many sources ; for sometimes the disease gives rise to no symptoms 
 at all, and its existence is not discovered till after death: and even 
 when symptoms are present, neither their character nor their intensity 
 bears any invariable relation to the extent of the local mischief or its seat ; 
 while, lastly, the symptoms that usually betoken tubercle of the brain 
 sometimes exist where no such morbid growth occupies the organ. 
 
 Cases in which no symptom whatever marks during life the presence 
 of the morbid deposit in the brain, are very unusual, and but one in- 
 stance of it has ever come under my own observation. In this case a 
 mass of crude tubercle as large as a walnut was imbedded in the back 
 part of the right hemisphere of the cerebellum, and adhered also to the 
 membranes lining the base of the skull. Much less rare, though still 
 constituting exceptions to the general rule, are the instances of complete 
 absence of all premonitory indications of cerebral disorder; symptoms of 
 disease of the brain manifesting themselves suddenly and with violence, 
 and carrying off in the course of a few days, or perhaps even in a few 
 hours, the child in whom tubercle has for months been developing 
 itself. No reason can be assigned for the complete latency of the affec- 
 tion in some instances, or for the sudden supervention of cerebral symp- 
 toms in others after the deposit has existed for a long time without 
 giving rise to any indications of its presence. It is true that the brain 
 in the immediate neighborhood of the tubercular deposit does not, to 
 the best of my knowledge, present any sign of softening in those cases 
 which have been characterized by absence of all premonitory signs of 
 cerebral disturbance, and that the tubercle itself always appears in the 
 crude state. This fact at once suggests a plausible explanation of these 
 cases, founded on the assumption that the symptoms, when observed, 
 do not depend simply on the presence of tubercle, but rather on the 
 changes in the surrounding brain. Such an hypothesis, however, is 
 contradicted by the fact, that cerebral symptoms sometimes occur in 
 cases where no perceptible disorganization of the brain has taken place 
 either around the tubercle or elsewhere. 
 
 1 The cases recorded by Dr. H. Green, in vol. xxv of the Medico-Chirurgical 
 Transactions, by MM. Rilliet and Barthez, in vol iii of their work, and by Pro- 
 fessor Hirsch, of Konigsberg, in a dissertation De Tuberculosi Cerebri, 8vo., 1847, 
 added to my own, made up a total of 72, which may be thus arranged : 
 
 From 6 months to 5 years, 
 From 5 years to 10 years, 
 Prom 10 years to 15 years, 
 
 lale. 
 
 Female 
 
 23 
 
 14 
 
 10 
 
 14 
 
 6 
 
 5 
 
140 
 
 TUBERCLE OF THE BRAIN. 
 
 In most instances some kind of premonitory symptoms manifest them- 
 selves before the commencement of the child's fatal illness; but these 
 are very variable in their character, and often very difficult of interpre- 
 tation. Dr. Hennis Green, in his very valuable piper " On Tubercle 
 of the Brain, in Children," mentions pain in the head as having been 
 present in 1 7 out of 20 cases ; but this symptom attends upon so many 
 other affections, that taken by itself its diagnostic value is but small. 
 In young children who are unable to describe their sensations, we can- 
 not be certain of the existence of headache; but must be content to 
 infer it from causeless fretfulness, drowsiness, or listlessness. One or 
 other of these indications of disorder of the sensorium was present, how- 
 ever, as the most marked premonitory symptom, in 13 out of 18 cases 
 in which fore warnings of mischief preceded the child's fatal illness. 1 
 
 1 In the following note I have endeavored to bring together the more important 
 points in the history of the 21 cases of cerebral tubercle on which my remarks are 
 founded. 
 
 There were no premonitory symptoms of head affection in 5 cases. 
 
 No. 
 
 Sex. 
 M. 
 
 Age. 
 
 Previous history- 
 
 Fatal illness. 
 
 Du 
 
 ration. 
 
 1 
 
 4 vears. 
 * 
 
 Convalescent 3 weeks 
 
 Tubercular meningi- 
 
 19 
 
 days. 
 
 
 
 
 from measles. 
 
 tis. 
 
 
 
 2 
 
 M. 
 
 1 yr. 5 mo. 
 
 Couijh for 2 months. 
 
 Fits, coma, died in fits. 
 
 6 
 
 (t 
 
 3 
 
 F. 
 
 2 " 6 " 
 
 Tabes mesenterica, 4 
 months. 
 
 Fits, coma, died com- 
 atose. 
 
 
 
 u 
 
 4 
 
 F. 
 
 10 " " 
 
 Constipation, debility, 
 2 months. 
 
 Typhoid symptoms, 
 no tits. 
 
 9 
 
 u 
 
 5 
 
 M. 
 
 1 " " 
 
 Phthisis, 5 months. 
 
 Drowsiness, fits, coma, 
 frequent fits. 
 
 7 
 
 (( 
 
 6 
 
 M. 
 
 9 " " 
 
 Phthisis, tubercular 
 peritonitis, 7 months 
 
 JN"o symptom whatever 
 of brain disorder. 
 Died of tuberculosis. 
 
 i 
 
 u 
 
 More or less marked signs of cerebral disturbance existed in the remaining 18 
 cases, namelv : 
 
 No. 
 
 Sex. 
 
 Age. 
 
 1 
 2 
 
 M. 
 
 F. 
 
 yr. mo. 
 
 2 
 
 3 3 
 
 3 
 
 F. 
 
 6 
 
 4 
 
 M. 
 
 8 
 
 5 
 
 M. 
 
 1 9 
 
 6 
 
 F. 
 
 3 6 
 
 7 
 
 F. 
 
 6 6 
 
 Premonitory symptoms. 
 
 Fretfulness. 
 
 Great drowsiness suc- 
 ceeding to cynanche 
 parotidea. 
 
 Duration. 
 
 8 days. 
 6 weeks. 
 
 1 mo. 
 
 Dull, drowsy, suppress- 
 ed eruption on scalp. 
 
 Drowsy, listless, fever-; 14 days, 
 ish. 
 
 Otorrhoea 6 weeks, pain 14 " 
 
 in head, crying atj 
 
 night. 
 Otorrhoea 9 months; 7 " 
 
 pain in head on its 
 
 sudden cessation, and 
 
 excited manner. 
 Headache, sickness,! 2 mo. 
 
 constipation. 
 
 Fatal illness. 
 
 Fit, coma. 
 
 Fits, for some hours, re- 
 turned in 5 days, then 
 frequent, drowsy in 
 intervals, coma. 
 
 Deepening stupor, fit, 
 coma. 
 
 Stupor, coma, ptosis of 
 right eyelid, dilatation 
 of right pupil, no fit. 
 
 Vomiting followed by 
 coma, fits, death co- 
 matose. 
 
 Several fits, furious de- 
 lirium, coma. 
 
 Supervention of acute 
 hydrocephalus, fits. 
 
 Duration. 
 
 99 hrs. 
 24 days. 
 
 6 " 
 
 1 week. 
 
 83 hrs. 
 
 3 days. 
 
 16 days. 
 
ITS SYMPTOMS. 
 
 141 
 
 When headache is present it is yet but seldom that any connection 
 can be traced between the seat of the tubercle and the situation of the 
 pain, which is, for the most part, referred to the forehead. It is often 
 very severe, so that during its continuance the child is entirely taken 
 up with its suffering, and shrieks with the severity of the pain ; but it 
 
 No. 
 8 
 
 Sex. 
 M. 
 
 Age. 
 
 vr. mo. 
 "3 6 
 
 9 
 
 F. 
 
 3 
 
 10 
 
 M. 
 
 1 11 
 
 11 
 
 M. 
 
 2 
 
 12 
 
 F. 
 
 3 3 
 
 13 
 
 F. 
 
 5 4 
 
 14 
 
 F. 
 
 5 
 
 15 
 
 M. 
 
 10 
 
 16 
 
 F. 
 
 5 
 
 17 
 
 M. 
 
 5 
 
 18 
 
 M. 
 
 10 
 
 Premonitory symptoms. 
 
 Habitual rotatory ra- 
 tion of head, pain in 
 forehead, feverish. 
 
 Fit, left side affected, 
 return in 4 days, 
 twitching of left side. 
 
 Duration. 
 
 2 tno. 
 13 days. 
 
 4 mo. 
 
 Epileptic fits from 7th 16 mo. 
 
 mo., drowsiness from 
 
 15th mo. 
 Head hung to left side 
 
 since measles. 
 
 Sudden twitching of 
 right hand, a' m, and 
 leg, torticollis, par- 
 alysis of right portio 
 dura, last two symp- 
 toms disappeared, 
 others improved, no 
 headache. 
 
 Fit, followed by par- 
 alysis of right side, 5 
 months before, and 
 impairment of intel- 
 lect ; febrile attack 3 
 months, almost con- 
 stant convulsions 6 
 weeks. 
 
 Headache after measles 
 4 months, ptosis of 
 right eyelid 1 mo. 
 
 Pain at back of head. 
 and occasional vomit- 
 ing, emaciation. 
 
 Fit, followed by par- 
 alysis of left side of 
 face. Nothing more. 
 
 Headache 6 weeks, re- 
 lieved by occurrence 
 of discharge from 
 left ear in 14 days. 
 
 Paralysis of left arm. 
 
 5 « 
 
 4 " 
 
 6 weeks 
 
 4 mo. 
 
 6 weeks, 
 
 Fatal illness. 
 
 Symptoms of acute hy- 
 drocephalus, fit 5 
 hours before death. 
 
 Symptoms of acute hy- 
 drocephalus, pneu- 
 monia supervened, 
 and caused death. 
 
 Slight fit, followed by 
 coma. 
 
 Two fits, stupor, auto- 
 matic movements of 
 rightside, death com- 
 atose. 
 
 Head heavy 10 days, 
 deepened into coma, 
 death comatose from 
 effusion of blood at 
 base of brain. 
 
 Increase of convul- 
 sions, deepening of 
 coma, death comatose. 
 
 Increase of headache, 
 convulsions 5 days be- 
 fore death comatose. 
 
 Increase of symptoms, 
 but death sudden in 
 sleep. Tubercle 2\ 
 inches in diameter in 
 centre of cerebellum. 
 
 Fever, frontal head- 
 ache, paralysis extend- 
 ing to tongue, gradual 
 occurrence of coma. 
 
 Cessation of discharge 
 from ear, followed by 
 vomiting and symp- 
 toms of tubercular 
 meningitis. No con- 
 vulsions. No par- 
 alysis. 
 
 Fever, frontal head- 
 ache, convulsions, 
 drowsiness, death in- 
 sensible after convul- 
 sions. 
 
 Duration. 
 
 13 days. 
 35 » 
 
 24 hrs. 
 5 days. 
 
 10 » 
 
 6 weeks. 
 
 14 days. 
 17 " 
 
 24 " 
 12 " 
 
 28 
 
142 SYMPTOMS OF TUBERCLE OF THE BRAIN. 
 
 does not continue with this intensity for more than a few hours, and on 
 the next day the child will be found to be no worse than usual. Vom- 
 iting in many instances attends these exacerbations of pain ; and, when 
 this is the case, the absence of any gastric disorder sufficient to account 
 for it will lead you to suspect the presence of tubercle in the brain. 
 In some cases, however, the headache, though severe, does not present 
 this remarkable intensity, while there is so much permanent impair- 
 ment of the general health, that an occasional attack of sickness does 
 not surprise you. On the other hand you will meet with delicate 
 children in whom attacks of violent headache, sometimes accompanied 
 by vomiting, come on from very slight causes, or apparently without 
 any cause at all, and return at irregular intervals for years together, 
 till they gradually subside as the health becomes more robust; and 
 cease altogether at the age of puberty or sooner. In a doubtful case, 
 the existence of irregularity of the pulse would to some extent govern 
 your decision ; though its occurrence in cases of cerebral tubercle is not 
 constant : while I have known children in whom every attack of gas- 
 tric or intestinal disorder was accompanied by this symptom in a very 
 marked degree. In infants, and in children under two years of age, 
 we of course lose the evidence which is afforded by the patient's com- 
 plaints of headache, and can only infer it to be present from the occa- 
 sional loss of cheerfulness, and the attacks of fretfulness and crying. 
 Sometimes too the suffering of the brain shows itself in other ways be- 
 sides headache. The temper becomes wayward and passionate, or a 
 general dulness steals over all the faculties, and the child grows quite 
 indifferent to what is going on around it. One little boy, aged two 
 years, whom I watched for some weeks before his death, never made 
 any complaint of headache. He was fretful, and cried if moved, but 
 was perfectly quiet if allowed to remain in his chair, where he would 
 sit half dozing for hours together. 
 
 Affections of the motor system are often among the early indications 
 of this disease, but neither are they so definite as to present anything 
 pathognomonic of cerebral tubercle. A boy who died at three and a 
 half years old, and in the left hemisphere of whose cerebellum there 
 was a tubercle * as large as a pea, had been subject from his earliest 
 infancy to an almost constant and involuntary rotatory movement of 
 the head when in the recumbent posture. And in another boy, who 
 was two years old at death, the head had hung for four months towards 
 the left shoulder before any other symptoms of mischief in the brain 
 appeared : convulsions then suddenly came on, and the child died in 
 72 hours. Sometimes paralysis of a limb comes on gradually; or, 
 though actual paralysis does not exist, yet the power over one side 
 becomes greatly weakened, and the child drags one leg, or is observed 
 invariably to use one arm in preference to the other. Convulsive 
 movements, however, are the most frequent of the affections of the 
 motor system, and paralysis of a limb or impaired power over it, usu- 
 ally succeeds to their occurrence, and but seldom takes place inde- 
 pendently of them. Regular epileptic seizures, attended with equal 
 affection of both sides during the fit, and followed by no impairment 
 of power over any part, are decidedly unusual, and have only once 
 
SYMPTOMS OF TUBERCLE OF THE BRAIN. 143 
 
 come under my notice ; but the convulsive movements generally as- 
 sume one of two characters. Either they are occasional in their 
 occurrence, attended with insensibility, though the movements are con- 
 fined to one side of the body or to one limb, the same being affected on 
 each occasion ; and these attacks are usually of comparatively short 
 duration, varying from a few minutes to a few hours ; or the intellect 
 is unimpaired, but movements like those of chorea affect one limb or 
 one set of muscles constantly. Of this I saw a striking instance in a 
 little girl who died from hemorrhage beneath the arachnoid at the base 
 of the brain when 3J years old, and in whom numerous tubercles were 
 present in the left optic thalamus, and one in the right hemisphere of 
 the cerebellum. Nine months before her death she was seized, when 
 apparently in perfect health, by twitching tremulous movements of the 
 right hand, which in 14 days extended to the arm, and in a month to 
 the leg, so as to prevent her walking. In 2 months the head was 
 drawn to the left shoulder, and in 4 the mouth to the left side. In 
 3J months the head was held straight, and in 5 months the mouth 
 was no longer drawn awry. The tremulous movements diminished, 
 the child began to walk about, and continued to improve till 20 days 
 before her death. She then grew dull, and the tremor returned. In 
 10 days she became comatose, and continued so, with occasional con- 
 vulsions, in which for the first time both sides were affected, till she 
 died. 
 
 This case illustrates another fact perhaps worth notice ; namely, that 
 convulsions affecting one side only are sometimes seen, although tuber- 
 cle is present in both hemispheres ; or in other instances both sides 
 are affected by the convulsions, and yet the deposit is found only in 
 one hemisphere of the brain. Lastly, it may be added, that when 
 convulsions, whether general or partial, attended with insensibility, 
 have once occurred, they are seldom absent for many days together, 
 though to this there are occasional exceptions, in which a pause of many 
 months ensues after the first convulsive seizure ; the general health, 
 indeed, being impaired, but no sign clearly indicating the special mis- 
 chief that exists in the brain. 
 
 The transition from the premonitory to the acute stage sometimes 
 takes place gradually, the convulsions becoming more and more fre- 
 quent, the other cerebral symptoms more serious, and the intervals of 
 freedom from suffering shorter ; or the change takes place suddenly, 
 and without such previous increase in the severity of the child's suffer- 
 ings as to make us anticipate its approaching death ; and yet we can- 
 not always discover such differences between the morbid appearances 
 in the two cases as suffice to explain the dissimilar course of the dis- 
 ease. Of the 24 fatal cases of which I have preserved a record, there 
 was 1 in which no sign of disorder of the brain appeared at all, while 
 in the remaining 23 the duration of the acute stage varied from 24 hours 
 to 42 days : being under a week in 8 instances ; between one and two 
 weeks in 6 ; between two and three in 4 ; twice extending to 24 days ; 
 once to 28 ; once to 35 days ; and in one instance convulsions were of 
 perpetual recurrence for six weeks, when at last the child died. In 
 five instances the acute stage was attended by the ordinary symptoms 
 
144 SYMPTOMS OF TUBERCLE OF THE BRAIN. 
 
 of acute hydrocephalus ; once death took place from apoplexy depend- 
 ent on effusion of blood at the base of the brain ; one boy died in his 
 sleep so quietly, that the nurse watching in the ward was unaware of 
 it ; once the child gradually sank into a typhoid condition, and died 
 without any convulsion ; and twice coma stole on gradually, death 
 again being unpreceded by convulsive movements. In the remaining 
 13 cases, convulsions took place, though obeying no definite rule as to 
 the frequency of their occurrence, or the intensity of the coma by 
 which they were succeeded. 
 
 Wide as the differences are between the effects mentioned as produced 
 by cerebral tubercle in one case from those which are observed in 
 another, and impossible as it is completely to account for them, they 
 are yet, perhaps, not so altogether inexplicable as at first sight they 
 may appear. The size or position of the deposit, or the rapidity of its 
 growth, may in one case produce pressure on the brain, occasion the 
 effusion of fluid, and thus cause the patient's death : or the accidental 
 congestion of the brain following the arrest of some discharge, or the 
 healing of some eruption, or attending on some intercurrent febrile dis- 
 order, may render it sensible of the presence of the morbid deposit 
 which it had endured quietly for weeks or months, and all the indica- 
 tions of serious cerebral irritation may at once become apparent. In 
 another case softening may take place in the tubercular mass, and ex- 
 tending to the adjacent tissue, inflammation of the brain maybe lighted 
 up ; or the deposit not being limited to the brain itself, but affecting 
 its envelopes also, tubercular meningitis may supervene, as it often 
 does, and destroy the patient. 
 
 These considerations may serve to explain cases where the tubercular 
 deposit has been found external to the substance of the brain, merely 
 pressing on it, but in no way altering its tissue. Such a case I once 
 saw in the person of a little girl, 10 years old, who for five months had 
 suffered from strumous disease of the knee-joint, but had never mani- 
 fested any head symptom during her six weeks' stay in the Middlesex 
 Hospital. She was taken home at the end of this time, but had not 
 left the hospital many hours when convulsions of the right side came 
 on, which were succeeded by coma : and this deepened, till in the 
 course of forty-eight hours it became absolute. Convulsions occasion- 
 ally returned, always affecting the right side, which from the first 
 continued paralyzed in the intervals between their occurrence. She 
 lay thus for eight days without any sign of amendment, and then 
 died. There was a large quantity of clear serum in the lateral ven- 
 tricles, and much escaped from the spinal canal. There was no disease 
 of the brain, nor any important morbid appearance in the spinal cord ; 
 but there was disease about the odontoid process and its articulation 
 with the atlas, with a collection of tubercular matter around it, forming 
 a tumor which, situated in the mesial line, encroached somewhat on 
 the occipital foramen, though pressing but very slightly on the cord. 
 In the quiet of the hospital this disease had produced no symptom ; 
 the excitement of her return home kindled the spark, and destroyed 
 the patient. 
 
 Bearing these things in mind too, we can account for the sudden 
 
DIAGNOSIS OF TUBERCLE OF THE BRAIN. 145 
 
 death of a child, in whom a solitary tubercle in the brain had already 
 passed into the cretaceous state, but where habitual otorrhoea had 
 ceased suddenly ; and we can understand the reason for the intermittent 
 character which the symptoms of cerebral tubercle so frequently 
 assume. 1 
 
 I do not wish for one moment to exaggerate the difficulties that 
 attend the diagnosis of this affection ; but, at the same time, if we 
 assume that we have to do with an incurable disease we are less likely 
 to use efficient means of treatment than if we feel that there is still 
 some room for hope. While, therefore, I would have you bear in 
 mind that the symptoms which we have been passing in review, espe- 
 cially if associated with indications of tubercle in other organs, render 
 the presence of tubercle in the brain in the highest degree probable, 
 yet they do not afford absolutely certain evidence of it ; and further, 
 that the occasional observation of cerebral tubercle which has under- 
 gone the cretaceous change, shows that recovery from the disease is not 
 absolutely impossible. Headache aggravated at intervals, and asso- 
 ciated with occasional convulsive movements of one limb, and even 
 with attacks of an epileptic character, may occur in children who yet 
 after a time recover, and show by the robust health they subsequently 
 attain to, that some cause of a less abiding nature than tubercular 
 deposit must have given rise to the disturbance of the brain ; or on the 
 other hand, though serious cerebral disease may exist, and such as 
 gives rise at length to a fatal result, yet it may appear after death that 
 it was such as would have been mitigated if not cured, by appropriate 
 treatment. 
 
 I need not remind you of the value of the ophthalmoscope in doubt- 
 ful cases, a value which additional experience in its use will probably 
 tend to increase. The appearances which it discovers are such indeed 
 as one might beforehand expect to find ; namely, a state of congestion 
 of the optic disk, which is swollen, its outline indistinct, its surface 
 often dotted with tiny ecchymoses, the arteries pale and diminished in 
 size, whilst numerous veins which were before invisible may now be 
 seen enlarged, full, tortuous, or even varicose. This appearance is 
 seldom wanting in cerebral tumors of any size, and is almost invaria- 
 bly present in tumors of the cerebellum, which is, as you will recollect, 
 the favorite seat of tubercular deposits. In doubtful cases I always 
 avail myself of the special knowledge of some colleague expert in the 
 use of the instrument. I advise you to learn to use it for yourselves. 
 
 There will, however, in spite of all diagnostic helps, remain cases in 
 which suspicion does not amount to actual certainty, and at any rate 
 we may often palliate when we cannot cure, and protract the life that 
 we are not able to save. You must not therefore remain merely 
 passive spectators of these symptoms ; and, if you watch cases of this 
 kind with attention, you will generally find that they afford you some 
 clue to the treatment that you should follow. Either there is manifest 
 
 1 See, with reference to the various effects of cerebral tubercle, and the different 
 ways in which it may prove fatal, the excellent chapter on tubercle of the brain in 
 Dietl's work, already referred to, pp. 346-356. 
 
 10 
 
146 HYDATIDS AND CANCER OF THE BRAIN. 
 
 gastric and intestinal disorder, or there are indications of a state of 
 general debility, or there are signs of inflammatory disease in the brain. 
 In the first case, the regulation of the bowels and the careful manage- 
 ment of the diet, are obviously indicated ; in the second, iron may be 
 given with advantage, and the shower-bath may be cautiously tried, 
 and, if it do not alarm the child, it may often be continued with much 
 benefit. In those cases where there seems to be some slow mischief in 
 the brain, I have once or twice seen recovery take place, contrary to 
 all my anticipations, from the employment of small doses of mercury 
 night and morning, persevered with for many w T eeks. In such cases, 
 too, counter-irritation to the back of the neck is often followed by the 
 happiest effects. A little girl, 14 months old, was some time since 
 under my care for the frequent recurrence of convulsive attacks of a 
 very anomalous character. So long as a discharge was kept up from 
 her neck by the tartar-emetic ointment, the fits did not occur ; but if 
 the discharge ceased for two or three days, they were sure to return. 
 
 These are the principles by which your conduct must be governed ; 
 but you will find that each case will present some special peculiarity, 
 and will need to be studied and treated for itself. 
 
 Tumors of other kinds may exist in the brain in childhood, though 
 they appear to be more frequent in the middle-aged or the old. 1 I once 
 saw a case in which hydatids had formed in the substance of the brain 
 in a girl of seven years old ; once also I saw cancer affecting the brain 
 and its membranes in a boy two and a half years old, and recently a 
 girl aged 8 years died in the Children's Hospital in whom a large mass 
 of glioma in the cerebellum furnished an explanation of various signs 
 of brain disease which had succeeded to a fall on the back of the head 
 eight months before her death. But, though such occurrences are in- 
 teresting from their rarity, I do not know any circumstance, except the 
 absence of the signs of tubercular disease in the patient, by which you 
 could determine during life that certain cerebral symptoms arose from 
 hydatids, or cancer of the brain, and not from tubercle in that organ. 2 
 
 1 Of the 34 cases of non-tuberculous tumors in the brain, which form the basis of 
 Friedreich's elaborate Beitrage zur Lehre von den Geschwiilsten innerhalb der 
 Schadelhohle, 8vo., Wurzburg, 1853, none occurred in children under 10 years old; 
 and only 4 in young persons between the ages of 10 and 20. 
 
 2 Dr. Charlton Bastian's excellent article on the morbid anatomy of adventitious 
 products in the brain, at p. 499 of vol. ii of Keynolds's System of Medicine, 2d ed., 
 1872, ought not to pass unnoticed. 
 
IRRITATION AND CONGESTION OF THE SPINAL CORD. 147 
 
 LECTURE XII. 
 
 Diseases of the Spinal Cord. — Their study rendered more difficult by the tender 
 age of children. 
 
 Irritation and Congestion of the cord. 
 
 Inflammation of the Membranes of the Cord. — Not common as a sporadic affec- 
 tion — Illustrative cases — Inflammation of the Substance of the Cord — 
 Extremely rare in its acute form — In its chronic form gives rise to symptoms 
 similar to those which occur when bones of the spine are diseased — Cases. 
 
 Trismus. — Extremely rare in this country. — Symptoms — Post-mortem appearances 
 — Causes of the disease — Influence of vitiated air — Treatment almost hopeless. 
 
 At the commencement of these Lectures I called your attention to 
 the predominance of the spinal over the cerebral part of the nervous 
 system, as constituting one of the grand characteristics of early life. 
 Since then, our daily course of inquiry has brought before us numerous 
 confirmations of this truth, and has shown us how slight a disturbance 
 of the functions of the brain may suffice to destroy the harmony of those 
 which belong to the spinal cord. 
 
 To-day we pass from the consideration of those cases in which the 
 brain is the original seat of disorder, and the spinal cord suffers only 
 secondarily, to the study of others, where that organ is primarily affected. 
 I need not remind you how much obscurity hangs over the ailments of 
 the spinal cord at all periods of life ; but in the young subject this is 
 not a little increased by the difficulty that attends the observation of 
 some of those symptoms which would be obvious enough in the adult. 
 Thus, for instance, while impairment or loss of the locomotive power in 
 the grown person could hardly escape our notice for a moment, it might 
 fail to attract much attention in a young child, who often totters in his 
 gait, or even becomes unable to walk, if from any cause his health 
 should fail. Or, again, the impaired sensation, or the vague pains in 
 the limbs, which the adult would be sure to tell us of, would be but ill 
 described by a child, even though it had long been able to talk, while 
 terror might cause it to cry if any attempt was made to examine its 
 back, and might thus prevent our ascertaining the presence or absence 
 of tenderness of the spine. These are difficulties, however, which 
 patience and tact will overcome ; for not only the diseases of the spinal 
 cord, but the symptoms by which they manifest themselves, are much 
 the same at all ages, the chief difference being that in the one case they 
 strike the eye even of the careless, while in the other, careful observa- 
 tion is necessary for their detection. 
 
 Irritation of the cord, however produced, gives rise in the child, as 
 well as in the adult, to impairment of the motor power. A little boy, 
 between two and three years old, remarkably strong and healthy, was 
 observed, without any obvious cause, to fail in his general health, and 
 at the same time to totter in his gait, to become indisposed to move, 
 
148 IRRITATION AND CONGESTION OF THE SPINAL CORD. 
 
 and, at last, almost entirely to cease walking ; and this impairment of 
 his power of walking was quite out of all proportion to the signs of ill 
 health by which it was attended. After watching him for a time, it 
 was discovered that the child had become addicted to the practice of 
 masturbation. This was put a stop to, and he soon regained his health, 
 and with it his power of walking. 
 
 In this instance the cause of the irritation of the cord, and of the 
 consequent impairment of its functions, was obvious enough, but cases 
 now and then occur in which symptoms of disorder of the spinal cord 
 manifest themselves without our being able to discover on what they 
 depend. Such cases, too, are all the more important from the circum- 
 stance that the symptoms which attend them simulate serious disease, 
 and are likely to lead us into the unguarded expression of a very un- 
 favorable prognosis as to their issue. 
 
 On the 30th of December, now many years ago, I saw a delicate boy, 
 between 4 and 5 years old, who had been drooping in health, though 
 without any definite symptom, for a week or two ; but had complained 
 of stiff neck for the first time on the previous Christmas Day. This 
 ailment, however, had disappeared and recurred more than once between 
 then and the 28th ; since which last date it had been constant, though 
 not always the same in degree, being less marked in the morning, more 
 so towards night. The child looked out of health, and seemed very 
 languid ; he moved very cautiously, as if afraid of the slightest jar ; his 
 shoulders being raised, his head thrown rather back, and kept most 
 carefully motionless ; while he complained bitterly of any attempt to 
 bend his neck, and said that pressure on the upper part of the cervical 
 spine occasioned him much pain. The boy's appearance and manner 
 were precisely those of a patient suffering from disease of the cervical 
 vertebrae ; and a most experienced surgeon, who saw the case with me, 
 expressed himself as very apprehensive that the case was a bad one, 
 though whether the disease was in the spinal cord or in the vertebrae 
 he considered to be uncertain. I certainly took a most unfavorable 
 view of the affection ; and was much surprised to learn subsequently 
 that after the application of four leeches to the back of the neck, the 
 child went to sleep, slept during the night, and awoke the next morning 
 with the most complete power over the muscles of the neck, showing 
 no pain in moving his head, complaining of no tenderness of the spine, 
 nor did any such symptoms manifest themselves at any subsequent 
 period. 
 
 I have since met with several cases of a somewhat similar kind, which 
 I believe to be of rheumatic origin. The symptoms come on too rapidly 
 to be due to disease of the cervical vertebra?, while they are not suffici- 
 ently severe to be attributed to inflammation of the spinal cord, or of 
 its membranes. Headache is not present, nor any distinct evidence of 
 cerebral disturbance. Rest in bed, attention to the bowels, diaphoretic 
 medicines, warm applications, and stimulating liniments to the back of 
 the neck, of which there is none better than the Linimentum Bella- 
 donnae, have sometimes removed in a couple of days symptoms that 
 seemed most threatening. 
 
CONGESTION AND INFLAMMATION OF THE SPINAL CORD. 149 
 
 In such cases, as in many others, the results of treatment yield a 
 most important help towards the formation of a correct diagnosis. 
 
 Whether in the instance above related the affection was a rheumatic 
 one I do not know, or whether there was some unusual congestion of 
 the vessels of the cord, which the local depletion at once removed, and 
 thus cured the patient. That such a condition existed in the following 
 instance is still more likely, for here there was a local injury amply 
 sufficient to produce it. 
 
 In May, 1845, a little girl, four years old, was brought to me by her 
 mother, who said that ten days before, the child had had a fall on her 
 back, while left in the charge of a servant; that on the following morn- 
 ing she was unable to stand or move, unless supported; and that she 
 had ever since continued in the same condition. Her appearance was 
 rather anxious, her face was slightly flushed, skin warm and dry, 
 tongue slightly furred, pulse frequent, and with power. If placed on 
 her feet, she clung hold of her mother, sank down into a stooping, half- 
 squatting posture, and immediately began to cry. She could walk if 
 firmly supported, but hurriedly and unsteadily, stepping on her toes, 
 her lefrs moving in a semicircle with her toes turned inwards, and one 
 foot being put down just in front of the other. On examining the 
 spine, the integuments from the tenth to the twelfth dorsal vertebra 
 presented a little puffiness, and there was very great tenderness of the 
 spine in that situation ; and even when not touched, the child com- 
 plained of pain in her back. There was no appetite but great thirst, 
 the bowels were constipated, the appearance of the urine was natural, 
 and neither faeces nor urine were voided unconsciously. 
 
 She was cupped on the loins to oiv, and on the following day was 
 much relieved, moving her legs more readily, and suffering much less 
 from pain in the back. On the 17th she was able to stand, and could 
 walk a little without suffering. Attention was paid to keep the bowels 
 open, and in a few days she was cmite well. 
 
 Besides cases of this kind, however, in which there is some uncer- 
 tainty as to the cause of the functional disorder of the spinal cord, 
 others are sometimes met with of a more formidable, though of a less 
 obscure kind. Such are the cases, fortunately by no means common, 
 in which the spinal cord or its membranes are the seat of inflammation. 1 
 
 I shall probably convey to you a more truthful impression of their 
 general characters by relating to you a few of those instances that have 
 come under my notice, rather than by attempting to draw a general 
 portraiture of them from too small a number of examples. 
 
 A boy, aged 11 years, of a phthisical family, who seven months pre- 
 viously had had severe and long-continued attacks of headache, was 
 
 1 I purposely omit all notice of the epidemic form of cerebro-spinal meningitis, 
 partly because it has never come under my own observation, partly because Undoes 
 not usually attack young children, and still more because most pathologists regard 
 it as a special disease, not a simple inflammation. I may, however, just refer to an 
 interesting account of an epidemic of the disease which prevailed exclusively among 
 children under 7 years of age, in the village of Barsen, near Neustettin, at the same 
 time with the epidemic prevalence of scarlatina; by Dr. Litten, in J. f. Kinderkr. 
 for 1865, vol. xliv, p. 333. 
 
150 IRRITATION AND CONGESTION 
 
 greatly distressed by hearing of the sudden death of a relation. On the 
 following day he had slight nausea, with pain in the head ; but in a day 
 or two he suffered more from pain in his linibs, especially in the calves 
 of the legs, and also shooting from the situation of the coccyx to the 
 middle of the back. He complained, moreover, of a constant pain at 
 the epigastrium, which, as well as that about the lower part of the back, 
 w r as always much aggravated when the bowels acted ; they being, how- 
 ever, usually constipated. These symptoms were associated with great 
 weakness of the legs, which he dragged when Avalking, and he reached 
 the Children's Infirmary, from which his home was about a mile dis- 
 tant, with much difficulty. On the following day I visited him, and 
 ascertained, on examining the spine, that there was considerable tender- 
 ness on pressure from about the middle of the dorsal vertebrae to the 
 apex of the sacrum, but greatest about the lumbar region. There was 
 no intolerance of light, but very distressing sense of giddiness, complete 
 loss of appetite, constant sensation of sickness, and a nasty taste in the 
 mouth. The intellect during the whole illness was only once affected, 
 and then but for a few hours ; and the child was remarkably acute, and 
 described his different sensations with great exactness. 
 
 The pain in the loins was relieved by cupping ; but on the next day 
 the headache was increased in severity, and there was some subsultus of 
 the tendons of the forearms, and a good deal of twitching of the hands. 
 This symptom disappeared after the boy had been depleted copiously 
 by leeches to the head, and after his gums had begun to be affected by 
 mercury, which was freely administered to him ; but his pulse, which 
 during the whole of his illness never exceeded 75, sank to 60 in the 
 minute, and its beat became irregular. As the mouth became decidedly 
 sore, first the shooting pains in the back and limbs ceased ; then the 
 pulse became regular, and rose in frequency ; then the epigastric pain 
 disappeared, and was succeeded for a time by a sense of weight there. 
 By degrees the tenderness of the spine diminished, and finally ceased, 
 and the headache grew less ; but his legs long continued weak, so that 
 he could not tread firmly, and the slightest noise, or any kind of over- 
 exertion, brought on an immediate increase of his sufferings. A seton 
 was put in the back of his neck, and the influence of mercury on the 
 system was cautiously maintained for four months before the boy ap- 
 peared sufficiently well to justify the discontinuance of remedies. 
 
 But the disease may run a more acute course, and to a less favorable 
 termination. 
 
 A little boy, one year old, who had cut four incisor teeth, and whose 
 health had been habitually good, was brought to me by his mother after 
 three weeks 7 illness. She told me that he had been suddenly seized 
 with great fever and heat of skin, accompanied, after a lapse of four 
 days, by violent screams. At the outset of his illness he had been 
 cupped at the back of his neck, and leeches had been applied to the 
 head without amendment, and for a week before I saw him all treat- 
 ment had been discontinued. The child then lay in his mother's lap, 
 frequently crying with a low distressed whimper ; his face was usually 
 pale, but occasionally flushed ; his head was thrown back, so that the 
 occiput and the back of the neck were nearly in contact with each other. 
 
OF THE SPINAL CORD AND ITS MEMBRANES. 151 
 
 The sterno-mastoid muscles were rather rigid, though there was no 
 trismus. The hands were clenched, the thumbs drawn into the palm, 
 and occasional attacks came on, in which he uttered a scream, and then 
 bent his body back into an arch. The child sucked eagerly, but fre- 
 quently dropped the nipple as if in pain ; the pupils acted naturally ; 
 the pulse was frequent, small, and hard. In the course of the succeed- 
 ing day frequent convulsive twitohings and startings of the limbs took 
 place, affecting the left arm more than any other part. His face grew 
 pale and more sunken, and the spine became habitually, though slightly, 
 curved forwards, notwithstanding which, occasional attacks of opistho- 
 tonos still occurred. The pupils still acted well, but a new symptom 
 appeared, in the labored breathing, w r hich sometimes became so difficult 
 that the child seemed almost choking, while phlegm collected in his 
 throat which he appeared unable to get rid of. This dyspnoea would 
 almost imply that the inflammation had been gradually travelling up- 
 wards till it began to involve the origins of the cerebral nerves — a sup- 
 position still further confirmed by finding two days afterwards that the 
 eyeballs were in a state of constant convulsive rotation. After this, 
 which was the fifth day from that on which I first saw the child, he 
 was not again brought to me ; but, though this case is incomplete, yet 
 it helps to fill up the portraiture of the disease. To complete it, how- 
 ever, I must relate one instance more, in which the results of examina- 
 tion after death confirmed the diagnosis. 
 
 Some years ago, I saw a little boy, five months old, of whom his 
 mother gave me the following history : A month before, he had been 
 attacked by shivering (an unusual occurrence in a young child) and, in 
 the night following this seizure, had many fits, during which he 
 screamed mueh and became very stiff. After they had continued for 
 three days, returning at intervals of an hour or half an hour, a little 
 diminution in their severity followed the use of some medicine pre- 
 scribed for him by a surgeon ; but, even when I saw him, ten or twelve 
 often occurred in the twenty-four hours, though a day would now and 
 then pass without any. The fits were described as presenting the char- 
 acters of opisthotonos, though in a less marked degree than when they 
 first came on. The retraction of the head by which they were attended 
 at first subsided as they passed off; but in the course of tw T o or three 
 days the tendency to keep the head thrown back became constant, and 
 for a fortnight the head had never been brought out of that position. 
 The mother thought, too, that the child had been blind for that period. 
 
 The child appeared well grown and well nourished, and the face was 
 not expressive of particular suffering, but the head was drawn back so 
 that the occiput rested between the shoulders, while the back was bent 
 forwards in a state of perfect emprosthotonos : the legs were drawn up 
 towards the abdomen, the palms of the hands turned backwards and 
 outwards, the fingers clenched, and the thumbs drawn into the palm. 
 On turning the child round on its face, the body formed a complete 
 arch resting on the chin and knees. The whole spine was very tender, 
 and this tenderness was greatest about its upper part. The pupils were 
 dilated and immovable : suction was difficultly performed, though there 
 was no trismus, but the child vomited everything it took almost im- 
 
152 MENINGITIS OF THE SPINAL CORD. 
 
 mediately. The pulse was at this time too rapid and too feeble to be 
 counted, and the child died in a fit of convulsions twenty-four hours 
 afterwards. 
 
 On examining the body, blood was found effused, though not in any 
 considerable quantity, within the spinal canal, but external to the dura 
 mater, from the third cervical to the third dorsal vertebra. A thick 
 layer of white lymph was present both under the arachnoid and in its 
 cavity along the whole posterior surface of the lumbar and dorsal por- 
 tions of the cord, and likewise existed in the cervical portion, though 
 in a less degree. Anteriorly, blood and lymph occupied the whole 
 cervical portion of the sac of the arachnoid, and were effused beneath 
 the membrane ; but in the remainder of the front of the cord there were 
 merely patches of lymph beneath the arachnoid. The substance of the 
 cord was apparently healthy. On lifting up the cerebellum, a consid- 
 erable quantity of serum, witli flakes of lymph, escaped from the base 
 of the skull, and the whole under surface of the cerebellum had a uni- 
 form coating of white lymph at least a line and a half in thickness, 
 which extended over the medulla oblongata, and was continuous with 
 the deposit of lymph along the spinal cord. The lateral ventricles of 
 the brain were much distended with fluid, in which large irregular 
 masses of yellow lymph were floating. The corpora striata and the 
 fornix were much softened, but the rest of the brain and the membranes 
 at its convexity were quite healthy. 
 
 It can scarcely be necessary that I should comment on these cases, 
 either to point out to you the many respects in Avhich inflammation of 
 the spinal cord differs from that of the brain, or to insist on the absolute 
 necessity of active antiphlogistic treatment being adopted at the very 
 outset of the disease. 
 
 But besides those cases in which the affection of the spinal cord and 
 its membranes so greatly preponderated, and in which the rapid course 
 of the disease served further to impress on it a peculiar character, 
 others are occasionally met with where the course of the disease is 
 slower, where the symptoms are less exclusively those of disease of the 
 spinal cord, and concerning which it seems almost doubtful whether 
 the membranes of the spinal cord suffer from extension to them of in- 
 flammation beginning in the lining of the lateral ventricles, or whether, 
 as indeed I believe to be the case, mischief beginning about the cord is 
 thence propagated upwards. 
 
 Such cases are of importance, because, if seen only when far advanced, 
 and considered without reference to their previous history, they often 
 present few points to distinguish them from the more hopeless tuber- 
 cular meningitis, while at the same time their course is slower, their 
 nature more purely inflammatory, and therefore their treatment may be 
 undertaken with some prospect of success. 
 
 A little girl, 20 months old, rather backward in her physical develop- 
 ment, and having cut only seven teeth, the last of which appeared at 
 the age of 18 months, was admitted into the Children's Hospital on 
 April 4. Two months previously, Avhile cutting her seventh tooth, 
 her right arm became somewhat stiff, and the power over it rather im- 
 
MENINGITIS OF THE SPINAL CORD. 153 
 
 paired, a condition which, though improved, had not altogether dis- 
 appeared at the time of her admission. 
 
 On March 24 she vomited, became hot and restless, ceased to talk, 
 and left off all attempts at standing, though her legs did not become 
 stiff, nor were they paralyzed. Her neck became stiff, though she 
 could move her head, she swallowed without difficulty, but had little 
 appetite, her bowels were disposed to be relaxed, her abdomen was 
 not shrunken, her pupils contracted well under light, her pulse was 
 frequent but regular, and there was no return of vomiting after the 
 first day or two of her illness. 
 
 On admission the child was in a state of great apathy but not of 
 coma, the surface w r as not hot, but the pulse 168, though regular. She 
 kept her head somewhat thrown back, but could move it about in any 
 direction, and even bend it forwards. The belladonna liniment was 
 applied constantly to the neck, small doses of the iodide of potassium 
 were given, and the child was fed with beef tea. 
 
 For a week improvement appeared to take place in her general con- 
 dition, but on April 11 the symptoms became aggravated without ap- 
 parent cause ; the pulse sank to 104 and became very irregular in 
 rhythm ; divergent strabismus of the left eye became apparent, and the 
 left pupil was more dilated than the right. The child occasionally 
 stretched out its limbs and trunk for a moment quite stiffly, almost 
 like a passing fit of tetanus ; but the features were not affected, there 
 was no trismus, and the head was not fixed, though usually retracted. 
 
 The pulse sank on the 12th to 80, and its irregularity became more 
 marked, the strabismus varied in degree, the pupils became gradually 
 dilated, and the left usually more so than the right. The application of 
 a blister to the' back of the neck was succeeded by an increase of con- 
 sciousness, and the addition of half a grain of quinine to each dose of 
 the mixture was followed by a still greater apparent amendment, which 
 lasted till the 20th. It was noticed, however, that the stiffness of the 
 right arm rather increased, that the right leg was moved rather less freely 
 than the left, that there was partial paralysis of the left side of the 
 face, and the rectus externus muscle of the left eye, while the left pupil 
 was more dilated than the right. 
 
 On the 25th the symptoms had increased. On May 2 the child had 
 lost both flesh and strength ; her pupils acted scarcely at all, though 
 they were not extremely dilated, and the strabismus persisted, though 
 it did not increase. 
 
 On May 4 a convulsive seizure occurred which lasted for a quarter 
 of an hour, affecting both sides equally. On the morning of the 7th 
 convulsions returned, chiefly affecting the left side, accompanied with 
 much movement of the eyeballs, though with but little distortion of the 
 face. These convulsions lasted for 4 J hours, and in them the child died. 
 
 There was no congestion of the vessels of the convexity of the 
 brain. The sac of the arachnoid was dry, the convolutions of the 
 brain were much flattened, and the enormously dilated lateral ventricles 
 contained six ounces of transparent serum. Their lining membrane 
 was coated with a thin layer of very soft greenish lymph, which was 
 already far advanced in fatty degeneration. This lymph was most 
 
154 ACUTE INFLAMMATION OF THE SUBSTANCE OF THE CORD. 
 
 abundant on the left choroid plexus, and on the walls of the posterior 
 cornua, while in some places it was so thin that it could be made 
 visible only by scraping a considerable surface. The ventricular lining 
 beneath it was perfectly natural, smooth, not thickened, not softened, 
 not extra vascular. In both descending cornua, however, where there 
 was more lymph than elsewhere, it was rather more adherent to the 
 subjacent membrane, and when removed seemed to leave a rather 
 rough surface, on which it was not easy to raise a membrane. 
 
 There was but very slight softening of the central parts of the brain. 
 At the base of the brain, from the optic commissure backwards, there 
 was much thick greenish puriform exudation, passing over both crura 
 cerebri, and incasing both lobes of the cerebellum in a thick layer of 
 puriform material, extending also over the inferior surface of the pons 
 Varolii, and both surfaces of the medulla oblongata. There was, how- 
 ever, no softening of the brain-substance. 
 
 From the third cervical to the second dorsal vertebra there was much 
 extravasation of blood external to the theca of the cord/ 
 
 On opening the dura mater, there was a thick layer of lymph of the 
 same kind as in the brain, which invested the whole cord, from the 
 medulla oblongata to the cauda equina. 
 
 In the cervical region the substance of the cord was much softened ; 
 but it could not be ascertained whether this softening was greater be- 
 fore, behind, or to one side. 
 
 Below this point the softening of the cord was inconsiderable. There 
 was no tubercle in any organ of the body. 
 
 Now I have seen other cases, in some of which the extent of lymph 
 deposited on the cord was less considerable, and the affection of the 
 ventricles of the brain and of its base also less. Some of these cases, 
 too, have run a slower course^ extending over three, four, or even six 
 months. In these the' spinal symptoms have been more marked, and 
 those of cerebral disturbance have come on more slowly ; convulsions 
 have often occurred, varying in frequency and severity, though usually 
 not of long duration, unattended by much distortion of the features, 
 not limited to one side, not succeeded by paralysis, nor by abiding 
 coma ; while even when the children took the least notice of surround- 
 ing objects, their condition was one rather of indifference than of insen- 
 sibility. 
 
 The above case, and these observations, will probably suffice to pre- 
 vent your misinterpretation of these rare instances of cerebro-spinal 
 meningitis, when they come before you in their less rapid forms. 
 
 I have not met with any instance of acute inflammation and conse- 
 quent softening of the substance of the spinal cord, although there are 
 many such on record. It has been supposed that paralytic symptoms 
 usually attend this affection, while stiffness and spasm of the muscles 
 characterize spinal meningitis ; but though this is probably true in 
 many instances, yet it does not by any means hold good in all. Three 
 cases are related by MM. Rilliet and Barthez, where the disease ran its 
 course with symptoms of tetanus and trismus, which continued up to 
 the time of the patient's death. In one of these cases the child died in 
 
CHRONIC INFLAMMATION OF THE SUBSTANCE OF THE CORD. 155 
 
 36 hours ; in the second, in 96 hours ; but in the third, a temporary 
 remission having occurred, the patient survived for thirteen days. 
 
 I select from Dr. Mauthner's valuable treatise on the Diseases of the 
 Brain and Spinal Cord in Children, a very characteristic case of acute 
 inflammatory softening of the spinal marrow. 1 
 
 A girl aged 11 years, whose occupation as a seamstress compelled 
 her to remain for many hours daily in a sitting posture, with her head 
 bent forwards, while she was at the same time much exposed to cur- 
 rents of cold air, was seized, after she had followed this employment 
 for three weeks, with dragging and tearing pains in the back of her 
 neck. As these pains grew more severe, voluntary power over the 
 arms became impaired, and the paralysis increasing rapidly in spite of 
 the application of leeches to the back of the neck, she was admitted 
 into the Hospital for Children at Vienna, under Dr. Mauthner's care, 
 on December 26. Both arms were at that time completely palsied, 
 flaccid, cool, and almost insensible, the lower extremities still obeyed 
 the will, but the girl was unable to stand firmly. The mind was per- 
 fectly clear, the appetite good, deglutition easy, and pulse natural ; and 
 in these respects her condition continued unchanged to the very last, 
 except that the pulse became very frequent on the day of the child's 
 death. On the 28th the legs were palsied, and the urine was passed 
 involuntarily. On the 29th, voluntary power over the hands and feet 
 was likewise completely lost, and sensation in them was imperfect. 
 On the 30th, sensation was perfectly lost in all extremities. The child 
 had desire to pass fseces, the bowels not having acted for three days, 
 but she had not power to do so. On the 31st, the sphincter ani was 
 likewise paralyzed, and opened to the size of a shilling. On January 
 4 the hardened fseces began to fall out of the gaping anus ; the respira- 
 tion was feeble, articulation difficult. On the 6th the child was in 
 much distress, and for many days had scarcely slept at all ; the whole 
 left side of the body was completely paralyzed, and only the right side 
 of the chest moved in respiration. Her exhaustion was so extreme that 
 her voice was scarcely audible, but the muscles of the face still retained 
 the power of motion and sensation perfectly, and the intellect was quite 
 clear, though the child died the same night. 
 
 The spinal cord presented the only morbid appearance ; the mem- 
 branes being perfectly healthy. The medulla oblongata was as soft as 
 butter, of a yellow color, not retaining a trace of its natural organiza- 
 tion ; and the same condition existed in the whole of the spinal cord 
 as low as the cauda equina, where it once more resumed its natural 
 appearance and characters. 
 
 The chronic form of inflammation of the cord will much oftener come 
 under your notice as one of the consequences of caries of the vertebrae. 
 You will remember, too, that this serious result, and the paralysis to 
 which it gives rise, are not produced simply by the distortion of the 
 spine and the mechanical compression of the cord, but rather by exten- 
 sion to it of inflammatory action. You have, then, in these cases, a 
 double danger to combat ; both that which arises from the disease in 
 
 1 Lib. cit., p. 421, case 117. 
 
156 CHRONIC INFLAMMATION OF THE SUBSTANCE OF THE CORD. 
 
 the spinal column itself, and that which depends on the probable ex- 
 tension to the cord of the disease which began in the bones. The 
 symptoms of the two affections present likewise so many points of re- 
 semblance in their early stages that you can never feel sure that the 
 cord is uninvolved. Of this we have ample proof in those rare cases 
 in which chronic softening of the eord occurs independent of any affec- 
 tion of the 'bones of the spine. You will find a case that illustrates 
 this fact very well in M. Louis's valuable paper, " On the Condition 
 of the Spinal Marrow in Cases of Caries of the Vertebrae ;" 1 and I 
 will relate to you another still more remarkable instance of it, which 
 came under my notice. 
 
 On March 31, 1846, a little girl, aged three years and a quarter, the 
 strumous child of unhealthy parents, in whose family phthisis was hered- 
 itary, was brought to me by her mother. Nine months previously, 
 her father having taken her in his arms and tossed her, she suddenly 
 cried out that she was hurt, and for several days afterwards refused to 
 walk, and seemed unable to stand, sinking down on her hams if set on 
 her feet. She made no definite complaint, however; no injury was 
 anywhere observable, and in about three weeks she seemed to have re- 
 covered her health, and continued well until the middle of March, 
 when her frequent complaints of pain in the neck attracted her moth- 
 er's attention. The appearance of the little girl, when first placed 
 under my care, was very remarkable ; for though the face wore no 
 expression of suffering, yet the neck was so much bent as to give an 
 unusual prominence to the seventh cervical vertebra, and the head was 
 constantly directed downwards. No part of the spine seemed partic- 
 ularly tender ; but any attempt to raise the head was forcibly resisted, 
 and seemed to occasion considerable pain. The child walked, though 
 with a tottering gait, and if left alone for a few minutes sank dpwn 
 upon her knees to play. Her constant complaint was of being tired 
 and drowsy, notwithstanding which she slept ill ; her appetite was bad, 
 and her bowels were constipated. I regarded the case as one of incip- 
 ient disease of the cervical vertebras, and was anxious to make an 
 issue in the back of the neck, but the parents refused to consent to 
 this proceeding. Medical treatment, therefore, was confined to the 
 administration of cod-liver-oil, and afterwards of the syrup of the 
 iodide of iron; but though no fresh symptoms appeared, the child 
 gradually lost strength. On May 12 she was able to walk a distance 
 of nearly half a mile ; but on the 14th, though not worse in other re- 
 spects, she was unable to raise her hands, and was forced to be fed by 
 another person. In the evening she complained of her eyes aching, 
 but nevertheless slept tolerably well till 1 A. M. She then awoke cry- 
 ing and fretful ; but on being taken up passed an evacuation, and on 
 lying down again, after a few efforts to vomit, which soon subsided, 
 spoke a few words to her mother, in whose arms she was lying. After 
 breathing in a sighing manner for a few moments she seemed to fall 
 
 1 Memoires, ou Keeherches Anatomico-Pathologiques, 8vo. Memoire viii, Ob- 
 serv. i, p. 411. Paris, 1826. 
 
INFANTILE TRISMUS. 157- 
 
 asleep, and in this sleep died so quietly, that her mother was ignorant 
 of it until awakened by her daughter's corpse beginning to grow cold. 
 
 On examining the body after death the brain was found to be quite 
 healthy, with the exception of some venous congestion of the arachnoid. 
 The muscles of the back and the bones of the spinal column were per- 
 fectly healthy : but on laying open the vertebral canal, the spinal cord, 
 from a level with the third down to the seventh cervical vertebra, 
 bulged considerably, so as completely to occupy the canal, though above 
 and below this its size was natural. 
 
 In this situation the two layers of the arachnoid of the cord were 
 firmly connected together by numerous filamentous adhesions, and the 
 membrane itself was opaque and thickened. 
 
 The cord in the situation of this bulging had a shining gelatinous 
 appearance, not unlike turbid and badly made jelly, with a yellowish 
 lymph-like matter infiltrated into it. This softening involved the pos- 
 terior columns of the cord much more than the anterior ; the bulging, 
 too, seemed due to the posterior columns, though the anterior presented 
 some degree of softening. 
 
 Three apoplectic effusions were discovered in the spinal cord. The 
 first was situated just below the calamus scriptorius, and was about the 
 size of a lentil ; the nervous matter all around being perfectly healthy. 
 The second, which was larger, was just at the commencement of the 
 swelling of the cord, and partially extended into the sound parts. It 
 just showed through the surface of the cord as big as half a pea, but 
 on longitudinally dividing the cord, was seen to be of the bigness of a 
 kidney bean ; and the third effusion just above the termination of the 
 swelling of the cord, was about as large as a big pea. Besides these 
 there were several small ecchymosed spots in the softened parts of the 
 cord, but all the effusions of blood were strictly limited to the posterior 
 columns of the cord. 
 
 This case presents many points of interest. The scrofulous diathesis 
 in the family ; the probable injury to the spine, followed for a short 
 time by impairment of the motor power, the subsequent occurrence of 
 pain in the bended neck, and the fixed position of the head, all seemed 
 to warrant the opinion that the vertebrae were diseased ; but all resulted 
 from inflammatory softening of the spinal cord, while the bones were 
 perfectly healthy. The softening of the posterior columns of the cord, 
 and the extravasation of the blood into their substance, while the an- 
 terior columns were in a state of comparative integrity, are occurrences 
 very remarkable when coupled with the impaired motor power. 1 Cases 
 such as this are warnings to us to avoid hasty generalizations on physi- 
 ological subjects ; they show us how hard some of the Sphinx's riddles 
 are to read. 
 
 There still remains one affection which we must notice in connection 
 with the diseases of the spinal cord, although it is one whose pathology 
 is by no means thoroughly understood. The trismus or tetanus of new- 
 born children is a malady which, though frequent in the West Indian 
 
 1 It is almost impossible in so young a subject to ascertain accurately the state of 
 sensation, but there was no obvious indication of its impairment in this case. 
 
158 INFANTILE TRISMUS — ITS SYMPTOMS. 
 
 Islands, is seldom seen in this country. Four instances of it have come 
 under my own notice, three of which occurred in the Dublin Lying- 
 in Hospital, while for the opportunity of observing the fourth I was 
 indebted to the courtesy of the late Mr. Stone, of Christ's Hospital. 
 
 The disease may come on within twelve hours after birth, or, on the 
 other hand, may not occur for several days ; but it very rarely makes 
 its appearance after the lapse of a week. I once saw it attack a child 
 fifteen hours after its birth, but in the other case it came on upon the 
 fifth day in one instance, and the sixth in the other two. Though it 
 runs a rapid course, yet its onset is gradual ; one of the first things 
 that attracts the mother's notice being in general, that the child does 
 not take the breast when put to it, but utters a whimpering cry, and if 
 the mouth is then examined, it will be found more or less firmly fixed. 
 Sometimes general convulsions come on suddenly, and usher in the 
 other symptoms, but they more frequently follow than precede the tris- 
 mus. When fully developed, these fits, which come on in paroxysms, 
 are ushered in by a screech, or are attended by some impairment of the 
 respiration, and during their continuance the whole surface becomes 
 livid. The hands are strongly clenched, the feet forcibly flexed on the 
 ankles, and the toes bent, and remain so during the fit, and the trunk 
 is turned back in a condition of opisthotonos : the mouth is generally 
 drawn slightly open, and the lower jaw firmly fixed. When the fit 
 subsides, the muscles do not become generally relaxed, but the child 
 still lies with its hands clenched, and its thumbs drawn into the palm, 
 the legs being generally crossed, and the great toe separated widely 
 from the others, while the head is thrown back, and the opisthotonos 
 continues, though in a diminished degree. The condition of the mouth 
 is peculiar and characteristic. The jaws at first are slightly open, and 
 the corners of the mouth drawn downwards and backwards, but as the 
 disease advances the jaws become quite closed, the corners of the mouth 
 even more drawn down, and the lips firmly compressed against the 
 gums. The power of sucking is early lost, but for some time the child 
 continues able to swallow; at length, however, it accomplishes this 
 with great difficulty, a convulsion sometimes following the attempt, 
 while even that fluid which had apparently been swallowed is for the 
 most part speedily regurgitated. The child dies either during some 
 paroxysm of convulsions, or, seeming much exhausted, it sinks into a 
 comatose condition, and so expires. There are few affections that run 
 so fearfully rapid a course as this ; its fatal termination almost always 
 taking place within thirty-six, often within twenty-four hours from the 
 appearance of the first symptoms. 
 
 The most frequent post-mortem appearance in these cases, and that 
 which I found in the bodies of all the four children whom I observed, 
 consists of effusion of blood, either fluid or coagulated, into the cellular 
 tissue surrounding the theca of the cord. Conjoined with this there is 
 generally a congested state of the vessels of \hQ spinal arachnoid, and 
 sometimes an effusion of blood or serum into its cavity. The signs of 
 congestion about the head are less constant, though much oftener pres- 
 ent than absent, and sometimes existing in an extreme degree, while in 
 one instance I found not merely a highly congested state of the cere- 
 
TRISMUS — ITS PATHOLOGY DOUBTFUL. 159 
 
 bral vessels, but also an effusion of blood in considerable quantity be- 
 tween the skull and dura mater, and also a slight effusion into the 
 arachnoid cavity. 
 
 In spite, however, of the striking nature of these morbid appearances, 
 I formerly hesitated in referring the symptoms of trismus with cer- 
 tainty to this apoplectic condition of the cord. My hesitation arose 
 from the circumstance that on examining the bodies of infants w 7 ho 
 died soon after birth in the Dublin Lying-in Hospital, I very frequently 
 found great fulness of the vessels of the cord, and a gelatinous matter, 
 which was frequently deeply tinged w r ith blood, effused around its theca. 
 It therefore became a question whether appearances such as are met 
 with in cases of trismus might not in reality be due to the position in 
 which the bodies had been allowed to remain, resting on the back, and 
 thus be rather the result of simple gravitation than the consequences 
 of the disease. These doubts, however, have been set at rest by the 
 very excellent observations of Dr. Weber, of Kiel, 3 who placed the 
 bodies of infants in various positions before examining them, and thus 
 was able to discriminate between morbid and pseudo-morbid appear- 
 ances, and Avho, moreover, although he on every occasion placed chil- 
 dren w 7 ho had died of trismus on their face immediately after death, 
 yet always found intense injection of the minute vessels of the cord and 
 its membranes, extravasation of blood external to the theca, and other 
 appearances similar to those wmich I have just described to you . 
 
 There are few 7 diseases respecting the cause of which opinions so va- 
 rious have prevailed as with regard to trismus. Bearing in mind the 
 frequency of external violence as a cause of lock-jaw in the adult, some 
 writers have sought to find in every case the histoiy of a blow or other 
 injury to which it might possibly be attributed ; while others have con- 
 ceived that it depended on awkward management of the navel-string, 
 or on injury of some kind or other inflicted on it. This last opinion 
 has appeared to derive support from some cases in w r hich the umbilical 
 vein has presented the signs of phlebitis : but further observation has 
 shown these appearances to be anything but constant, aud though care- 
 fully sought for, they were not found in any of the cases which came 
 under my notice. Moreover, Dr. Mildner, of Prague, 2 who has re- 
 corded the results of 46 cases of fatal inflammation of the umbilical 
 vessels in children born in the Lying-in Hospital in that city, states 
 that convulsions occurred in only 5 of the number, and that in no in- 
 stance had these convulsions the least resemblance to those wmich char- 
 acterize trismus. Congestion of the liver, impairment of its functions, 
 and icterus, were among the symptoms which attended it, as well as, in 
 many of the cases, peritonitis, inflammation of the abdominal integu- 
 ments, purulent infection of the blood and the formation of abscesses in 
 the joints, which occurred 33 times, while in 4 cases hemorrhage took 
 place from the umbilicus. We may, then, fairly conclude that the 
 
 1 Beitrage zur pathologischen Anatomie der JNeugebornea, 8vo., part i, pp. 7, 
 63, and 73. Kiel, 1851. 
 
 2 Prager Vierteljahrsschrift, v. 2, 1848 ; and Schmidt's Jahrb., No. 7, p. 64, 
 1848. 
 
loO CAUSES AND TREATMENT OF TRISMUS. 
 
 connection between this disease and trismus is merely an accidental 
 coincidence. 
 
 The remarkable frequency of the disease in hot climates, where the 
 heat of the day is succeeded by intense cold at night, favors the opin- 
 ion that interruption of the function of the skin, by sudden alternations 
 of temperature, is a powerful cause of the disease. In an epidemic of 
 this disease in the Lying-in Hospital at Stockholm, in 1834, 1 there 
 seemed also to be a most marker) connection between the periods of its 
 greatest prevalence and the fluctuations of temperature. Nothing, 
 however, can be more satisfactorily proved, than the tendency of a viti- 
 ated state of atmosphere to produce it. Where such a condition exists, 
 there trismus abounds, be the peculiarities of climate or temperature 
 what they may. It is very frequent among the children of the negroes 
 in the Southern States of America : it is depopulating the island of St. 
 Kilda, and 64 per cent, of the infants born in Westmannoe, a small 
 islet off the coast of Iceland, clie of it between the 5th and 12th day from 
 birth. 2 Dirt, and defective ventilation, are probably almost the only 
 points in common between the dweller in the Southern States of North 
 America and the inhabitants of Northern Europe and the Arctic 
 regions. But, if any further proof were needed that to this cause, and 
 not to some fancied displacement of the cranial bones, 3 this disease is 
 really to be attributed, we are furnished with it in the records of the 
 Dublin Lying-in Hospital, which point out both the evil and its 
 remedy. Sixty years ago, every sixth child born in that institution 
 died within a fortnight after birth, and trismus was the cause of the 
 death of J§ of these children. Dr. Joseph Clarke adopted means to 
 secure the efficient ventilation of the hospital, and the mortality of the 
 children fell at once to 1 in 19| ; and during Dr. Collins's mastership 
 from 1826 to 1833, was only 1 in 58 J; and but little more than the 
 ninth part of that mortality depended on trismus. 4 
 
 But though we may hope by wise hygienic measures to avert this 
 disease, yet, when once it has become developed, our prospects of cure 
 are so slender that I may almost say the task is hopeless. I have not 
 seen leeches employed, but, bearing in mind the post-mortem appear- 
 ances, should certainly be disposed to apply them freely at the outset 
 of the disease. I have seen the hot bath used with temporary relief; 
 but though I have witnessed the employment of calomel and of anti- 
 spasmodics, as assafoetida, and the administration of an enema of gr. iij 
 of tobacco infused for half an hour in Sviij of water, yet I have never 
 known any of these means followed by even a temporary pause in the 
 symptoms ; and the endeavor to excite the action of the skin is the only 
 measure that in the cases which I witnessed seemed to be of the slightest 
 service. 
 
 1 Cederschjold, in Busch's Zeitschrift fur G-eburtsk., x, 345. 
 
 2 See a very interesting notice, in the British and Foreign Medico-Chirurgieal 
 Review for April, 1850, of a work by Dr. Schleisner on the Sanitary Condition of 
 Iceland. 
 
 3 A theory propounded by Dr. Sims, of Alabama, in the American Journal of 
 the Medical Sciences for 1846, and further expanded in the same journal for July 
 and October, 1848. 
 
 4 Collins's Treatise on Midwifery, p. 513. 
 
ACUTE FORM OF CONVULSIONS. 161 
 
 LECTURE XIII. 
 
 Convulsions, independent of organic cerebral disease — Their two forms — The 
 acute form, how distinguishable from those dependent on disease of the brain — 
 Practical importance of the distinction — Kules for their treatment — The chronic 
 form — Eelation to them of Spasm or the Glottis — Import of this spasm — 
 One of several signs of disorder of nervous system — Eelation of these convul- 
 sions to processes of development in teething — But exciting causes various — ■ 
 Symptoms — Description of carpo-pedal contractions — Ways in which death is 
 produced — Treatment — Rules for diet and for the regulation of the bowels — 
 Caution with respect to lancing the gums — Occasional necessity for free deple- 
 tion — Case in illustration — Suggestions as to general management, and preven- 
 tion of an attack — Use of chloroform — Remarks on some anomalous forms of 
 convulsion, and on the Eclampsia Nutans. 
 
 In the third of these Lectures, when passing in review the different 
 signs of disorder of the nervous system I made some remarks on the 
 subject of convulsions. I tried to show you how their import varies 
 in different circumstances ; how at one time they betoken real disease 
 of the nervous centres, at another only betray their irritation from some 
 cause which, if death Occur, may yet leave behind no trace such as the 
 skill of the anatomist can discover. 
 
 Cases of the former kind have hitherto exclusively engaged our at- 
 tention, but we must not quit the study of disorders of the nervous 
 system without some consideration of the latter. In the adult, fits 
 sometimes occur independent of obvious cerebral disease ; the patient 
 falls to the ground struggling and insensible ; but after a time the con- 
 vulsion ceases, consciousness returns, and the patient recovers. Our 
 anxiety in such cases is much less for the present than for the future : 
 death in a fit is a rare accident, but what we dread is the recurrence of 
 the fits, the weakening of the intellect, the slow impairment of the 
 health which epilepsy brings with it. In the child our apprehension 
 is twofold; for the frailer machinery is more readily brought to a 
 standstill, and the risk of death in the fit is far greater than in the 
 adult ; while should the child survive, the convulsions of infancy may 
 issue in the epilepsy of riper years ; and, in fact, seem to do so in a very 
 large number of instances. 
 
 The convulsions of infancy and early childhood generally assume 
 one of two characters. Either they are sudden in their onset, violent 
 in their characters, frequent in their return, or they come on gradually, 
 and after various forebodings, present less violence, occur at longer in- 
 tervals, but are not therefore by any means devoid of peril. Cases of 
 the first kind run some risk of being overtreated, from their supposed 
 dependence on active cerebral mischief; cases of the second kind often 
 excite less apprehension than they really warrant, until their symptoms 
 have become manifest in their full intensity. 
 
 Some of the most marked examples of the sudden access of violent 
 
 11 
 
162 ACUTE FORM OF CONVULSIONS. 
 
 convulsions which have come under my notice have been in children 
 in whom they succeeded to the sudden drying up of an eruption on the 
 scalp. Even in such cases, however, where we might most readily 
 suspect some direct influence on the brain, the character of the fits is 
 widely different from that which we observe in instances of real cere- 
 bral disease. The illness preceding them is neither very marked nor 
 of long duration, while, when the fits come on, instead of only one 
 side of the body, or one set of muscles being affected, sometimes one 
 side is convulsed, sometimes the other, or both are involved equally. 
 Even after the fits have frequently returned, paralysis does not succeed 
 to them, and often neither sleep nor coma, while frequently conscious- 
 ness returns, even before the convulsive movements have completely 
 ceased, and the pupils, though dilated during the fit, act again almost 
 or quite as well as ever as soon as it has passed off. Vomiting does 
 not precede nor accompany the attack ; nor an obstinately constipated 
 state of the bowels ; and the abdomen is often much distended with 
 flatus, the endeavor to get rid of which produces troublesome hiccup, 
 while the inspiration is often accompanied by a peculiar crowing sound. 
 There is at no time the burning heat of the head which is observed in 
 active inflammatory disease of the brain ; there are not the piercing cry, 
 nor the constant wail, nor the tearless eyes, nor the shrunken abdomen, 
 nor the automatic movements of one side and the contraction of the 
 limbs on the other, which attend upon tubercular meningitis. 
 
 These characteristics are such as ought to prevent the by no means 
 unusual error of regarding the attack as symptomatic of active disease 
 of the brain ; and under that impression depleting the child freely, 
 dosing it with mercury in large quantities, and at short intervals ; a 
 course of proceeding by which all chances of recovery are frustrated, 
 and hopes, small at first, are altogether destroyed. 
 
 The state of the child before the occurrence of the fits, and the amount 
 of apparent congestion of the brain, must in cases of this kind determine 
 the question of depletion. Moderate depletion once is often well borne, 
 but the persistence of the fits must not be thought necessarily to indi- 
 cate the propriety of its repetition. If the attack succeeded to the 
 rapid disappearance of some eruption on the scalp, an attempt may be 
 made to reproduce it by rubbing in every three hours an ointment 
 composed of one drachm of powdered ipecacuanha to an ounce of lard ; 
 which generally produces an abundant papular eruption in the course 
 of from 12 to 24 hours. If a purgative is indicated, a single dose of 
 calomel has the advantage of acting surely and speedily, but mercury, 
 given in any other manner or with any other object, is out of place. 
 The flatus by which the intestines are distended is got rid of better by 
 an assafoetida enema than by any other means ; while the application to 
 the abdomen of a cloth dipped in a stimulating liniment (such, for 
 instance, as a drachm of oil of turpentine, five drachms of the simple 
 camphor liniment, and six drachms of olive oil), and that covered by a 
 light linseed-meal poultice, both serves as a counter-irritant, prevents 
 the reproduction of the flatus, and relieves that spasm of the abdominal 
 muscles which in many of these cases adds very painfully to the in- 
 fant's sufferings. These measures having been adopted, you may now, 
 
SPASM OF THE GLOTTIS. 163 
 
 according to the general condition of the patient, prescribe either some 
 carminative medicine with small doses of ether, or of the foetid spirits 
 of ammonia, or a single dose of Dover's powder, or of chloral if 
 restlessness and excitability have outlasted the other symptoms ; or a 
 simple saline, as the citrate of potash, with small doses of the tincture 
 of henbane ; or the hydrocyanic acid with a little chloric ether at short 
 intervals — a sedative which, whenever there is a doubt as to the ex- 
 pediency of employing direct narcotics, has always seemed to me of 
 especial value. 
 
 Within certain limits, this treatment must of course be modified 
 according to the exact nature of the case, but enough has already been 
 said to mark out the general principles upon which your treatment 
 should be conducted ; while even if the attack had seemed at first to 
 present some obscurity as to its cause, a few hours will suffice for its 
 removal, will develop the signs of cerebral inflammation if that were 
 impending, or will bring to light the character of the fever which is 
 making this stormy onset. So long as, notwithstanding the frequency 
 of the return of the fits, recovery is complete after each, so long as the 
 power of deglutition subsists, and the natural hue of the lips and face 
 announces the oxygenation of the blood to be well performed, you may 
 give on the whole a favorable prognosis, though always guarding it by 
 admission of the possibility of the child dying in a fit from that spasm 
 of the glottis, and consequent arrest of breathing, which is the great 
 source of danger in infantile convulsions. 
 
 This Spasm of the Glottis is, indeed, one of the most remarkable 
 features in many convulsive affections of infancy and childhood ; 
 though more especially of that variety to which I have referred as 
 coming on gradually and pursuing a somewhat chronic course. 
 
 So prominent a feature, indeed, is it of this latter class of convul- 
 sions, that attention has been very generally directed to this one symp- 
 tom, almost to the exclusion of the other signs of disorder of the 
 nervous system by which it is accompanied, and the various terms, 
 spasmodic croup, child-crowing, spasm of the glottis, and laryngismus 
 stridulus, show how .great has been the disposition to regard it as a 
 distinct and independent disease. Hence has resulted the inconveni- 
 ence, that attention being directed exclusively to the affection of the 
 respiratory function, local causes have been too much sought for to 
 account for the local symptom ; defective, if not erroneous explana- 
 tions of its occurrence have been proposed, and sufficient regard has 
 not been paid in its treatment to the great diversity of conditions 
 under which it may supervene. 
 
 The sobbing breathing, or the sense of choking, so characteristic of 
 the hysterical patient, are but instances of spasm of the respiratory 
 muscles similar to those which we observe in the infant, and equally 
 due to the great excitability of the nervous system. In the hysterical 
 girl, fits are frequently superadded to the affection of the respiratory 
 muscles; and in the child, spasm of the muscles of the extremities, 
 giving rise to the drawing of the thumb into the palm, and to the 
 separation of the great toe from the other toes, or to the forcible ex- 
 tension of the foot upon the ankle, is seldom absent; while general 
 
164 SPASM OF THE GLOTTIS. 
 
 convulsions often supervene under slight causes, or even without any 
 apparent reason. In both cases the affections are usually attendant 
 upon important processes of development, since while in the former 
 instance they generally come on about the period of puberty, they 
 oftenest occur in the latter during the time of teething; and this with 
 so great frequency, that in 31 out of 37 cases of which I have pre- 
 served a record, the symptoms manifested themselves between the age 
 of 6 months and 2 years, or just at that time when the process of den- 
 tition is going on with the greatest activity. The direct irritation of 
 the trifacial nerve in teething has no doubt a great share in the produc- 
 tion of the symptom at that time, but I apprehend that we should be 
 in error, if we confined our attention entirely to the local cause, and 
 attributed this, more than any other form of convulsive affection, 
 which occurs at this time, simply to the mechanical irritation of the 
 teeth, pressing on or cutting through the gum. The period of teeth- 
 ing, like that of puberty, constitutes one of the great epochs of life ; 
 it is a time when great changes are going on in the whole organism — 
 when the animal machine, being in a state of increased activity, its 
 parts are more than usually apt to get out of order. New diseases ap- 
 pear, or such as were before of rare occurrence become frequent; catar- 
 rhal affections and disorders of the intestinal mucous membrane are 
 extremely prevalent, and the brain grows more than ever liable to con- 
 gestion of its vessels. In these circumstances, the various spasmodic 
 affections, of which spasm of the glottis is the most striking and the 
 most important, often occur as the secondary rather than as the primary 
 result of dentition. The child has cut some of its teeth without any 
 symptom of disorder of the nervous system making its appearance, 
 but at length it suffers an attack of diarrhoea, or the bowels are 
 allowed to become constipated, or signs of cerebral congestion show 
 themselves. A crowing sound now becomes audible with the inspira- 
 tion, and with it some or all of the whole train of convulsive symp- 
 toms which 1 shall presently describe make their appearance. It may 
 be that the gums are not swollen, nor any tooth near the surface just 
 at the moment when the signs of disturbance of the nervous system 
 occurred, but their connection with the process of dentition is not the 
 less undeniable. In many instances, too, though these symptoms may 
 subside as the health improves^ yet so great is the nervous excitability 
 of the patient, that they return when he cuts another tooth, and this 
 even without a recurrence of that general disorder which attended them 
 on the former occasion. 
 
 The various sources of irritation, however, that give rise to these 
 affections are not limited to the period of teething ; and hence they 
 may be met with before the commencement of that process as well as 
 after its termination. By no one has this fact been more clearly stated, 
 or the mode of action of the various exciting causes more successfully 
 explained than by the late Dr. Marshall Hall. 
 
 " Spasm of the Glottis/' says this distinguished physiologist, 1 " is an 
 excitation of the true spinal or excito-motory system. It originates in 
 
 i Lib. cit.,p. 171. 
 
CAUSES AND SYMPTOMS OF SPASM OF THE GLOTTIS. 165 
 
 I. 1. The trifacial, in teething. 
 
 2. The pneumogastric, in over- or improperly-fed infants. 
 
 3. The spinal nerves, in constipation, intestinal disorder, or ca- 
 
 tharsis. 
 These act through the medium of 
 
 II. The spinal marrow, and 
 
 III. 1. The inferior or recurrent laryngeal, the constrictor of the 
 larynx. 
 2. The intercostals and diaphragmatic, the motors of respiration." 
 
 In illustration of these observations as to the various causes on which 
 these symptoms depend, I may mention that I have seen them in a 
 child ten weeks old as a consequence of improper feeding : in another, 
 aged nineteen months, they followed the sudden suppression of long- 
 continued diarrhoea ; while in a third, aged two years, they came on 
 during an attack of purging with severe pain in the abdomen. In 
 another child, aged two years and a half, they seemed to depend on a 
 state of cerebral congestion which succeeded to habitual constipation ; 
 in a fifth, aged nine months, they supervened in the course of chronic 
 hydrocephalus; and, not needlessly to swell the list, in a sixth child, 
 who died when two months old, convulsions occurred for a period of 
 six weeks, and eventually occasioned its death, without its having been 
 possible to discover, either from the symptoms or from the appearances 
 found on examination of the body, any cause to wdiich they could be 
 attributed. 
 
 But this principle admits of a wider application. Not only are the 
 convulsions which occur during dentition symptomatic of something 
 more than the undue pressure of a tooth against the gum, but in by far 
 the greater number of instances, we have to look deeper than the local 
 cause to which at last the signs of disturbance of the nervous system 
 were due, and find that it is only on the removal of some influence 
 which acted injuriously on the whole constitution that the liability to 
 convulsions ceases. Thus, for instance, in the child brought up by 
 hand, the commencement of teething is ushered in by convulsions, a 
 wet nurse is procured, the convulsions cease ; or medical care has failed 
 to relieve the infant resident in London, — it is removed to the country, 
 and the fits previously so frequent disappear. 
 
 In spite, however, of the illustration of this fact which the action of 
 remedies affords, it is yet too often lost' sight of. The defective nutri- 
 tion which shows itself in the bowed limbs, and distorted form of the 
 rickety patient, is attended in early life by special proneness to convul- 
 sions. So intimate indeed is the relation between rickets on the one 
 hand, and convulsions and spasm of the glottis on the other, that Dr. 
 Gee 1 states as the result of his most careful observations among the 
 out-patients at the Children's Hospital that 48 out of 50 cases of spasm 
 of the glottis presented evidences of rickets; that 19 of them suf- 
 fered also from convulsions ; while further in 56 out of 61 children 
 who were attacked by convulsions before the completion of the first 
 dentition, there were also signs of rickets in a more or less advanced 
 
 1 Bartholomew's Hospital Keports, vol. iii, 1867, p. 101. 
 
166 CAUSES AND SYMPTOMS OF SPASM OF THE GLOTTIS. 
 
 degree as deduced from enlargement of the growing ends of the bones. 
 It is true that these observations were made among the poor ; but it 
 must also be admitted that the minor degrees of rickets are far from 
 unusual even among the children of the richer classes ; and I doubt 
 whether even as applied to them these figures would much overstate 
 the truth. It was a partial recognition of the important part played 
 by rickets in predisposing both to convulsions and laryngeal spasm 
 that led a German physician 1 some years ago to think that he had dis- 
 covered, in the tardy ossification of the skull in such children, an ade- 
 quate explanation of their liability to disturbance of the functions of 
 the imperfectly protected brain, and putting a part for the whole, 
 wrote by a very pardonable, but not the less mistaken synecdoche, an 
 essay on " The soft Occiput." Again, one of the commonest manifes- 
 tations of the tuberculous diathesis is glandular enlargement ; and the 
 late Dr. Hugh Ley 2 propounded a theory which explained the symp- 
 toms of spasm of the glottis by an assumed pressure of the enlarged 
 cervical glands on the recurrent laryngeal nerve. Still more recently, 
 we find a practitioner of considerable experience struck by the connec- 
 tion of spasm of the glottis 3 with enlargement of the liver, and 
 framing a mechanical explanation of the trouble of respiration by the 
 impediment to the descent of the diaphragm which is occasioned by 
 the great size of the organ. Of the frequent coexistence of the enlarged 
 and fatty liver with spasm of the glottis there can be no doubt ; but it 
 does not therefore follow that we are to accept the mechanical expla- 
 nation of the^ fact which Mr. Hood suggests. Some years ago, my 
 friend and former colleague, Doctor Rolleston, now Linacre Professor 
 at Oxford, wrote a paper which I wish that his modesty had not with- 
 held from publication, in which he shows that this same fatty liver is 
 present in many instances of the hydrocephaloid disease of early in- 
 fancy ; the extreme anaemia, the feeble powers, the rapid sinking under 
 slight ailments, the supervention of signs of disorder of the nervous 
 system (among which spasm of the glottis is by no means necessarily 
 present), being found associated with this grave defect in nature's great 
 alembic, and consequently with imperfect depuration and depraved 
 character of the blood. But modern physiology 4 gives a still graver 
 import to this, as to other morbid conditions of the liver in connection 
 with those disorders of the uervous system in early life which are asso- 
 ciated with anaemia or with deranged nutrition. The liver would 
 seem to be not merely a purifier, but an actual generator of the blood ; 
 its disease, therefore, interferes immediately with sanguification, and 
 prevents the best devised tonic remedies from exercising that influence 
 which otherwise they would not fail to produce. 
 
 1 Der weiche Hinterkopf, &c, von Dr. C. L. Elsasser. 8vo. Stuttgart, 1843. 
 
 2 On Laryngismus Stridulus, 8vo. London, 1836. 
 
 3 On Scarlet Fever and Crowing Inspiration. 8vo. London, 1857. 
 
 4 Funke, Lehrbuch der Physiologie, vol. i, 2d ed. 8vo. Leipzig, 1858, says in 
 g 35, on the metamorphosis of the blood in the liver : " It is the more correct view- 
 to regard the liver as an organ the special function of which is the formation of new 
 blood-cells, and to consider the change of the materials which during and probably 
 in consequence of that new formation are excreted from the blood into bile, only 
 as its secondary duty.''' See p. 147. 
 
CAUSES AND SYMPTOMS OF SPASM OF THE GLOTTIS. 167 
 
 It follows then, with reference to all the disorders of the nervous 
 system in early life, that while the mode in which they manifest them- 
 selves varies from slight and unimportant causes, and while local acci- 
 dents may account for their assuming this or the other special form, we 
 must in all instances endeavor to look beyond them to the constitutional 
 ailment, sometimes of one kind, sometimes of another, but always im- 
 plying some deepseated impairment of nutrition, to which as their ul- 
 timate occasion, they are due. 
 
 Bearing in mind now what I have just said with reference to the 
 import of Spasm of the Glottis, — how it is but one of many signs of the 
 general disorder of the nervous system, — we may proceed to examine 
 the conditions under which it usually manifests itself; the symptoms by 
 which it is generally attended. It is a disorder that almost always 
 comes on by degrees ; and its early symptoms are seldom such as to 
 excite the alarm of non-professional persons. It does not often occur 
 in perfectly healthy children ; but an infant who is attacked by it has 
 usually been observed to be drooping for some time previously, to have 
 lost its appetite, to have become fretful by day and restless at night, 
 and to present many of those ill-defined ailments which are popularly 
 ascribed to teething. At length, after these symptoms have continued 
 for a few r days or weeks, a slight crowing sound is occasionally heard 
 with the child's respiration. The sound is something between the hoop 
 of hooping-cough and the stridor of true croup ; it must be heard to be 
 known, but when once heard will easily be recognized. Usually it is 
 first noticed on the child awaking out of sleep, but sometimes it is per- 
 ceived during a fit of crying, or comes on while the infant is sucking. 
 Now and then the first crow is very loud, and, by its resemblance to 
 the sound of croup, at once alarms the family : but this is not gen- 
 erally the case; and its loudness usually increases in proportion as 
 its return becomes more frequent. The spasm may have been excited 
 by some temporary cause, and the sound which is its token may in 
 that case not be heard again ; but generally it returns after the lapse of 
 a few hours, or of a day or two. It will soon be found, as its return 
 becomes more frequent, that certain conditions favor its occurrence; 
 that the child wakes suddenly from sleep with an attack of it, that ex- 
 citement induces it, or deglutition, or the eifort of sucking ; so that the 
 child will suddenly drop the nipple, make a croupy sound with its 
 breathing, and then return to the breast again. Throughout the whole 
 course of the affection its attacks will be found to be more frequent by 
 night than by day ; and to occur mostly either soon after the child has 
 lain down to sleep, or towards midnight, when the first sound sleep is 
 drawing to a close. 
 
 At first the child seems, during the intervals of the attack, in as 
 good health as before, — except, perhaps, that it is rather more pettish 
 and wilful ; but it is not long before graver symptoms than the occa- 
 sional occurrence of an unusual sound with inspiration excite attention, 
 and give rise to alarm. Fits of difficult breathing occasionally come 
 on, in which the child throws its head back, while its face and lips be- 
 come livid, or an ashy paleness surrounds the mouth, slight convulsive 
 movements pass over the muscles of the face ; the chest is motionless, 
 
168 CAUSES AND SYMPTOMS OF SPASM OF THE GLOTTIS. 
 
 and suffocation seems impending. But in a few seconds the spasm 
 yields, expiration is effected, and a long, loud, crowing inspiration suc- 
 ceeds, or the child begins to cry. Breathing now goes on naturally ; 
 the crowing is not repeated, or the crying ceases ; a look of apprehen- 
 sion dwells for a moment on the infant's features, but then passes away ; 
 it turns once more to its playthings, or begins sucking again as if noth- 
 ing were the matter. A few hours, or even a few days, may pass before 
 this alarming occurrence is again observed; but it does recur, and 
 another symptom of the disturbance of the nervous system is soon su- 
 peradded, if it has not, as is often the case, existed from the very be- 
 ginning. This consists in a peculiar contraction of the hands and feet; 
 a state which may likewise not infrequently be noticed during infancy, 
 unattended by any spasmodic affection of the respiratory organs; though 
 it is often overlooked, since unlike the peculiar noise in breathing, it 
 does not force itself on the attention even of the most unobservant. It 
 differs much in degree: sometimes the thumb is drawn into the palm 
 by the action of its adductor muscles, while the fingers are unaffected ; 
 at other times the fingers are closed more or less firmly, and the thumb 
 is shut into the palm ; or coupled with this, the hand itself is forcibly 
 flexed on the wrist. In the slightest degree of affection of the foot, the 
 great toe is drawn a little away from the other toes ; in severer degrees 
 of the affection this abduction of the great toe is very considerable, and 
 the whole foot is forcibly bent upon the ankle and its sole directed a 
 little inwards. Affection of the hands generally precedes the affection 
 of the feet, and may even exist without it ; but I have never seen spas- 
 modic contraction of the feet when the hands were unaffected. At first 
 this state is temporary, but it does not come on and cease simultane- 
 ously with the attacks of crowing inspiration, though generally much 
 aggravated during its paroxysms. Sometimes a child in whom the 
 crowing inspiration has been heard will awake in the morning with 
 the hands and feet firmly flexed, although he may not have had any 
 attack of difficult breathing during the night. At other times, though 
 but seldom, this state will subside during sleep ; while very often it is 
 impossible to assign any reason for its cessation or return. The hands 
 may often be umiexed by bending the fingers, but they will resume 
 their former position on the withdrawal of the force ; and such at- 
 tempts are painful to the child. When the contraction is but slight, 
 children still use their hands; but when considerable, they cannot em- 
 ploy them, and they sometimes cry, as if the contraction of the muscles 
 were attended with pain. Coupled with these carpopedal contractions, 
 the back of the hand and the instep are sometimes swollen, tense, and 
 livid ; and occasionally there is slight puffmess about the face. This 
 condition is sometimes more general, and on two successive years the 
 same child was brought to me, in whom these attacks of crowing inspi- 
 ration were accompanied by a state of tense anasarca of the whole 
 body. 1 The swelling of the hands and feet may be due merely to the 
 
 1 This case presented a remarkable similarity to one described by Dr. M. Hall, 
 at p. 185 of bis work on the Diseases and Derangements of the Nervous System. 
 8vo. London, 1841. 
 
SYMPTOMS OF SPASM OF THE GLOTTIS. 169 
 
 impediment to the circulation presented by the continuous spasm, and 
 will then subside of its own accord as the spasm abates. The general 
 anasarcous condition, of which I have now seen several instances, de- 
 pends on a different cause. The urine in these cases, if it can be col- 
 lected, will be found to be albuminous, and under the employment of 
 diuretic and diaphoretic medicines, the removal of the dropsy and the 
 abatement or disappearance of the spasmodic symptoms will take place 
 together. 
 
 "When the disease has reached a high degree of intensity, a slight 
 crowing sound often attends each inspiration, and the paroxysms of 
 difficult breathing are much more severe ; they last longer, and some- 
 times terminate in general convulsions. The breathing now does not 
 return at once to its natural frequency, but continues hurried for a few 
 minutes after the occurrence of each fit of dyspnoea ; and it is sometimes 
 attended with a little wheezing, from the accumulation of mucus in the 
 trachea and larger bronchi during the paroxysm. When this wheezing 
 is permanent, I do not apprehend that it usually constitutes any essen- 
 tial part of the disease, but regard it either as due to an accidental 
 complication with catarrh, which is so frequent during the period of den- 
 tition, or as the result of the affection being associated with tubercle in 
 the lungs or bronchial glands, or it may perhaps be owing to a degree 
 of pulmonary congestion, such as takes place in hooping-cough in con- 
 sequence of the frequent interruption to the regular performance of res- 
 piration. The slightest cause is now sufficient to bring on an attack 
 of difficult breathing; it may be produced by a current of air, by a 
 sudden change of temperature, by slight pressure on the larynx, by the 
 act of deglutition, or by momentary excitement. The state of sleep 
 seems particularly favorable to its occurrence, and the short fitful dozes 
 are interrupted by the return of impending suffocation. 
 
 The general condition of the child varies much during the existence 
 of these symptoms, but is always widely removed from a state of health. 
 The bowels are almost invariably disordered, constipation being more 
 frequent than diarrhoea. The mouth is sometimes hot, and the gums 
 are swollen — the child is evidently suffering from the process of teeth- 
 ing; and this is the state with which spasm of the glottis is perhaps 
 most frequently associated. Sometimes there is evident congestion of 
 the brain, and the face is flushed, the head hot, and the pulse frequent; 
 but these flushes of the face are usually temporary, and the skin is 
 generally pallid. When the affection has continued for some weeks, 
 the countenance often assumes a haggard, miserable aspect ; and though 
 it may come on in children apparently in good health, I have never 
 known the health continue good, after the disease, even in a mild form, 
 has lasted for any time. 
 
 Death sometimes takes place during one of the paroxysms of dyspnoea, 
 the child being suffocated by the long continuance of the spasm ; or at 
 other times the often-repeated difficulty of breathing induces a state of 
 permanent cerebral congestion : general convulsions occur, and the 
 child dies convulsed or comatose, serous effusion having taken place 
 into the ventricles of the brain. Should the child escape both these 
 dangers, and should no tubercular disease of the lungs or bronchial 
 
170 TREATMENT OF SPASM OF THE GLOTTIS. 
 
 glands exist, recovery is almost sure eventually to take place ; though 
 the convalescence is often very protracted, and the attack is apt to re- 
 turn under the influence of the same causes as originally excited it. 
 
 The treatment of spasm of the glottis must be regulated by the nature 
 of its exciting cause ; and this, as you have already seen, varies much 
 in different cases. In infants before the period of dentition, it is usually 
 induced by overfeeding, or by food of an improper kind. Our in- 
 quiries, therefore, must at once be directed to ascertain how the infant 
 is fed; and supposing it to be still suckled, it will be wise to interdict 
 any other food than the mother's milk — or, at most, to allow only a 
 little barley-water. Spasm of the glottis, however, occurs much oftener 
 in infants who are brought up by hand, or in those who have been 
 weaned, than in children still at the breast. In such cases, much pains 
 are sometimes necessary in order to ascertain precisely the kind of food 
 that best suits the infant. Two parts of milk, and one of barley-water, 
 sweetened with a little loaf-sugar; or equal parts of milk and of a 
 solution of isinglass, made of the thickness of barley-water, generally 
 agree very well ; but much caution must be used in the introduction 
 of farinaceous articles into the child's diet. Asses' milk, which forms 
 the nearest approach to its natural food, must sometimes be given till 
 the child has decidedly improved ; while, if it is puny, and does not 
 appear to thrive, and the crowing inspiration continues undiminished, 
 it may become absolutely necessary to restore it to the breast. 
 
 The state of the bowels requires no less attention than the regulation 
 of the diet. The tendency to constipation must be combated, not by 
 drastic purgatives, but by mild aperients. Castor oil often answers 
 the purpose very well, but sometimes each dose of it nauseates a child 
 for several hours, and then it is not desirable to employ it if a daily 
 aperient should be needed. Both senna and manna are apt to gripe ; 
 and if they should be found on trial to produce this effect, their use 
 must not be persevered in. Few medicines act more mildly or more 
 certainly in children than aloes ; and the bitter of the compound decoc- 
 tion may be much concealed by extract of licorice. The bulk of a 
 medicine, however, often opposes a great difficulty to its employment in 
 infancy ; and if that is the case, the powder may be substituted for the 
 decoction. If slightly moistened, mixed with a little coarse sugar, and 
 placed on the tongue, it will often be swallowed very readily. The 
 habitual use of mercurials to overcome the constipation is not desirable: 
 their employment is better limited to those cases in which not only 
 the bowels are sluggish, but the evacuations are unnatural in char- 
 acter. 
 
 The action of the bow T els may be encouraged by rubbing the abdo- 
 men twice a day with a liniment composed of equal parts of soap lini- 
 ment and tincture of aloes; or the bowels may sometimes be induced to 
 act regularly in young infants by the daily employment of a small soap 
 suppository. Enemata, consisting either of warm water or of gruel, 
 may also be given for the same purpose. 
 
 Sedulous attention to the diet and the state of the bowels will some- 
 times effect a cure ; but in many instances tonics may be employed with 
 advantage, and none with such decided benefit as the preparations of 
 
TREATMENT OE SPASM OF THE GLOTTIS. 171 
 
 iron and cod-liver oil. Indeed, if we bear in mind the observations 
 which I have already referred to as to the connection between laryngeal 
 spasm, convulsions, and the rickety constitution, we shall at once have 
 recourse to cod-liver oil as the great remedy for the past, and prophy- 
 lactic for the future. Removal to pure air, however, or to the sea- 
 coast, is often a tonic of greater power in these cases than all the con- 
 tents of the laboratory, and one which you will find in some instances 
 to be absolutely indispensable to the child's cure. 
 
 All these cares are not less needed in children in whom the process 
 of dentition has already commenced. In them, however, the irritation 
 of teething is often the exciting cause of the affection, and lancing the 
 gums is frequently needed in addition to the other treatment. The 
 relief thus afforded is sometimes very striking ; and the frequent repe- 
 tition of the operation may be necessary to diminish the swelling and 
 tension, and to ease the pain of the congested gum. It is not, how- 
 ever, a proceeding to be adopted, irrespective of all other considera- 
 tions, simply because the child had begun to cut his teeth when the 
 attack of spasm of the glottis came on. Dentition does not go on 
 continuously from the time when the first tooth is cut until the com- 
 pletion of the whole set, but there are regular pauses in the process, 
 during which its advance is suspended for several weeks together. 
 Thus, for instance, after the appearance of the incisors, there is a 
 pause for several weeks or months before the first molar teeth appear, 
 and then there is another cessation in the process before the child 
 begins to cut its canine teeth. The spasm of the glottis, therefore, 
 may come on during one of these pauses, and be excited by some 
 cause quite unconnected with dentition. Lancing the gums, too, is 
 not well borne in every case, even when it may have appeared to be 
 indicated ; and I have more than once been compelled to discontinue 
 it, on account of the pain and alarm which it excited bringing on a 
 violent spasmodic seizure whenever I attempted to practice it. 
 
 In some instances the spasm of the glottis is associated with mani- 
 fest uneasiness in the head. It has been suggested that, in some of 
 these cases, the brain is kept in a state of constant irritation, owing to 
 the deficiently ossified skull being too thin to defend it from injury, 
 while at the same time it affords no adequate counter-pressure to check 
 the overdistension of the cerebral vessels. There is no doubt but that 
 rickety children are peculiarly liable to this affection ; and though the 
 constitutional condition of such children has certainly much to do with 
 its production, yet the imperfect bone formation of the cranium prob- 
 ably has a share in such cases in aggravating it. I have seen many 
 instances in which the recommendation that a horsehair cushion should 
 be made for the head to rest on, having a hole in its centre, so as to 
 relieve the occiput from all pressure, has been acted on with manifest 
 advantage. The supervention of attacks of spasm of the glottis, in a 
 case of well-marked chronic hydrocephalus, would call for little change 
 in the treatment, though it must evidently add much to the danger of 
 the patient. 
 
 Symptoms of cerebral congestion are sometimes associated with this 
 condition. They are seldom such a.^to call for active interference; 
 
172 TREATMENT OF SPASM OF THE GLOTTIS. 
 
 but the tepid bath and neutral salines, with small doses of hyoscyamus, 1 
 are often of much service in quieting the general excitement of the cir- 
 culation, while the occasional application of a leech to the head may 
 be beneficial, especially if general convulsions are beginning to super- 
 vene on the attacks of dyspnoea. 
 
 It is possible that you may meet with a case in which active deple- 
 tion is indicated, and you must not allow the consciousness that, as a 
 general rule, it is inappropriate, to prevent you from having recourse 
 to it in such exceptional instances as the following. In this case, in- 
 deed, it was found necessary to carry depletion beyond that point which 
 is in general expedient in so young a child. 
 
 Some years since I saw a little boy, 2J years old, who had already 
 suffered from several attacks of spasm of the glottis. A return of the 
 affection had taken place about seven weeks before, though not at- 
 tended by any very alarming symptoms until after the lapse of a 
 month, when a general convulsive seizure occurred. From this he re- 
 covered, and he had for some days appeared to be convalescent from 
 the spasmodic attacks, when his bowels became disordered and a good 
 deal purged, and after they had been so for two or three days his 
 mother noticed one afternoon that his thumbs were forcibly drawn into 
 the palms of his hands. With the exception of this contraction of 
 his thumbs, however, he seemed as well as usual and had a tolerably 
 good night ; but immediately on awaking at six o'clock on the follow- 
 ing morning he had a paroxysm of stridulous breathing, in which he 
 crowed so loudly as to be heard over the whole house. His face at the 
 same time became greatly flushed, and his hands and feet contracted, 
 as they were when I visited him three hours afterwards. His face 
 was then much flushed, his head hot, his pupils rather dilated, his 
 pulse full and bounding ; his thumbs were drawn across the palm ; 
 the fingers were not closed, but the hands were forcibly flexed on the 
 wrist ; the great toe was drawn apart from the other toes, which were 
 flexed, and the whole foot was stiffly bent on the ankle. The child 
 was then breathing quietly and seemed drowsy, but he screamed out 
 the moment he was touched, as if the least disturbance of his limbs 
 gave him pain. 
 
 Eight leeches were applied to his temples, and drew much blood, 
 but without producing any amelioration of his condition. A croupy 
 sound continued to attend his respiration, and he had a fit of urgent 
 dyspnoea, with loud stridulous breathing, between my first visit at 9 
 in the morning and my second at 5 in the evening. I now bled him 
 from the arm to §vj, which subdued the fulness of the pulse, blanched 
 his lips, and diminished the flush of his face, though it did not cause 
 actual fainting. I ordered cold to be applied to the head, and saw him 
 again at 7 J p.m., when I found that he had been lying quiet ever since 
 I left him, and had had some tranquil sleep, without any crowing sound 
 attending the breathing. His pulse was less full, the flush of his face 
 was diminished, the heat of the head was gone, and the contractions of 
 the hands and feet were both less, and less firm. 
 
 1 See Formula No. 3, p. 53. 
 
CAUTIONS IN TREATMENT OF SPASM OF THE GLOTTIS. 173 
 
 A powder with gr. j of calomel and gr. viij of rhubarb, which had 
 been given in the morning, and had produced one evacuation, was now 
 repeated. 
 
 The child had some sleep in the night, and no access of dyspnoea 
 returned, nor did the croupy sound again accompany the inspiration. 
 In the course of the day the spasmodic contractions of the hands and 
 feet greatly diminished, and the child became cheerful. In five days 
 from this formidable attack he Avas quite well, and continued so for a 
 year, when a slight return of spasm of the glottis took place, in the 
 course of a severe impetiginous eruption on the scalp. 
 
 Before concluding this lecture, I will suggest a few cautions, appli- 
 cable alike to all cases of spasm of the glottis. Sudden excitement, and 
 especially a fit of crying, are likely to bring on the attack, and since 
 there is a possibility of any one of these attacks proving fatal, the 
 greatest care must be taken in the management of the child to avoid all 
 unnecessary occasions of annoyance or distress. 
 
 Although the benefit that accrues from fresh air, or from a change 
 of air, is often very great, yet it is very important that the child should 
 not be exposed to the cold or wind, lor I have seen such exposure fol- 
 lowed by a severe attack of dyspnoea, -or by the occurrence of general 
 convulsions. The hazard of such an occurrence is greater in proportion 
 to the severity and long continuance of the affection, and, in such cases, 
 the excitability of the spinal cord, and the irritability of the surface, 
 seem sometimes to become as great as they may be observed to be in 
 frogs when narcotized, whom you may then throw into convulsions by 
 merely shaking the table on which they are placed. It is possible that 
 this condition in the infant may be due to a cause not unlike that which 
 produces it in the lower animal. In the latter, it is manifestly due to 
 the influence on the nervous system of blood impregnated with opium; 
 in the former, a similar influence may be exerted by blood the proper 
 depuration of which has been prevented by the frequent recurrence of 
 spasm of the glottis. 
 
 There is also another reason for caution in exposing the child to cold 
 or wind, namely, that the occurrence of catarrh is almost sure to be 
 followed by an aggravation of the spasmodic affection. On more than 
 one occasion I have seen the supervention of catarrh convert a very 
 mild into a very serious attack ; and once the exacerbation of the symp- 
 toms thus produced was the cause of the infant's death. 
 
 The parents should in every instance be made fully aware of the un- 
 certainty that attends this affection — of the possibility of death taking 
 place very suddenly and unexpectedly. 
 
 In the paroxysm itself but little can be done. Cold water may be 
 dashed on the face, and the fauces may be irritated, or the finger passed 
 down into the pharynx, so as to bring on if possible the effort to vomit, 
 while at the same time the legs and lower part of the body may be 
 placed in a hot bath. 
 
 The remarkable observations of MM. Braun and Chiari 1 on the 
 employment of chloroform in puerperal convulsions, and a short paper 
 
 1 Klinik der Creburtshulfe, &c, part ii, p. 249, 8vo. Erlangen, 1853. 
 
174 GENERAL MANAGEMENT OF 
 
 by Dr. Simpson, of Edinburgh, 1 on its utility in the convulsions of 
 children, drew my attention to it, and I have tried it extensively, and 
 in many instances with advantage. In cases where depletion is inad- 
 missible, where the convulsions are not obviously due to organic disease 
 of the brain, while they are both severe in their character and are 
 returning with frequency, the inhalation of chloroform sometimes 
 altogether arrests them. It is also of service in attacks of a more 
 chronic kind, in which, though convulsions are less violent, yet the 
 irritability of the nervous system is extreme, and every change of pos- 
 ture, and every attempt at deglutition, are followed either by threaten- 
 ings of a fit, or by actual convulsions. Its efficient use, however, is 
 not easy to secure, since it requires the constant presence in the house 
 of some one competent to administer it; while if intrusted to the parents 
 or to a nurse, the fears of the former, and the want of intelligence of 
 the latter, generally render its employment merely nominal. Even 
 when most skilfully administered, too, the efficacy of the remedy soon 
 ceases, if from the return of the convulsions/the necessity should arise 
 for its being given at very short intervals. In these circumstances 
 the narcotism soon becomes very partial, and the fits recur altogether 
 unmitigated by it — a result which I have also observed in puerperal 
 convulsions. I have never seen mischief follow from its use; but 
 its power of doing good seems usually to be more evanescent than that 
 of other sedatives. 
 
 Of late years we have become acquainted with two remedies, each of 
 which alone, or the two combined, seem sometimes to exert a marvel- 
 lous power in controlling convulsions, whether accompanied or not by 
 laryngeal spasm. These two remedies are the bromide of potassium, 
 and the hydrate of chloral ; and their most remarkable results are pro- 
 duced in cases where there is no ground for suspecting organic disease, 
 and where there are no distinct indications for treatment beyond such 
 as are furnished by the frequent recurrence of the convulsions. Of 
 the two remedies the bromide has appeared to me the more reliable ; but 
 in order to obtain' decided results from it, it needs to be given in doses 
 larger than those which are commonly employed : as, for instance, from 
 two to three grains every four hours for a child of one year old, and from 
 three to five grains from the age of three to five. If it does not give 
 earnest of good within the first thirty-six hours, there is little use in 
 continuing it, though it may still be persevered with, with the addition 
 of one or two grains of hydrate of choral. The depressing effects of 
 the bromide must not be lost sight of; and either their occurrence, or 
 the failure of the remedy, may compel us to use the choral in similar 
 doses though at an interval of every six or eight, instead of every four 
 hours. I think, however, that on the whole I have obtained the best 
 results from the bromide every four or six hours, accompanied with a 
 single full dose of chloral every night at bedtime. 
 
 There are still a few points connected with the derangements of the 
 nervous system in early life, which require a brief notice before I close 
 this lecture. And first, with reference to cases, happily rare, of violent, 
 
 1 Obstetric Works, vol. ii, p. 470, from Ed. Monthly Journal, Jan. 1852. 
 
CASES OF SPASM OF THE GLOTTIS. 175 
 
 causeless, and fatal convulsions in early life, independent of disease of 
 the brain. Such attacks are very unusual after the completion of den- 
 tition ; sometimes they occur without any apparent exciting cause, but 
 more frequently they follow on some slight error in diet, or on slight 
 exposure to the heat of the sun, or on the drying up of some cutaneous 
 eruption, or of some long-existing strumous sore. They are char- 
 acterized by the violence of the convulsive movements, by the depth 
 of the coma which succeeds to them, and by the very rapid failure of 
 the child's powers. I think, too, it may be said, that convulsions 
 attended by such circumstances warrant more serious apprehension in 
 children of three or four years old, than in infants of a year or eighteen 
 months. For this the reason doubtless is, that at an age when the 
 nervous system is less susceptible than in infancy, an attack of this 
 kind implies a graver disturbance, and one less likely to pass aw 7 ay. 
 Death in these seizures seems to take j)lace, not from sudden asphyxia, 
 as in spasm of the glottis, but from the slow r er influence of the per- 
 petual disturbance of the respiratory process, or from exhaustion of the 
 nervous power, just as one sees it do in cases of puerperal convulsions ; 
 the skin becoming colder, the pulse more feeble after each attack, and 
 complete collapse being induced w r ithin twenty-four, sometimes within 
 twelve hours from the first seizure. With reference to the share 
 which is borne by the imperfect aeration of the blood in destroying the 
 patient in some of these cases, M. Trousseau 1 makes some remarks, 
 distinguished by his usual acuteness. He notices that the state is not 
 dissimilar from that of a person on w 7 hom tracheotomy has been per- 
 formed in the extreme period of croup. The obstacle to the entrance of 
 air may have been removed by the operation, but the consequences of 
 the previous long-continued interruption to the aeration of the blood 
 remain, and they gradually destroy life. Just in the same w r ay, the 
 often-repeated convulsions bring w'ith them great disturbance of respi- 
 ration and circulation, and scarcely is one fit over when a second and a 
 third return, and leave no time for breathing and the heart's action to 
 resume their regular course. " Thus it happens that when at length a 
 state of calm succeeds to the attack, even though respiration may seem 
 to be regular, it is a delusive calm, and the child dies some hours later 
 without any fresh convulsion, without marked oppression, without the 
 appearance of any new symptom of importance. He dies, if I may be 
 allowed to say so, not of actual asphyxia but of the results of asphyxia." 
 
 Far less hopeless are cases, w 7 ith which we also meet occasionally, of 
 the exceedingly frequent recurrence of convulsions ; five, ten, or more 
 taking place every day, for days or weeks together. Such attacks are 
 seldom or never met with after the completion of dentition. The 
 danger to life seems to lessen with the frequency of their recurrence, 
 but there is hazard lest they should end by becoming habitual ; w T hile, 
 further, there seems to be a very decided relation between the liability 
 to convulsions in early infancy, and the development of epilepsy in 
 subsequent childhood. 
 
 One word, in conclusion, with reference to that peculiar form of 
 
 1 Clinique Medicale de l'Hotel Dieu de Paris, 2iemeed., Paris, 1865, vol. ii, p. 133. 
 
176 ECLAMPSIA NUTANS. 
 
 convulsion, to which, from the movements which characterize it, the 
 name of Eclampsia Xutans, 1 or the Salaam convulsion, has been given, 
 and in which some observers have thought they recognized the signs 
 of a special disease. Infants and children affected by. it bow the head 
 and bend the body slightly forward, a movement which is repeated 
 with great rapidity, sometimes twenty, fifty, or even a hundred times, 
 and then ceases, but returns once or oftener in the twenty-four hours. 
 During the attack the child seems bewildered, but complete conscious- 
 ness returns as soon as the movements end ; and in one case which 
 was under my care, the infant seemed relieved, and quite bright and 
 happy the moment that the movements ceased. In connection with 
 these attacks, there is a general failure of health, and enfeebling of the 
 mental powers, but they do not tend to destroy life, nor are they con- 
 nected with any special form of cerebral disease, nor have they any in- 
 variable issue. 
 
 In one instance that came under my observation, the convulsions 
 gradually lost their peculiar character, became like those of the so- 
 called epileptic petit mal, and then finally ceased at about the age of 
 three years, after having continued for a year, though not obviously 
 connected either with the process of teething or with its cessation. 
 Their tendency, however, unquestionably is to pass into confirmed epi- 
 lepsy, and the bowing of the head seldom lasts for more than a few 
 weeks without some other convulsive movement becoming associated 
 with it. Often it is a slight convulsive movement of one or other arm, 
 . but attacks of general convulsions occasionally intervene, and at last 
 they take the place almost or altogether of the previous bowings of the 
 head, and the case becomes one of ordinary epilepsy, with in general 
 very considerable impairment of the intellect. Just the same course 
 is observed to be followed by other partial convulsions, though such 
 convulsions seldom attract attention by their singularity to the same 
 extent as the Eclampsia Nutans. Some years ago I saw an infant, 
 seven months old, in whom attacks of an oscillatory movement of the 
 head from side to side came on just in the same manner, and associated 
 with the same impairment of the general health, as usually attends the 
 Salaam convulsion. The rarity of the latter affection, too, consists not 
 in the nature of the movement, but in its frequent repetition, and I 
 have often observed the first sign of incipient epilepsy in the child to 
 be a sudden bowing downwards of the head, instantaneously recovered 
 from, and just attracting notice by the bruising of the forehead, which 
 had struck against a table or a chair. Next this bowing ceases to be 
 confined to the neck, and the child falls forwards on the ground, though 
 still the attack is so momentary, that it rises again immediately, and 
 it sometimes is not until after an attack of general convulsion has 
 awakened the anxiety of relatives, that any meaning begins to be at- 
 tached to what was long supposed to be merely the effect of a child's 
 
 1 Four cases of this affection were described by Mr. ZSTewnham in the British 
 Record of Obstetric Medicine, March 15, 1849; two are related by Dr. Faber, in J. 
 f. Kinderkr., vol. xiv, p. 260 ; two by Dr. Ebert, Annalen der Charite zu Berlin, 
 1850; one by Dr. Willshire, at a meeting of the Westminster Medical Society, 
 March, 1851 ; and probably others may be found in the medical journals. 
 
CAUSES OF EPILEPSY, 
 
 177 
 
 heedlessness, or of its not having thoroughly learned to walk. Such 
 cases are but a few illustrations of the fact already so often insisted on, 
 that in the study as in the treatment of the diseases of early life, noth- 
 ing is too trivial to notice — that the slightest occurrences often have 
 the gravest import. 
 
 LECTUKE XIV. 
 
 Epilepsy. — Its causes — Illustrative tables— Its general character and influence on 
 the mind. — Circumstances which must regulate our prognosis — Treatment — 
 Futility of specifics — General management — Employment of belladonna, and 
 of the bromide of potass. 
 
 Chorea. — Not exclusively a disease of childhood — Causes which influence its oc- 
 currence — Symptoms — Paralytic chorea — Relation to rheumatism, and to heart 
 disease — Theory of embolism as producing it — Treatment — Estimate of various 
 remedies. 
 
 We yesterday studied the convulsions of early childhood in their 
 gravest aspect, as immediately threatening life ; but a painful interest 
 attaches to them independent of the anxiety which they excite lest they 
 should prove immediately fatal. That is, the dread of their persistence, 
 or of the child being left with his nervous system so shaken that fits 
 may recur at some later period ; that convulsions in infancy or child- 
 hood may issue in epilepsy in youth or manhood. Nor, indeed, does 
 this seem to be a groundless fear, for of 68 cases which form the basis 
 of M. Herpin's 1 elaborate work on epilepsy, 17 or 25 per cent, date 
 from the first five years of existence ; and of 83 cases of which I have 
 a record in young persons under the age of 12 years, 49 dated back to 
 the first four years of life, 28 occurred between the ages of 4 and 10, 
 and 6 between 10 and 12. 
 
 TABLE 
 
 Showing Age of Patients at Commencement of Attacks of Epilepsy. 
 
 Age at Commencement. 
 
 Male. 
 
 Female. 
 
 Total. 
 
 Under 6 months, .... 
 
 4 
 
 4 
 
 8 
 
 Between 6 and 12 months, 
 
 
 
 6 
 
 5 
 
 11 
 
 " 1 " 2 years, . 
 
 
 
 8 
 
 7 
 
 15 
 
 it 2 " 3 " 
 
 
 
 3 
 
 7 
 
 10 
 
 " 3 " 4 " 
 
 
 
 4 
 
 1 
 
 5 
 
 " 4 " 5 » 
 
 
 
 2 
 
 4 
 
 6 
 
 " 5 " 10 " 
 
 
 
 13 
 
 9 
 
 22 
 
 " 10 " 12 " 
 
 
 
 3 
 
 3 
 
 6 
 
 
 43 
 
 40 
 
 83 
 
 i Du Pronostic, &c, de l'Epilepsie, 8vo., Paris, 1852, p. 336. 
 12 
 
178 CAUSES OF EPILEPSY. 
 
 In the above table the alleged age at the commencement of epilepsy 
 does not represent that at which some isolated convulsion may have 
 occurred, but the age since which there had been a succession of fits 
 coming on at intervals more or less regular, and without the interven- 
 tion of any fresh exciting cause. It will be seen that in nearly a fifth 
 of the cases the attacks date back to very early infancy, to a time when 
 the ordinary exciting causes of epilepsy have as yet not come into play, 
 when we must seek for the origin of the disorder in some conditions 
 profoundly affecting the general nutrition, not in such as specially act 
 upon the nervous system. But the gravity of those apparently cause- 
 less convulsive seizures which sometimes occur in very early infancy is 
 still further seep, if we bear in mind that in many other cases where 
 epilepsy is stated to have come on during dentition, or even at some 
 later period of childhood, it will be found on close inquiry, that many 
 of the patients had suffered from convulsions in early infancy, although 
 a period of months or even of years may have passed without their re- 
 turn ; and the very fact may have been forgotten until our inquiries 
 recall it to the parent's recollection. 
 
 In 12 of the cases hereditary tendency to epilepsy was admitted to 
 exist ; x and I have no doubt but that its real frequency is far greater 
 than the friends of our patients admit ; and in not a few instances, es- 
 pecially of the earliest occurrence of epilepsy, a strict inquiry will elicit 
 that other children have had fits during teething, or have suffered from 
 chorea; or that mental peculiarities, more or less remarkable, have 
 been observed in different members of the family. A distinct exciting 
 cause for the attack was assigned in 1 only of the 8 cases in which the 
 fits dated back from the first six months of life ; and in that instance 
 they were said, with what truth I know not, to have followed inflam- 
 mation of the brain. 
 
 In 41 of the remainiug 75 cases, the attacks were said to have been 
 induced 
 
 By fright in 6 instances. 
 
 " injury to the head ..... 4 " 
 
 " a fall 1 
 
 " weaning ....... 1 " 
 
 " errors in diet ...... 2 " 
 
 " gastric disorder ..... 2 " 
 
 " vaccination, 1 " 
 
 " scarlatina, coming on during convalescence, 2 " 
 
 " measles, coming on during convalescence, 1 " 
 
 " anger, ....... 1 (r 
 
 " first dentition, 19 " 
 
 " second dentition, 1 " 
 
 In one of the above cases the epileptic attacks, which came on during 
 the first dentition, ceased with its completion, and did not recur till the 
 commencement of the second dentition, when they returned frequently 
 and severely. This statement of the alleged causes of epilepsy is im- 
 perfect, to a great degree no doubt inaccurate, but still the coincidence 
 
 1 Herpin, op. cit. p. 328, estimates the frequency of epilepsy at from four to five 
 times greater in the family of epileptics than in the population at large. 
 
STATE OF MIND IN EPILEPSY. 179 
 
 of the attacks in 20 of the 41 cases with the active progress of teething 
 deserves to be borne in mind as a fresh illustration of the peculiar 
 excitability of the nervous system at that important period of develop- 
 ment. 
 
 In the cases on which my remarks are founded I have not included 
 instances of mere epileptic idiots, in whom the occurrence of fits was 
 only a subordinate and often a secondary manifestation of the general 
 disorder of the nervous system. In childhood, however, more surely 
 even and more speedily than in the adult, the return of epileptic 
 attacks impairs, and at length even completely abolishes, the mental 
 powers. In 7 boys and 5 girls the weakness of the mind amounted to 
 idiocy ; in the case of 1 girl there were occasional attacks of maniacal 
 excitement ; and in 3 other girls epilepsy coexisted with peculiarities of 
 manner and disposition, such as appeared to me to justify their being 
 regarded as instances of moral insanity. In 28 other cases the child 
 was either duller than the average of children of the same age, or, 
 more painful still, the early dawn of intellect was becoming gradually 
 overclouded with the recurrence of the epileptic seizures, and in 6 of 
 these 28 cases the blunting of the mind was associated with perversion 
 of the character, with violence or obstinacy. 
 
 I am aware that these results are more unfavorable than those which 
 are commonly obtained in the case of epileptic adults, and am aware 
 also that it has been alleged on high authority that late rather than 
 early epilepsy is favorable to intellectual failure, and that the duration 
 of epilepsy is by itself without influence on the mental condition of the 
 epileptic. 1 It must be borne in mind that my remarks have reference 
 exclusively to epilepsy in childhood, and that I do not profess to have 
 any such experience as would justify me in speaking about it in the 
 adult. There seems to me, however, to be a very obvious and very 
 sufficient reason for the speedier and graver deterioration of the moral 
 and intellectual character in the young than in the adult epileptic, 
 furnished by the undeveloped state of the nervous system in early life. 
 It stands a shock less well, it bears graver marks of injury in propor- 
 tion as the shock and the injury are earlier inflicted ; while, on the 
 other hand, it may well be that late in life the opposite cause may 
 produce a similar effect, just as one often sees that the two extremes of 
 youth and age appear morally and physically to touch each other. 
 My belief indeed is — and it is this which attaches the gravest import 
 to the apparently causeless occurrence and causeless return of fits in 
 infancy and childhood — that in proportion as epilepsy comes on early 
 will the chances of its being associated with serious disorder of the 
 mind be increased. M. Cazauvieilh, 2 in his elaborate essay on the 
 connection between epilepsy and insanity, states as the result of a 
 comparsion between 26 female epileptics in whom the disease preceded 
 menstruation, and 26 in whom its occurrence succeeded it, that in 19 
 of the former, and in only 10 of the latter, it was associated with in- 
 sanity. This fact is always to be borne in mind when consulted about 
 
 1 Dr. Eeynolds, in his System of Medicine, vol. ii, 2d ed., 1872, p. 312. 
 
 2 Archives Gen. de Medecine, Janvier, 1826, p. 43. 
 
180 CHARACTERS OF EPILEPSY IN CHILDHOOD. 
 
 a case of epilepsy in early life, since it obviously must exercise a great 
 influence upon our prognosis. 
 
 To the best of my knowledge, the general characters of epilepsy in 
 childhood agree closely with those which it presents in after-life. I 
 have observed the 'petit mal, as it is termed, continue in children for a 
 period of several months, and finally issue in regular epileptic seizures. 
 In the child, I have sometimes noticed the loss of consciousuess during 
 the seizure to be imperfect, and this in spite of very marked convulsive 
 movements ; fits with complete insensibility occurring occasionally in 
 the same patient, and being of longer duration though not attended 
 with a greater amount of convulsion, than those in which the loss of 
 consciousness was incomplete. In one instance, attacks of apparently 
 causeless alarm, accompanied by much excitement and incoherent talk- 
 ing, passed in the course of a few months into regular epileptic seizures ; 
 in another instance, a girl, who came under my care at the age of 10 
 years and 10 months, had had an attack of general convulsions when 8 
 years old, for which no cause could be assigned. Since that time she 
 had been liable to occasional attacks of strange excitement of manner ; 
 and these had for six months been attended with a sort of cataleptic 
 condition, in which she stood motionless for a minute or two, wildly 
 staring at vacancy, and uttering a few incoherent words, which ap- 
 parently had reference to some object she saw, though she could never 
 be induced to describe her imaginings. Eleven months after the com- 
 mencement of these attacks their peculiar character disappeared, and 
 she began to have regular epileptic seizures, while, in the intervals, her 
 actions and manner, though often rational enough, were frequently 
 those of an insane person. In a boy aged 9, in whom for a year 
 epileptic fits had occurred causelessly, and with a rapidly increasing 
 frequency, until at length three or four came on weekly, and sometimes 
 more than one in a day, a sort of maniacal excitement seized him 
 occasionally, in which he struck other children, though they had given 
 him no provocation. These manifestations of mental disorder are pre- 
 cisely analogous to the momentary delirium observed in the epileptic 
 adult, during which the patient commits some act of gross impropriety, 
 or attacks his friends or attendants, or some bystander, with savage 
 fury, and recovers his consciousness a minute or two afterwards, to 
 learn with horror the act which he has committed. 1 They are, as 
 might be expected, most observable in cases in which epilepsy has not 
 come on till about 5 or 6 years of age, or somewhat later : the con- 
 vulsions which date from early infancy lead to a more complete obscuring 
 of the mind, and the cases in which they have occurred often present 
 themselves to us as instances of idiocy complicated with epilepsy, rather 
 than as cases of epilepsy producing disorder of the mind by their fre- 
 quent return. I do not know that the age of the patient makes any 
 important difference in the characters of the epileptic seizure. They 
 
 1 With reference to the relation between epilepsy and affection of the mind, there 
 are some important observations by M. Trousseau in his Clinique Medicale, 2d ed., 
 vol. ii, pp. 69-79; and by M. Falret, in Archives de Med.., 18ti0, vol. ii, p. 661; 
 1861, vol. i, p. 461, and vol. ii, p. 421. 
 
PROGNOSIS IN EPILEPSY. 181 
 
 seem to be the same, in all essentials, in the child as in the adult. The 
 aura epileptica is often described of their own accord by children ; 
 though many are of course too young to explain their sensations, and 
 others, with the strange tendency to exaggeration which one often 
 observes in early life, seeing that their story is listened to with atten- 
 tion, will dress it up with such details as to their young imagination 
 seem most wonderful. In some cases the attacks begin invariably 
 with convulsive movements of one limb. Thus, in a little boy who 
 was some time since in the hospital, the attacks always began with 
 painful convulsive movements of the right hand, which he seized with 
 the left and endeavored to keep still. In a few seconds or a minute 
 these movements ceased ; the tonic spasm came on, and then the 
 general convulsive movements as in an ordinary epileptic seizure. 
 These peculiarities seldom last for very long : sometimes for a season 
 one limb is habitually the first to be affected, sometimes another ; or 
 the fits invariably predominate on one side, and then, with no other 
 change in the patient's condition, the attack will commence in another 
 limb, or predominate on the other side. Stupor more or less continued, 
 or a heavy sleep, usually follows the attack, but now and then a state 
 of excitement precedes the sleep ; a noisy delirium which, but for the 
 tender age of the patient, would be identical with the temporary mania 
 that sometimes follows the epileptic seizure in the adult, and renders 
 him for the time one of the most dangerous class of insane patients. 
 
 The question is often put to us in practice as to the probability of 
 fits terminating in epilepsy ; or, on the other hand, as to the ground 
 for hope in any case that epileptic attacks which have already fre- 
 quently recurred will eventually cease. 1 With reference to neither of 
 these inquiries, however, are we in possession of data such as to enable 
 us to give an answer with much certainty. I do not think that those 
 fits of which spasm of the glottis is a prominent symptom, often pass 
 into confirmed epilepsy ; long-continued struggling is not a character- 
 istic of them, but more often drowsiness or stupor immediately suc- 
 ceeding to the fits, and heaviness and dulness continuing for some 
 hours after them. It is not the violence of a single fit, nor even the 
 frequent return of fits for a limited time, which warrants the gravest 
 apprehension. It is the recurrence of fits when all observable cause of 
 irritation has passed away ; it is their return when the patient is other- 
 wise apparently in perfect health ; and hence it is that the statement 
 has been made that attacks of the 'petit mal warrant a graver prognosis 
 than the violent convulsion. As to the prospect of epileptic seizures 
 ceasing at puberty, I fear that the hope is a very groundless one. It 
 is scarcely to be expected that a new period of development should be 
 attended by anything else than a fresh excitement, and an increased 
 disturbance of the nervous system ; so that there is more reason for an- 
 ticipating a deterioration in the patient's condition, than for expecting 
 
 1 I am averse to referring to my own writings, but want of room for saying more 
 here compels me to refer to my Lumleian Lectures, "On Some Disorders'of the 
 Nervous System in Childhood," 8vo., London, 1871, for further remarks with refer- 
 ence to these and kindred subjects. 
 
182 PROGNOSIS IN EPILEPSY. 
 
 an improvement from the changes of puberty. It is true, that if epi- 
 lepsy comes on while dentition is in active progress, we may hope for, 
 though we cannot with certainty calculate on amendment when teething 
 is accomplished ; and though I have no statistics bearing on the subject, 
 yet my impression is, that I have oftener known epilepsy cease sponta- 
 neously between the fourth and sixth years than at any other period. 
 In the same way, if epilepsy occurs during the changes that usher in 
 puberty, we may look forward with some degree of cheerfulness to the 
 time when all of those changes shall have been completed. In each of 
 these cases, however, it is not the period of excitement, but the season 
 of repose, on which our hopes are founded ; while, to leave the case un- 
 treated, in the vague expectation of what at a certain critical epoch of 
 life the healing power of nature may be able to effect, would be to trifle 
 alike with our own reputation and with our patient's prospects of re- 
 covery. The first point in every case is obvioulsy to make out, if 
 possible, the cause on which the fits depend ; or to ascertain by the 
 most minute observation and inquiry, the peculiarities of health with 
 which their occurrence is associated. The diet, the bodily exercise, 
 the mental pursuits, all need the most rigid investigation : the condi- 
 tion of the bowels, the state of the evacuations, require to be most care- 
 fully examined ; and' the fact of the first dentition having been accom- 
 plished is no adequate reason for omitting to watch the process of 
 teething most sedulously. I have seen one or two instances in which 
 convulsive attacks of an epileptic character attended the cutting of the 
 permanent molar teeth ; and illustrations of this fact (to which Dr. 
 Ashburner 1 was the first to call attention) are to be found in all our 
 medical journals. In proportion as the fits admit of being traced with 
 probability to causes of a remediable character, may our prognosis be 
 favorable. The severity of the fits is a matter of less importance with 
 reference to prognosis than the frequency of their occurrence ; and the 
 oftener they recur, even in a mild form, or the more frequent their 
 forebodings, such as dizziness, or momentary stupor, the less is the 
 prospect of their cessation. In forming our prognosis, also, regard 
 must be had to the state of the child's mind in the intervals between 
 the fits ; and the less the intellect seems to be dulled, or the moral 
 faculties perverted, the more encouraging may be our opinion. In 
 judging of this last point it is well to bear in mind that a child who 
 has been liable to any such affection is almost sure to be backward in 
 learning ; very likely to be wayward in temper, for his friends will 
 have been afraid to overtax him with work ; and they will probably, 
 from fear of crossing him, have indulged many of his caprices. We 
 must judge of his intellect, less by the child's amount of actual knowl- 
 edge, than by his power of answering simple questions concerning 
 things familiar to him ; and must draw our conclusion as to the state 
 of his moral faculties from his general childlike character, his fondness 
 for the same pursuits, his showing the same dispositions, manifesting 
 similar attachments, having similar good and bad qualities to those 
 
 1 In his work On Dentition and its Coincident Disorders, 12mo. 
 
GENERAL MANAGEMENT OF EPILEPTICS. 183 
 
 which we observe in other children of his own age, or a few years 
 younger. 
 
 With reference to the treatment of epilepsy, I know of no specific 
 for it ; and the much-vaunted oxide of zinc has proved as powerless in 
 my hands as in those of most who have tried it on the strength of the 
 high encomiums bestowed on it by M. Herpin. I fear, indeed, that it 
 will not be in the search for specifics that we shall light upon the ap- 
 propriate treatment of a disorder which depends upon causes so almost 
 numberless as epilepsy. We meet every now and then with cases in 
 which some profound impression on the nervous system has been fol- 
 lowed by temporary cessation of the fits, and with others in which they 
 seem under the influence of such a cause to have been permanently 
 cured ; but the difficulty is how to apply such observations in practice. 
 A girl, aged 10 years, was admitted into the Children's Hospital, suf- 
 fering from epilepsy, fits of which occurred about seven times in a 
 week. These fits were said to have affected her for a considerable 
 time, though the history given of her w 7 as very imperfect. After a 
 month's stay in the hospital, during which time 24 fits occurred, she 
 was attacked by typhoid fever of a mild character, accompanied by 
 abundant rash, but which ran its course in 21 days, unattended by any 
 complication. During the whole course of the fever the fits completely 
 ceased ; but on the 31st day from the first complaint of frontal head- 
 ache and first accession of fever the fits returned, assumed their former 
 severity, and returned afterwards with their former frequency. A boy, 
 10 years old, suffered from occasional attacks of petit mat in February. 
 In the following August the attacks became regular epileptic seizures, 
 which increased in frequency, and in the succeeding March returned 
 several times in a day, and were accompanied by marked impairment 
 of his mental powers and by an unsteady and tottering gait. After a 
 two months' trial of various remedies, and the insertion of a seton in 
 the back of his neck, he left the hospital worse than on his admission. 
 On June 13th he fell in a fit, and struck his occiput a violent blow. 
 A large abscess formed there, which burst of its own accord, continued 
 discharging for a few days, and then healed up. I saw the boy again 
 two years after this accident had happened, and there had then been no 
 return of fits ; but the boy had regained his power of walking, and had 
 all the intelligence and cheerfulness that befitted his years. These 
 cases are of interest, they forbid us to despair even when there seems 
 least ground for hope ; but I fear they give us little help in our search 
 after remedies, for how are we to obtain any therapeutic agent as far 
 reaching as the poison of typhoid fever, which yet exerted but a tem- 
 porary influence, or how can we safely imitate the profound shock of 
 the accident concerning which, too, w T e do not know whether its salu- 
 tary influence was due to the blow or to the suppuration that followed 
 it? There is of course the most ground for hope, and the fairest op- 
 portunity for treatment, when the attacks can be referred to any ob- 
 vious, or even probable exciting cause. Our first attempts must be 
 directed to its removal; and, according to its nature, depletion may or 
 may not be indicated ; or the administration of alterative or purgative 
 medicines may be desirable, and now and then some wisely chosen 
 
184 GENERAL MANAGEMENT OF EPILEPTICS. 
 
 \ 
 
 remedy may in these circumstances remove, almost as if by magic, the 
 cause and its effect together. Unfortunately, however, in a large 
 number of instances, no definite cause is discoverable, and we are 
 thrown entirely upon general principles for the regulation of our con- 
 duct. As violent and sudden excitement of any kind will often bring 
 on an epileptic seizure, so the influence of the opposite condition in 
 warding off its attacks is very remarkable ; and on several occasions I 
 have received patients into the Children's Hospital, who were reported 
 to have epileptic seizures several times in a day, and who nevertheless 
 remained a fortnight or more in the institution without any attack 
 coming on. The disorder, however, was not cured, but only kept in 
 check by the regularity of the gentle rule to which the little ones are 
 subjected. The order goes for much in these cases ; the novelty goes 
 for something too, for almost invariably I have found that after a time 
 the apparent improvement became less marked, and though they con- 
 tinued better than when they first came to the hospital, the children 
 were still epileptic: the advance of the disease had* been retarded, but 
 its progress had not been arrested. The quiet which suits the epileptic 
 is not the quiet of listless, apathetic idleness, but the judicious alterna- 
 tion of tranquil occupation and amusement. The mind must not be 
 left to slumber, from the apprehension of work bringing on a fit, but 
 the work must as far as possible be such as to interest the child. It is 
 an observation often made, that adult epileptics who follow dangerous 
 trades, as that of a bricklayer, for instance, scarcely ever have attacks 
 when occupied in their pursuit; and children are rarely seized when at 
 play, but oftenest either when in bed at night, or before getting up in 
 the morning, or when sitting quiet in the evening, tired and unoccu- 
 pied. The good results, too, which I hear have followed the introduc- 
 tion of gymnastic exercises among the epileptic patients at the Bicetre, 
 in Paris, point in the same direction. In the occupations of epileptics, 
 therefore, pursuits which not merely employ the mental faculties, but 
 also give work to the hands, such as gardening, carpentering, or the 
 tending of animals, are especially to be recommended ; and if by these 
 the mind can be kept awake, the grand object of teaching is answered, 
 and backwardness in reading, writing, or those kinds of knowledge 
 which other children at the same age have acquired, is of very little 
 moment. Many epileptics have an indistinct articulation, and almost 
 all have a slouching gait and an awkward manner. The former can 
 often be corrected to a considerable degree by teaching the child simple 
 chants, which are almost always easily acquired, and practiced with 
 pleasure. The latter may be rectified by drilling, not carried into 
 tedious minutiae, but limited to simple movements, and the irksome- 
 ness of drill is almost completely done away with by music ; while I 
 believe that the accustoming a child to the strict control and regulation 
 of all its voluntary movements is of very great importance indeed as 
 a curative agent. Many of these measures could be much better car- 
 ried out in class than by a child alone, and whatever may seem at first 
 to be the objections to the association of epileptics, I have no doubt 
 but that they would be more than compensated for by its advantages. 
 Epileptic children cannot be educated with such as are healthy — partly 
 
MEDICAL TREATMENT OF EPILEPSY. 185 
 
 for the sake of the latter, but at least equally so for their own ; since 
 the different regulations to which they must be subjected, the difference 
 in their education, their amusements, and often in their diet, would be 
 to them a source of ceaseless distress. If educated alone, however, not 
 only do they lose all the advantages of association with other children, 
 though both intellectually and morally this is of great moment, but 
 also they become, far too obviously for their own benefit, the centre 
 around which everything in the household turns, while rules become 
 doubly irksome when apparently made for themselves alone, and not 
 part of a general system to which others besides have to submit. 
 These advantages, however, are not at present to be obtained, and we 
 are compelled to put up with the more imperfect carrying out of our 
 directions, either at the patient's home, or, still better, under the su- 
 perintendence of some competent person who devotes the whole of his 
 time to the care of the child. 
 
 The diet should be mild, nutritious, but usually unstimulating, and 
 as a general rule, should include meat comparatively seldom, and in 
 small quantities. I have certainly seen epileptic fits increased both in 
 frequency and severity by an abundant meat diet, and diminished in 
 both respects when a diet chiefly of milk and vegetables was adopted. 1 
 This diet, however, must not be adopted invariably, nor in disregard of 
 the patient's general symptoms. In feeble children with cool skin, 
 soft pulse, languid manner, and deficient energy, a generous diet with 
 wine, and the mineral acids with quinine, or -small doses of zinc or 
 iron, have certainly proved of service, not only in improving the gene- 
 ral health, but even in lessening the frequency of the occurrence of the 
 fits. When the approach of a fit has been usually preceded by stupor, 
 or headache, or drowsiness, I think that I have sometimes warded off 
 its occurence by putting a few leeches on the head; but epilepsy is not 
 to be. cured by systematic bleeding, nor by systematic purging, nor, I 
 may repeat, by any of the various medicines which at different times 
 have been employed for its cure, and the very number of which is 
 perhaps the best proof that could be adduced of the inefncacy of all. 
 
 There are two remedies which must not be passed over without 
 some special notice- — belladonna and bromide of potassium, the latter 
 of which seems indeed to have cast the former into the shade, and to 
 have led to its passing for a time at least into scarcely merited forget- 
 fulness. The action of the bromide is decidedly much more speedy 
 and much more remarkable when it is exerted at all than that of 
 belladonna. It seldom indeed fails within the first few days of its 
 administration to arrest the frequency of the attacks, and now and 
 then it has seemed entirely to prevent them ; and the crucial test of 
 
 1 My attention was first drawn Tb the importance of abstinence from a meat diet 
 in epileptics by Dr. Maxwell, formerly resident physician to the Asylum for Idiots. 
 This caution, too, gains still greater weight from the testimony of Dr. Jackson, of 
 Boston, in America, who, in his Letters to a Young Physician, 12mo., Boston, 
 IT. S., 1855, p. 67, insists very strongly on its importance. As already stated, I 
 have little faith in the influence of mere drugs; but I have a yearly increasing 
 confidence in the influence of diet, judicious management, and mental and moral 
 as well as physical hygiene in epilepsy occurring in early life, independent of hered- 
 itary predisposition, and unconnected with approaching puberty. 
 
186 MEDICAL TREATMENT OF EPILEPSY. 
 
 arresting fits by bromide of potass, of suspending the remedy and seeing 
 the fits return, and of once more putting a stop to them by the resump- 
 tion of the medicine, has on some occasions established its value 
 beyond question. This result has been arrived at by me more fre- 
 quently in cases of persistent, frequently repeated infantile convulsions 
 than in the distinct epilepsy of childhood, though even here I have 
 had some few apparent successes. In the great majority of cases the 
 amendment, though very marked at first, has not entirely maintained 
 itself; the system has after a time become habituated to the remedy, 
 and after several augmentations of the dose, each of which has seemed 
 to renew the old influence, I have been compelled to discontinue it in 
 consequence of the depression of the pulse, the general loss of power, 
 and the appearance of the peculiar pustular eruption which occasionally 
 follows its long-continued use. In other cases, too, the agent which at 
 first worked wonders ceased to have any influence. The constitution 
 tolerated the increased dose, but so did the disease j the patient con- 
 tinued to take the medicine, but the fits, though once controlled, re- 
 turned after a time just as before. 
 
 Still, with all these drawbacks, the bromide remains the only agent 
 which in my hands has made the least approach to the character of a 
 specific. I always employ it when I can find no distinct indication to 
 guide me. I confess that I use it empirically, for I have found no 
 means by which to distinguish beforehand the cases where the bromide 
 will do permanent good from the other apparently similar but much 
 more common instances in which its influence is merely temporary. 
 
 The action of belladonna is much slower, and its results, I fear, are 
 also much more uncertain than even those of the bromide, for all that 
 M. Trousseau could allege in its favor was that he had been "less 
 unsuccessful with it than with any other remedy." I have once seen 
 epileptic seizures of the most marked character and of daily recurrence 
 in a boy of 9 years of age cease under the use of belladonna when they 
 had been entirely uninfluenced by bromide of potass, and I have also 
 seen the frequency of the return of fits diminished under its steady and 
 long-continued use, the best results being apparently obtained by its 
 long-continued administration in small doses for months, not by its 
 employment in large or in rapidly increasing doses. 1 
 
 But if the cause of epilepsy is so deeply seated that it yields so rarely 
 to even the most powerful remedies, it may be inquired whether there 
 are no means of mitigating the severity, or of warding off the occur- 
 rence of individual attacks. Something, though I fear not very much, 
 may be accomplished. It suffices occasionally, in attacks of the 'petit 
 mal, to call to the patient in order to cut short at once the condition 
 which might otherwise last for half a minute, and even after actual 
 convulsions have begun to characterize tne epileptic fit, I have, in chil- 
 dren, seen it equally arrested in the same way. A certain attitude in 
 bed will sometimes bring on a fit on the child waking from sleep, and 
 its careful avoidance will postpone the occurrence. The principles 
 
 1 See, with reference to the use and administration of belladonna in epilepsy, the 
 remarks of M. Trousseau in his Clinique Medicale, 2d ed., vol. ii, p. 95. 
 
MEDICAL TREATMENT OF EPILEPSY. 187 
 
 implied in suddenly arousing the attention, and thus stopping the fit, 
 may be carried further, and the immediate application of a tight lig- 
 ature, as a twisted handkerchief, for instance, around the arm or leg, 
 will sometimes entirely arrest a commencing fit, though more fre- 
 quently it will only postpone it for a few minutes. It is on the same 
 principle that cold water thrown in the face will sometimes retard a fit, 
 or even prevent it, and so long as any of these measures check or 
 mitigate the attacks, they may be persevered in. A trial of chloroform 
 naturally suggests itself to us as a means of mitigating the severity of 
 the attacks. Its influence is too slow to prevent the seizure, for, as you 
 know, to the momentary bewilderment succeeds the tonic spasm, and 
 on that follows the convulsion with the imperfect respiratory move- 
 ments that attend it, during which the lungs are filled but imperfectly, 
 and the inhalation of chloroform must be very incomplete. Usually, 
 therefore, a convulsive attack would pass away of its own accord long 
 before the influence of the anaesthetic had been produced. In long- 
 continued convulsions, however, I know of no objection to its use, and 
 it certainly is something gained if we can control the violent convul- 
 sions, and secure thereby the better peformance of respiration — ends 
 which we can usually attain, though I have found that with each repe- 
 tition of the chloroform its influence becomes harder to produce, and 
 tends to pass away more quickly. 
 
 One last caution I still have to offer with reference to cases where 
 either convulsions have occurred with frequency in infancy, or where 
 actual epileptic seizures, having occurred several times, appear to have 
 ceased for months or even for years. A cause so slight as to seem inad- 
 equate to lead to so grave a result will waken the dormant evil, and 
 awaken it to slumber no more. A sudden fright, a fall, the disorder 
 produced by neglect or constipation, a little overstrain of the mind in 
 the endeavor to make up for lost time, will suffice to disturb the bal- 
 ance of the nervous system and to reproduce the ftts. You walk on 
 hidden fires ; I know not how to avoid the danger which in each case 
 arises from a different source. I can but warn you and urge you to 
 warn the patients' friends of its existence. 
 
 Almost every lecture has furnished some fresh illustration of that 
 connection between the development of an organ, or of a set of organs, 
 and their liability to disorder, which characterizes the diseases of early 
 life. The growing brain is readily overfilled with blood, readily emp- 
 tied of it ; cerebral congestion, cerebral hemorrhage are frequent, and 
 so is the opposite state of anaemia, producing as we have seen the signs 
 of spurious hydrocephalus. The balance is so easily disturbed between 
 the different parts of the nervous system, that convulsions occur with 
 a frequency proportionate to the tender years of the patient, assuming 
 all sorts of strange forms ; now threatening life in one way, now in 
 another, destroying the child suddenly by spasmodic closure of its glot- 
 tis, or exhausting it by their violence and their ceaseless return ; or, 
 lastly, working a change so subtle that the knife of the anatomist 
 cannot detect it, and yet so serious as to induce their perpetual recur- 
 rence, and to convert the once bright and hopeful child into the dull 
 and all but hopeless epileptic. 
 
188 
 
 INFLUENCE OF AGE AND SEX ON CHOREA. 
 
 But we have not yet completed our survey of this class of affections, 
 for there are various forms of impairment of the motor power which 
 are still unnoticed, ailments which indeed rarely threaten life or per- 
 manently disturb the mental faculties, but which are yet tedious in 
 their progress, often distressing in their character, and difficult of cure. 
 I shall reserve for another lecture those cases in which there is mere 
 loss of power over a limb, or over some of its muscles, and will now 
 notice those in which that power is imperfectly exercised, in which the 
 will no longer exerts its full control, but the muscles of some parts are 
 left in a state of involuntary activity, though still performing imper- 
 fectly their proper duties. 
 
 The characters just enumerated are those which mark a disorder 
 with which you are doubtless all familiar, the Chorea Sancti Viti, or 
 St Vitus's Dance. It is, however, by no means one of the most fre- 
 quent affections of early childhood ; but its occurrence coincides, as 
 the subjoined table 1 shows, rather with that period of development 
 which intervenes between the second dentition and the completion of 
 the changes that attend on puberty. 
 
 Age. 
 
 Male. 
 
 Female. 
 
 Total. 
 
 At or under 4 years, .... 
 
 More than 4, but not exceeding 6 years, 
 " 6, " » 10 " 
 ci io, » " 15 » 
 
 Total, 
 
 4 
 
 22 
 
 64 
 - 87 
 
 177 
 
 6 
 
 11 
 
 142 
 
 220 
 
 379 
 
 10 
 
 33 
 
 206 
 
 307 
 
 556 
 
 It must also be added, that the liability to chorea does not cease 
 entirely with the completion of the changes that accompany puberty, 
 but that it has been computed that a fourth of all cases of it occur 
 during adult life. I believe, indeed, though I cannot prove, that this 
 estimate of the frequency of chorea in the adult is exaggerated, while 
 when it does occur in the grown person, it is probably due either to 
 the influence of some grave internal inflammation, such as pericarditis 
 or endocarditis, or to that peculiar state of the constitution which gives 
 rise to rheumatism, or to both these causes combined, or else to some 
 far-reaching cause which acts on and disturbs the whole nervous sys- 
 tem, such, for instance, as the state of pregnancy. 
 
 The reason of the greater rarity of chorea in early childhood than 
 subsequently is, I apprehend, to be found in the circumstance that with 
 the progress of growth and the increase of strength the nervous system 
 becomes less impressionable, and the causes which in the infant would 
 have produced a fit, or would have given rise to that more chronic form 
 of convulsive disorder of which spasm of the glottis is a common ac- 
 
 1 Deduced from the cases reported by Dr. Hughes, in Guy's Hospital Reports, 
 Second ISeries, vol. iv, 1846; by M. Rufz, in Archives de Medecine, February, 
 1834; and from the statistics of M. Wicke, as reported by Romberg, Nervenkrank- 
 heiten, vol. ii, part 2, p. 177. 
 
INFLUENCE OF AGE AND SEX ON CHOREA. 
 
 189 
 
 companiment, no longer produce such grave results. They do not 
 endanger life, they do not even abolish consciousness, but they shake 
 the control of the will over the voluntary movements, and produce 
 chorea. As the boy grows older, his liability to all convulsive diseases 
 diminishes ; and as the girl grows older, hers lessens too, but not to 
 the same extent. In her, disorders of a milder kind show themselves 
 with a frequency from which the boy's hardier frame altogether defends 
 him ; and chorea occurs only as one form of disturbance of the nervous 
 system, having reference to an earlier stage of development than that 
 at which hysteria commonly appears, when, in connection with the 
 first performance and first consciousness of new functions and a new 
 destiny, the mind and the emotions participate in disorders previously 
 limited to the motor powers. 
 
 The attack of chorea is sometimes excited by a violent shock to the 
 nervous system, such as a fright, a blow, or some sudden violent emo- 
 tion ; but even in those cases it is comparatively seldom that it occurs 
 in children previously in perfect health, and the attack of chorea, as 
 far as my observation goes, has never come on until after the lapse of 
 
 TABLE 
 
 Showing the Age and Sex of 1141 patients brought to the Children 's Hospital suffering 
 
 from Chorea. 
 
 Age. 
 
 Male. 
 
 Female. 
 
 Total. 
 
 At or under 4 years, . 
 
 
 21 
 
 36 
 
 57 
 
 Between 4 and 5 years, 
 
 
 
 
 19 
 
 35 
 
 54 
 
 » 5 » 6 » . 
 
 
 
 
 26 
 
 45 
 
 71 
 
 k g » 7 " . 
 
 
 
 
 46 
 
 63 
 
 109 
 
 7 " 8 » . 
 
 
 
 
 38 
 
 104 
 
 142 
 
 " 8 " 9 " . 
 
 
 
 
 56 
 
 132 
 
 188 
 
 " 9 " 10 " . 
 
 
 
 
 66 
 
 155 
 
 221 
 
 " 10 " 12 " . 
 
 
 
 
 75 
 
 224 
 
 299 
 
 
 347 
 
 794 
 
 1141 
 
 several days from the action of its alleged exciting cause. For the 
 most part, whether one can point to a distinct exciting cause or no, 
 there has been some previous failure of the general health ; such.as at 
 an earlier age would have ushered in a fit of convulsions, or an attack 
 of spasm of the glottis. In many instances, too, a minute inquiry into 
 the child's previous history, or into that of his family, will show a 
 special liability to exist to convulsive affections, to chorea, or to epi- 
 lepsy. The preponderating frequency of its occurrence in girls is but 
 another expression of the same fact, namely, of its association with 
 special excitability of the nervous system. 
 
 Just as hysteria, too, comparatively seldom occurs in the robust, but 
 is usually connected with some marked disorder of nutrition, such as 
 anaemia or chlorosis, so, as I have stated, in almost all cases, of chorea 
 the commencement of its symptoms is preceded by failing health, by 
 constipation, or by some other form of disorder of the digestive system, 
 
190 INFLUENCE OF AGE AND SEX ON CHOREA. 
 
 or even by some disease intimately connected with defects in the blood- 
 formation, as rheumatism, or one of the eruptive fevers, most fre- 
 quently the former. 
 
 The approaches of the disorder are for the most part very gradual. 
 
 It is first noticed that the child has certain awkward, fidgety move- 
 ments, which it seems unable to check ; or which, at any rate, it repeats 
 almost constantly, though they may cease for a few moments. On 
 closer watching, it is next observed that these movements are almost 
 or altogether confined to one side, and generally to the arm, the leg 
 being at first almost always unaffected ; but my own observations do 
 not confirm the statement that there is any preponderating frequency 
 of affection of the right side either at the commencement or in any 
 stage of chorea. In a few days the leg becomes the seat of these move- 
 ments also, and the child in consequence stumbles or falls occasionally 
 in walking. Now, too, if not previously, the muscles of the face par- 
 ticipate in the irregular movements, and the child almost constantly 
 makes the strangest grimaces, and soon, with very rare exceptions, the 
 affection ceases to be limited to one side, but both legs and both arms, 
 and at length all the muscles of the trunk, become involved. 
 
 It is almost impossible to describe the condition of a chorea patient 
 exactly, so much does it vary according to the intensity of the disease 
 in different cases, and so much also in the same case at different times. 
 Excitement increases the movements, fixed attention to any object 
 usually quiets them, while even when severe they generally, though 
 not invariably, cease during sleep. 
 
 In some instances the ailment never passes beyond a comparatively 
 mild form ; inability to hold objects steadily in the hand, or to keep 
 * one or both arms from an occasional twitching movement, with slight 
 momentary distortion of the muscles of the face, or spasmodic motion 
 of the head, being all that is apparent. If the disorder is more severe, 
 both sides are almost invariably affected ; the patient is unable to grasp 
 any object, or, holding it for a moment or two, drops it from the hand, 
 which with the greatest effort of will he is yet unable to keep closed. 
 At the same time his gait is so unsteady that attempts to walk are dan- 
 gerous, or sometimes the power over the legs is so imperfect that the 
 child is quite unable to stand. The face is not merely constantly dis- 
 torted, but, if the child is desired to show his tongue, he puts it out 
 with . difficulty , hurriedly, and imperfectly, while, owing to the affec- 
 tion of its muscles, articulation is stammering and almost unintelligible, 
 and deglutition is also performed difficultly and by sudden gulps. The 
 movements still continue even when the child is lying in bed ; those of 
 the lower extremities, indeed, are often most marked in the horizontal 
 position. In the worst cases the intellect is generally dulled, and the 
 child's manner almost idiotic, while if the illness, though not very 
 severe, is yet of long continuance, there is often an imbecility of manner 
 over and above what may be due to the child's inability to control its 
 movements or to articulate with distinctness. My own impression is, 
 that in almost all cases, those alone excepted in which the attack is 
 slight and of very short duration, there is a temporary dulling of the 
 intellect, and instances are sometimes met with where the weakness of 
 
PARALYTIC CHOREA. 191 
 
 the mind is quite out of proportion to the severity of the movements. 1 
 Now and then the patient's condition is most distressing. It was so in 
 a little girl whom I saw some years ago in the Children's Hospital at 
 Paris. All the muscles of her body were affected ; her spine was often 
 bent back in an extreme degree of opisthotonos, while her movements 
 were so violent and so incessant, that it was necessary to place a board 
 three feet in height around her bed to keep her from throwing herself 
 over its edge, and by the violent grinding of her jaws together she had 
 forced almost all her teeth from their sockets. 
 
 The violence of the movements of necessity greatly exhausts the mus- 
 cular power, but there are also cases of chorea in which the loss of 
 power is from the first quite out of proportion to the amount of muscu- 
 lar movement. We know such cases at the Children's Hospital as cases 
 of limp chorea, a very good name, which one of our house surgeons 
 gave them, and which describes them as well as the more scientific term 
 of paralytic chorea. 
 
 In January, 1872 a little girl of excitable temperament, who had 
 had slight twitchings of her limbs for 3 months, which had become 
 more marked for six weeks since a sudden fright, was admitted into 
 the Children's Hospital. The movements thus suddenly increased had 
 again greatly lessened, but in spite of that apparent improvement she 
 had become more and more helpless, and at length could neither stand 
 nor feed herself, nor even talk. The child was fairly nourished, but 
 she lay in bed like a log, quite helpless and sweating profusely, unable 
 to sit up, unable to speak, unable to feed herself, and even when food 
 was put into her mouth it often rolled out again. Her grasp was so 
 weak as scarcely to be felt, her tongue could be protruded only for an 
 instant; her pulse was 120, feeble, and very irregular, and there was 
 an occasional prolongation of the heart's first sound. For a fortnight 
 her state continued almost stationary ; she could not indeed be said to 
 be aphasic, for she tried to shape her lips to the sound ; but nothing 
 came bat the faintest whisper, and usually she was voiceless. By very 
 slow degrees and under the use of Xux Vomica, whether in consequence 
 of it I cannot say, she improved; at the end of 10 weeks she went out, 
 walking very slowly and quietly, and in the country she gradually re- 
 gained her strength. 
 
 Xor are cases such as this of extreme rarity ; oftener they are less 
 severe, but sometimes more so, and I have even seen a loss of power 
 for a few days almost as complete as in diphtheritic paralysis. But the 
 power is scarcely ever permanently lost, though sometimes it is very 
 long in being regained. Sometimes too the involuntary movements 
 
 1 See with reference to the mental state of patients suffering from chorea, the dis- 
 cussion in the Academie de Medecine on occasion of a paper on the subject by M. 
 Marce. The hallucinations and the maniacal delirium with which that gentleman 
 appears sometimes to have met, are probably in part due to his field of observation 
 having been a peculiar one, in the Bicetre and the Salpetriere, in part to the coex- 
 istence of hysteria in some of the cases. My own impression, however, coincides 
 very closely with the opinion of M. Trousseau, who regards disturbance of the in- 
 tellectual powers as occurring in the greater number of cases of chorea. Bulletin 
 de l'Academie, 1861, April 12, July 5 and 19. See also Trousseau's Clinique Medi- 
 cale de l'Hotel-Dieu, vol. ii, p. 139. 
 
192 COMPLICATIONS IN CHOREA 
 
 have been so slight as not to have attracted the notice of the friends, 
 and the affection perhaps being partial, the child who drags one leg or 
 who uses one arm imperfectly and difficultly is supposed to be para- 
 lyzed ; and his condition causes great and needless anxiety. The same 
 too may be said about the impairment of the intellect, to which I just 
 now referred, and also to the loss of the power of speech which is some- 
 times a real aphasia ; not silence owing to the difficulty of articulation. 
 Both are but temporary states, though there is no rule by which their 
 duration is governed ; one child remaining dull and listless and foolish 
 for weeks after movements have ceased, the other brightening as soon 
 as the movements have lessened, and long before power has returned 
 to the limbs. In the same way the power of speech is sometimes lost ; 
 and that neither in proportion to the affection of the muscles which 
 subserve it, nor to the degree of general intellectual dulness ; but the 
 memory of words for the time is lost, and the child will labor in 
 search of words to convey the ideas with which its little brain is busy ; 
 will look wistfully around as if for help ; and then despairingly give 
 up the effort ; and yet day by day return to it at intervals till the 
 power comes back again, sometimes by degrees as one may have heard 
 a little bird strive to recover the lost notes of a tune it had been 
 taught, sometimes all at once as a forgotten dream flashes back Avithout 
 effort on our memory. 
 
 I might, if I had the time, say much more about chorea in its various 
 phases of violent uncontrollable movement, of impaired muscular power, 
 dulled intellect, and sometimes temporary loss of speech. But there 
 are two complications of the disease so important with reference to our 
 prognosis, and with reference also to our theories as to the nature of 
 the affection, that I must stop to consider them. The first of these 
 complications is rheumatism, the second, disease of the heart; and 
 often, though not always, the two conditions are associated. 
 
 The late Dr. Hughes was, I believe, one of the first who drew atten- 
 tion to the existence of a distinct relation between rheumatism and 
 chorea, but it was M. See 1 who pointed out how intimate this relation 
 is, and who adduced figures in support of his statement. He alleged 
 that of 109 cases of rheumatism admitted into the Hopital des Enfants 
 61 were complicated with chorea. Still more decided is the opinion 
 of M. Roger, justified as every opinion is which he ever expresses by 
 an amount of careful observation and minute clinical research which is 
 all but conclusive. 2 He regards chorea and the heart affection with 
 which it is frequently associated as but another manifestation of rheu- 
 matism ; he believes that rheumatism does more than predispose to, 
 that it ^actually produces it, that indeed it is the common cause of 
 chorea, which is a rheumatic symptom just as much as the pains in 
 the limbs or the swelling of the joints, Or the inflammation of the en- 
 docardium ; and, as he justly observes, this view renders the prognosis 
 in chorea far graver than it used to be considered, and brings with it 
 
 1 Memoires de l'Academie de Medecine, vol. xv. 
 
 2 In the Archives de Medecine, 1866 and 1867. 
 
WITH RHEUMATISM AND HEART DISEASE. 19'3 
 
 important practical modifications in the treatment of what used once 
 to be regarded as a mere neurosis. 
 
 It has been contended, however, that these statements are too abso- 
 lute, as is shown by the fact that rheumatism is very frequent in 
 places where chorea is very rare; 1 that even in the same conditions 
 the frequency of chorea and rheumatism is governed by a different 
 law, 2 and that the coincidence of chorea with acute rheumatism is of 
 extreme rarity. 3 
 
 My own notes show 35 out of 93 cases of chorea in children under 
 12 years of age, in whom the chorea was preceded by rheumatism, 
 sometimes immediately, sometimes several weeks or even months be- 
 fore, and in 4 instances the rheumatism followed scarlatina. In 2 
 more instances, rheumatism, once preceded by scarlatina, came on 
 during the decline of chorea. The chorea did not in these two in- 
 stances seem to be modified by the acute disease, though it was in both 
 associated with very grave affection of the heart, but the movements 
 ceased gradually in the course of the convalescence. I have not in- 
 cluded in this statement cases where there was merely a rheumatic 
 diathesis in the family, since it may in several instances not have been 
 noted ; and I further suspect that my numbers understate the fre- 
 quency of the rheumatic complication, since I find that my later ob- 
 servations yield a much higher average than the earlier. 
 
 But in addition to the cases of distinct rheumatism, 27 in number*, 
 in 16 of which there was evidence of heart affection, there were 12 
 others in which affection of the heart existed independent of any past 
 or present evidence of rheumatism. M. Roger indeed would add these 
 to the other cases, and regard them as instances of rheumatism of the 
 heart, which may exist without equally as well as in conjunction with 
 articular rheumatism. In the majority of cases the heart disease pre- 
 ceded the chorea, but I have observed a very slight and occasional mur- 
 mur become both loud and permanent in the course of chorea, and have 
 watched the advance of heart disease, and the progress of dilatation 
 take place while the child was confined to bed by the violence 'of the 
 choreic movements. It has indeed occurred to me to ask myself 
 whether in some of these cases the heart affection may not be due to 
 the disturbance of the organ in its attempts at regular contraction 
 rather than to trouble directly produced by the increase of valvular 
 disease, which in many instances even as shown by post-mortem exam- 
 ination is comparatively small in degree. 4 I must further add, that 
 while mere irregularity of the heart's action may be an occasional and 
 temporary attendant on chorea, a distinct bruit is almost always per- 
 manent, and is neither a hsemic murmur, nor a sound " plausibly ascrib- 
 
 1 Lombard and Rilliet ; in the latter's Traite de Malades des Enfants, 2d ed., 
 vol. ii, p 585 
 
 2 Blache, Memoires de l'Academie de Medecine, vol. xix, p. 608. 
 
 3 Radcliffe, in Reynolds's System of Medicine, 2d ed., vol. ii, p. 190, who says 
 that while chorea may occur before or after, it never occurs with rheumatic fever ; 
 and Steiner, in Prager Yierteljahrsschrift, vol. xix, who mentions the coincidence 
 as being so rare as 4 out of 252 cases. 
 
 4 Dr. Tuckwell, in Medico-Chirurgical Review, Oct. 1867. 
 
 13 
 
194 OBJECTIONS TO THEORY OF EMBOLISM 
 
 able to disordered action of the muscular apparatus connected with the 
 valve. 7 ' 
 
 These facts concerning the concurrence of rheumatism and of cardiac 
 disease with chorea whether accepted to the full extent, or whether re- 
 ceived subject to those exceptions which some, and I confess that I am 
 of that number, would make to their universal application, add greatly 
 to the gravity of our prognosis. But they do more ; for they have 
 suggested a theory of the disorder in support of which strong evidence 
 and much ingenious reasoning have been adduced. The late lamented 
 Dr. Kirkes first propounded the hypothesis of embolism, as explaining 
 by the irritation of the nerve centres from detached fine molecules of 
 fibrin, the production of the disorder. Dr. Hughlings Jackson 1 has 
 tried to advance this theory a step further, and to prove that plugging 
 of the minute vessels of the convolutions near the corpus striatum is 
 the cause of the affection, the tissues not being absolutely destroyed, 
 as in the case of hemiplegia, but undernourished owing to a deficient 
 supply of blood. 
 
 Now this theory rests partly on the results of microscopic observa- 
 tions, and these I do not venture to criticize ; and can but regret the 
 world of curious scientific research into which I am unskilled to follow. 
 But it seems to me that if propounded as of universal application, the 
 following weighty considerations may be urged against it. 
 
 1st. The occasional occurrence of chorea from mere imitation, so 
 that we have sometimes been compelled to change the position of pa- 
 tients in the Children's Hospital from observing the involuntary mim- 
 icry by one child of the movements of another. 
 
 2d. The extreme rarity of a sudden attack of chorea ; the great 
 slowness with which it almost invariably comes on. 
 
 3d. The very small number of the instances in which chorea con- 
 tinues limited to one side ; and the comparatively short time within 
 which hemichorea almost always becomes bilateral. 
 
 4th. The almost invariable recovery of complete power over all the 
 limbs in cases of chorea, and this even in instances where the para- 
 lytic character of the symptoms has most predominated ; so that I 
 have only two or three times in my life met with cases in which per- 
 manent loss of power over a limb could be reasonably referred to ante- 
 cedent chorea. 
 
 5th. The fact that as a general rule, and one with very few excep- 
 tions, the second attack of chorea is slighter than the first, and the 
 third than the second ; a result wholly unintelligible if organic mis- 
 chief were the ordinary cause of the attack. 
 
 But while I demur to the theory of embolism as capable of account- 
 ing for the phenomena of chorea in all or even in the majority of cases, 
 I have no other generally satisfactory explanation to suggest. Fatal 
 chorea is rare, and when death does take place it usually seems to be 
 due to exhaustion produced by the violence and ceaselessness of the 
 
 1 The arguments of different pathologists in favor of the theory of the embolic 
 origin of chorea are well summarized by Dr. Radcliffe in his article on chorea in 
 Reynolds's System of Medicine, vol. ii, 2d ed., pp. 198-206. 
 
AS SOLE CAUSE OF CHOREA. 195 
 
 movements ; it is preceded by a sudden failure of the vital powers, by 
 delirium, or failure of intelligence, and at last by a comatose condition, 
 which seldom lasts longer than a few hours. In such circumstances 
 there does not appear to be anything constant in the appearances dis- 
 covered after death; and, though congestion of the vessels of the spinal 
 cord and the effusion of blood or of a bloody fluid around the theca of 
 the cord are generally discovered, as they were in the only two cases of 
 the morbid appearances in which I have a record, yet the presence of 
 these conditions is by no means constant, and in some instances a post- 
 mortem examination discovers absolutely nothing to explain the pa- 
 tient's death. 1 
 
 I believe, then, as I have for many years, that chorea falls into the 
 same category with the majority of the convulsive affections of early 
 life ; that its phenomena depend on irritation, direct or indirect, of the 
 nervous spstem ; and that, consequently, the intensity of its symptoms, 
 and the danger that attends them, are greatly influenced by the excit- 
 ing cause to which they are due. Idiopathic chorea is therefore almost 
 always less serious than the symptomatic, and the disorder which is 
 excited by some momentary shock generally calls for far less anxiety 
 than that which manifests itself in connection with acute rheumatism, 
 or with inflammation of the heart or pericardium. 
 
 It is with idiopathic cases only that I here concern myself, and in 
 the majority of them the question fortunately is less one of whether 
 the patient will recover, than within what time recovery may be ex- 
 pected, and I fear also of what sequelae may be left behind. The dis- 
 ease is essentially slow in its course, and the average of 117 cases, as 
 reported by M. See, 2 is 69 days; the extremes either way, however, 
 vary considerably, for while recovery in the less severe cases is some- 
 times complete in a month, the convulsive movements persist in others 
 for a period of several months, or longer. Cases of very chronic 
 chorea are, however, usually of the partial kind, the affection having 
 either involved only one limited set of muscles from the outset, or re- 
 maining in them after other parts had ceased to be its seat. Not only 
 is chorea slow in departing, it is also very apt to return, and the attacks 
 have been known to recur as often as six or seven times in the same 
 patient, though generally with a progressive diminution in their severity. 
 
 In estimating the value of different modes of treatment, it must not 
 be forgotten that chorea is one of those affections in which there is a 
 tendency to spontaneous recovery. Not only does this show itself in 
 almost all cases where improvement has taken place up to a certain 
 point under the influence of remedies, but very often the improvement 
 once advanced to this point goes on to perfect recovery with the same 
 rapidity, whether those remedies are continued, modified, or abandoned. 
 Now and then, too, we meet with instances in which even the severer 
 forms of chorea, after bidding defiance to all remedies, spontaneously 
 
 1 Leudet, Sur les Chorees sans Complication terminees par la Mort ; in Archives 
 de Medeeine, 1853, vol. ii, p. 285: and likewise the most acute and valuable re- 
 mark? of Dr. Radcliffe on the Pathology of Chorea, at pp. 198-206 of vol. ii of 
 Reynolds's System of Medicine, already referred to. 
 
 2 " Op. cit., p. 408. 
 
196 TREATMENT OF CHOREA. 
 
 improve when all have been discontinued, and such improvement is as 
 complete and as lasting as that which we ever attain by any mode of 
 medication or by any form of treatment. 
 
 Next it is well to remember that there are some forms of choreic 
 movements in which the parts affected vary in the course of a few days, 
 or even within a shorter time, and which consist in winking the eyes, 
 in grimacing, or in twitching the muscles of the face or neck, or in 
 some awkward gait, or awkward gesture, that often occasion much 
 anxiety to parents, but which are best left unnoticed and without any 
 direct treatment. These cases, which are scarcely ever met with among 
 the children of the poor, appear to depend on some temporary irritation 
 of the nervous system, generally, I believe, on mental strain : not of 
 necessity on undue length of the hours of study, or on the difficulty of 
 the tasks imposed, but often on a child's anxiety to make progress, and 
 to keep up with his schoolfellows. In corroboration of this being their 
 cause, I may say that, contrary to the rule which obtains with chorea 
 in general, these movements are much more frequent in boys than in 
 girls. The overmental strain of girls comes later in life, just about 
 the time of puberty, when it produces hysteria, and all sorts of men- 
 strual disorders ; but from the age of seven to twelve girls are usually 
 in the nursery or at any rate at home, and are rarely overworked. In 
 cases of this kind, lessening the mental strain is almost always accom- 
 panied by a cessation of the twitches, change of air, country amuse- 
 ments, and a generally tonic treatment perfect the cure, and dancing 
 and gymnastics overcome the remains of any awkward habit. But I 
 have never seen any good from calling the child's attention directly to 
 the habit ; but, on the contrary, the more his attention is aroused to it, 
 the more in spite of all his endeavors does it become aggravated. 
 
 In cases of genuine chorea, usually those of the slighter kind, but 
 yet more definite than those tricks of the facial muscles to which I 
 have just referred, gymnastics are often of great service, and cases in 
 the Children's Hospital sometimes receive no other treatment. They 
 may always be employed with benefit when attention rouses the child 
 to steadier movements of its hands or to a less uncertain gait, and in 
 nothing do two cases of chorea differ more than in this. Notice one 
 child and tell it to take care, and the movements which before it exe- 
 cuted tolerably well, become absolutely uncontrollable. Let another 
 see that he is watched, and so long as he attends to what he is about 
 he walks more steadily and grasps more firmly. The great drawback 
 from the success of gymnastics consists in the difficulty of arousing the 
 child's will to activity, for it is not the mere mechanical movement 
 of the limb which suffices, as it does in a stiff joint for which passive 
 exercise is needed; but here it is essential to success that we should 
 be able to evoke the conscious attention of the patient, and that the 
 patient's nervous system should be equal to the effort to attend. Hence 
 it is that gymnastics are of service very much in proportion to the age 
 of the children ; hence, too, they are of more use when practiced in a 
 class than by one child alone; and hence, too, music or any simple 
 chant, in time with which the movements are made, helps greatly to 
 fix the attention and expedite the cure. 
 
TREATMENT OF CHOREA. 197 
 
 I have never been able to put adequately to the test the employment 
 of gymnastics, or of regulated movements in cases of severe chorea. 
 No one, indeed, who had the honor even of a slight acquaintance with 
 the late M. Blache 1 but must attach the most implicit faith to his state- 
 ments, but I am not aware that any one has repeated his observations 
 on an equally large scale, and the use of movements seems passing into 
 undeserved forgetfulness. I am quite sure that regulated movements 
 of the limbs, even in cases so severe as to necessitate their being gener- 
 ally kept motionless by bandages at other times, do help in a very 
 important degree the recovery of the patient. I cannot say of my own 
 knowledge what, without other aid, they would effect. 
 
 Having spoken about movements in chorea, I must also say a few 
 words about rest. In cases of chorea of even moderate severity I have 
 perpetually seen the ailment aggravated by the child being allowed to 
 be up and about. The sense of intense fatigue which follows an epi- 
 leptic fit is not all due to the sensorial disturbance : it is owing in no 
 small measure to the violent muscular movements by which it has 
 been accompanied, and in just the same way the unceasing movements 
 of the legs in attempts to walk, or of the muscles of the back in the 
 vain endeavor to sit still, tire the child, and exhaust the muscular 
 power. It is often well worth noticing how much better a child be- 
 oomes after three or four days' rest in bed in the hospital without any 
 medical treatment having been adopted for its cure ; nor less instruc- 
 tive to see how the moment that the child is taken up, the limbs, which 
 before were almost motionless, w r rithe and t\yist about in the attempt 
 to stand or to w T alk. In all cases of considerable severity, therefore, 
 the child should at once be placed in bed, and if the movements are 
 still violent and continuous, their severity is much abated and the 
 child is saved much distress and much subsequent exhaustion by put- 
 ting splints on the legs and arms and swathing the child completely in 
 soft bandages. As the child gets better they may be removed, but 
 not seldom it is wise to apply them by day, even though they may be 
 removed at night, if, as is sometimes the case, the child should then 
 sleep tranquilly. 
 
 It were useless to go over the list of all the medicines which have 
 been vaunted for the cure of chorea. There is of course a large num- 
 ber of cases in which the existence of some distinct indication leaves 
 no room for doubt as to the remedies to be employed. Such are the 
 cases of habitual constipation ; such, too, those of marked debility, in 
 which there can be no doubt as to the propriety of administering pur- 
 gatives in the one case, chalybeates in the other ; and there is a period 
 in most instances of chorea during which each of these remedies com- 
 monly finds a place. But there still remain a good many cases in 
 which the movements constitute the disease, and in which there is no 
 special indication to guide us. It is in these cases that we meet with 
 the large class of antispasmodic remedies, each of wdiich lias been 
 vaunted and abandoned in its turn, and from none of which have I 
 ever seen the slightest benefit. Neither have the sedatives been more 
 
 1 See his paper in the Memoires do l'Academiede Medecine, vol. xix, pp. 598-608. 
 
198 TREATMENT OF CHOREA. 
 
 successful in my hands, except when given in a single dose for the 
 purpose of obtaining sleep ; henbane, conium, and belladonna have all 
 been given under nry observation, or have been prescribed by myself, 
 and have all proved equally unsuccessful, though I have known them 
 to be tolerated in poisonous doses without any result either for good or 
 evil. I have heard of chloral exerting a marked influence over choreic 
 movements, and it may deserve a larger trial than I have yet given it ; 
 though in the cases where I have employed it it seemed to have no 
 power apart from its action in producing sleep; and the bromide of 
 potass, which sometimes acts like a charm in epilepsy, appears to have 
 no power at all in controlling chorea. 
 
 The want of accommodation at the Children's Hospital has prevented 
 me from giving a fair trial to the sulphur baths from which French 
 physicians appear to have often obtained very satisfactory results. I 
 am certain, however, that in many instances the violence of the choreic 
 movements is lessened in proportion to the degree to which the action 
 of the skin can be excited ; and the extreme dryness of the skin in a 
 large number of choreic patients cannot have escaped general observa- 
 tion. I often employ the hot air bath at night for the purpose of 
 exciting the action of the skin, giving at the same time a diaphoretic 
 dose of antimonial wine, and continue this for three or four consecutive 
 nights, even though the general condition of the patient should be such 
 as to indicate an otherwise tonic plan of treatment. 
 
 I have also in a few instances, when the choreic movements were 
 very violent, employed yith marked advantage large doses of tartar 
 emetic, as first proposed by Dr. Gillette of Paris, and employed by M. 
 Roger, certainly no reckless practitioners ; and approved by M. Trous- 
 seau in those exceptional cases for which alone I should reserve it. 
 The plan which they followed consisted in giving three grains of tartar 
 emetic the first day of treatment, six the second, nine the third, then 
 allowing a pause of from three to five days, and recommencing with 
 four grains the first day, eight the second, twelve the third, and so on 
 for three series. When I have employed the remedy, I have begun 
 with an eighth of a grain for a child of ten years old ; but by doubling 
 the quantity every four hours, a very large dose is soon arrived at, 
 which is no further augmented so soon as the movements are distinctly 
 controlled; while vomiting, diarrhoea, or failure of the power of the 
 pulse is a reason for its immediate discontinuance. In any case, too, 
 the remedy should be discontinued if marked improvement does not 
 take place within three days, and should not be resumed until after 
 an interval of at least 48 hours. These precautions are all the more 
 needed, since while a sudden failure of power sometimes takes place in 
 chorea quite independent of the treatment adopted, I have met with 
 one instance in which death took place from apparently causeless ex- 
 haustion 36 hours after the discontinuance of large doses of antimony, 
 which yet had produced neither vomiting nor purging, and in which 
 the diminished power of the pulse before the child began to die was by 
 no means remarkable. 
 
 I should scarcely have thought it necessary to add that I do not 
 recommend this heroic use of antimony except in those cases where the 
 
TREATMENT OF CEOREA. 199 
 
 violence of the movements, uncontrolled by ordinary means, itself 
 threatens life, if it were not that I have been misunderstood and been 
 supposed to advocate this as a common plan of treatment. 1 I ought to 
 add that I have heard of one case in which chloral in frequently re- 
 peated doses checked the violent movements in a case of great severity, 
 and should certainly be disposed to give it a trial before employing 
 antimony. I may add that chloroform has in my hands been only 
 temporary in the good it effected, and that its influence to produce 
 even that temporary good was soon exhausted. 
 
 The only remedy which has appeared to me to exert any specific 
 power over chorea is the sulphate of zinc, given in increasing doses, as 
 I believe was first done by the late Dr. Barlow of Guy's Hospital. 
 Beginning with one grain or even half a grain three times a day, and 
 increasing the dose by a grain daily, a very remarkable tolerance of 
 the medicine is speedily established, and it is by no means unusual to 
 find 10, 15, or 20 grains taken three or four times a day with perfect 
 impunity. I have never increased the dose beyond the latter amount, 
 thinking that if three weeks' trial, at the end of which so large a dose 
 was arrived at, produced no result, the remedy might be considered to 
 have failed. Neither have I ever increased the dose merely to ascertain 
 how much could be borne with impunity, but have continued the 
 remedy at whatever dose fairly controlled the movements; and if it 
 produced sickness, have continued a smaller dose until the movements 
 were controlled, or till I had become satisfied of its inutility. At one 
 time, in accordance with Dr. Barlow's caution, I was accustomed to 
 leave off the zinc gradually, just as I had increased it ; but I have 
 since tried the discontinuance of it abruptly, and have not found any 
 return of symptoms follow from this course. 
 
 I have made comparatively few trials of arsenic, probably fewer . 
 than I ought to have done, considering the invariable success which 
 some physicians of very high authority have met with in its employ- 
 ment. I have used it in chronic chorea when other remedies had 
 failed, and have found it fail too. I have, however, never given it, as 
 counselled by Dr. Begbie, who used to prescribe it twice a day after 
 meals, increasing the dose daily until the special injurious effects of 
 arsenic became apparent, when he suspended its use for a few days, 
 resuming it again as soon as these symptoms had passed off. Dr. 
 Radcliffe, who has employed it in this way and with success, states 
 that he has often been compelled to discontinue it on account of the 
 gastric disturbance which it produced, and which often became urgent 
 before the remedy had had time to influence the chorea. In these cir- 
 cumstances he suggests a trial of the arsenic hypodermically, from 
 which he has obtained good results on some occasions ; and in instances 
 of chorea rebellious to other means, this suggestion, and I may say 
 the same about every suggestion of Dr. Radcliffe's, deserves to be borne 
 in mind. 
 
 I have never employed strychnine as a general remedy in chorea, 
 
 1 The very kindly critic of my Lumleian Lectures in the Edinburgh Medical 
 Journal for Sept. 1871, seems to me to have fallen into this misapprehension. 
 
.200 TREATMENT OF CHOREA. 
 
 in the way in which I employ zinc; for notwithstanding the high 
 recommendation of M. Trousseau, I have felt afraid of it. He him- 
 self was accustomed to push the medicine to a dose at which the 
 physiological effects of the remedy became apparent, and speaks of 
 headache, stiffness of the muscles of the neck, pains in the limbs, oc- 
 casional spasms, and itching of the surface of the body, as indications 
 that the medicine has been carried to the limit of safety. But the 
 twitching of the limbs in chorea prevents our being aware of the occur- 
 rence of spasms; while a child's inability to describe its sensations de- 
 prives us of another most important guide : and I have seen convul- 
 sions occur more than once in young children who were taking strych- 
 nine, apparently unpreceded by any of the ordinary physiological effects 
 of the remedy. 
 
 On these accounts I have never given it in cases of severe chorea in 
 which the dulling of the intelligence as well as the violence of the 
 movements prevent our learning when the medicine has begun to pro- 
 duce its specified effects. I also very rarely use it in children under 
 the age of seven. I begin with a small dose, increase it slowly, sus- 
 pend it for two or three days at a time when its administration is long 
 continued ; and limit its use almost entirely to cases in which there is 
 loss of power rather than violence of movement. In those conditions 
 in which the limbs cannot be exerted without the irregular movements 
 being at once induced, although these movements are comparatively 
 slight so long as the patient remains quiet in bed, the strychnine has 
 seemed to me sometimes very useful, just as it is in cases of diphther- 
 itic paralysis. 
 
 The above are the chief, I do not say that they are by any means 
 the only, remedies for chorea. I have not dwelt on the various indi- 
 rect means (in the more chronic form of the disorder they are indeed 
 the most important) by which you must endeavor to improve your 
 patient's health. Residence in the country, sea-air, and sea-bathing, a 
 well-regulated but nutritious diet, and generally a careful use of stimu- 
 lants, when combined with the most sedulous avoidance of overexcite- 
 ment in any form, often do as much as medicine, or even more, for the 
 restoration of your patient. 
 
 In the great majority of cases you may, as I have already mentioned, 
 assure the friends of your patient that the disease will ultimately sub- 
 side, though it may last for many weeks. Two qualifications, however, 
 you are forced to add to this cheering assurance, — the one that slight 
 causes may occasion its return, and the other that there exists a con- 
 nection between it and the rheumatic diathesis ; and the development 
 of heart disease either with or without rheumatism in the course of 
 chorea is a hazard against which you can furnish no guarantee. 
 
INFANTILE PARALYSIS. 201 
 
 LECTURE XV. 
 
 Paralysis. — Sometimes congenital, but this is not true infantile paratysis — Its char- 
 acteristics — Age at its occurrence — Most frequent during period of dentition — 
 Diagnosis — Identity with spinal paralysis in adults — Prognosis not very favor- 
 able — Consequences of its persistence — Treatment — Aids to walking — Modes of 
 exercising the limbs — Galvanism. 
 
 Facial Hemiplegia in new-born infants. 
 
 Neuralgia in infancy and childhood. 
 
 Disturbance of the nervous system shows itself in children as well 
 by loss of the motor power as by the occurrence of involuntary move- 
 ments ; and such an accident as the palsy of a limb naturally occasions 
 parents the greatest anxiety. In the adult, a paralytic seizure is gen- 
 erally the result of very serious disease either in the brain or spinal 
 cord, and the sign of the commencement of a series of morbid processes 
 which issue sooner or later in the destruction of the patient's life. 
 Non-professional persons are aware of this fact, and often suppose that 
 the same rule holds good in the case of the child as in that of the 
 adult ; but you may in most instances quiet their fears with the assur- 
 ance that paralysis in infancy and childhood seldom betokens any peril 
 to life, though the affection is often very slow in disappearing, and 
 sometimes is quite incurable. 
 
 Paralysis in childhood occasionally dates from so early a period that 
 there seems every reason for believing it to be the result of some orig- 
 inal defect of conformation. In such cases the power over both ex- 
 tremities of one side is greatly impaired, and the limbs on that side 
 are much smaller and less well nourished, and sometimes the defective 
 growth and want of power are evident on the whole of the same side 
 of the face and body. Some years ago, I saw a girl, 18 years old, in 
 w T hom not only were the left extremities much shorter and smaller than 
 the right, but the left half of the face and body was so likewise. The 
 parents of the girl stated that this inequality in size of the two halves 
 of the body had existed from earliest infancy, and that the defective 
 power over her limbs had not succeeded to a fit, nor to any other in- 
 dication of acute cerebral disease. The left side was weak, and motion 
 imperfect, but sensation seemed to be unimpaired. The patient in this 
 case was rather deficient in intellectual endowments. In another instance 
 the body was well formed, but the patient, a girl of eight years of age, 
 had had from her earliest infancy but very imperfect use of her right 
 side. She limped with her right leg as she walked, always treading 
 on her toes, with the heel raised considerably above the ground, and 
 turning the foot inwards at every step. She had but very incomplete 
 power over her right arm ; the fingers of that hand were constantly 
 flexed and drawn into the palm ; and though by a great effort she 
 could extend them, yet the moment her attention was withdrawn they 
 
202 INFANTILE PARALYSIS. 
 
 returned to their former flexed position. Sensation was as perfect in 
 the right limbs as in the left, but their wasted condition and smaller 
 size, as compared with the left extremities, showed that their nutrition 
 had been but imperfectly carried on. 
 
 It is almost needless to observe, that in cases such as these there is 
 no room for treatment other than the employment of whatever mechan- 
 ical means may be best calculated to relieve inconvenience or to dimin- 
 ish deformity. 
 
 Real congenital paralysis, however, apart from idiocy, is a much 
 less frequent accident, than the occurrence of partial or complete loss of 
 power over certain limbs or muscles at a subsequent period. Such 
 sudden loss of power, unattended by any symptoms which endanger 
 life, is so frequent an occurrence in infancy and early childhood as to 
 have received a special designation ; and the terms Infantile Paralysis, 
 Spinal Paralysis of Infants, Essential Paralysis, Atrophic Paralysis, 
 Atrophic Fatty Paralysis, all apply to the same affection, either desig- 
 nating one of its special features, or expressing some theory as to 
 its nature. On this one point all are agreed, that there is a form of 
 paralysis frequent in early life, but which differs in its symptoms and 
 its course from any that we commonly meet with in the adult. In 
 many instances its commencement can be traced to some attack, though 
 often a very brief one, of cerebral disturbance, which showed itself, 
 perhaps, by nothing more than a single convulsive seizure, or by an 
 unusual heaviness of the head, that lasted for a day or two, and then 
 subsided of its own accord. In the majority of cases, indeed, the 
 cerebral disturbance that preceded infantile paralysis is neither severe 
 nor long continued; and only two instances have come under my notice 
 in w r hich there seemed to be reason for supposing that it was associated 
 with abiding mischief in the brain. It is therefore of importance to 
 examine an infant carefully, even after a very mild convulsive seizure, 
 in order to make sure that it moves its limbs as freely as before, or 
 that, if its power over them is impaired, appropriate treatment may be 
 at once adopted. 
 
 Paralysis sometimes comes on independently of any evident cerebral 
 disturbance, seeming to be induced by the irritation of dentition, or 
 supervening on the long continuance of a constipated state of the 
 bowels, or appearing in connection with all the indications of general 
 debility, or succeeding to a short feverish seizure, which came on sud- 
 denly when the child was in bed at night, and left it with one limb 
 palsied in the morning* I believe, indeed, that in cases even of the 
 most sudden attack of paralysis, there have almost always been some 
 previous indications of disorder of the general health; the few instances 
 only excepted in which the immediate action of cold, as from a child 
 sitting on a stone step, has been followed by paralysis of one or of both 
 legs. 
 
 The whole subject of paralysis in early life calls for, and would well 
 repay, a thorough investigation. Unfortunately, however, the difficul- 
 ties which beset any inquiry into the subject are numerous ; and are 
 the less easy to overcome, since they arise in great measure from the 
 chronic nature of the ailment, which renders it almost impossible ade- 
 
INFANTILE PARALYSIS. 203 
 
 quately to test the value of remedies, or to estimate the changes which 
 time may bring about, either in improving or deteriorating the patient's 
 condition. Of the large number of cases which I have seen, few have 
 continued for more than a few weeks under my observation ; so that I 
 am unable to answer, with reference to them, more than a few of the 
 questions which suggest themselves as deserving a reply. 
 
 I have spoken of Infantile Paralysis as peculiar in its characters ; 
 and I think that it is important before entering on its special study 
 that we separate from it all other forms of palsy which may be observed 
 in childhood, but which with few exceptions are far more frequent in 
 the adult. 
 
 First, then, we leave out of consideration all instances in w r hich the 
 loss of power, as in the two cases which I mentioned at the commence- 
 ment of this lecture, is actually congenital ; and next those cases, too, 
 most of which date from birth or from very early infancy, where the 
 paralysis is associated with idiocy ; and nervous power is wanting to 
 the limbs just in the same way as it is wanting for the exercise of the 
 faculties of the mind. Neither do cases of simple Facial Paralysis 
 belong here, for they either depend on local injury, as from the pres- 
 sure of the forceps in labor ; or they arise fr§m the same class of causes 
 as produce the affection in the grown person, though I have seen tem- 
 porary paralysis of the portio dura associated with true infantile 
 paralysis. 1 
 
 The characteristics of infantile paralysis appear to be : 
 
 1st. The suddenness of its occurrence. 
 
 2d. The absence in many cases of any previous sign of disorder of 
 the cerebro-spinal system, and the fact that when such disorder does 
 occur, there is no constant proportion between its severity and the ex- 
 tent or completeness of the paralysis. 
 
 3d. The continuance throughout of undiminished sensation, and the 
 absence in the early stages of the affection of all rigidity or contraction 
 of the paralyzed limbs. 
 
 4th. The occasional onset of the affection by severe pains lasting for 
 some hours in the limbs which afterwards become paralyzed, or the 
 existence of greatly exaggerated sensibility of the limbs in the early 
 stages of the affection, and the direct proportion existing between the 
 pain or the hyperesthesia and the subsequent loss of power. 
 
 5th. The tendency of the affection to implicate permanently the 
 lower rather than the upper limbs, and this, even though all should 
 have been paralyzed in the first instance; while in nearly half of the 
 cases the paralysis is throughout limited to the lower limbs. 
 
 6th. The direct relation which subsists between the early date of the 
 improvement and its completeness. 
 
 7th. The comparative rarity of absolute recovery even in the most 
 favorable cases, for not only does a degree of weakness continue, but 
 in many instances one or two muscles of a limb remain almost power- 
 less, even when the others have gained much of their former vigor. 
 
 8th. The tendency to retarded growth and impaired nutrition in the 
 
 1 See also Laborde, Paralysie de l'Enfance, 8vo. Paris, 1864, p. 37. 
 
204 INFANTILE PARALYSIS. 
 
 permanently paralyzed limb, to which there is usually superadded a 
 greater or less degree of fatty degeneration of the muscular tissue. 
 
 The wasting of the limb, however, does not bear a uniform relation 
 to the degree of paralysis ; nor even if the paralysis does not improve 
 is the wasting continuously progressive, but it remains stationary at an 
 uncertain stage, as also does the degeneration of the muscular fibre. 
 
 9th. The tendency to the production of deformity in the affected 
 limb ; in occasioning which the mere weight of the limb, and the load 
 which it has to support or to move, and which is now disproportionate 
 to its weakened powers, bears, as Volckmann 1 has pointed out, a more 
 important share than mere antagonism between the paralyzed and non- 
 paralyzed muscles. It may be added in further confirmation of this 
 opinion, that when paralysis of either leg takes place in infants or in 
 young children who have scarcely begun to walk, no deformity occurs 
 for months, so long as the child remains upon the couch, but it speedily 
 shows itself when the child begins to make attempts to stand or to 
 walk upon the sound limb, while the weight of the other necessarily 
 remains unsupported. 
 
 The following table shows the sex of patients affected with Infantile 
 Paralysis, and also their age at the time of the attack. 
 
 In 
 
 1 
 
 1 occurred 
 
 under 
 
 6 
 
 month! 
 
 5. 
 
 
 
 
 1 
 
 u 
 
 between 6 
 
 u 
 
 and 1 year. 
 
 12 
 
 7 
 
 u 
 
 " 
 
 1 
 
 year 
 
 and 
 
 2 years. 
 
 3 
 
 9 
 
 u 
 
 (i 
 
 2 
 
 years 
 
 " 
 
 3 years. 
 
 3 
 
 3 
 
 [( 
 
 " 
 
 3 
 
 " 
 
 u 
 
 4 » 
 
 1 
 
 1 
 
 It 
 
 (c 
 
 4 
 
 u 
 
 « 
 
 5 " 
 
 1 
 
 
 
 " 
 
 CI 
 
 5 
 
 '< 
 
 it 
 
 6 " 
 
 1 
 
 
 
 " 
 
 c« 
 
 7 
 
 (< 
 
 it 
 
 8 " 
 
 22 22 
 
 In 32 out of 44 cases, or in nearly two-thirds of the total number, 
 the paralytic symptoms came on between the age of 6 months and 3 
 years, or in other words, during the time when the process of dentition 
 was going on most actively. In many instances, indeed, it was not 
 preceded by any of the local signs of difficult dentition, but still it is 
 quite apparent that the changes which are going on in the constitution 
 during that important period of development predispose to it, as to so 
 many other affections of the nervous system. But, nevertheless, in 
 two-thirds of the cases, no indications of cerebral disturbance either 
 occurred before the paralysis or came on afterwards, while in only 8 
 instances were the signs of affection of the brain other than exceedingly 
 transient. With reference to the parts affected — 
 
 In 1 case only was the arm paralyzed, the legs not being involved. 
 
 18 cases the legs alone were affected, viz , 5 times the right, 5 the left, 8 both. 
 
 25 
 
 ■it 
 
 " and arms were both involved, viz., 
 
 8 
 
 c< 
 
 ri^ht leg and arm. 
 
 6 
 
 it 
 
 left 
 
 4 
 
 it 
 
 both legs and ri»;ht arm. 
 
 3 
 
 a 
 
 " " left " 
 
 4 
 
 u 
 
 " " both arms. 
 
 
 1 
 
 Sammlung klinischer Vortrage, Heft i. Leipzig, 1870. 
 
DIAGNOSIS OF INFANTILE PARALYSIS. 205 
 
 Of these 25 cases there were 13 in which the arm had perfectly, re- 
 covered while the leg had not; 4 in which the leg had recovered while 
 the arm had not ; and 8 in which both had continued paralyzed at the 
 time when the patients came under my care, though these figures do 
 not in the least express what may have been the ultimate issue of the 
 cases. 
 
 In almost all instances a certain small amount of voluntary power 
 over the affected side remains after the seizure. Thus, if the arm is 
 paralyzed, the child can move it a little, though with difficulty, and 
 not so as to answer any useful purpose ; or if the leg is affected, the 
 child can flex and extend it when lying in bed, or, perhaps, can make 
 some slight attempt at progression if the weight of its body is sup- 
 ported by some one else ; and this even though it be wholly unable to 
 stand for a moment without assistance. Owing to this circumstance, 
 the date of the occurrence of paralysis of the lower limbs is very apt 
 to be overlooked in infants who have not begun to walk, so that the 
 affection may not attract notice until it is in reality of several months' 
 duration. 
 
 But though the existence of this affection may for a time be alto- 
 gether overlooked in early infancy, diagnosis is not otherwise attended 
 with much difficulty, for the history of the case and the painlessness 
 of the affected limb will at once show that the loss of power over it is 
 not the result of any injury. Often, however, sensation in the affected 
 limb appears to be exalted when the paralysis is recent, the degree of 
 hyperesthesia in the early stage being in such cases proportionate to 
 the completeness of the loss of power which afterwards is apparent. 
 In some instances, the exaggerated sensibility continues for several 
 weeks, though this is unusual ; but when this is the case, the leg being 
 the seat of the affection, and the paralysis incomplete, the existence of 
 hip-joint disease may very likely be suspected. In such a case the 
 child bears all its weight on the healthy limb, turns the foot of the 
 affected side inwards when walking, and stands with the toes of that 
 foot resting on the dorsum of the foot of the healthy side. Still it will 
 usually be found that the exaggerated sensibility of the paralyzed 
 limb varies greatly at different times, while that extreme increase of 
 suffering produced in cases of hip-joint disease, on striking the head of 
 the femur against the acetabulum by a blow upon the heel, and the 
 fixed pain in the knee of the affected side, so characteristic of disease of 
 the hip-joint, are absent; and these points of difference will enable you 
 to distinguish between the two affections. One other important means 
 of diagnosis is furnished by the presence or absence of an increased 
 temperature over the suspected joint. The value of this easy observa- 
 tion in determining the presence or absence of inflammation about any 
 particular spot is dwelt on by Mr. Hilton, 1 in his lectures delivered at 
 the College of Surgeons. I cannot refer to them without recommend- 
 ing them to your most careful perusal, or without expressing my con- 
 viction that, more than almost any work which has recently appeared 
 
 1 Lectures on Kest and Pain, 8vo. London, 1863. See p. 64. 
 
206 DIAGNOSIS OF INFANTILE PARALYSIS. 
 
 on subjects connected with our profession, they bear the stamp of origi- 
 nal thought, and of that simplicity which characterizes real genius. 
 
 Another important question is, how we may distinguish between 
 forms of paralysis, such as I am here speaking of, and those more 
 serious cases in which the palsy is a sign of organic disease in the 
 brain. In many cases the history of the patient will of itself be suf- 
 ficient to guard us from error ; for if paralysis occurs suddenly, affect- 
 ing both limbs on one side, and is neither preceded nor attended by 
 any cerebral symptom, it is almost certain that it does not depend on 
 serious organic disease of the brain. Our decision will be more diffi- 
 cult if the loss of power has been gradual, and especially if only one 
 limb is affected ; but, if the brain is diseased, we shall rarely find a 
 mere weakening of the motor power ; for connected with it there will 
 usually be occasional involuntary tremor or nervous twitching of the 
 limb, or contraction of the fingers or toes, and that independent of the 
 general wasting of the affected limb which takes place in all cases of 
 long-standing essential paralysis, and is then accompanied with. con- 
 traction, owing to the predominance of the flexor over the extensor 
 muscles. 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 ; w T hile, if it depends 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 peculiar movement, or is sometimes the only part where 
 convulsive movements occur. 
 
 And now, having gone with some detail into the various character- 
 istics of infantile paralysis, we come to the question of its nature. Is 
 it, as I have been used to teach, and as my remarks at the commence- 
 ment of this lecture seemed to imply, an essential paralysis, indepen- 
 dent of organic lesion and peculiar to early life, or are its characteristics 
 to be sought in certain changes of the muscular tissue ; or is its point 
 of departure to be found in the spinal cord ? Is it in fact analogous 
 to or identical with certain forms of paralysis met with in the adult ; 
 its one remarkable peculiarity being the frequency of its occurrence ; 
 just as all forms of disorder of the nervous system, and especially of 
 the spinal system, predominate in early life; and the other being that 
 disposition to the production of various deformities inseparable from 
 the fact that the paralysis occurs in parts still in a state of growth and 
 development ? I believe this last assumption to be correct ; that Heine 1 
 was right when he termed it Spinal Paralysis, and that Laborde and 
 others who have adopted the same view have done good service by 
 leading us to sounder opinions with reference to its nature ; though we 
 may still hesitate as to the value to be attached to the alleged micro- 
 scopic appearances in the substance of the cord. I have been much 
 struck by observing the exact identity of character between the pa- 
 ralysis of infancy, and the paralytic symptoms which have come on 
 in children after a fall on the back, or a blow on the spine, and which 
 were undoubtedly due to spinal congestion. 
 
 1 Spinale Kinderlahmung, 8vo., 1860. Laborde, op. cit. 
 
PROGNOSIS IN INFANTILE PARALYSIS. 207 
 
 I do not know that I can better sum up the points of resemblance 
 between the two, or better state my present conviction, than in the 
 words of my friend Dr. Radcliffe. 1 
 
 " It seems to me," says he, " that the peculiarities of infantile paraly- 
 sis instead of showing that it is unlike paralysis in adults, only show 
 a close analogy to, if not an actual identity with, the paralysis which 
 has been seen to result from spinal congestion. In infantile paralysis 
 the paralysis is partial ; in paralysis from spinal congestion it is the 
 same. In infantile paralysis sensation is exaggerated rather than 
 dulled in the paralyzed parts ; in paralysis from spinal congestion it is 
 the same. In infantile paralysis the bladder and lower bowel are 
 obedient to the will, so also in paralysis from spinal congestion. In 
 infantile paralysis the limbs are limber, not rigid ; so also in paralysis 
 from spinal congestion. In infantile paralysis recovery more or less 
 complete is the rule rather than the exception ; so also and very much 
 in the same order in paralysis from spinal congestion. In infantile 
 paralysis ' head symptoms ' are exceptional phenomena at any time ; so 
 also in the paralysis from spinal congestion. Neither do I know of 
 anything to invalidate the conclusion which those resemblances would 
 seem almost to necessitate, that infantile paralysis is nothing more than 
 paralysis from spinal congestion." 
 
 I do not know that one can lay down any decided rules with refer- 
 ence to prognosis in these cases as deducible from the sudden or gradual 
 access of the paralysis, though it is my impression that the former, 
 which is the more common mode of onset of paralysis at the time of 
 dentition, warrants a more hopeful view of the case than the latter. 
 The duration of infantile paralysis, indeed, in whatever circumstances 
 it may have come on, is extremely variable. In those instances in 
 which recovery is most complete, amendment generally manifests itself 
 within a few days, and this sometimes wholly independent of treat- 
 ment, though it often er occurs under the employment of some simple 
 remedy directed against the symptoms of constitutional disorder with 
 which it was accompanied ; so that the same medicine suffices at once 
 to remove the child's indisposition and to cure its paralysis. In other 
 cases, even though all signs of disordered health may pass away w T ith 
 the same rapidity, the child may continue for weeks or months with the 
 power over one side of its body, or over one-half of its face, or one of 
 its limbs greatly impaired ; or this condition may persist through the 
 remainder of its life. 
 
 The evils resulting from the persistence of the paralysis are also 
 much greater in childhood than in after-life, for the disfigurement 
 which it produces is far more serious. In the course of time the mus- 
 cles of a paralyzed limb become almost always wasted, and the sinking 
 of its temperature attests its imperfect nutrition ; but in childhood the 
 growth of the part also is arrested, or retarded, so that in the course of 
 a year or two the affected limb will be half or three-quarters of an inch 
 shorter than the corresponding member on the opposite side. A little 
 girl had paralysis of her left leg at the age of 1 year and 9 months, 
 
 1 In Keynolds's System of Medicine, 2d ed., 1872, vol. ii, p. 708. 
 
208 PROGNOSIS IN INFANTILE PARALYSIS. 
 
 after a febrile attack accompanied with pain, and which seemed to have 
 been of a rheumatic character. At the age of 6 years, she having re- 
 covered power over her left leg sufficient to walk without a crutch or 
 other support, a line drawn from the anterior superior spine of the 
 ilium to the external malleolus measured 20J inches on the right side, 
 19 on the left; the circumference of the right calf was 8 J, that of the 
 left 6f inches ; while, owing to the relaxation of the ligaments about the 
 ankle-joint, a line drawn obliquely from the internal malleolus to the 
 end of the heel measured 2} inches on the left side, 2 J on the right. Two 
 years later, a similar disparity between the two limbs still existed ; the 
 measurements on the left side yielding 20, 7J, and 3 inches respectively, 
 those on the right side 22, 8 J-, and 2f inches. The arrest of growth, 
 too, had affected the foot as well as the leg, for while the right measured 
 6j inches from toe to heel, corresponding measurements of the left foot 
 yielded only 5f inches. The relaxation of the ligaments mentioned in 
 this case sometimes exists in even a much greater degree, and tends to 
 increase the deformity and to diminish the usefulness of the limb; and 
 this is generally most marked when the upper extremity is affected. 
 On three occasions I have seen the arm completely dislocated, owing 
 to long-standing paralysis, the ligaments about the shoulder-joint having 
 become so relaxed that the head of the humerus hung quite out of the 
 glenoid cavity ; and on measuring the distance from the acromion to 
 the tip of the finger in one of these cases, I found that an apparent 
 elongation of the paralyzed limb to the extent of three-quarters of an 
 inch had thus been produced. 
 
 The deformity in these cases, however, depends in the first instance 
 mainly on the weight of the paralyzed limb ; next, on the wasting of 
 the paralyzed muscles and the relaxation of the ligaments, and further 
 on the permanent contraction of some muscles when their antagonists 
 are paralyzed. In some cases of long-standing paralysis, the deformi- 
 ties thus produced are very serious indeed, while their removal con- 
 stitutes one of the greatest triumphs of orthopaedic surgery. 
 
 It must be borne in mind in estimating the gravity of paralysis in 
 infancy and childhood that the deformities just referred to are not 
 merely the occasional consequences of very serious or very protracted 
 paralysis, but that there is a tendency to their occurrence in every in- 
 stance ; and that the restoration of a very large measure of power to the 
 affected limb furnishes no guarantee against their taking place. From 
 this it follows that in every case of paralysis in infancy or childhood 
 the patient will require the most careful watching during the w T hole 
 process of recovery — a process not infrequently prolonged over several 
 years ; and this the rather, since so long as one set of muscles continues 
 feebler than another, one most influential cause of deformity of the 
 limbs is constantly in operation. But even though treatment be 
 adopted early, and continued long, it must still be owned that the pros- 
 pects of complete recovery in these cases are far from cheering. I can- 
 not indeed attempt to state the proportions in which recovery takes 
 place, still less to give a numerical estimate of the complete as opposed 
 to the partial recoveries. Whether in hospital or in private practice 
 the majority of cases come under my notice for but a short time, and 
 
ITS TREATMENT. 209 
 
 most of them are instances where either all treatment has been neglected, 
 or where the paralysis has been unusually complete, or the consequent 
 deformity unusually great. I believe therefore that more cases of in- 
 fantile paralysis get well of their own accord than my individual ex- 
 perience would have led me to suppose, and I believe further that the 
 cases of complete palsy of a limb, or of deformity, irremediable by 
 orthopaedic surgery, are less numerous. 
 
 One or two observations may be added here with reference to our 
 prognosis in this affection. A certain amount of spontaneous amend- 
 ment takes place in almost every case ; sometimes beginning within a 
 few hours after the occurrence of the paralysis, and going on to the 
 complete restoration of power in the course of a few days, or even of a 
 few hours. Between this, however, which has been termed Kennedy's 
 paralysis, and the true spinal paralysis, I know of no difference in kind, 
 only of a difference in degree ; nor do I know of any means by which 
 within the first few hours after its commencement one can tell whether 
 the affection will be temporary or abiding, beyond our knowledge of 
 the fact that the earlier the improvement commences the greater is the 
 probability of its continuance. Usually, even in the worst cases, the 
 amendment begins within a week or two, and is at first very obvious, 
 but soon goes on more slowly, and at last usually comes to a complete 
 standstill, and so continues for months or forever, if no treatment is 
 adopted, except that now the wasting of the muscles and the degenera- 
 tion of their tissue begin, and continue for an indefinite time, when they 
 too, cease to grow worse, and the child remains for life with a shrunken 
 limb, over which habit and the action of the non-paralyzed muscles at 
 length give it some degree of useful control, greater probably than one 
 might have anticipated, though the deformity still remains unremedied, 
 perhaps irremediable. 
 
 Nothing more can be needed than a knowledge of these facts to en- 
 force the necessity for the early adoption of appropriate treatment. Its 
 nature must of course vary according to the circumstances in which the 
 affection comes on, and these, as we have already seen, differ very 
 widely ; paralysis in one instance occurring during dentition ; in another, 
 following one of the eruptive fevers ; in a third, succeeding to rheu- 
 matic symptoms. There is in the majority of instances an acute stage 
 which, even when short, is generally sufficiently obvious, accompanied 
 with febrile symptoms, sometimes with marked signs of cerebral dis- 
 turbance ; in other cases with severe pains in the limbs, or with marked 
 hyperesthesia which prevents all attempts at movement.. No special 
 rules for treatment can be laid down for this stage, beyond the observ- 
 ance of absolute quiet, the use of antiphlogistic remedies, lancing the 
 gums if the attack appeared to be connected with dentition, the employ- 
 ment of sedatives to relieve suffering, and complete rest of the affected 
 limbs so long as pain is produced by any attempts at movement. A 
 time, however, comes, and generally even in the least favorable cases 
 within a few days, when every sign of acute ailment has passed away, 
 and little remains besides the loss of power to engage our notice. Some- 
 times no disorder of the general health is present, while in the majority 
 of instances in which any such ailments exist they are limited to a con- 
 
 14 
 
210 TREATMENT OF PARALYSIS. 
 
 stipated state of the bowels and a condition of general debility. Hence 
 purgatives and tonics are the internal remedies which are most usually 
 indicated, and of these the gentle aperients are more suitable than those 
 of a drastic kind : and preparations of iron and cod -liver oil are usually 
 of greater service than other tonics. There is, however, one tonic which 
 has, and not altogether undeservedly, a special reputation in cases of 
 paralysis, and that is the nux vomica, the employment of which has 
 seemed to me to have been succeeded, in many bad cases, by a rise of 
 the temperature of the limbs, and an increase in power over them. I 
 have not seen it produce those twitchings of the limbs which attend on 
 the administration of strychnine in the adult, but I have seen general 
 and rather severe convulsions come on during its employment, which 
 were followed by no evil consequences, though I cannot say they were 
 unattended with danger. But on this point I have only to repeat the 
 caution which I already gave when speaking of the employment of 
 strychnine in chorea. 
 
 Be the purely medical treatment what it may, unceasing efforts must 
 be made so soon as the exalted sensibility has passed away, to bring 
 the palsied limb once more into use, while, when the power is most 
 impaired, we must seek, by the regular employment of passive exer- 
 cise, and by friction of the limb, to prevent that wasting of the muscles 
 which is sure to follow on long-continued inaction. If the leg is 
 affected, a child who has not very long learned to walk will be taken 
 completely off its feet, while even after power has returned, quite suffi- 
 ciently to enable it to make some attempts at walking, it will be de- 
 terred from the effort by its sense of insecurity, will cry even though 
 carefully supported by its nurse, and will refuse to make the slightest 
 movement. The attempts thus evidently distressing the child are dis- 
 continued, and in the hope, too often a vain one, that in the course of 
 months the child will gain more power, much valuable time is thrown 
 away : the muscles waste, and permanent deformity of the limb results. 
 In these cases, two very simple means are often of great service in pre- 
 venting this untoward occurrence. The baby-jumper, which all infants 
 delight in, exercises the legs most effectually, while as soon as there is 
 even a very moderate return of power in the legs, the go-cart is of 
 great use, since it completely removes all sense of the risk of falling, 
 and the little one, thus convinced of its safety, soon begins to walk 
 again. The go-cart, however, has this disadvantage, that it exagger- 
 ates the disposition to lean very much forward in walking, which is 
 observable in all children even for some time after they have learned 
 to walk pretty well : and thus renders the gait very unsteady. So soon, 
 then, as the child can walk tolerably in the go-cart, it is as well to dis- 
 continue its use, either entirely or in great measure, and to substitute 
 for it the following contrivance. A little jacket, made of some stout 
 material, lined, and padded under the arm-pits, is put on the child. 
 To it are attached a couple of straps of stout webbing, one end of 
 which is fastened to the front, and the other to the back of the jacket. 
 The straps are of sufficient length to be conveniently held by the child's 
 attendant, and by means of them its weight is supported more or less 
 completely, while in walking the child is not thrown forwards as when 
 
TREATMENT OF PARALYSIS. 211 
 
 stepping in a go-cart. Feeling perfectly safe, the child now perseveres 
 in walking: many of the worst consequences of paralysis are avoided, 
 and a more speedy and more complete recovery is obtained than could 
 at first have been anticipated. If the child is old enough to be taught 
 to walk with crutches (and at five or six years old the lesson is soon 
 learned), it is desirable that as soon as possible it should be furnished 
 with them, for it will certainly make greater and surer progress if en- 
 tirely dependent on itself, than if its weight is borne, or the possibility 
 of falling prevented, by a nurse or attendant. With all this care, how- 
 ever, it is yet quite possible that some deformity of the leg may take 
 place, calling for the employment of splints or of other contrivances, or 
 even for surgical interference. 
 
 When the arm is affected, the principles just laid down are of equal 
 importance, though the mode of carrying them out must, of course, 
 differ. Passive exercise must be strictly carried out : the sound arm 
 must be tied up, either altogether or for a considerable part of the day ; 
 coaxing, bribes, and all the inducements which move a little child's 
 heart, must be brought into play as rewards for using the feeble limb. 
 Raising a weight by means of a rope passing over a pulley, is a mode 
 of exercising the arm which can be put in practice even in very young 
 children; while in those who are older, trundling a hoop with the feeble 
 arm is a capital plan for joining work and play. I need not say that 
 much care and much patience are needed in carrying out any of these 
 suggestions, and not a little of that intuitive love for children which 
 teaches those who are its possessors, how to extract fun and merriment 
 from what might in other hands be a most irksome task. 
 
 In many cases, however, something more is needed than even the 
 best directed attempts at exercising the paralyzed limb will supply, and 
 this, either from the completeness of the paralysis, or from its long 
 continuance. In these circumstances we generally find the nutrition 
 of the limb greatly impaired, its temperature very low, and its sensi- 
 bility less acute than natural. In such cases, while rubbing the limbs, 
 and other forms of passive exercise, must be most sedulously persevered 
 in, I think that I have seen benefit from the warm douche to the lower 
 limbs and the sacral region once or twice a day, when steadily con- 
 tinued for weeks together. One objection to the employment of blisters 
 is, that they of necessity preclude perseverance with the douche ; and a 
 similar objection, though not to the same extent, applies to the employ- 
 ment of stimulating liniments. In cases of this kind, however, we 
 constantly find that one remedy, though serviceable for a time, ceases 
 at length to be of benefit: so, when improvement under the douche 
 seems to be at a standstill, a stimulating liniment may be tried for a 
 season. I usually employ a croton-oil liniment, or one containing the 
 tincture of cantharides in quantity sufficient to produce a rubefacient 
 effect, but not to blister. Blisters not merely cause much distress by 
 vesicating, but have also seemed to me of more transient benefit than 
 liniments. Galvanism is another remedy from which much good is 
 often derived, but its proper application requires an expenditure of 
 time which it is not always easy to bestow, as well as a tact in its em- 
 ployment scarcely attainable except by long practice. Between the 
 
212 TREATMENT OF PARALYSIS. 
 
 results which follow the ordinary rough mode of employing galvanism 
 and its more scientific application by means of that "localized gal- 
 vanism/' for a knowledge of which we are indebted to Duchenne, 1 the 
 difference is immense, and I look forward to an increased dexterity in 
 the use of the latter as to a means by which we may remedy conditions 
 that hitherto we have been accustomed, and not without reason, to 
 regard as all but absolutely hopeless. 
 
 Of late years much has been said about the so-called Swedish Ex- 
 ercises as a means of restoring the usefulness of paralyzed limbs ; and 
 though, unfortunately, the direction of them has fallen into the hands 
 of persons not the most likely to maintain the reputation of our pro- 
 fession, we must not on that account undervalue the benefit which they 
 are capable of affording. Two principles seem involved in their em- 
 ployment, — the one, the devising of such movements as shall best bring 
 into play those muscles the power over which is deficient ; the other, 
 the calling forth the active exercise of the will in determining them. 
 Of the efficacy of the will, as a subsidiary means of restoring power to 
 the partially paralyzed limb, I have no doubt whatever. Of course in 
 the child, whose will is feeble, and liable to be distracted by very triv- 
 ial causes, this power is far less energetic than in the grown person ; 
 but still it is a power well worth cultivating, and the steady perseve- 
 rance in it exercised from childhood up to adult age will, I am sure, 
 do more towards the recovery of a paralyzed limb than would ever be 
 imagined from its casual employment on one or two occasions. 
 
 It would be useless to go into details as to all contingencies in these 
 cases, or to furnish you with rules for the management of each different 
 degree or stage of this affection. The remarks I have already made 
 will at any rate put you in possession of the principles by which your 
 conduct must generally be regulated. 2 
 
 I may just add one word with reference to cases of paralysis of the 
 portio dura. In the child, as in the adult, they usually improve very 
 
 1 For an account of his researches, as well as for most valuable practical information 
 in addition to Duchenne's own treatises, Del'Electrisation localisee, 8vo., Paris, 1861, 
 and Physiologic des Mohvements, 8vo., Paris, 1867, Dr. Reynolds's Lectures on the 
 Clinical Uses of Electricity, 8vo., London, 1871, and Dr. Tibbitt's excellent Hand- 
 book of Medical Electricity, 8vo. r London, 1873, may be recommended as con- 
 taining the best and clearest epitome of the present state of our knowledge on the 
 subject. 
 
 2 I have not spoken at all of those rare cases of paralysis which are attended by 
 fatty degeneration of the muscles, and as Cruveilhier has shown, by wasting of the 
 anterior roots of the spinal nerves ; since they are by no means confined to early 
 life, nor dependent on causes with which the patient's age has anything to do. 
 The treatise of Dr. Roberts, on Wasting Palsy, 8vo., London, 1858, and his article 
 in vol. ii of Reynolds's System of Medicine, contain a very good abstract of our 
 knowledge concerning this disease, for our first acquaintance with which we are 
 indebted to Cruveilhier. See his essay " Sur la Paralysie musculaire progressive 
 atrophique," in the Archives de Medecine for May, 1853. 
 
 Both of this and of the still rarer Pseudohypertrophic Paralysis of Duchenne, 
 cases have been under m} r observation at the Children's Hospital. The cases were 
 both typical ones, but as they would only confirm facts already noticed by others I 
 abstain from taking up space with their description, for it is so difficult, and yet so 
 important, to avoid swelling the bulk of a book in each successive edition, that I 
 feel it my duty often to omit many things which yet are neither uninteresting nor 
 unimportant. 
 
FACIAL HEMIPLEGIA. 213 
 
 much ; often, indeed, get quite well in the course of time and under 
 treatment directed to the state of the patient's general health, while, in 
 those instances in which the facial paralysis is associated with other 
 forms of infantile palsy, the muscles of the face are*almost always those 
 over which power is first regained. You must bear in mind, however, 
 the possibility of the nerve having undergone pressure from some en- 
 larged gland : and if you find reason for believing this to be the case, 
 you may apply a leech in the situation where the nerve passes out of 
 the skull. 
 
 Lastly, I may just mention, that infants are sometimes born with 
 facial hemiplegia, as the result of injury to the nerve from application 
 of the midwifery forceps, or, as has in one or two cases been observed, 
 from injury received during the passage of the head through the pelvis 
 without any instruments having been employed. Such occurences are 
 rare, but it is well that you should be aware of the possibility of their 
 being met with independent of any injury to the brain. The paralysis, 
 in these cases, generally disappears in the course of a few days or 
 weeks. 1 In the only instance of the kind which has come under my 
 own observation, the distortion of the face, though very great at birth 
 — one eye being wide open, and the corresponding side of the face 
 powerless, so that the child was unable to suck — had already greatly 
 diminished within forty-eight hours, and disappeared completely in a 
 week. 
 
 It would not be right to take leave of this class of subjects without 
 a brief reference to the occasional occurrence of hypercesthesia and neu- 
 ralgia in early life. It is certainly singular, when one considers the 
 extreme liability of infants and children to disorders of the nervous 
 system, that cases of exalted sensibility, frequent as they are in the 
 adult, should in them be so rare. Still I have met with these ailments 
 on several occasions; sometimes preceding the loss of power in limbs 
 which subsequently became paralyzed, and then almost invariably 
 lasting for only one or two days, though I have known exceptions to 
 this, and have observed a state of extreme sensitiveness of the lower 
 part of the spine and of both legs to continue for several weeks, and 
 then gradually to pass away, but leaving the power over the limbs 
 much diminished. Besides these cases, however, I have twice ob- 
 served in children during teething a state of increased sensibility of 
 the Avhole surface, but chiefly of the lower extremities, so excessive as 
 to render it almost impossible to move them for the purpose of washing 
 or dressing. For many weeks one of these children could not be moved 
 out of the horizontal position on account of the severe suffering which 
 any change of position occasioned ; while the other was thrown into an 
 agony of crying whenever its legs were touched, either to wash them 
 or to put on or take off its stockings. Both of these children, of whom 
 one was ten and the other twenty months old at the time of their 
 coming under my care, were much out of health, suffering from severe 
 
 1 See Kennedy's Observations on Apoplexy, Paralysis, &c, of New-born Infants, 
 in Dublin Journal of Med. Science, 1846 ; and Landouzy, Sur l'Hemiplegie faciale 
 cbez les Enfants nouveau-nes. 8vo., Paris, 1839. 
 
214 HYPERESTHESIA AND NEURALGIA. 
 
 odontitis, with bleeding and spongy gums, and in proportion as their 
 general condition was ameliorated, fche excessive sensitiveness lessened, 
 and in the case of the younger infant disappeared in about three 
 months. In the case of that child the symptoms had existed only 
 about a month ; in the case of the other, more than three months be- 
 fore it came under my notice. When I last heard of him, he was 2J 
 years old, greatly improved in health, having cut all his teeth, and 
 his gums having become nearly sound. His limbs had for two months 
 ceased to pain him, and he had begun to sit up for an hour at a time, 
 though he had not made any attempt to walk. In both instances, 
 iron, quinine, and the chlorate of potass were employed, with a mode- 
 rate use of wine ; and it was under this treatment that the improve- 
 ment, tardy though it was, took place. 
 
 Intense neuralgic pain, like that of tic douloureux in the grown 
 person, coming and going without apparent cause, is extremely rare in 
 childhood ; so uncommon in infancy that I do not remember ever to 
 have met with any instance of pain — severe, obstinate, recurrent — for 
 which sooner or later a distinct local cause was not found. I know, 
 however, of one instance of its occurrence in a little girl aged 10 years, 
 forcing from her shrieks of agony when the paroxysm of pain in her 
 heel came on, but final ly ceasing, and leaving behind no impairment of 
 power over the limb, no tenderness on pressure, nor any evidence 
 whatever of local disease. Her health, however, never good, grew 
 worse as she approached to womanhood, and she suffered besides from 
 all those varied ailments of the nervous system which, for want of 
 better knowledge, we commonly class under the head of* hysteria. 
 Once, too, I saw a little girl, 7 years old, in whom, after a few days of 
 what seemed like a mild attack of remittent fever, agonizing pain in 
 the head came on, with extreme intolerance of light and sound. The 
 symptoms had been regarded by some medical men who had seen her, 
 as those of tubercular meningitis, and treatment in accordance with 
 that supposition had been adopted without benefit ; but it had not 
 escaped the notice of the very intelligent practitioner who had the chief 
 charge of the child, that vomiting had not preceded nor obstinate con- 
 stipation accompanied these symptoms; that the cries were too vocifer- 
 ous, the suffering too intense, and the occasional intervals of ease too 
 complete to accord with what might be anticipated if organic disease 
 of the brain were present, while, though the treatment had aggravated 
 rather than improved her condition, no additional sign of cerebral mis- 
 chief had appeared in the course of four or five days, but pain con- 
 tinued as at first to be the only symptom. Regarding the condition 
 as neuralgic, quinine was substituted for the previous antiphlogistic 
 medicines, and the child was at once removed to Tunbridge Wells. 
 Even on the journey the pain lessened in severity, and in a few days 
 had altogether ceased, and the child rapidly regained her health. Two 
 or three cases of a similar kind have also come under my notice in the 
 Children's Hospital, and the symptoms have got better under good 
 diet, perfect quiet, and the employment of quinine. The intensity of 
 the pain, the completeness of its cessation, the persistence of the symp- 
 toms, with their non-progressive character, the absence of constipation 
 
NIGHT TERRORS. 215 
 
 or of permanent heat of head, as well as of that rapidly advancing 
 emaciation which is rarely absent when active tubercular disease is 
 going on in the brain or its membranes, will generally help us to a 
 correct diagnosis. I have on more than one occasion, when in doubt, 
 experimented for twenty-four hours with quinine, giving a full dose 
 of it every four hours, and have had the satisfaction of finding the ex- 
 periment succeed, and the symptoms which had seemed to bode such 
 ill, abate and at last disappear under its continued use. 
 
 But while cases such as the above are very uncommon, it is by no 
 means unusual for children to have attacks of headache, often of con- 
 siderable severity, and attended with temporary intolerance of light 
 and sound as the result of slight gastric disorder, or produced by slight 
 overfatigue, or overexcitement. Such attacks closely resemble the 
 sick headache, or the hysterical headache, to which delicate women are 
 liable. They come on suddenly ; they do not last above twelve or at 
 the utmost twenty-four hours, they cease spontaneously (though a mild 
 aperient or an alterative dose of mercury accelerates their departure), 
 and, except a little languor, they leave behind them no sign of indis- 
 position. Anxious parents are often solicitous about these attacks, lest 
 they should portend disease of the brain ; their very suddenness and 
 their frequent recurrence, however — circumstances which awaken the 
 alarm of non-professional persons — may serve rather to allay your 
 apprehensions when taken in connection with the speedy cessation of 
 each attack, and the absence of any abiding evidence of cerebral ailment 
 in the intervals. 1 
 
 LECTURE XYI. 
 
 Night Terrors. — Usually depend on intestinal disorder, not on primary disease of 
 the brain — Their symptoms not to be mistaken for those of incipient hydroceph- 
 alus — Sometimes continue to occur for many weeks. Treatment. 
 
 Disorders or the Mind in childhood. — Knowledge of them very imperfect — Misuse 
 of the term Cretinism. Mental peculiarities in childhood, how they are obvi- 
 ous in its disorders, which partake of nature of moral insanity, and why they 
 do so. Hypochondriasis, and Malingering in children — Illustrative cases — Sug- 
 gestions for their management. Moral Insanity — Conditions resembling it 
 sometimes arise from overexertion of mind — Casein illustration, and principles 
 of treatment. — Cases of more aggravated character, and independent of that 
 cause. Mode in which intellect becomes dulled in such cases. 
 
 Idiocy. — Difference between idiocy and backwardness, how to be distinguished from 
 ench other. Deficiency of our knowledge on the subject of idiocy — Its fre- 
 quency as a congenital condition overstated — Characteristics of idiocy in early 
 infancy and as the child grows up. Objects of education of idiots — Its difficul- 
 ties, and principles which should direct it. 
 
 It happens sometimes that a child who has gone to bed apparently 
 well, and who has slept soundly for a short time, awakes suddenly in 
 
 1 For further observation on neuralgia in childhood, I must again refer to my 
 Lumleian Lectures. 
 
216 NIGHT TERRORS. 
 
 great terror, and with a loud and piercing cry. The child will be 
 found sitting up in its bed, crying out as if in an agony of fear, " Oh dear ! 
 oh dear ! take it away ! father ! mother ! " while terror is depicted on 
 its countenance, and it does not recognize its parents, who, alarmed by 
 the shrieks, have come into its room, but seems wholly occupied with 
 the fearful impression that has aroused it from sleep. By degrees con- 
 sciousness returns ; the child now clings to its mother or its nurse, 
 sometimes wants to be taken up and carried about the room, and, by 
 degrees, sometimes in ten minutes, sometimes in half an hour, it grows 
 quiet and falls asleep. As the terror abates, the child in some instances 
 becomes quiet at once, but frequently it bursts into a fit of passionate 
 weeping, and sobs itself to rest in its mother's arms. In some instances 
 a quantity of limpid urine is voided as the fit passes off, but this occur- 
 rence is by no means constant. Usually, the remainder of the night 
 is passed in tolerably sound sleep, and the following night the child 
 may rest quite undisturbed ; or the terrors may again return, and with 
 precisely the same symptoms as before. The attack usually comes on 
 after the child has been from half an hour to a couple of hours asleep ; 
 and two attacks do not generally occur in the same night. They are 
 always more or less distinctly associated with the impression of some 
 object which occasions alarm— as a cat or dog, which is fancied to be 
 on the bed ; and this illusion continues even after the child has recog- 
 nized those who are around it. The condition is not one of delirium, 
 for the child has no other hallucinations, but the attack may return 
 night after night with precisely the same characters. The previous 
 sleep sometimes seems sound, and though often uneasy, yet talking in 
 the sleep does not usually occur, and after the child has been pacified 
 it generally sleeps heavily, perhaps till morning, or till a second usually 
 slighter attack comes on, but this scarcely ever happens until after 
 sleep has again lasted for an hour or longer. 
 
 Seizures of this kind may come on in a great variety of circum- 
 stances, and, according to the cause whence they have arisen, may 
 continue to return for many weeks together, or may occur but a few 
 times. As far as I have had the opportunity of judging, they are 
 never the indications of primary mischief in the brain, but are always 
 associated with some disturbance of the intestinal canal, and more or 
 less obvious gastric disorder. 
 
 Some years ago I saw a little boy, aged 11 months, in whom the 
 process of dentition was just beginning, and who for ten days had had 
 slight diarrhoea, with dark and slimy evacuations. He then awoke 
 one night, though before apparently sleeping soundly, with a sudden 
 start, and a scream so violent that all the people in the house heard it. 
 When taken out of bed he continued crying loudly for some minutes, 
 but by degrees grew quiet and fell asleep again, sweating profusely. 
 This sleep was as heavy as it had been before, though the eyes were 
 not always closed during it, but after an uncertain interval of from 
 half an hour to two hours he would again wake with the same loud 
 and terrified scream, and again in a few minutes sink into slumber. 
 The first of these attacks had taken place six days before the child was 
 brought to me : they were increasing in frequency, as many as seven 
 
NIGHT TERRORS. 217 
 
 or eight having occurred in the course of a single night, and even 
 during his sleep in the daytime the child was not free from them. 
 He was cheerful, however, at other times ; he sucked well, did not 
 vomit, his head was not hot, and the anterior fontanelle was depressed 
 rather than prominent; but the abdomen" was rather full, and some- 
 what tender; the gums were much swollen, and the tongue was rather 
 furred. 
 
 The gums were lanced, the child was put in a tepid bath every 
 night : a powder containing one grain of Hydr. c. Creta, and one of 
 Dover's powder, was given daily at bedtime, and 5j of castor oil every 
 morning, and the attack subsided. 
 
 Cases of this kind illustrate a point of practice which though im-" 
 portant in the adult (you will find it insisted on by Andral in his 
 Clinique Medicale), is still more so in the child. It is, that in many 
 affections of the brain there is a stage quite at the commencement in 
 which depletion may be out of place, but opiates or sedatives will 
 allay the irritation, which, if let alone, would issue in dangerous or 
 fatal congestion, or inflammation. 
 
 In the majority of cases of these night terro?*s, the condition of the 
 bowels is one of constipation, not of diarrhoea. Sometimes, after gas- 
 tric disorder has continued for a few days, in the course of which, per- 
 haps, vomiting may have occurred, an attack of this nocturnal alarm 
 may throw the parents into a state of great apprehension lest disease 
 of the brain should be impending. I have seen a very severe attack 
 of jaundice come on with these symptoms ; and in such a case it is 
 important to bear in mind the difference between the sudden, sympa- 
 thetic disturbance of the brain, and the more gradual approach of 
 tubercular meningitis with the drowsiness the child experiences, and 
 yet the difficulty it has in going to sleep, the restlessness all night 
 long, or the unquiet slumber with the moaning and starting which I 
 pointed out to you when speaking of that disease. If, then, bearing 
 in mind these facts, you find that the child who has had this attack in 
 the night yet does not complain of intolerance of light, or of much or 
 of any headache, and that Avhile the head is cool and the pulse regular, 
 the abdomen is full and hard, and perhaps slightly tender, you will 
 scarcely take the less for the more dangerous affection. 
 
 But these symptoms may last for weeks or months together, neither 
 diminishing nor much increasing in severity, so that they seem almost 
 to constitute an independent disease; a view which Dr. Hesse of 
 Altona, 1 who has written a very good pamphlet on it, is disposed to 
 take somewhat too generally. 
 
 Such a case was that of a delicate boy, 7 years old, who during the 
 previous twelve months had been cutting his first permanent molar 
 teeth, and for the whole of that time had suffered from attacks of 
 night terrors, which usually came on about half an hour after he had 
 fallen asleep. He then started up with a wild and terrified look, and 
 loud outcries, appearing not to know any one for some time, then 
 
 1 Ueber das nachtliche Aufschrecken der Kinder im Schlafe. 8vo. Altenburs;, 
 1845. 
 
218 DIS011DERS OF THE MIND IN CHILDHOOD. 
 
 begging to be taken up, and becoming pacified after being carried about 
 for half an hour in his father's arms. As the seizure passed off he 
 used to void a large quantity of limpid urine, and having fallen asleep 
 again, never but once had a second attack of it in the same night, 
 while sometimes none occurred for two or three nights together. In 
 other respects he seemed to be tolerably well, and was a lively and 
 intelligent child, though for about fourteen days before he was brought 
 to me his health had appeared less good, and there were evident indi- 
 cations of gastric disorder. I never saw this child but once again, so 
 I cannot tell you his subsequent history ; but his case affords a good 
 illustration of the occasional persistence of these symptouis for a long 
 time without the supervention of any really serious disease. 
 
 Although these symptoms may be the result of sympathetic affec- 
 tion of the brain through the medium of the abdominal viscera, still 
 you should watch a child in whom they had frequently occurred with 
 especial care, knowing that long-continued irritation of the nervous 
 centres may, under the influence of comparatively trivial causes, issue 
 in serious disease. Your chief attention, however, must be directed to 
 the removal of the disorder of the intestinal canal ; and this should be 
 attempted by gentle means — by the careful regulation of the diet, and 
 the judicious combination of aperients and tonics, rather than by dras- 
 tic purgatives. Better, too, than either opium or henbane in these 
 cases is a combination of bromide of potass and chloral as a means 
 of allaying the irritability of the nervous system, and obtaining quiet 
 sleep. The attacks usually come on in the early part of the night, so 
 that to secure sleep for the first two or three hours is an almost certain 
 prevention of a seizure. At the same time, too, it is right that the child 
 should not be left in the dark or alone; the affection resembles night- 
 mare, and in childhood dream-images seem to mingle with the waking 
 impressions much more than in adult age. A light burning brightly 
 in the room, and a familiar face meeting the child's eye at once on 
 waking, will do much towards breaking the spell and towards allaying 
 its fears. Harshness in such cases is quite out of place, and few pieces 
 of cruelty can be greater than forcing a timid little child, in whom 
 threatenings of these attacks have occurred, to go to bed in the dark, 
 or to lie there without a candle, while its active imagination conjures 
 up before its eyes, out of the bed-curtains or other objects in the room, 
 the outlines of all sorts of terrific forms. 
 
 I have noticed this affection, not merely on account of its own im- 
 portance as the occasion of much distress to the child, and sometimes 
 also of much anxiety to its parents, .but also because from it we may 
 pass by a very fit transition to the brief consideration of some other 
 forms of disorder of the highest functions of the brain in early life. 
 
 My remarks on these subjects must of necessity be very fragmentary 
 and imperfect ; so much so, indeed, that if I knew to what authors to 
 refer you for information concerning them, I should feel that, by send- 
 ing you to consult their writings, my duty w T ould be best discharged. 1 
 
 1 For further remarks on the mind in childhood, and on its disorders, see my 
 Lumleian Lectures. 
 
DISORDERS OF THE MIND IN CHILDHOOD. 219 
 
 Bat books will not help you here : and I will try to tell you the little 
 that I know, in the hope that it may at least prevent you from going 
 into practice with the impression that perversion of the intellect may 
 not occur in the child as well as in the adult ; or from supposing, if 
 you do meet with a case too striking to be overlooked, that you have 
 done all which can be expected of you in the way of diagnosis when 
 you have pronounced the child an idiot ; or all that is possible in the 
 way of treatment, when you have provided for its safe custody. 
 
 The first step towards a better knowledge of these affections was 
 taken when that form of idiocy which is endemic in certain localities, 
 and is connected with various disorders of physical development, began 
 to attract general attention. To Dr. Guggenbiihl unquestionably be- 
 longs the merit of having given the first impulse to this study by his 
 observations on cretinism. Cretinism is, however, but one of many 
 forms of disordered development of the intellect ; and there seems to 
 be some risk of our being led into error by the extension of this term 
 to a very large number of cases of idiocy occurring under conditions 
 which have but a very slight resemblance to those which induce the 
 endemic form in Alpine districts. But not only are the causes of idiocy 
 various, and the characters that it presents very different in different 
 cases, but perversion of the intellect or of the moral faculties, as dis- 
 tinguished from mere feebleness of mind, is met with in childhood as 
 w T ell as in adult age, and deserves to be regarded and to be treated as 
 insanity no less in the one case than in the other. 
 
 In the first of this course of lectures, I pointed out to you the pecu- 
 liarities impressed on the diseases of early life by the fact that child- 
 hood is a period of development. The peculiarities of the mind in 
 early life are, however, more numerous and more important than even 
 those of the body, and impart their characters to its diseases. 
 
 A child's experience is small, his ideas are few, and those are gath- 
 ered from the world around him, not from his own reflections, while 
 one impression succeeds another with greater rapidity than his feeble 
 memory can hold fast. Hence, in disorders of the mind in early life, 
 we do not meet with the distinct hallucinations, the fixed ideas, which 
 characterize insanity in the adult. But though the intellectual powers 
 are imperfectly developed, the feelings and the impulses are stronger, 
 or at least, less under control, than they become with advancing years; 
 and one great object of education is to bring them into proper subordi- 
 nation. Mental disorders, then, show themselves in the exaggeration 
 of those feelings, the uncontrollable character of those impulses ; in 
 the inability or the indisposition to listen to that advice or to be swayed 
 by those motives which govern other children. The affection, in short, 
 is of that kind to which the name of moral insanity is usually given. 
 With this state of mind, however, the child is of course less teachable 
 than others — less able to apply to any form of learning ; while fits of 
 passion or of sullenness sometimes for days together put a stop to every 
 attempt at instruction. The disorder of the moral faculties thus reacts 
 upon the intellect ; the child learns but little, and consequently grows 
 up ignorant as well as ungovernable till at length either the evidences 
 of insanity become with its advancing years unmistakable, or the 
 
220 HYPOCHONDRIASIS AND MALINGERING. 
 
 mind, growing more obtuse from long want of culture, the case sinks 
 clown into one of mischievous idiocy. 1 
 
 Now it is my belief that practitioners in general have not their at- 
 tention sufficiently alive to some of these forms of mental disorder in 
 early life. They are familiar with the idea of the idiot, as a being in- 
 capable of learning anything, unfit to take care of himself, still pleased 
 with the toys of babyhood, but with a heart as stainless and affections 
 as overflowing as the infant's. They are acquainted, too, with the 
 general characters of cretinism, where the mind and body are alike 
 dwarfed and misshapen by the influence of an unhealthy dwelling ; 
 but cases such as I have just referred to scarcely attract their notice. 
 They are passed by as anomalies, as painful instances of some extreme 
 badness, or of ungovernable temper, or of strange oddity about the 
 child, from the study of which there is nothing to be learned, and for 
 its remedy nothing to be suggested. 
 
 Many of these anomalous cases are, I believe, instances of a kind of 
 mental disorder especially liable to issue in confirmed insanity. I 
 have already assigned reasons for the opinion that affections of the 
 mind in childhood must oftener display themselves in perversion of 
 the moral faculties than in disorder of the intellectual powers ; and 
 bearing this in mind, I would always watch with close attention those 
 cases of extremely bad disposition, of unconquerable stubbornness, or 
 unmanageable fury, of which sorrowing parents sometimes tell us, 
 though with but little hope of our suggesting anything that may 
 remove or mitigate their bitter grief. 
 
 One of the least serious, though by no means of the least puzzling 
 of these perversions of the moral faculties in childhood, is the disposi- 
 tion occasionally noticed to exaggerate some real ailment, or to com- 
 plain of some ailment which is altogether imaginary. It is difficult to 
 assign any sufficient reason for this conduct, mere indolence seems 
 sometimes to be the chief motive for it, oftener vanity; the sense of 
 importance in finding everything in the household arranged with ex- 
 clusive reference to itself appears to have led to it — a feeling which 
 may sometimes be observed to be very powerful even at an exceedingly 
 early age. In many instances a morbid craving for sympathy is 
 mingled with the love of importance, and both these sentiments are 
 not infrequently gratified and exaggerated by the conduct of a foolishly 
 fond mother. Seal illness, however, in almost all of these cases 
 exists at the commencement, though the child persists in complaining 
 of its old symptoms long after their cause has disappeared. 
 
 I met some years since with a case which illustrates these remarks 
 extremely well. A lad, aged 13, whose family were not very healthy, 
 and who himself had at no period been robust, fell ill nine months be- 
 fore I saw him, with headache and other vague cerebral symptoms ; 
 
 1 My remarks refer to those slighter forms of mental unsoundness which present 
 themselves to the notice of the ordinary practitioner. The subject of insanity in 
 early life will be found specially noticed by Dr. Conolly in Medical Times, March 
 and April, 1852; and bv Brierre de Boismont, Annales d'Hygiene, 2d Series, 
 vol. x, 1858, p. 362. 
 
CASES OF MALINGERING. 221 
 
 his illness having apparently been brought on by grief at the death of 
 a fayorite sister. This sister, too, had died of some disease of the 
 brain, as had two other members of the family previously, and the anx- 
 iety about himself, which a knowledge of these facts naturally excited, 
 was still further increased by his mother's desponding tone, and by the 
 anxiety expressed by her in his hearing lest he should likewise fall a 
 victim to the same disease. 
 
 From the very commencement his symptoms had presented a nearly 
 uniform character, and had varied but little in intensity. They con- 
 sisted of headache, with extreme sensibility to sound, even more than 
 to light, so that if an organ was played in the street he would some- 
 times rush into another room, and bury his head in a pillow to be out 
 of hearing of the noise. Coupled with this, there was extreme sensitive- 
 ness of the scalp and of the hair ; for several months he had not al- 
 lowed his hair to be brushed, combed, or washed, but this sensibility 
 did not extend to the face or the spine. 
 
 The boy's appetite was very bad : he not infrequently suffered pain 
 after eating, and for some four months had complained of pain and 
 tenderness in the right hypochondriac and iliac regions ; his bowels 
 were constipated, his urine scanty, with considerable deposits of lithates, 
 and occasional pain in voiding it ; and erection of the penis sometimes 
 took place during the act" of micturition. 
 
 The boy was rather small for his age, ill-nourished but not emaciated, 
 his upper lip slightly swollen, his abdomen soft and not at all full, and 
 though he said that he had pain in the right hypochondrium, yet the 
 abdomen was quite as soft there as elsewhere. His pulse was about 
 113, and very feeble; his tongue moist, slightly coated; respiration was 
 quite good in both lungs. 
 
 As he came into the room the lad stopped ; he walked feebly and 
 with a slouching gait : but seated himself opposite the light without 
 any apparent discomfort, and answered questions intelligently, though 
 his speech was a little thick and hesitating ; and there were slight 
 twitchings of his face as he talked. 
 
 The question raised in this case was, whether the symptoms which 
 I have just enumerated did or did not depend upon organic disease of 
 the brain. I believed that no disease existed ; for in spite of the long 
 continuance of the symptoms, the boy was confessedly no worse than 
 he had been many months before. Moreover, the absence of any fit, 
 of any paralytic affection, or of impaired power over any limb ; the 
 fact that vomiting had never occurred, and that the pulse presented no 
 other character than that of extreme feebleness, negatived, in my opin- 
 ion, the supposition that disease of the brain existed. Besides, though 
 he complained of so much tenderness of the scalp that the slightest 
 touch of his hair caused extreme distress, yet on several occasions, when 
 the hand had been laid gently on his head without his being aware of 
 it, he made no complaint till he saw the hand. His father also said 
 that he walked better when not noticed than when he was aware of any 
 one's presence ; that though he was unable to read, he yet was very 
 fond of playing at cards; and that of an evening, when so occupied, he 
 often seemed quite cheerful and like other children ; and moreover, his 
 
222 CASES OF MALINGERING. 
 
 sleep at night was in general tolerably good. In these circumstances — 
 the intervals of ease, the quiet sleep, the manifest influence of notice in 
 increasing his ailments, and of amusement in removing them — there 
 seemed to be further and conclusive reasons against the supposition 
 that the symptoms depended on organic cerebral disease. 
 
 Treatment of various kinds having been long pursued without any 
 benefit, I recommended the complete discontinuance of all medicines 
 with the exception of the cod-liver oil, to which the boy showed no 
 repugnance, while the very imperfect manner in which he was nourished 
 seemed to furnish a good reason for its employment. His health 
 having previously somewhat improved at the seaside, I advised that 
 he should go thither again, but to a fresh place, and unaccompanied by 
 his mother; that while there all obvious reference to his head, either 
 in general management or medical treatment, should be sedulously 
 avoided, while an endeavor should be made, by fresh occupation and 
 fresh amusements, to turn his thoughts into a. new channel. 
 
 This advice was not completely carried out, for an appearance of 
 medical treatment was still kept up, though no active remedies were 
 any longer employed. The boy, however, was sent to the seaside, and 
 without his mother; and three months after, I heard of him as being 
 in no respect worse, and in many better, than when I saw him ; and 
 eventually he perfectly recovered. 
 
 Another case of a somewhat similar kind may also deserve a brief 
 notice. A little girl, aged 10J years, whose mother, though a woman 
 of considerable talent, had shown many peculiarities of character, came 
 under my care on account of attacks of headache of the most intense 
 severity. She had suffered from convulsions when 18 months old, and 
 a slight illness at the age of 3 was attended by their return. When 6 
 years old, she began to suffer from a peculiar spasmodic cough, suc- 
 ceeded in the course of some months by considerable tenderness of the 
 epigastrium. During the course of treatment for these ailments, she 
 began to experience attacks of headache, which, from the age of 8 years 
 until the time of her coming under my care, were reported to have re- 
 turned frequently and without cause. Apparently nothing could be 
 more arbitrary than the occurrence of these headaches ; present at one 
 time with excruciating severity, absent at another for weeks together. 
 A constipated state of the bowels, and a capricious appetite, were the 
 only abiding symptoms of ill-health which existed: but there did seem 
 to be some connection between her occasional residence in a damp situa- 
 tion, and an increase in the frequency and intensity of her headaches. 
 
 The first time that I saw her, her countenance was anxious and ex- 
 pressive of intense suffering. She sat with her hand to her head, cry- 
 ing out vociferously, and asserting her inability to move from one room 
 to another ; though on being told decidedly that she must walk, she 
 at once rose from the chair where she was crouching, and walked easily 
 and firmly into another apartment. The child's pulse was rather fee- 
 ble, but otherwise natural ; her tongue a little coated, but there were 
 no symptoms of serious illness about her. Sometimes she lay all night 
 grievously complaining of headache ; sometimes she slept well, and 
 her sleep was usually more sound if she took some stimulant at bed- 
 
CASES OF MALINGERING. 223 
 
 time. Accompanying the complaints of headache, there was a loss of 
 interest in all childish pursuits, a waywardness and irritability quite 
 unnatural in a girl of her age ; and though now and then roused by 
 some occurrence which interested her, she soon relapsed into her former 
 condition. Sometimes she would rise before six o'clock in the mora- 
 ine, and go for a walk with her maid ; while at other times she would 
 lie in bed till a late hour. Her appetite was never large, but there 
 were times when she took food moderately well ; while at others she 
 rejected it; and at last absolutely refused to feed herself; so that it 
 became necessary to feed her like an infant. She clung to her mother 
 during the whole of this time with the most exaggerated protestations 
 of affection, but it was obvious that her complaints were always louder 
 and more constant in her mother's presence ; and when accidental cir- 
 cumstances took her mother for a few days from home, there was a 
 marked improvement in the child's condition. If I came into the 
 room unexpectedly, the child was often found at cheerful play ; but 
 the moment she perceived me, her hand was reapplied to her head, and 
 her moan recommenced. Treatment of the most different kinds had 
 been tried for years ; the mother's conviction in the existence of some 
 very serious disease was strengthened by the inutility of medicine, and 
 her sympathy with her child, and lamentations over her sufferings, 
 were often expressed in the child's presence. My opinion that no seri- 
 ous disease existed, that the complaints were exaggerated, that the 
 mind needed discipline more than the body did medicine, that the 
 child's cure would be difficult, if not impossible, so long as she re- 
 mained with her mother, was unpalatable, and was considered unkind. 
 To turn the attention into new channels ; to lay aside ordinary tasks, 
 such as hitherto, when apparently well enough to engage in them, she 
 was set to ; to give her the charge of live animals, and to endeavor, by 
 teaching her something of their habits, or something of plants and 
 flowers, which a country residence would have rendered easy — did not 
 seem to be the rules that a doctor was expected to give. Physic was 
 what the mother came to me for, and as I could not undertake the 
 child's cure by drugs, she was soon removed from under my care. 
 She returned home, and in a few days well-marked globus hystericus 
 was added to her other symptoms ; she next had general convulsions, 
 though not accompanied by complete loss of consciousness, then hys- 
 terical dysphagia, during the continuance of which she was nourished 
 chiefly by enemata of beef tea; and at last these symptoms assumed 
 the character of complete hydrophobia : the appearance of water in a 
 cup caused her to shudder, and the attempt to swallow any fluid pro- 
 duced an attack of general convulsions. This condition lasted for 
 several clays ; by degrees its worst features subsided, the child regained 
 health, and six months afterwards, when I heard of her, she was gal- 
 loping about the country on her pony, and cured for the present of all 
 her ills. 
 
 Now in cases of this description, and in others of a similar kind 
 which have come under my notice, it is much less the state of the body 
 than that of the mind which excites my apprehension. The constant 
 watching its own sensations, the habit of constantly gratifying every 
 
224 DISORDER OF MIND FROM OVERWORK. 
 
 wayward wish and temper under the plea of illness, and the constant 
 indulgence which it meets with in this from a mother's overkindness, 
 exert a most injurious influence on the child's character, and it grows 
 up a juvenile hypochondriac. It is well to be on our guard against 
 the possibility of this occurrence in all the more protracted diseases of 
 childhood; to warn the parents of it, in order that they may join with 
 us in the endeavor to keep the child's mind healthy during the long 
 illness of its body. It is but seldom that this condition comes to be so 
 marked as in the cases which I have related, without very injudicious 
 management on the part of the parents or friends. In such circum- 
 stances we often find it necessary to use great caution in conveying to 
 their minds the suspicion which we entertain, and the expression of 
 which they will be disposed to regard as a most unkind and unfounded 
 libel on the child. 
 
 Another phase of mental disorder in childhood sometimes presents 
 itself to us as the result of overtasking the intellectual powers. This 
 overwork, too, is by no means in all cases due to the parents unwisely 
 urging the child forward, but is often quite voluntary on its part. 
 Sometimes, too, the friends of the child are so alive to this risk, that 
 they limit the hours of work — a precaution which nevertheless often 
 proves inadequate, from the want of some due provision for turning 
 the thoughts and energies during play hours into some perfectly differ- 
 ent channel. 
 
 In many of these cases nature happily takes matters into her own 
 management. For a year or two, or more, the mind has grown appar- 
 ently at the expense of the body ; the parents take a fearful joy in 
 their darling's acquirements ; and if it should but live, think they, of 
 what remarkable talents will it not be the possessor ! By degrees, the 
 extreme quickness of intellect becomes less remarkable ; but the body • 
 begins to increase in robustness; and a year will sometimes suffice to 
 transmute the little fairy, so quick, so clever, but so fragile, into a very 
 commonplace, merry, rosy, romping child. I may add, that it is well 
 to bear in mind the converse of this ; to remember that body and mind 
 rarely grow in equal proportion at one time ; that the incorrigible little 
 dunce, though not likely to prove a genius as he grows older, will yet 
 very probably be found at twelve or fourteen to know as much as his 
 playmates. A dull mind and a sickly or ill-developed frame, may 
 make us anxious ; but if the physical development is good, the mind 
 will not be likely to remain long below the average standard. 
 
 But sometimes the overtasked mind leads to mischief which nature 
 cannot rectify ; an attack of cerebral inflammation comes on — often 
 partakes of a tuberculous character, and destroys the patient ; or if 
 not, the child sinks under almost any accidental disease. In other in- 
 stances, however, neither of these results takes place, but the whole 
 nervous system seems profoundly shaken, and the moral character of 
 the child seriously, and even permanently, injured. 
 
 A little girl, of whom her mother gave me the following history, 
 came under my notice when seven years old. Never very robust, but 
 quick and clever, her governess took pleasure in urging her forward, 
 though never at the expense of what was supposed to be sufficient rest 
 
MORAL INSANITY. 225 
 
 from study, and amusement suited to her years. However, when 5£ 
 years old, the first signs of overtaxed brain appeared in frequent ex- 
 treme irritability, and occasional causeless attacks of fury, amounting 
 almost to madness. A few weeks after the commencement of these 
 svmptoms, the child began to suffer from chorea, affecting both sides 
 of the body, though not severely ; and at the same time she occasionally 
 stumbled, and even fell when walking, though not from the violence 
 of the spasmodic movements ; and made complaints of frequent head- 
 aches, which were attended with great heat of head. 
 
 The chorea disappeared, the child improved altogether, though still 
 having occasional headaches, and retaining much irritability of manner.. 
 Her improvement took place during a quiet residence at the seacoast, 
 and a return to London was followed by an attack of influenza and an 
 aggravation of her symptoms, with the exception of the chorea, which 
 did not return. Revisiting the country, she once more improved, but 
 the return to London, and the resumption of her education, even in 
 the most careful manner, were followed by increased headache and 
 more ungovernable temper ; and it was in these circumstances that she 
 came under my observation. 
 
 She was a fair-haired, delicate-looking child ; but with the exception 
 of slight contraction of the left orbicularis palpebrarum muscle, there 
 was nothing remarkable in her appearance. Her pulse was rather 
 feeble ; and her mother stated that she was soon tired, and that every day 
 she needed quiet rest upon a sofa for a couple of hours. Occasionally, 
 whether at work or play, she would be attacked with very severe head- 
 ache, which never lasted for more than a few minutes, but during its 
 continuance incapacitated her, by its intensity, for anything. Equally 
 sudden, and almost equally causeless, were the attacks of fury which 
 she now and then manifested, and which a word, a look, or her favor- 
 ite companion entering a room before her, or stepping before her up 
 the stairs, would suffice to bring on. At one time she had vented 
 her anger in blows ; but though she did not now strike those who 
 offended her, she would burst forth into the most violently abusive 
 language, though seldom uttering above a sentence or two. Sometimes 
 she denied, and her mother believed with truth, that she knew what 
 she had said ; at other times she seemed aware of it, and throwing her 
 arms round the person whom she had so addressed, would express her 
 sorrow, and beg to be forgiven. There was still some disposition to 
 fall when walking, though nothing like a fit had ever been observed ; 
 and if anything was given to her to hold or to carry, she would not 
 infrequently let it fall. The child's general disposition was amiable ; 
 she was very intelligent in her manner, but was morbidly solicitous 
 about her health, and disposed to exaggerate every ailment — a dispo- 
 sition, however, which had been most judiciously controlled by her 
 mother. 
 
 In this case, while conceding the possibility that the occasional 
 stumbling in her walk might be the prelude of epilepsy, and that the 
 fits of fury might issue in abiding disorder of the mind, I yet was dis- 
 posed to entertain a more favorable prognosis — and this, founded in no 
 
 15 
 
226 MORAL INSANITY. 
 
 slight degree on the great good sense with which the child's mother 
 recognized these dangers, and applied herself to guard against them. 
 
 As the return to her previous pursuits, even though attempted with 
 the greatest care, was followed on each occasion by a deterioration in 
 the child's condition, I advised that for a time they should be com- 
 pletely laid aside; that she should go into the country; that for French, 
 and music, and history, should be substituted botany, the keeping and 
 managing of pet animals, the studying their habits, and all that class 
 of quiet occupations which the country offers, especially to those whose 
 friends, as was the case with this little girl, have the intelligence to 
 derive from them the full measure of advantage which they can be 
 made to yield. 
 
 I believe the recognition of the real danger, and the adoption of a 
 proper plan of management, to be of the greatest possible importance 
 in these cases; and yet the doing so is often attended with great diffi- 
 culty. Not merely is the danger at which we hint so fearful, but the 
 idea of permanent disorder of the mind occurring in childhood seems 
 to the parents so strange, even so improbable, that they are disposed 
 too often to think the risk an imaginary one, and to reject the counsel 
 which we offer concerning the best manner of its avoidance. More- 
 over, the recommendation, which I believe to be a sound one, that in 
 almost all of these cases the child should be separated from its parents, 
 while it adds to their distress, diminishes at the same time the proba- 
 bilities of their compliance. I am certain, however, that the parents 
 are very rarely the best persons to carry out the management of the 
 child ; often, that they are the very worst to whom it could be intrust- 
 ed. The very motives which, in the proper relation between parent 
 and child, are the most cogent to induce the latter's obedience, are not 
 of a kind to be exposed to the wayward caprices of that child when its 
 moral faculty is perverted. With the most undeviating kindness, 
 there is yet necessary in the management of such a patient a complete 
 impassibility, if I may use the word. " You grieve me," "You make 
 me sad by this or that conduct, by this wilfulness, or this fit of fury," 
 is in these cases too often but an announcement to the child of a never- 
 failing mode of annoying those whom he may wish to vex, and the 
 discovery of this power is alone sufficient to weaken their authority 
 and control. Moreover, the steady undeviating pursuit of a cer- 
 tain plan for weeks, or months, can scarcely be intrusted with safety to 
 persons so deeply interested in its issue, so apt prematurely to rejoice in 
 its success, and to diminish their precautions, or equally prematurely to 
 despair of benefit, and therefore to relax in their vigilance, as the 
 parents of the suffering child. Besides all the thousand recollections 
 of infancy, which link together parents and children, instead of 
 strengthening, do but fetter their hands if they undertake this office. 
 
 I should not have thought it necessary to add, that a school is not 
 the place for such children, if I had not sometimes known them to be 
 sent thither, under the vain expectation that the society of other chil- 
 dren would amuse, and the necessary regulations of the place would con- 
 trol and amend them. Ordinary school discipline, however, is intoler- 
 able to them ; occasions of anger constantly abound there, while the 
 
CASES ILLUSTRATIVE OF INSANITY IN CHILDHOOD. 227- 
 
 frequent outbreaks of fury, characteristic of this condition, can neither 
 be passed over without notice, nor subjected to controlling influence of 
 the proper kind. 
 
 The houses of those who receive imbecile and idiot children are, 
 however, not fit places for this class of patients. Their intellect is 
 active enough : they are revolted by the stupidity of those around them, 
 and find a mischievous pleasure in tormenting and annoying them, while 
 no rules can be laid down suited for the management of cases so differ- 
 ent as the idiotic and the insane. I believe that children in this con- 
 dition do best as the only inmates of a quiet family, under the constant 
 control and supervision of some person competent to enter into their 
 pursuits, and to share their pleasures ; to whom they may become at- 
 tached, but whose relation to them will not be so intimate as to place 
 it in their power, even when most wayward, to cause serious vexation 
 or distress. At intervals, as the child improves, it may be allowed to 
 associate with other children ; at first in their play, as in dancing, for 
 instance, or in some out of doors amusement — afterwards at other times, 
 and with fewer restrictions ; but a course of education, apart from other 
 children, different in its manner and its objects is, I am sure, desirable 
 till the mind has quite recovered its balance, and the power of self- 
 control has been developed and strengthened. 
 
 The cases that I have hitherto related were instances of only the 
 slightest degrees of a condition which, if not remedied, may pass into 
 confirmed insanity. I believe the gradations to be almost impercepti- 
 ble by which the one state passes into the other, and I know of some 
 cases in which the ungovernable temper and occasional fury of the 
 child have changed after puberty to complete mania, which rendered 
 the patient the inmate, and, I fear, the permanent inmate, of a lunatic 
 asylum. 
 
 One more history I may add, to show some of the steps by wdiich 
 the change from bad to worse takes place. A girl, 12 years old, an 
 only daughter, pretty, clever, but very vain and very fond of dress, 
 the object of her parents' cloating fondness, which she returned with 
 equal affection, was urged by the love of display, and the desire of 
 praise, beyond her powers. She grew w T ilful, unmanageable, ungov- 
 ernably passionate ; but in spite of this, her expressions of attachment 
 to her mother became stronger and stronger, and on the occasion of 
 her mother's illness it was almost impossible to keep her from the 
 sick-room ; and she gave way to fits of fury if ever of necessity denied 
 admittance. 
 
 She was now, by medical advice, sent to school, in spite of her most 
 earnest entreaties to the contrary. She remained there two months, 
 during which time she had been extremely unhappy, and returned 
 decidedly worse. The first indication that she showed of positive in- 
 sanity consisted in lacing her stays as tight as possible over her abdo- 
 men, and in tying a handkerchief tight round her body for the same 
 purpose. For this she assigned no reason, but became furious if pre- 
 vented from accomplishing this purpose. Soon afterwards she had 
 another delusion with reference to the state of her bowels, which she 
 
228 CASES ILLUSTRATIVE OF INSANITY IN CHILDHOOD. 
 
 was always trying to relieve, spending sometimes several hours to- 
 gether running up and down stairs to and from the water-closet. 
 
 Under a very partial adoption of a plan such as I have mentioned, 
 combined with due attention to the state of her levels, which were 
 very constipated, considerable improvement took place, and continued 
 for nearly a year. By degrees, however, the ungovernable temper 
 returned, the child's paroxysms of rage became frightful in their vio- 
 lence, and lasted sometimes for hours' together, and the desire to be per- 
 petually on the water-closet became as strong as ever. In this condi- 
 tion, about two years from the date of her first showing signs of mental 
 disorder, she died; but of what disease, or, in what special circum- 
 stances, I am unable to tell. 
 
 But it is not only in these circumstances that moral insanity pre- 
 sents itself to us in children. Mental disorder in childhood seems, as 
 I have already stated, almost invariably to assume this character, 
 whatever be the condition in connection with which it comes on. 
 
 I once saw a little girl, six years old, who from the age of one year 
 had been subject to fits of an epileptic character, which sometimes were 
 severe, and lasted for several hours, but did not seem to exercise any 
 abiding influence on her general health. They recurred at uncertain 
 intervals of from two to seven months, and though sometimes ap- 
 parently induced by sudden alarm, often came on independent of any 
 obvious exciting cause. But besides the fits, there were some mental 
 peculiarities about the child which excited her parents' apprehension, 
 and the more so, since the older she grew the naore striking did they 
 become. 
 
 When I saw her she was a tall, fair-haired, blue-eyed child, and the 
 abiding expression of her countenance was pleasant. She walked 
 awkwardly, however, with her head very much bent down ; and when 
 she stood, she kept up an almost unceasing mechanical movement of 
 her hands up and down the front of her dress, or tossed them about 
 not unlike a child with chorea, except that the movements were less 
 violent. Her manner was tolerably intelligent, indeed not without a 
 certain precocious shrewdness, but she laughed once or twice unmean- 
 ingly, and on my refusing to give her a toy to keep, which she had 
 amused herself by playing with, she at once struck me. 
 
 She was decidedly backward in knowledge as compared with other 
 children; but owing to her condition, had never been taught much. 
 Her parents said that she was quick if she could be induced to apply, 
 but that she would never apply to anything for more than a few min- 
 utes. She was said to show a fondness for music ; and, though unable 
 to write, it was a favorite amusement with her to scribble over paper 
 in imitation of the writing of her elder sisters. 
 
 In disposition she was said to be either an angel or a demon ; though 
 fond of her sisters, she would strike them on the slightest provocation, 
 and she had occasional fits of most ungovernable fury. 
 
 The advice which I gave with reference to the management of this 
 child was similar to that which I have already given you. It was 
 partially adopted, and with some improvement in her condition, though 
 I do not know what was its ultimate issue. My object in relating the 
 
DISTINCTION BETWEEN BACKWARDNESS AND IDIOCY. 229 
 
 case, was to add another illustration to those already given, of the 
 peculiar character which disorder of the mind assumes in early life, 
 and of the differences between it and mere idiocy or feebleness of in- 
 tellect. The earlier these symptoms manifest themselves, and the more 
 aggravated their form, the greater will be their influence on the intel- 
 lectual powers, and the more completely will they interfere with the 
 education of the child, who may in consequence sink in the course of 
 time as low in intelligence as the most hopeless idiot. 
 
 Idiocy is unquestionably of much more frequent occurrence in child- 
 hood than are those affections of the mind which have hitherto engaged 
 our attention. The term idiocy, however, is a very wide one, includ- 
 ino; conditions differing remarkablv from each other, both in kind and 
 in degree, while not seldom it is misapplied to cases in which there is 
 mere backwardness of the intellectual powers. 
 
 Backward children — enfants arrieres, as the French call them — con- 
 stitute a class by no means seldom met with. They generally attain 
 their bodily development slowly, and the development of their mind is 
 equally tardy. They cut their teeth late, walk late, talk late, are slow 
 in learning to dress and to wash themselves, are generally dull in their 
 perceptions, and do not lay aside the habits of infancy till far advanced 
 in childhood. When the time comes for positive instruction, their 
 slowness almost wears out every one's patience ; and among the poor 
 indeed, the attempt at teaching snch children is at length given up in 
 despair, and, growing up in absolute ignorance, it is no wonder that 
 they should be regarded as idiots. Still, dull as such children may be, 
 and duller still they must needs become if allowed to grow up untaught 
 to manhood, there is a difference between them and idiots, and one 
 which I cannot better describe than in the words of M. S^guin, 1 who 
 has both written and worked so well on this very subject. 
 
 " The idiot," says he, " even in the slightest degree of the affection, 
 presents an arrest of development both of body and mind ; the back- 
 ward child does not remain stationary, but his development goes on 
 more slowly than that of other children at his age • he is behind them 
 in the whole course of their progress, and his delay, increasing every 
 day, places at length an enormous distance between them — a distance 
 which, in fact, is insurmountable." 
 
 In some of its minor degrees even, this backwardness not infrequently 
 excites the solicitude of parents. I have observed it in children who 
 had been ill-nourished in infancy, or who had been weakened by some 
 serious and protracted illness, even though unattended by any special 
 affection of the brain ; but I have also observed it in other instances in- 
 dependent of any such cause. Be the history, however, what it may, 
 the ground on which you rest your opinion that the case is not one of 
 idiocy is this, — that though, at four years old, the child may not seem 
 to be intellectually superior to most children at two, yet in manners, 
 habits, and intelligence it does agree with what might be expected from 
 the child at two ; less bright perhaps, less joyous, but still presenting 
 
 1 Traitement Moral, &c, des Idiots, p. 72, 12mo., Paris, 1846. 
 
230 DISTINCTION BETWEEN BACKWARDNESS AND IDIOCY. 
 
 nothing which, if it were but younger, would awaken your appre- 
 hension. 
 
 It is well, in all cases of unusual backwardness, to ascertain the con- 
 dition of the sense of hearing, and of the power of speech ; for I have 
 known the existence of deafness long overlooked, and the child's dul- 
 ness and inability to speak referred erroneously to intellectual deficiency ; 
 and have also observed mere difficulty of articulation, partly dependent 
 on malformation of the mouth, lead to a similar misapprehension. In 
 both the instances referred to, the complete inability to keep up inter- 
 course with other children, or the great difficulty in the attempt, had 
 cast a shadow over the mind ; and the little ones were dull, suspicious, 
 unchildlike. A similar effect is not infrequently produced by serious 
 illness, even after the time of infancy is passed. The child will for 
 months cease to walk, or forget to talk, if these had been but compara- 
 tively recent acquirements ; or will continue dull, and unequal to any 
 mental effort, for weeks or months together, and then the mind will 
 begin to develop itself once more, though slowly ; possibly so slowly as 
 never altogether to make up for lost ground. 
 
 In idiocy, 1 however, there is much more than this ; more even than 
 the mere arrest of the intellect at any period. The idiot of eight years 
 old does not correspond in his mental development to the child at six, 
 or four, or two ; his mind is not only dwarfed, but deformed ; while 
 feebleness of will is often as remarkable as mere deficiency of power of 
 apprehension. Numerous questions suggest themselves to us with 
 reference to this subject ; to many of which I can attempt no answer 
 whatever, to none of which can I return anything like a satisfactory 
 reply. The causes of idiocy, the influence which our knowledge of 
 them should exercise on our prognosis, the relations of epilepsy and of 
 paralysis to it, and the extent to which their existence should modify 
 our opinions, are only some among several very important questions 
 to which I can do no more than refer as requiring elucidation. 
 
 Down to the present time, the only systematic attempt with which 
 I am acquainted to collect and arrange information on the subject of 
 idiocy, is that which has been made by Dr. Howe, of Boston, by 
 authority of the legislature of Massachusetts. 2 Valuable, however, as 
 such an inquiry is in many points of view, its results can never yield 
 more than mere approximations to truth, and cannot be regarded as 
 positive medical facts. For instance, Dr. Howe states, 3 as the result 
 of his inquiries, that in 420 out of 574 cases the condition of idiocy 
 was congenita] ; but these numbers, if received as absolutely correct, 
 would, I am sure, lead to a very considerable overestimate of the fre- 
 quency of congenital idiocy ; and it is admitted, indeed, that all cases 
 have been classed as congenital in which the affection dated from in- 
 
 1 It is almost needless to observe, that idiocy is here spoken of independent of 
 that peculiar variety, endemic in certain localities, and which, under the name of 
 cretinism, has attracted so much attention of late years, and has been the subject of 
 several reports, both to the Sardinian, Austrian, and Swiss Governments. 
 
 2 Eeport made to the Legislature of Massachusetts upon Idiocy, by S. G. Howe, 
 Chairman of the State Commission, 8vo., Boston, 1848. 
 
 3 See pp. 57 and 95 of the Eeport. 
 
CHARACTERS OF IDIOCY. 231 
 
 fancy, or early childhood. It is quite certain that a very large num- 
 ber of cases of idiocy date from early infancy ; but a sense of hopeless- 
 ness attaches to congenital disease, which renders it very desirable that 
 this impression should not be adopted hastily ; and, though my opinion 
 is necessarily founded on a comparatively small number of cases, I must 
 nevertheless express my decided conviction that instances of really 
 congenital idiocy actually form a minority of the cases of that con- 
 dition. 
 
 The distinct evidence, however, of the really congenital character of 
 idiocy is not by any means sufficient ground for regarding a case as 
 absolutely hopeless, so far as obtaining a very considerable ameliora- 
 tion of the patient's condition is concerned ; and no one who saw the 
 children that were exhibited years ago in London, as Aztecs, need 
 despair of being able to teach much even to those whose cerebral con- 
 formation is most imperfect. The history most commonly obtained 
 on closely questioning the relations of idiot children, is to the effect 
 that their health having been good up to a certain period, which 
 usually falls within the first year of life, they then had one or more 
 fits, or perhaps a succession of them, recurring at uncertain intervals 
 for one, two, or three years, or even becoming habitual ; and that 
 from this date their mental development was retarded in all respects, 
 completely arrested in some ; while the signs of idiocy have since then 
 become more marked with each succeeding year. The cessation of 
 these fits, even though once very frequent, does not seem to be by any 
 means generally followed by improvement in the patient's condition ; 
 nor, as far as I know, are epileptic idiots, even when the fits date from 
 a very early period, those whose intellectual powers are by any means 
 invariably the loAvest. This, however, is but one of the modes in 
 which idiocy comes on ; in other instances there is no point in the 
 child's history which can be laid hold of as marking the commence- 
 ment of this condition ; but as the body grew the mind remained sta- 
 tionary, till by degrees the painful conviction that it was an idiot 
 forced itself on the friends ; while, again, in other cases some serious 
 cerebral disease which threatened life at two, three, or four years old, 
 or later, has left the mind permanently obscured and weakened. 
 
 Even in earliest infancy there is usually a something in the idiot 
 child which marks him as different from babies of his own age. He 
 is unable to support his head, w T hich rolls about from side to side 
 almost without an effort on his part to prevent it ; and this often awak- 
 ens a mother's anxiety long before any other circumstance has excited 
 her apprehension. Next it is perceived that the child does not notice ; 
 that his eye does not meet his mother's with the fond look of recogni- 
 tion, accompanied with the dimpling smile, with which the infant, 
 even of three months old, greets its mother. Then it is found to have 
 no notion of grasping anything, though that is usually almost the first 
 accomplishment of babyhood ; if tossed in its nurse's arms there seems 
 to be no spring in its limbs ; and though a strange, vacant smile some- 
 times passes over its face, yet the merry ringing laugh of infancy, or 
 the joyous chuckle of irrepressible glee, is not heard. As time passes 
 on, the child shows no pleasure at being put down — " to feel its feet," 
 
232 MENTAL FACULTIES OF IDIOTS. 
 
 as nurses term it ; if kid on the floor, probably it cries, but does not 
 attempt to turn round, nor try to crawl about, as other babies do. If 
 it learns to stand or walk, it does not do so till late, and then stands 
 awkwardly and walks with difficulty, while not infrequently the power 
 of the adductor muscles of the thigh so predominates in the feeble 
 limbs, that the legs are crossed immediately on the child assuming the 
 erect posture ; and this infirmity may continue for years. The teeth 
 are cut late; often they appear irregularly, and out of their usual 
 order ; not infrequently the incisors begin to decay even before the 
 molar teeth have made their appearance; while the excessive secretion 
 of the salivary glands, and the constant dribbling of the saliva, are a 
 very frequent and very loathsome characteristic of many idiot children. 
 
 Disorder of the process of dentition is often one of the earliest in- 
 dications of deranged physical development which we meet with in the 
 idiot. The jaws do not grow in proportion as the teeth appear ; and 
 generally a high roof to the mouth, narrow jaws, and crowded teeth, 
 are met with in these cases. Growth everywhere goes on but slowly ; 
 and in spite of the aspect of premature old age which his face often pre- 
 sents, were Ave to judge from the height and size and general conforma- 
 tion of the idiot, we should imagine him to be some years younger than 
 his real age. 1 Just as the idiot is slow to notice, slow in learning to 
 grasp any object in his hands, or to stand or walk, so he is late in learn- 
 ing to talk : often* acquires but few words, and those with difficulty, 
 often using the same to express many different ideas, generally articula- 
 ting them indistinctly — often, indeed, so imperfectly as to be almost 
 unintelligible. 
 
 There is a class of idiots who make no progress, who remain all their 
 lives below the level of the brute; but the majority more or less slowly 
 and painfully make such advances as I have described ; and then with 
 each succeeding year the peculiar characteristic of their idiocy becomes 
 more and more apparent. Some one faculty of the mind seems often 
 to be partially exempted from the dulling of the rest ; one child shows 
 a perception of tune ; another a fondness for some mechanical occupa- 
 tion ; a third manifests an idea, of numbers ; and it is of great impor- 
 tance to seize in each case on these peculiarities, since they indicate the 
 direction in which efforts must be made to raise through them the other 
 mental powers from their state of weakness. Even those faculties, how- 
 ever, which are least obscured, are generally far inferior to the same in 
 other children ; real mechanical dexterity, or musical power, or nu- 
 merical skill, is very rare. They strike us by contrast with the other 
 powers of the child : of themselves they are usually most humble. 2 
 
 It is well to bear this in mind in order to avoid disappointment at 
 the results which may be obtained at any institution for the education 
 of idiots. To teach cleanliness, order, and neatness ; to impart knowl- 
 
 1 Dr. Howe, in the most interesting tables appended to his Keport, has some facts 
 corroborative of the above statement; bis measurements, however, refer to-the adult, 
 not to the idiot in the years of childbood. 
 
 2 Assuming the sensibility to musical sounds in ordinary persons to be as 10, Dr. 
 Howe found it to be as 6.3 as the average in 574 idiots ; skill in language as 5, and 
 numerical skill as 3 to 10. See p. 41 of the Appendix to the Eeport. 
 
EDUCATION OF IDIOTS. 233 
 
 edge enough to enable the idiot to take eare of himself; to develop his 
 affections ; to enable him to read and write ; to practice some easy- 
 handicraft ; to partake of some simple pleasures — is an object well 
 worth some trouble to accomplish. Exaggerated expectations will not 
 contribute to its realization. 
 
 Two great. difficulties interfere with every attempt to teach the idiot. 
 One of these is presented by his habitual indolence ; the other by his 
 inability to fix his attention. I am not speaking here of those cases of 
 almost utter absence of all intellectual power, in which safe custody 
 of the unfortunate is all that can be attempted ; but of those instances 
 concerning which your advice may be asked, where some powers 
 of memory, some degree of teachableness, evidently exist. In such 
 cases, however, you must not fix your expectations too high, or you 
 will inevitably meet with disappointment; for the child who, by care- 
 ful education, has been brought to answer certain simple questions, and 
 who to your first inquiry will give a correct reply, will yet be unable to 
 command his attention sufficiently to answer the second, although a few 
 moments after he will, if the question is repeated, answer it quite cor- 
 rectly. The lower we descend in the scale of intellectual power, the 
 more striking does this inability to fix the attention become, until at 
 length we reach a point in which, the perceptive powers also being dull, 
 the child may sit for hours together noticing nothing. It is in a grade 
 above this that we meet with that perpetual restlessness so character- 
 istic of some idiots, who are constantly in motion, examining every ob- 
 ject within their reach, but not stopping above a few seconds at any ; 
 and this mental infirmity constitutes one great bar to their improve- 
 ment. The habitual indolence of the idiot, the dislike to exertion of 
 any kind, bodily or mental, is almost invariably manifest in all ; and 
 its existence is quite compatible with the restlessness, the sort of busy 
 idleness, which I have just mentioned as so often characteristic of his 
 condition. 
 
 Both of these evils are extremely difficult to combat successfully, 
 even with the best endeavors, so long as a child remains at home with 
 his parents; and I am therefore disposed always to recommend the 
 sending such a child to an institution specially set apart for the in- 
 struction of idiots. Another reason for this course is furnished by the 
 circumstance that the imitative faculty, which is usually very strongly 
 marked in the idiot, furnishes one great means of his improvement; 
 while, besides, there are many of his moral powers which cannot be 
 brought out except in the society of other children of his own age, and 
 not differing too widely from him in mental power. 
 
 To obtain, however, all that is possible in the education of idiots, it 
 is of great importance that they should be classified with greaf care; 
 that the hopeless idiot should not be associated with those who are 
 capable of improvement; that insane children should not be inter- 
 mingled with the idiotic; and that children of very different degrees 
 of mental capacity should not be thrown together at their work, nor 
 even, without much care and oversight, in their amusements. Im- 
 portant, too, as reading, writing, and a knowledge of numbers unques- 
 tionably are, the time at which it is expedient to teach them varies 
 
234 PECULIARITIES OF THE 
 
 greatly in different cases. Mere verbal memory, too, is by no means a 
 fair index of a child's mental condition ; for the idiot may often be 
 taught, parrot-like, to repeat many things of the meaning of which he 
 has not the slightest notion. This sort of acquirement, too, while it 
 exercises but very little influence on the general mental condition, is 
 lost very speedily so soon as the constant teaching is interrupted, and 
 therefore, though not without a certain utility, does not rank by any 
 means among the first objects to which the attention should be turned. 
 There is not time, however, nor indeed have I the experience to en- 
 able me to enter into so wide a subject as that of the education of idiots. 
 I must content myself with having pointed out to you the general 
 characteristics of their condition — the objects towards which your en- 
 deavors must be chiefly turned in any attempt at its improvement. I 
 can w T ish for nothing better than that, before long, the labors of others 
 shall render these observations of mine as superfluous as I know them 
 to be imperfect. 
 
 LECTUEE XVII 
 
 Diseases of the Bespiratory Organs, their frequency and fatality. — Peculiar- 
 ities of the respiratory function in early life — Causes of the rapid pulse and 
 quick breathing in infancy — Feebleness of inspiratory power, and consequent 
 tendency to collapse of the lung. 
 
 Asphyxia, or still-birth. — Its dependence on interruption of placental circulation 
 — Its degrees, symptoms, and treatment. 
 
 Imperfect Expansion of the Lungs. — Sometimes congenital — Appearance of the 
 lung — Influence of inflation upon it — Its causes and symptoms — Case of its 
 fatal termination — Case of recovery from it — Diagnosis from congenital phthisis 
 — Treatment. 
 
 We now come to the examination of the diseases of those two grand 
 systems of the organism by which the blood is kept in motion, the 
 requisite changes in it are effected, and the animal heat is maintained. 
 Your attention was lately called to the fatality of the diseases of the 
 nervous system in early life as one grand reason for their attentive 
 study ; but this argument is still more cogent if applied to the maladies 
 of the organs of respiration and circulation, since they destroy a far 
 greater number of children, and occasion a mortality almost equal to 
 that produced by diseases of the nervous and digestive systems together. 
 It appears, indeed, from our tables of mortality, that very nearly a 
 third of all deaths under five years of age are due to the diseases of the 
 respiratory organs ; while not above one child in four dies under that 
 
RESPIRATORY ORGANS IN EARLY LIFE. 
 
 235 
 
 age from disease? of the nervous system, and not above one in seven 
 from those of the digestive system. 1 
 
 While the study of these diseases is of paramount importance, we 
 meet with inducements to their investigation which in a great measure 
 failed us in the case of diseases of the nervous system. Peculiar diffi- 
 culties then attended us, and the truth was veiled in so much obscurity, 
 that we often saw it but indistinctly — sometimes, perhaps, altogether 
 failed to perceive it. The means, however, which have enabled us to 
 bring medical knowledge with reference to the diseases of the chest in 
 the adult, almost to the state of one of the exact sciences, still stand us 
 in stead here; and care and patience will enable us to discover the 
 condition of the lungs with nearly as much certainty in an infant as in 
 a grown person. 
 
 Xor is the greater facility of their diagnosis the only circumstance 
 that lightens their study, but a feeling of hopefulness attends their in- 
 vestigation which we often missed in the subjects that have lately 
 engaged our attention. They, indeed, furnished us with interesting 
 pathological studies : we stood around the sick-bed, and watched 
 nature's struggles with disease that was irremediable, and we traced 
 its effects afterwards as we examined the dead body ; but the diagnosis 
 of the affection was in many instances but the sentence of the patient's 
 death ; and we often felt that, as practical physicians, there was but 
 little for us to do. We shall, it is true, meet with some such affections 
 in our study of diseases of the chest; but, happily, they are few in com- 
 parison with those which, in addition to much that would interest the 
 mere pathologist, present still more that will give ample scope for all 
 the skill of the practical physician. 
 
 At first sight, it may seem to you that there can be little in the 
 organs of respiration and circulation in early life different from their 
 condition in riper years. And it is true that the part they play is as 
 important at the first hour of existence as in the most advanced old 
 age, and that their structure and functions undergo no such changes as 
 we have noticed taking place in the brain during infancy and child- 
 hood ; but, nevertheless, they present some important peculiarities in 
 the young, with which you must be acquainted before you can hope to 
 treat their diseases with success. 
 
 The condition of infancy is one of unceasing development ; all the 
 organs of vegetative life have, so to speak, double work to do — not 
 
 1 Table showing the proportion per cent, of deaths from different causes in child- 
 hood, in the metropolis, as compared with subsequent life. [Deduced from the 5th 
 and 8th Keports of the Registrar-General, fur 1842 and 1845.] 
 
 
 Under 
 1 year. 
 
 Between Between 
 1 and 3. 3 and 5. 
 
 Under 
 5. 
 
 5 to 10. 
 
 10 to 15. 
 
 At all 
 ages 
 above 
 
 15. 
 
 From Diseases of the Ner- 
 vous System, 
 
 Do. , do. , Eespiratory System 
 Do., do., Digestive System. 
 
 1 30.5 
 
 26.9 
 17.5 
 
 18.5 17.6 
 
 39.5 33. 
 12.8 5.5 
 
 24 3 
 
 32.8 
 14.1 
 
 15.1 
 
 29.5 
 6 5 
 
 10.6 
 
 30.7 
 8.8 
 
 10.4 
 
 38.0 
 
 7.7 
 
• 
 
 236 RAPID PULSE AND QUICK BREATHING IN INFANCY. ' 
 
 merely to supply the daily waste, and to remove effete and useless 
 matter, but to build up that wondrous edifice, the human body. It is 
 probably in great measure on this account that the blood in infancy 
 and childhood runs its course more rapidly, and that the lungs vivify 
 it more frequently than in adult age. "We shall probably not be far 
 wrong if we estimate the average frequency of the pulse in the grown 
 person, when making no exertion, at 75, and of the respirations at 12 
 in the minute. 1 In infants not above a week old, the average fre- 
 quency of the respirations is 39, and of the pulse 102; but the former 
 may rise to 84, and the latter to 140, as the result of some transient 
 excitement or disturbance, and wholly independent of disease. Until 
 the sixth year the average frequency of the pulse continues at 102 ; 
 and though that of the respiration diminishes, yet it does not fall below 
 30. The variations between their maximum and minimum frequency 
 are now, however, circumscribed within limits which grow narrower as 
 the child approaches manhood. 2 
 
 Although the rapid pulse and quick breathing of early life are 
 probably in great measure due to the activity of the vital processes, 
 yet the wide variations in their frequency induced by very slight acci- 
 dents lead to the suspicion that this is not their only cause, but that 
 both phenomena are to a certain extent indications of the infant's 
 weakness. This suspicion is still further strengthened by our knowl- 
 edge of the fact, that the quantity of carbonic acid exhaled at each 
 expiration diminishes in proportion as the expirations are more fre- 
 quent; 3 so that it is plain that the rapidity of the respiratory move- 
 ments is not of itself a measure of the activity of the respiratory pro- 
 cess. But still stronger proof of this fact may be adduced. Animal 
 heat is generated almost entirely by respiration. If, therefore, the 
 activity of the vital processes were in proportion to the rapidity of the 
 breathing, the new-born infant should be warmer than the child, and 
 the child than the youth. But this is not so, for the temperature of 
 health appears to vary but very little after the first week of life; at- 
 taining a slightly higher point after that time than it had before, and 
 maintaining it almost unchanged through childhood and adult age ; but 
 falling again, though slightly, with far advancing years. 4 
 
 There seems, then, good reason for believing that the rapid breathing 
 of the child is to some extent the result of its more delicate frame, ren- 
 dering it unable, at a single effort, to inspire as deeply as the more 
 
 1 This result is afforded by the numerous and careful observations of Professor 
 Vierordt: see his article Respiration, in Wagner's Handwcirterbuch der Physiologie, 
 Part 12, 8vo., Brunswick, 1845, p. 874. 
 
 2 The chief authority for the statements in the text is the valuable essay of M. 
 Koger, De la Temperature chez les Enfants, 8vo., Paris, 1844, and the more recent 
 confirmatory observations in his Recherches Cliniques, already referred to. The 
 researches of M. Seux, Sur les Maladies des Enfants Nouveau-Nes, 8vo., Paris, 1855, 
 do but confirm, in the main, the 'results already arrived at with reference to the 
 wide variations in the frequency of the pulse in new-born infants. 
 
 3 See Vierordt's experiments on this subject, loc. cit., p. 887. 
 
 4 The researches of Dr. v. Barensprung, published in Muller's Archiv., 1851, p. 
 125, do not confirm the above statement ; but they are too few in number to invali- 
 date it, and therefore it is still retained in the text. See § 5 of v. Barensprung's 
 essav. 
 
FEEBLENESS OF THE INSPIRATORY POWER. 237 
 
 robust adult, so that it is compelled, by the frequent repetition of its 
 efforts, to make up for their comparative feebleness. Quite in keeping 
 with this is the small power of resisting cold, or of maintaining an inde- 
 pendent temperature, which is a distinguishing peculiarity of early life. 
 If the young of any warm-blooded animal is exposed to a low tempera- 
 ture, its respiration at first increases in frequency; but, if not soon 
 restored to a warmer atmosphere, the nervous energy that should set 
 the respiratory apparatus in motion becomes still more depressed; air 
 enters the lungs imperfectly, the inspirations grow less frequent, and 
 the warmth of the body sinks rapidly down to that of the surrounding 
 medium. Nor is this all; but it often happens if a young infant has 
 been thus exposed to the cold, and especially if this has been done 
 before the respiration had become properly established, that no subse- 
 quent removal to a warmer atmosphere will suffice to raise the tem- 
 perature, or to set in proper activity the respiratory process. 
 
 But not merely is the respiratory apparatus more delicate in the child 
 than in the adult — for so are all the organs in early life — but it is 
 feebler, as compared with the work it has to do, with the difficulties 
 it has to overcome ; and this constitutes a most important peculiarity 
 in the physiology of respiration in early life, and greatly modifies its 
 pathology. 
 
 The interesting researches of Mr. Hutchinson 1 have shown us that 
 in the case of the adult " the resistance to the ordinary breathing force, 
 independently of the elastic power of the lungs, is equal to lifting more 
 than 100 lbs. at every ordinary inspiration." The elasticity of the 
 walls of the chest which present this resistance is, in proportion to the 
 size of the thorax, nearly as great in the infant as in the adult ; but 
 how much smaller is the muscular power by which this resistance is to 
 be overcome ! You see proof of it in the ordinary mode of respiration 
 of a young infant, which presents something almost of difficulty. The 
 breathing is quick and short, then after a few seconds there succeeds a 
 pause, and then the hurried respiratory movements begin again, while 
 the slightest disturbance, or the most trivial excitement, will at any 
 time raise the frequency of the inspirations by ten or twelve in the 
 minute. This respiration, too, is almost entirely abdominal; the chest 
 moves but little, its walls are but little expanded, and the ear detects 
 in the respiratory murmur little or nothing of that clear, loud sound 
 which is so characteristic of a subsequent period of childhood, and with 
 which you are all familiar by the name of puerile respiration. This 
 peculiarity of the breathing in early infancy, to which M. Trousseau 
 was, I believe, the first to call attention, is another token of the feeble- 
 ness of the inspiratory power. As the child grows older, and its 
 strength increases, and its muscular system becomes more developed, 
 the chest expands with each inspiration, and the faint respiratory mur- 
 mur is succeeded by the loud puerile breathing which is heard as the 
 air enters into the smaller air-cells. 
 
 The resistance of the w 7 alls of the chest, however, is not the only ob- 
 
 1 On the Respiratory Functions, in vol. xxix of the Medico-Chirurgical Transac- 
 tions. 
 
238 IMPERFECT EXPANSION OF THE LUNGS. 
 
 stacle to be overcome at each inspiratory effort, but the lungs them- 
 selves are furnished with an elastic fibrous investment, processes of 
 which dip down into their substance, and form the parietes of the dif- 
 ferent lobules. If you blow air forcibly into the lungs after their re- 
 moval from the body, the resiliency of their tissue will expel a large 
 proportion of the air the moment your effort at* inflation is suspended. 
 This elasticity of the lungs, then, which has been estimated as offering 
 in the adult male an obstacle to each inspiration equal to 150 lbs., and 
 in the female equal to 120 lbs. avoirdupois, is constantly tending to 
 empty them of air, and constantly resisting the introduction of more. 1 
 The want of breath, however, puts the respiratory muscles into play ; 
 the man takes a deep inspiration, and by this effort he unconsciously 
 overcomes the resistance of the chest and the elasticity of the lungs. 
 The new-born infant feels the same want, and makes the same effort ; 
 but its muscular power is small, and its inspirations are often so feeble 
 as to draw the air in some parts only into the larger bronchi, while 
 many of the smaller air-tubes remain undilated, and much of the lung 
 continues in its foetal state. The blood being thus but imperfectly 
 aerated, all the processes of nutrition go on imperfectly ; the vital 
 powers languish, the inspiratory efforts become more and more feeble, 
 the temperature sinks, and the infant dies. But not only may this 
 state persist as the result of imperfect respiration at birth, but cold, or 
 the want of sufficient food, or any other cause that impairs the already 
 feeble muscular power, favors its supervention. As the power of the 
 inspiratory muscles is impaired, the air no longer penetrates into the 
 lungs so far as it once did, while the residual air is gradually driven 
 out of the pulmonary cells by the elasticity of the lung, and portions 
 once permeable to air become in the course of time, altogether use- 
 less. Or, an increase of the ordinary resistance to the entrance of the 
 air will have the same effect ; and if the pouring out of mucus into the 
 bronchial tubes should much obstruct them, large portions of lung will 
 by degrees become emptied and collapsed, the dyspnoea will grow 
 urgent, and the child will die from symptoms such as in the adult re- 
 sult only from most serious structural disease. 
 
 The possibility of a large portion of the respiratory apparatus re- 
 maining useless from birth, or becoming so afterwards, without any 
 serious disease of these organs, is a most important element in the 
 pathology of infancy and early childhood. It warns us to be on our 
 guard, during the course of various maladies, against a danger which, 
 in more advanced life, we have not to apprehend ; while, at the same 
 time, it teaches us that the dyspnoea, the hurried breathing, and many 
 other symptoms which in the adult would call for most active treat- 
 ment, may result in infancy from simple weakness, and require stim- 
 ulating rather than depletory measures. 
 
 1 The investigations of Professor Donders, and of Mr. Hutchinson, into the 
 amount of this elasticity of the lungs, though carried on independently, conduct to 
 ver}' similar results: the former estimating it as equal to ^ix gx avoirdupois per 
 square inch as a maximum ; the latter estimating it on the average at Hbss. per square 
 inch See the researches of Prof. Donders, in the Nederlandsche Lancet, Dec. 1849 ; 
 and Schmidt's Jahrb., Dec. 1850; and article Thorax, by Mr. Hutchinson, in Cyclo- 
 paedia of Anatomy and Physiology, vol. iv, p. 1058. 
 
IMPERFECT EXPANSION OF THE LUNGS. 239 
 
 Before we proceed to study the diseases of the respiratory organs in 
 infancy and childhood, we must make ourselves thoroughly acquainted 
 with this state of imperfect expansion of the lungs. It presents itself to 
 us in two different circumstances. 
 
 1st. As a congenital condition : a more or less considerable portion 
 of the lung never having become penetrated by air, but having re- 
 mained in its foetal state. 
 
 2d. As an acquired condition : portions of the lung which once were 
 freely traversed by air ceasing to admit it ; and this not from alteration 
 of structure, but from a simple collapse of the pulmonary tissue. 
 
 But, even before this, we must notice that condition in which, on 
 the child's birth, the air fails, for a time at least, to enter at all. The 
 child is born asphyxiated; it does not breathe, does not show the 
 ordinary signs of life, but, to use the common, homely, but expressive 
 phrase, is stillborn. 
 
 I said, many days ago, 1 that a stillborn child may present a very 
 great degree of cerebral congestion, or that there may even be actual 
 extravasation of blood within its skull, and that such apoplectic con- 
 dition may interfere with the success of any effort for its resuscitation, 
 but that, nevertheless, the apoplexy, or the extravasation of blood, is 
 not the immediate cause of its death ; but the inability to breathe is. 
 
 In some rare cases a child may be stillborn, owing to the existence 
 of souie intra-uterine disease affecting it ; but it is not with these ex- 
 ceptional cases that we have to do here, nor with those in which a child 
 ill-nourished, or born before its time, dies from mere feebleness. In 
 cases of true Infantile Asphyxia, interference with the placental respi- 
 ration, however produced, is the real cause of all the subsequent 
 phenomena. Hence it is that we see the death of the child follow 
 almost immediately on that of the mother; that the surgeon, waiting 
 for her last breath in order at once to perform the Caesarian section, 
 scarcely ever succeeds in rescuing her infant. !Not otherwise, though 
 more slowly, is the child's death brought about if the mother's system 
 is greatly drained of blood by partial separation of the placenta ; for 
 then enough does not remain to produce the necessary oxygenation in 
 the circulating fluid of the child. We see the same result, too, in pro- 
 tracted labors, when the frequent and violent contractions of the womb 
 interfere with the circulation of the maternal blood in the placental 
 sinuses ; and though the cause is different, the result that follows is 
 just the same when pressure on the umbilical cord interferes with the 
 afflux or the reflux of the foetal blood to or from the placenta. 
 
 These causes tend to produce an effort at respiration, and this prob- 
 ably in proportion to the suddenness of their operation ; and now and 
 then a striking illustration of it is afforded by the vagitus uterinus — 
 the unborn babe not breathing only, but even crying, in its mother's 
 womb ; while evidence of the unsuccessful effort is oftener furnished 
 by the presence of the liquor amnii in the bronchi of the dead child, 
 or in the large mucous rale which accompanies its first attempts to 
 breathe, if it recovers. The unsuccessful respiratory efforts do but 
 
 1 Lecture V, p. 59. 
 
240 TREATMENT OF ASPHYXIA. 
 
 disturb still more the placental breathing ; while the longer and the 
 more gravely, in any case, the circulation in the placenta is disturbed, 
 and the oxygenation of the foetal blood interfered with, the more does 
 the excitability of the medulla oblongata become lessened, and, with it, 
 the prospect of resuscitating the child. 
 
 There are, then, different degrees of infantile asphyxia, though, in 
 all, the object to be aimed at is the same ; namely, to establish pulmo- 
 nary respiration as speedily and as completely as possible. 
 
 Cases of asphyxia may be divided into two great classes, according 
 as the muscular system has lost its tone, or still retains it. In the 
 latter and more hopeful cases the limbs still yield a degree of resist- 
 ance, and the muscles of the neck give a partial support to the head ; 
 the surface is warm, of a red, often of a livid red color; the conjunc- 
 tivae are red, sometimes ecchymosed; the heart and umbilical arteries 
 beat, though slowly, and the vessels of the cord are full of blood. 
 In this condition the mere exposure to air, or some simple irritation of 
 the surface, suffices to excite respiratory efforts, and the child recovers. 
 
 This, however, is not always so; and sometimes the child, who was 
 born in what might seem this hopeful condition, and who even had 
 made inspiratory efforts, does not recover. The attempts at breathing 
 become more feeble, and the heart's action grows slower ; the muscular 
 system loses its tone, and the limbs their resistance ; the surface be- 
 comes cool and pale as well as livid; the umbilical vessels cease to 
 pulsate, and the cord grows flaccid ; the foetal mode of existence comes 
 to an end, while pulmonary respiration fails to be established, and the 
 child dies. This different result, the immediate cause of which is the 
 more or less sunken sensibility of the medulla oblongata, is doubtless 
 connected with different degrees and kinds of disturbance of the pla- 
 cental circulation, and with the degree in which fruitless respiratory 
 efforts have been made before birth. I do not know, however, that we 
 are able at present to adopt any definite formula as representing the 
 degree of risk to the foetus in different cases; for while, on the one 
 hand, we know that in cases of long-protracted labor the child is often 
 stillborn and pale, and with no prospect of resuscitation, even a very 
 short pressure on the cord, in cases of breech presentation or of pro- 
 lapsus of the funis, suffices to destroy it. In these latter instances, 
 indeed, it is probable that actual extravasation of blood in the cranium 
 may have had a share in producing this result, as well as the mere 
 disorder of placental circulation. 
 
 We come now to the practical question of what treatment to adopt 
 in cases where the child does not breathe immediately on its birth. 
 First of all, I need scarcely say that, so long as the umbilical vessels 
 are forcibly pulsating, there is nothing to do but to wait patiently and 
 allow the placental circulation to go on undisturbed, until the besoin 
 de respirer — I do not know why we should not use plain English, and 
 say till the want of breath — is felt, and efforts at respiration are made 
 by the infant. In many cases the contact of the cold air excites this 
 want ; the child attempts to breathe, and r as it does so, the placental 
 circulation diminishes in force, and at length altogether ceases. When 
 this is not the case, but the heart-beat grows slower, and the placental 
 
TREATMENT OF ASPHYXIA. 241 
 
 circulation feebler, without any effort at respiration being excited, no 
 more time should be lost, but the cord should be at once divided, and 
 the escape of a drachm or two of blood from its cut surface will often 
 relieve the overloaded heart, and facilitate the establishment of respi- 
 ration and the flow of blood in its new channels. The first endeavor 
 now, too, should be to arouse the respiratory efforts by stimulation of 
 the surface ; as by dashing cold water on the face and chest ; by 
 plunging the child for a few seconds in a hot bath at a temperature of 
 100° or 102°, and then exposing it to the air; by swinging it a few 
 times backwards and forwards in the air, by slapping its nates, by ap- 
 plying ammonia to the nostrils, or by tickling the throat and nares 
 with a feather. 
 
 If, however, these measures do not very speedily prove successful, or 
 if the child, when born, is in what may be termed the second degree 
 of stillbirth, with cool, pale surface, and flaccid limbs, and non-pul- 
 sating cord, no time must be wasted over these measures, but the en- 
 deavor must be made without delay to excite respiration. It might at 
 first seem that this would be best done by direct inflation of the lungs; 
 but experience — at least, the experience of private practice — does not 
 seem to confirm this expectation, and, on the whole, more success ap- 
 pears to follow the attempt to introduce air into the lungs by the arti- 
 ficial imitation of the respiratory movements. To the late Dr. Mar- 
 shall Hall 1 belongs the credit of having been the first to suggest this 
 proceeding as applicable to the treatment of persons apparently 
 drowned, not by forcing the air into the lungs directly, but by drawing 
 the air into them by changes of posture which imitate the respiratory 
 movements. The plan of proceeding which he suggested for this pur- 
 pose has, however, been generally superseded by that recommended by 
 Dr. Silvester, on which a committee of the Medico-Chirurgical So- 
 ciety has reported very favorably. 2 "An inspiratory effect is produced 
 by extending the arms upwards by the side of the head, and restoring 
 them to their original position by the side of the body ; or still better, 
 by pressing them on the lower third of the sternum the expanded walls 
 are allowed to resume their previous state, and expiration takes place, 
 the quantity of air expelled being in proportion to that which had 
 been previously inspired." 
 
 So long as the surface retains its warmth, and so long as an occa- 
 sional heart-beat shows that life is not absolutely extinct, these efforts 
 should be persevered with, it may be for several hours ; and my own 
 conviction is, that in not a few instances failure is due to want of per- 
 severance rather than to the absolute uselessness of the endeavor. 3 
 
 The stillborn child, however, sometimes recovers only imperfectly; 
 air indeed enters its lungs, but not completely, and we then have to do 
 with congenital imperfect expansion of the lungs. 
 
 1 Prone and Postural Eespiration, &c, 12mo., London, 1857, pp. 24 and 56. 
 
 2 In vol. xlv of the Transactions of the Society. 
 
 3 Schultze, Op. cit., pp. 161-163, suggests another mode of carrying out respiratory 
 movements, which he believes to be still more efficient ; but of the merits of which 
 my discontinuance for some years of obstetric practice prevents my being a com- 
 petent judge. 
 
 16 
 
242 EFFECTS OF INFLATION ON COLLAPSED LUNG. 
 
 It is now forty years since Dr. Edward Jorg gave the first clear de- 
 scription of the former of these two conditions, to which he applied the 
 rather cramp name of atelectasis, from arsX^q, imperfect, and exrafftq, ex- 
 pansion. 1 We will first study this, since it is the simpler form of the 
 affection, and we shall thereby obtain a clue to the understanding of 
 the second form. 
 
 If you examine the body of a new-born infant, or of one that has 
 survived its birth but a few days, you will sometimes find patches of 
 the lung of a dark red color, and depressed below the surrounding 
 tissue, thus giving to the surface of the organ an uneven appearance. 
 These darker portions, which exactly resemble foetal lung, are solid to 
 the touch, do not crepitate at all under the finger, and sink immedi- 
 ately if thrown into water, while no minute air-bubbles are inter- 
 mingled with the small quantity of reddish serum which pressure 
 causes to exude from their divided substance. They are not friable 
 nor easily torn, their cut surface is perfectly smooth, closely resem- 
 bling a piece of muscle, and, if examined under a lens, the pale col- 
 lapsed air-tubes are seen intersecting their substance, and scarcely dis- 
 tinguishable from the small vessels, which are almost devoid of blood. 
 
 If air is blown into a lung some lobules of which have this appear- 
 ance, it will permeate the collapsed air-tubes ; the pulmonary vesicles 
 will by degrees become distended, and the solid lobules will rise to a 
 level with the rest of the lung, will ■ acquire the same color and con- 
 sistence, and, like other parts of the organ, will float in water. A 
 single inflation, however, is by no means sufficient to render this 
 change permanent, but the moment the tube is withdrawn the air will 
 escape, and the recently distended lobules will again collapse, and sink 
 below the rest of the lung ; their color, too, will become dark, though 
 less so than before. Even if, after you have distended the lung to the 
 utmost, you pass a ligature round the bronchi, and allow the lung to 
 dry, a difference will still in general be very perceptible between the 
 size of the air- vesicles which had been inflated by your efforts, and of 
 those which had been distended during life by the natural process of 
 respiration. 
 
 The force required thus to distend the collapsed portions of the lung 
 is very variable : sometimes it requires all the force you can possibly 
 exert, and continued for some minutes. If the child had survived for 
 several weeks, the air will penetrate only very imperfectly into the 
 collapsed lobules, while in some parts the resistance will be greater 
 than it can overcome, and the most forcible inflation will be followed 
 by no effect. The situations in which this condition is most frequently 
 met with, are the languette and lower edge of the upper lobes, the 
 middle lobe of the right lung, and the posterior part and lower edge 
 of the lower lobes ; and inflation restores these parts to a natural con- 
 dition much less easily than it does any patches of the same kind in 
 other situations. Whether the impermeability of some collapsed lob- 
 
 1 In his dissertation De pulmonum vitio organico, &c, Lips., 1832; and after- 
 wards more fully in his work Die Fotuslunge im gebornen Kinde, 8vo., Grimma, 
 1835. 
 
CAUSES OF IMPERFECT EXPANSION OF THE LUNGS. 243 
 
 ules is owing to adhesions having taken place between the opposite 
 surfaces of the minuter bronchi, as has been suggested, I cannot pre- 
 tend to say, but the supposition is plausible, and microscopical re- 
 searches, according to which the bronchi of a portion of collapsed lung 
 lose their lining of tessellated epithelium, lend it a still further degree 
 of probability. 1 
 
 It is usual to find, in connection with this state of the parenchyma 
 of the lungs, that the pulmonary vessels contain less blood than usual, 
 that the foramen ovale is unusually open, and the ductus arteriosus but 
 very imperfectly closed. If the child have survived its birth but a 
 short time, the brain is frequently found congested; but otherwise there 
 is often nothing observable more than anaemia of all the organs, together 
 with a general state of atrophy. Sometimes bronchitis attacks a lung 
 thus affected, and besides the presence of mucus in the air-passages, 
 there is then very often a state of congestion of the lungs, which ren- 
 ders the contrast between the collapsed and the healthy lobules less 
 striking. 
 
 The causes of this condition are not clearly made out. Dr. Jorg 
 has attributed great importance to precipitate labor as a frequent cause 
 of its occurrence, and has suggested a somewhat fanciful theory to ex- 
 plain its mode of production. "He conceives that one grand use of the 
 uterine contractions is gradually to enfeeble the circulation through the 
 placenta, and thus to induce in the foetus that besoin de respirer which 
 shall excite the complete establishment of respiration immediately on 
 its birth. If, however, by the very rapid course of labor, the child 
 should-be born while the foetal circulation is still going on with unim- 
 paired vigor, the want of air will not be experienced by the child, and 
 its attempts to breathe will be feeble and imperfect. It is probably 
 better, instead of indulging in speculations of this sort, to content our- 
 selves with the simple statement that when, from any cause whatever, 
 the establishment of respiration at all has been attended with difficulty, 
 there is a very great probability that its establishment wall never be 
 complete, but that some lobules only will receive the air, while it will 
 not penetrate into other parts of the lung. The probability of this 
 occurring, too, will be still greater if the children are weakly or ill- 
 nourished when born, or if they are exposed soon after birth to cold or 
 other unfavorable hygienic influences, such as are calculated to inter- 
 fere with the due performance of respiration. 
 
 Cases in which this condition of the lungs exists usually present the 
 history of the child having been apparently stillborn ; and, though 
 resuscitated after a time,, yet still continuing unable to utter a strong 
 and loud cry like that of other children. Even after breathing has 
 gone on for some time, such children usually appear feeble; and though 
 they may have attained the full term of foetal life, yet they can scarcely 
 suck, although they often make the effort. An infant thus affected 
 sleeps even more than new-born infants usually do ; its voice is very 
 feeble, and rather a whimper than a cry ; and the chest is seen to be 
 
 1 See a paper on this subject bv Prof. Kostlin, in 'Schmidt's Jarbiieher, 1850, 
 No. 1, p. 28. 
 
244 CASES ILLUSTRATIVE OF SYMPTOMS 
 
 very little, if at all dilated by the respiratory movements. The tem- 
 perature falls, the skin becomes pale, and the lips grow livid, and often 
 slight twitching is observed in the course of a few hours about the mus- 
 cles of the face. The difficulty in sucking increases, the voice grows 
 weaker and more whimpering, or even altogether inaudible, while res- 
 piration is attended with a slight rale, or an occasional cough ; and the 
 convulsive movements return more frequently, and are no longer con- 
 fined to the face, but affect also the muscles of the extremities. Any 
 sudden movement suffices to bring on these convulsive seizures : but 
 even while perfectly still the child's condition is not uniform, but it 
 will suddenly become convulsed ; and during this seizure the respira- 
 tion will be extremely difficult, and death will seem momentarily im- 
 pending. In a few minutes, however, all this disturbance ceases, and 
 the extreme weakness of the child, its inability to suck, its feeble voice, 
 and its frequent and imperfect inspirations, are the only abiding indi- 
 cations of the serious disorder from which it suffers. But the other 
 symptoms return again and again, till at length, after the lapse of a few 
 days, or a few weeks, the infant dies. 
 
 But I will relate a case which may serve to impress these character- 
 istics on your memory. A little boy, three weeks old, was brought to 
 me at the Children's Infirmary, on March 13, 1846. He was puny, 
 emaciated, with a cold surface and bloodless conjunctivse. His face, 
 which was wizened like that of an old man, was occasionally distorted 
 by slight convulsive twitches ; and these fits, as the mother termed 
 them, were, according to her account, sometimes much more severe. 
 The abdomen was tympanitic, and it alone was seen to move during 
 respiration, there being hardly any lateral expansion of the chest. The 
 ear applied to the chest heard but little air entering ; and the cry was 
 a stifled whimper, in which none of the inspiratory sound, the reprise 
 of French writers, was distinguishable. The child sucked with diffi- 
 culty, and had wasted ever since its birth, though no diarrhoea ex- 
 isted ; but the bowels, on the contrary, showed a tendency to consti- 
 pation. 
 
 The chest was rubbed twice a day with a stimulating liniment, and 
 a mixture was given containing some ammonia and the compound tinc- 
 ture of bark. Under this treatment the child appeared to improve ; it 
 began to breathe less rapidly and in a less labored manner, and its cry 
 became louder. The parents, however, were miserably destitute, the 
 mother in an ill state of health, so that her milk afforded but a very 
 imperfect sustenance for the child. From the beginning of April he 
 grew less well, and began to have occasional attacks of general convul- 
 sions, in one of which he died on April 26, 1846. 
 
 On examining the body, large portions of both lungs presented the 
 appearances which I have described as characteristic of their imperfect 
 expansion ; but inflation restored them to a crepitant state. Some 
 patches, however, though they admitted air and assumed the same 
 color as the rest of the lung, yet could not by any effort be dilated so 
 completely as to rise to a level with the surrounding tissue. The 
 foramen ovale was o^en, the margin of the valve for fully half its 
 circumference not being adherent, although the valve was sufficiently 
 
OF IMPERFECT EXPANSION OF LUNGS. 245 
 
 large for its closure. The ductus arteriosus also was quite permeable, 
 although of considerably less calibre than during foetal life. 
 
 This case affords a very good specimen of one way in which the 
 affection leads on to a fatal termination ; but sometimes, and probably 
 in those instances in which the affected portion of lung is not so con- 
 siderable, a less formidable train of symptoms usher in the fatal 
 event. Convulsive twitchings, such as I have before mentioned, do 
 not occur, nor are periodic exacerbations of the symptoms observed ; 
 but the child is merely feeble and its breath is short, and it has an 
 occasional cough. It sucks, though with difficulty, but it loses flesh, 
 the bowels become disordered, and medicine is unable to restrain the 
 diarrhoea. The unchecked diarrhoea increases the emaciation and ex- 
 haustion of the child, which dies at length worn out and wasted to a 
 skeleton. 
 
 Sometimes, too, we meet with cases in which the child eventually 
 recovers, and it is then very interesting to watch the gradual diminu- 
 tion in the frequency and violence of the paroxysms of dyspnoea, while 
 the respiration grows by degrees more equable, and the cry louder, the 
 power of sucking increases, and the child at length attains to perfect 
 health. 
 
 A little boy, four months old, was placed under my care by his 
 mother, who informed me that the child had presented in some un- 
 natural position during labor, so that manual interference was required 
 to effect her delivery : and when born the infant appeared dead, and 
 was recovered only after very great difficulty, and after the occurrence 
 of convulsions : the convulsions had since returned almost every day 
 — sometimes, indeed, they occurred several times in the same day — 
 and always came on with greater frequency by day than by night. 
 The attempt to suck often induced them, as did also any rapid move- 
 ment about the room, or any sudden change of posture. During the 
 fits the child did not struggle much, but he always turned extremely 
 livid about the face and mouth. No fit ever lasted longer than five 
 minutes, and during the intervals between them the child seemed 
 pretty well, except that he often suffered from a suffocating cough. 
 
 He appeared tolerably well-grown and well-nourished, and the 
 temperature of the surface was nearly natural. The respiration, how- 
 ever, was very hurried, and was almost entirely abdominal, the chest 
 being hardly at all expanded. The cry, moreover, was feeble, and 
 without reprise. There was a considerable want of resonance of both 
 sides of the chest posteriorly, and deficient entrance of air into the 
 back of both lungs. Both the dulness and the scanty admission of 
 air were more obvious in the left than in the right infrascapular region, 
 and some mucous rale was heard in the former situation. 
 
 The child was placed in a hot bath, and an emetic was given it 
 every night ; the chest, both in front and back, was rubbed -twice a 
 day with a stimulating liniment, and the face was ordered to be 
 sprinkled with cold water whenever any threatenings of the fits 
 came on. 
 
 At the end of five days the child was better, and the cry louder, 
 though without any distinct reprise. Small doses of the ferrocitrate 
 
246 DIAGNOSIS AND TREATMENT OF EXPANSION OF LUNGS. 
 
 of quinine were now combined with the other remedies, while the 
 emetics were discontinued, as on some occasions they had appeared to 
 excite the convulsions. First the cry grew louder, then the appear- 
 ance improved and the manner became more cheerful, then the cough 
 was less troublesome and the breathing less habitually wheezing, and 
 at the same time the chest began to expand more, and the marked 
 dulness of its lower parts gradually diminished. At the end of five 
 weeks, the child was discharged with increased flesh, invigorated 
 strength, and with no ailment more serious than a slight degree of 
 wheezing respiration. 
 
 The history of this patient may serve to show us that even very 
 serious symptoms should not lead us to despair of recovery, while it 
 illustrates the importance of forming an accurate diagnosis between 
 this aifection and congenital phthisis (the only malady with which it 
 is likely to be confounded), lest we either cherish unfounded expecta- 
 tions, or discourage hopes that might reasonably be entertained. 
 
 A little care will usually suffice to enable us to distinguish between 
 these two affections, notwithstanding some general points of resem- 
 blance between them. The symptoms of the imperfect inflation of the 
 lungs date from the infant's birth : but it scarcely ever happens that 
 tuberculous disorganization of the lung is so extensive in the new-born 
 child as to interfere with the establishment of the respiratory function. 
 But not only do not the symptoms of phthisis appear so early, but 
 they likewise seldom advance so rapidly, as those of atelectasis. 
 Phthisis, too, is not from the beginning attended with the same debil- 
 ity, nor with difficulty in sucking, while it is associated with a febrile 
 action which is quite wanting in atelectasis. The head symptoms, 
 which in so large a number of cases attend the imperfect inflation of 
 the lungs, are absent in phthisis ; while, lastly, auscultation would 
 furnish some clue to the real nature of the case : in the one instance 
 there would, in general, be simply a deficiency of air; in the other, 
 respiration accompanied with rales, and often with bronchial breathing. 
 
 The treatment required by this affection need not detain us long. 
 The importance of maintaining an equable temperature around every 
 child in whom respiration is not duly performed, cannot be too much 
 insisted on ; and the power of generating heat being, as you know, 
 much diminished, this temperature ought not to be below 70°, and in 
 bad cases may be even 10° higher. Besides attending to produce this 
 warmth around the child, benefit often accrues from the employment 
 of the hot bath once or twice every day, at a temperature of 100° 
 Fahrenheit, to which mustard may be added to render it more stimu- 
 lating to the surface. The child should not be allowed to remain 
 longer than five minutes in the bath, and should be enveloped in hot 
 flannels immediately afterwards, to prevent its taking cold. The back 
 and chest should be rubbed twice or oftener every day with a stimu- 
 lating liniment, as r camphor or soap liniment, which may be diluted 
 w T ith a little oil, if it is too irritating to the skin. If the child is very 
 feeble, stimulants may be given, of which there are none better than 
 the compound spirit of ammonia or ether, or the spiritus ammonias 
 succinatus, the unpleasant pungency of which remedies is concealed by 
 
COLLAPSE OF LUNG AFTER BIRTH. 247 
 
 milk better than by any other menstruum. The daily employment of 
 a gentle emetic of ipecacuanha has, in some instances, appeared to be 
 of service, not merely by relieving the air-tubes of any mucus that 
 may have accumulated there, but by inducing several deep inspirations, 
 and thus aiding the complete establishment of respiration. As the 
 child improves, the more directly stimulating medicines may be with- 
 drawn, and tonics substituted for them, among which few are better 
 than the extract of cinchona. 1 It has the great advantage of not dis- 
 ordering the bowels ; a point of no small importance in any case in 
 which diarrhoea is likely to occur. In some cases there is a sluggish- 
 ness of the bowels, and a deficiency in the secretion of bile ; very mi- 
 nute doses of the Hydr. c. Creta will often remedy the latter, and the 
 use of a soap suppository will frequently render the internal employ- 
 ment of any purgative needless. The child should be put to the breast 
 unless it is very feeble, but in that case should not be allowed to ex- 
 haust its strength in fruitless attempts to suck. It will be better to 
 draw the breast, and give the child its mother's milk by means of a 
 spoon or from a bottle, which latter plan has this advantage, that while 
 it costs the child but little effort to get its food, we avoid the risk of its 
 forgetting how to suck, an inconvenience which attends the use of the 
 spoon if continued for any length of time. Artificial feeding is not at 
 all desirable in such cases, though sometimes, if the child is very weak, 
 it may be necessary at first to give a few drops of brandy in its milk 
 every three or four hours. This plan of treatment must be patiently 
 persevered in, nor must the supervention of symptoms of an appar- 
 ently acute character induce too wide a deviation from it. The head 
 symptoms in particular must be combated cautiously, lest by too great 
 a solicitude to overcome them w T e destroy the patient rather than the 
 disease. 
 
 LECTURE XVIII. 
 
 Collapse of Lung that has once been Expanded. — Described as lobular pneu- 
 monia by various writers — Its characters — Symptoms and differences from true 
 pneumonia — Observations of Bailly and Legendre — Is not to be regarded as a 
 post-mortem occurrence — Illustrative cases — Instances of its occurrence in the 
 adult — Similar causes tend to produce it at all periods of life — Hence very fre- 
 quent in old age. 
 
 Induration of the Cellular Tissue. — Its characters — Kemarkable reduction of 
 temperature that attends it — Appearances after death — Frequent association 
 • with pulmonary collapse, congestion, or sometimes with pulmonary apoplexy 
 — Its cause still obscure — Treatment. 
 
 The condition of the lungs, which we were occupied in examining 
 at the last lecture, is of importance, even if regarded merely as a con- 
 
 1 See Formula No. 4, p. 57. 
 
248 COLLAPSE OF LUNG AFTER BIRTH. 
 
 genital state, the result of nature having failed in the attempt to estab- 
 lish respiration, and to fit the child thoroughly for the new mode of 
 existence to which it is destined after birth. But its claims on our 
 attention are still greater when we bear in mind the possibility of its 
 occurrence in consequence of a variety of causes operating after birth, 
 so that lungs once permeable to air may cease to admit it, and death 
 may at length occur from apncea without any serious structural change 
 having taken place in the organs of respiration. 
 
 Appearances supposed to be the result of pneumonia had long at- 
 tracted the notice of writers on diseases of children, by the wide differ- 
 ences which they presented from those which inflammation of the lungs 
 gives rise to in the adult. 1 It had been observed that infants and 
 children under five years of age often died after presenting some of the 
 symptoms of inflammation of the lungs, such as cough and difficult 
 breathing, together with more or less extensive dulness of the chest on 
 percussion, and some or other of the auscultatory signs of solidification of 
 the lung. In such cases these peculiar morbid appearances were espe- 
 cially well marked. But while they seemed to prove that these changes 
 in the lung were the consequences of pneumonia, it happened not in- 
 frequently that the fever and the pneumonic symptoms underwent a 
 great abatement before any sign of approaching death appeared, or 
 that children, who had seemed to die worn out from various causes, 
 and during whose lifetime no indication of inflammation of the lungs 
 had existed, presented the supposed anatomical evidences of pneumonia 
 in a most remarkable degree. The frequency of occurrences of this 
 kind led to the assumption that pneumonia was an extremely frequent 
 concomitant of almost all the diseases of infancy and early childhood ; 
 that this pneumonia was very often latent (that is to say, that it did 
 not manifest its existence by those symptoms which usually attend it) ; 
 and, lastly, that, owing to causes which were differently stated by dif- 
 ferent observers, it gave rise to alterations in the lung very dissimilar 
 from those which it occasioned in the adult. 
 
 One of the most remarkable peculiarities of this supposed infantile 
 pneumonia led to its receiving the appellation of lobular jmeumonia, as 
 expressive of the fact that it did not attack a large tract of lung, or the 
 whole of a lobe, at one time, but that it affected isolated lobules, which 
 might be seen of a dark color, solid, often depressed below the surround- 
 ing parts, and sinking in water if detached from the healthy tissue in 
 the midst of which they were situated. Sometimes the affection was 
 strictly limited to a single lobule, the boundaries of which could be 
 exactly traced ; and though it often happened that a cluster of lobules 
 was thus hard, and dark, and solid, still there was no gradual shading 
 off from the darker to the lighter parts ; so that it was evident that, in 
 whatever way the disease extended, at any rate it did not advance by 
 mere continuity of tissue. Sometimes almost the whole of one lobe 
 was thus affected, a few lobules only still retaining a healthy aspect, 
 
 1 In the British and Foreign Medico-Chirurgical Eeview for October, 1853, is a 
 very clear and interesting sketch, by Dr. TVillshire, of the progress of knowledge 
 with reference to pneumonia, and conditions of the lung resembling it in early life. 
 
COLLAPSE OF LUNG. 249 
 
 and crepitating under the finger ; and it often happened that the bron- 
 chi leading to it were full of mucus or pus, while at other times there 
 was marked congestion of the lung; and in the midst of this congested 
 tissue were two or three solid hepatized patches. All these circum- 
 stances, as it may be conceived, variously modified the morbid appear- 
 ances. In the last case the lobular pneumonia was thought to be be- 
 coming generalized; or, in other words, the inflammation originally 
 limited to certain lobules was supposed to have begun to extend to the 
 adjacent tissues, constituting a kind of transition state between lobular 
 and lobar pneumonia. The lower edge of the different lobes, the whole 
 of the middle lobe of the right lung, and often a very considerable por- 
 tion, or the whole of one or other lower lobe, were also sometimes 
 found in a state to which, among other names, that of carnification was 
 applied, on account of its close resemblance to a piece of muscular tis- 
 sue. A portion of carnified lung showed the closest possible similarity 
 to a lung that had been compressed by effusion into the pleura. It 
 was dark, tough, solid, contained no air, presented a smooth surface 
 when cut, yielded a small quantity of bloody serum when pressed, and, 
 indeed, seemed almost like a piece of flesh ; in all which respects it 
 resembled a portion of lung hepatized by lobular pneumonia, and dif- 
 fered from the lung of the adult when that has been rendered solid by 
 inflammation. 
 
 The course of the disease in many of these cases during the lifetime 
 of the patient, and the results of medical treatment, tended to enhance 
 the difficulties which the above-described anatomical peculiarities 
 placed in the way of referring lobular pneumonia to the same category 
 of affections with the pneumonia of the adult. Venesection, leeches, 
 and mercurials, the ordinary antiphlogistic apparatus in the pneu- 
 monia of the adult, often appeared to hasten the child's death ; blisters 
 rarely effected any good, and the blistered surface often showed a re- 
 markable indisposition to heal. On the other hand, emetics and rube- 
 facients were frequently of service; a stimulant plan of treatment was 
 almost always necessary at an early period, and sometimes seemed to 
 be required nearly from the outset of the affection. The rapidity of 
 the changes that took place in the physical condition of/ the lung was 
 another peculiarity which rendered the nature of the affection still 
 more obscure ; for where air was heard entering freely on one day, none 
 would be perceptible on the morrow, but percussion of that part of the 
 chest would yield a sound of complete dulness. On the other hand, it 
 happened sometimes, though much less often, that dulness was suc- 
 ceeded just as quickly by resonance on percussion, and that breathing 
 became distinctly audible where on the previous day no sound of air 
 was to be heard. 
 
 Nothing 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 concur- 
 rent testimony of every one that neither in its progress nor in its results 
 was it similar to inflammation of the lungs in the adult, much less 
 identical with it. Having, however, once been called pneumonia, 
 
250 RESEARCHES OF BAILLY AND LEGENDRE 
 
 every person continued to call it so, though often with a full recogni- 
 tion of its peculiarities. Even the close resemblance which the lung 
 presented to foetal lung, or to those undilated portions which are char- 
 acteristic of atelectasis, was noticed and discussed by myself, and by 
 many far better observers, apparently without a suspicion that both 
 states were identical. 
 
 But while the peculiarities of lobular pneumonia were thus gener- 
 ally commented on, it seems strange that no one should have had 
 recourse to the experiment of inflation in order to obtain a solution of 
 some of the difficulties that existed with reference to its nature. This 
 oversight seems the more extraordinary, when we call to mind that 
 this very means had cleared up so many doubts concerning appear- 
 ances in the lungs of new-born infants, which had once been supposed 
 to be the result of pneumonia in the foetus, or of some arrest of devel- 
 opment. At length the experiment was tried by MM. Bailly and 
 Legendre, 1 and though, as in the old tale of Columbus and the egg, 
 the thing seems so obvious that there is some risk of our underrating 
 the merit of those who were the first to do it, it must not be forgotten 
 that, by that simple means, they have thrown more light on the affec- 
 tions of the lungs in infancy and childhood, than all the writers of the 
 previous ten years together. 
 
 MM. Bailly and Legendre state, as the result of their observations, 
 that the appearances to which the name of lobular pneumonia has 
 commonly been given are in reality produced by an occlusion of the 
 pidmonary vesicles. This occlusion, say they — and the correctness of 
 their opinion is now universally admitted — is due to the inspiratory 
 power having been inadequate to overcome that elasticity of the lung, 
 which I described to you in my last lecture as constantly tending to 
 empty the pulmonary vesicles of air, and constantly impeding its en- 
 trance. Coupled with this, however, there is another cause, the full 
 influence of which had not been recognized till dwelt on by Professor 
 Gairdner, of Glasgow, 2 namely, the presence of the secretions in the 
 bronchi, and the obstacle which they present, sometimes at one point 
 and sometimes at another, to the admission of air. The child inspires, 
 and the secretion, which it could neither expectorate nor expel by 
 coughing, closes the entrance to some small bronchial tube. With the 
 succeeding expiration, a little of the air retained behind this obstacle 
 escapes, and on the next occasion a little more, till at length no single 
 inspiratory effort having been strong enough to surmount the obstruc- 
 tion, while with each expiration the quantity of air behind it is lessened, 
 the vesicle collapses, and its situation is betrayed by the small, dark, 
 depressed spot which may be seen on the surface of the lung, and felt 
 solid or non-crepitant beneath the finger. 
 
 In bronchitis, where this secretion is abundant, perhaps excessive, 
 the obstacle to the entrance of air which thence arises becomes, in the 
 case of young children, a very serious source of danger, and the pos- 
 
 1 Nouvelles Kecherches sur quelques Maladies du Poumon ; in the Arch. Gen. 
 de Med., Jan., Fev., Mars, 1844. 
 
 2 On the Pathological Anatomv of Bronchitis, &c. : reprinted from the Monthly 
 Journal of 1850 and 1851. 
 
ON COLLAPSE OF THE LUNG. 251 
 
 sible occurrence of collapse of the lung must make you very guarded 
 in the expression of your prognosis, even when the symptoms do not 
 appear to be formidable. In such cases, too, the congestion of the 
 pulmonary tissue, and the consequent pressure of the gorged vessels 
 on the air-cells, both favor their collapse and impede their expansion. 1 
 
 But besides these cases, in which the collapse of the lung becomes a 
 grave, perhaps even a fatal complication of disease already existing, 
 there are others in which this condition occurs independently of any 
 affection of the air-passages, and destroys life suddenly and unexpect- 
 edly. If from any cause the inspiratory powers are feeble, the obstacle 
 in the air-tubes need be but very slight in order to produce collapse — 
 need, certainly, be nothing more than may be presented by the gradual 
 accumulation in the bronchi of their natural secretions ; while in some 
 instances, such as the one which I will now relate to you, the collapse 
 of the lung may be considerable, though the bronchi may contain no 
 appreciable amount of secretion. 
 
 A little girl was attacked, when a month old, by very severe diar- 
 rhoea, which lasted for three weeks, and then left her greatly exhausted 
 and much emaciated. No return of the purging occurred, and the 
 child lived, though in a state of great weakness, till she was five 
 months old. For the last five weeks of her life she was under my 
 care, and sometimes she seemed, for a day or two, as if she were gain- 
 ing strength and might recover; but these signs of improvement were 
 never of long duration. Three days before she died, her breath grew 
 suddenly hurried ; the dyspnoea was not attended with any cough, but 
 from the time of its coming on, the child's exhaustion increased, and 
 her respiration grew more rapid until her death. 
 
 No organ showed any sign of disease, but all presented a most re- 
 markable degree of anaemia. Two-thirds of the upper, and almost the 
 whole of the lower lobe of the right lung, were dark, solid, and non- 
 crepitant ; and a few lobules of the left lung presented the same ap- 
 pearance. Inflation restored them to exactly the same state as 'the rest 
 of the lungs. The bronchi were preternaturally pale, and contained 
 no secretions. It is not possible to say why the child's inspiratory 
 power grew too feeble to fill the lungs at one moment rather than at 
 another, but few would doubt that it had become so just at the time 
 when the dyspnoea occurred. A portion of the lung having become 
 collapsed, the elastic ribs tended to render abortive any faint effort to 
 draw in more breath, and thus the vital flame went out for want of air 
 to feed it. 
 
 Sometimes the occurrence of this condition is long preceded by in- 
 dications of the imperfect performance of the respiratory functions, but 
 yet they go on sufficiently to keep the machinery of life in motion, till 
 some trivial, perhaps some inappreciable cause — a draught of cold air, 
 a little overexertion, the horizontal posture too long continued, the 
 
 1 With reference to this point, there are some conclusive experiments of MM. 
 Killiet and Barthez, recorded in vol. i, p. 427, note, of the second edition of their 
 work on Children's Diseases. 
 
252 CASES OF COLLAPSE OF THE LUNG. 
 
 customary food delayed an hour beyond the usual time — sinks them 
 so low that they soon cease forever. 
 
 Some time ago I saw a little girl ten months old, who had lost her 
 mother soon after her birth, and had been indebted to a stranger for 
 what should have been a mother's care. She never throve ; her chest 
 presented that peculiar malformation commonly called pigeon-breast, 
 and that circular constriction around the base of the thorax, which 
 used to be regarded as due to the direct action of the diaphragm draw- 
 ing in the receding parts at each contraction ; but which Sir W. Jenner's 
 careful observations have shown to be produced by atmospheric pres- 
 sure acting on the chest-walls just above the upper margin of the liver, 
 spleen, and stomach. 1 But though she was a backward child, and 
 though her respiration was always almost as abdominal as that of a 
 new r -born infant, there was no definite evidence of disease till she was 
 nine months old. She then lost flesh rapidly, and began to cough 
 without having had any previous catarrh. Her case seemed to be one 
 of bronchial phthisis. 
 
 Four days before she died her breath suddenly became much op- 
 pressed, and her cough far more severe than it had been before. The 
 dyspnoea rapidly increased, but her cough soon grew less frequent A 
 few hours before her death her lips were quite livid ; she was breath- 
 ing from 80 to 86 times in the minute, the abdominal muscles acting 
 most violently, but the chest being scarcely at all expanded. Ausculta- 
 tion detected nothing more than some rather large mucous rale in the 
 lung. 
 
 After death no tubercle was found in any organ, but large portions 
 of both lungs presented the undilated condition, which disappeared 
 entirely on inflation. The bronchi were pale, and contained very little 
 mucus, but the right side of the heart was greatly distended with 
 coagulated blood, which its thin, pale, and flaccid substance had evi- 
 dently been unequal to propel with the requisite vigor. 
 
 The imperfect respiration had here for some time manifested itself; 
 the vital powers had long been feeble ; nutrition had been ill perform- 
 ed, and the heart itself had shared in the general feebleness, till at 
 length the secretion of a comparatively small amount of mucus pre- 
 sented an obstacle to the free entrance of air, which, though slight in 
 itself, was greater than the child could overcome; and the whole 
 machinery of life was thus suddenly brought to a standstill. 
 
 In both of these cases the feebleness of the inspiratory power was 
 one chief cause of the collapse of the lung. The result is the same, 
 however, if the obstacle is increased, as if the power is diminished ; 
 and hence, as I have already mentioned, the supervention of this state 
 of lung becomes one of the most perilous, while it is one of the most 
 frequent complications of infantile bronchitis. A little girl, previously 
 quite healthy, was seized when ten months old with symptoms of 
 acute bronchitis, suffocative cough returning in paroxysms, and some- 
 
 1 The commonly received explanation of the mechanism by which this deformity 
 of the chest is produced is given by MM. Rilliet and Barthez, op. cit., vol. i, p. 45. 
 The careful observations of Sir W. Jenner are contained in his Lectures on Rickets, 
 in Med. Times, March 17, 1860, p. 262. 
 
COLLAPSE PRODUCED BY SAME CAUSES AT ALL AGES. 253 
 
 times followed by the rejection of a muco-purulent fluid. The symptoms 
 throughout did not seem to allow of depletion ; but ammonia, with 
 decoction of senega and tincture of squills, and other expectorants of a 
 stimulating kind, were given with temporary amendment. The child 
 did not, however, appear to have undergone any marked change, either 
 for better or worse, except that she had certainly lost both flesh and 
 strength, when coldness, faintness, and exceedingly labored respira- 
 tion suddenly came on, and continued till her death, which took place 
 in the course of twenty-four hours. 
 
 A few recent adhesions were found on each side of the chest, between 
 the costal and pulmonary pleura. The trachea contained a large 
 quantity of muco-purulent matter, and the same secretion abounded in 
 the bronchial tubes, many of which were filled by it, while nowhere 
 did air-bubbles appear intermixed with it. There was some conges- 
 tion of both lungs, especially posteriorly ; the upper and posterior part 
 of the upper lobe of the right lung, the whole of the middle lobe, and 
 the posterior part and lower edge of the lower lobe, were dark, solid, 
 non-crepitant, and depressed below the adjacent tissue. The same 
 state existed in the whole inferior third of the upper lobe, and the 
 lower edge of the lower lobe of the left lung. On inflating the lung, 
 most of these parts were restored to a perfectly natural condition, but 
 some patches still remained less dilated than the others, and some of 
 the darker, almost violet-colored portions of the lower lobes appeared 
 but little affected by it. 
 
 But you may naturally inquire whether any occurrence of a similar 
 kind is ever met with in the adult, since there is certainly no such pe- 
 culiarity in the structure of the lung in childhood as should render it 
 then exclusively liable to a morbid process from which at all other 
 ages it is exempt. My own experience would not have enabled me to 
 answer this question ; but my lamented friend Dr. Baly communicated 
 to me some years ago the particulars of three cases in which he found 
 large portions of tire lung in the adult presenting the characters that 
 we have been studying in the child, and, like it, resuming a natural 
 appearance on the insufflation of air into the bronchi. The patients 
 in all of these cases died of fever, attended with dysenteric symptoms; 
 and for some days before their death were in a state of great exhaus- 
 tion, such as appeared to indicate the free employment of stimulants. 
 In two instances distinct dyspnoea occurred some days previous to 
 death ; but though the chest lost its resonance in the situation of the 
 affected parts of the lung, and the breathing there was deficient, yet 
 the minute crepitation of pneumonia was not detected in either case, 
 but merely some mucous rale. In addition to extensive disease in the 
 intestines, this collapsed condition of portions of the lung was found; 
 unconnected with any disease of those organs in one of the cases, com- 
 bined with the effusion of tenacious mucus in the bronchi leading to- 
 wards the collapsed portions in a second, and associated with true 
 pneumonia and a state of red or gray hepatization of other parts in a 
 third. 1 
 
 1 The minute accuracy of Dr. Baly's description induces me to subjoin the fol- 
 lowing particulars of one of the examinations: "No effusion, lungs healthy, ex- 
 
254 COLLAPSE OF THE LUNG IN THE ADULT. 
 
 But these are by no means isolated cases ; for it would seem that in 
 some diseases which are attended by much depression of the vital 
 power, this collapse of the lungs is by no means unusual. To adduce 
 but one illustration of the fact, it may be mentioned that M. Louis 1 
 found in nineteen out of forty-six post-mortem examinations of patients 
 who had died of typhoid fever, a condition of the lungs which he calls 
 " carnification," and which it is evident (although he did not try the 
 effect of inflation) was identical with the state so frequent in the child. 
 He describes the parts thus affected as of a deep purple-red, having lost 
 the natural suppleness of the lung, being solid and sinking in water : 
 they were, moreover, tougher than healthy lung ; if divided, the sec- 
 tion became covered with a reddish fluid, perfectly destitute of air, 
 while the tissue neither resembled that of healthy lung, nor presented 
 the peculiar granular appearance characteristic of lung in the second 
 stage of pneumonia. More recently, too, Professor Gairdner, in his 
 very important essays on the pathological anatomy of bronchitis, al- 
 ready referred to, has mentioned this condition of the lungs as having 
 been of frequent occurrence during the epidemic fever of 1847. 
 
 It is true, however, that in these cases the condition of the lung was 
 merely superadded to other lesions in themselves adequate to occasion 
 the patient's death ; and hence, though interesting to the mere patholo- 
 gist, it yet loses much of its value in the eyes of the practical physician. 
 But it will not seem to you that too much stress has been laid on this 
 state, if it should appear that whenever the power of the inspiratory 
 muscles is much diminished there is a tendency to its supervention, so 
 that it alone may be the cause of death ; and this, which I have put 
 hypothetically, really does occur in old age. 
 
 The term " second childhood " is not a mere figure of speech, ex- 
 pressive solely of the decay of the mental powers, by which the even- 
 ing of life is obscured and made like the twilight of the mind in early 
 infancy, but it is in many points the statement of a physical truth. 
 Thus, as old age creeps on, and the nutrition is n# longer adequate to 
 supply the waste, the respiration loses the character which it presented 
 in the adult, and the extremes of life in this respect present a close re- 
 semblance to each other. The muscles of the chest grow too feeble to 
 dilate it fully ; the diaphragm becomes, as it was in early infancy, the 
 principal inspiratory muscle, and the vertical diameter of the thorax 
 is that in which its chief enlargement takes place. The ear applied to 
 
 eept in lower and posterior fourth of right inferior lobe, which is of a dark purple 
 color, is depressed somewhat below the level of other parts, does not crepitate, 
 feels solid, but flexible and tough, almost leathery, and sinks quickly in water : 
 the part having these characters is distinctly defined by boundaries of lobules. The 
 whole lung being inflated, the part just described receives air with greater difficulty 
 than the other parts, but at length becomes distended lobule by lobule, and assumes 
 the same pale red color as the rest of the lungs. The change takes place, as has 
 been stated, lobule by lobule, separate lobules appearing suddenly of the paler color, 
 not merely at the margins of the dark mass, but also in its centre On cutting 
 through the lungs and tracing the bronchi, it is found that the ramifications of 
 those tubes which go to the dark, contracted, and condensed parts are filled up with 
 tough mucus, from which those going to other parts are Iree." 
 
 1 Kecherches sur la Gastro-enterite., 8vo., Paris, 1829; tome i, pp. 361-364. 
 
COLLAPSE OF THE LUNG IN THE AGED. 255 
 
 the chest no longer detects the puerile breathing of youth, nor the clear 
 vesicular murmur of manhood; but the respiration is coarser, some- 
 times almost bronchial. There is not occasion, as in infancy, for more 
 rapid breathing to maintain the high activity of the vital processes, 
 but the wornout machinery needs to be put in motion more frequently 
 than in the adult, in order to obtain oxygen enough to support exist- 
 ence; and, accordingly, MM. Hourman and Dechambre 1 found the 
 average frequency of the respiration in 252 old women at the Salpe- 
 triere to be 21.79 in the minute, while in some whose frame seemed 
 most decayed it was far more rapid. Just as in infancy, too, so in old 
 age these respiratory movements are most irregular. Sometimes the 
 parietes of the thorax continue for a long time motionless, and then 
 there succeed a series of rapid movements, while at other times the in- 
 tervals between the inspirations are irregular, but the inspiratory 
 movements are of the same intensity and duration. Here, then, with- 
 out pursuing the comparison further, we have ample proof of the 
 many points of resemblance between the physiological condition of the 
 respiratory function in early life and in old age. The respiratory 
 organs, too, in their pathological state, present, as might be expected, 
 the same resemblance; and, accordingly, MM. Hourman and Decham- 
 bre 2 notice a state in which the pulmonary parenchyma is of a very 
 deep, sometimes almost of a blue color, or nearly black, non-crepitant, 
 and presenting a smooth surface on a section of it being made. The 
 lung thus altered is often remarkably tough, almost like india-rubber ; 
 while under pressure, a viscous fluid, generally of a reddish color, and 
 containing no air-bubbles, exudes from it. The idea of inflating the 
 lung had not occurred to these observers ; but they remark, that if 
 portions of lung presenting these characters are dried, the air-cells have 
 a tendency to reappear without having undergone any other change 
 than a well-marked contraction. 
 
 I have dwelt long on this pathological condition, though I think not 
 longer than its importance demands ; because we shall find that in some 
 form or other it presents itself, modifying the symptoms, determining 
 the prognosis, and influencing the treatment of almost all the affections 
 of the lung in early infancy. 
 
 I do not know where more appropriately than here to introduce a 
 brief mention of an affection about whose nature there has been much 
 controversy, and concerning which much obscurity still exists; although 
 there is a marked connection between it and imperfect performance of 
 the respiratory function. Though very rare in this country, indura- 
 tion of the cellular tissue is extremely common in the foundling hospitals 
 of the Continent, where so many causes contribute to depress the new- 
 born infant's feeble powers; and I may add, that it happens there with 
 far greater frequency in the winter than in the summer months. The 
 children in whom it occurs are usually w T eakly, not seldom premature, 
 and its first symptoms generally appear between the first and fifth day 
 
 1 The above facts with respect to respiration in the aged are derived from the in- 
 teresting papers of MM. Hourman and Dechambre, in the Arch, de Med. for 1835 
 and l>-36. See especially the number for Nov. 1835. 
 
 2 Op. cit, Mars, 1836, p. 272. 
 
256 INDURATION OF THE CELLULAR TISSUE. 
 
 after birth, though occasionally they do not come on till later. In 
 many instances a livid redness of the whole surface is obvious from 
 birth ; but the appearance of a circumscribed hard spot on one or other 
 extremity, or on some prominent part of the face, as the end of the 
 chin, or the cheek-bone, is the first sign of the commencement of this 
 affection. Other spots of a similar kind are soon discovered on differ- 
 ent parts of the surface; and the body generally, and the hardened spots 
 in particular, are found to present a temperature much below the natu- 
 ral warmth of the body. It appears, indeed, from M. Roger's re- 
 searches, 1 that a general redaction of the temperature precedes the 
 induration, or, at least, exists in a very marked degree, while the indu- 
 ration is still extremely slight. Sometimes, too, the premonitory loss 
 of temperature 2 may be perceived in weakly children without being 
 succeeded by the appearance of spots of induration. This, however, is 
 exceptional, and in the majority of instances the sinking of the tem- 
 perature and the extension of the induration advance together, and the 
 warmth of the surface may eventually fall from 100° to 90°, 80°, or 
 even lower. If the induration becomes very extensive, it affects the 
 integuments of the chest and the abdomen, as well as the extremities, 
 and the body feels cold and stiff as though it were frozen. 
 
 This condition is, as might be expected, attended with great impair- 
 ment of the general health, and with a very remarkable degree of 
 emaciation. 3 Children suffering from it are extremely weak, often too 
 weak to suck : their pulse is very small, their respiration abdominal, 
 and their cry is faint and whimpering, wholly unlike that of a healthy 
 infant. In some of the worst cases, too, a bloody fluid is discharged 
 in considerable quantity from the nose and mouth. If the indurated 
 parts are punctured, a small quantity of reddish serum escapes from 
 them, though generally without much diminution of their previous 
 hardness. 
 
 If the induration is at all general, death almost invariably takes 
 place ; and so great is the fatality of the affection, that, including even 
 slight cases, five-sixths of those children who are attacked by it in the 
 hospitals of Paris, die. In very slight cases, however, if the infant is 
 at once placed in favorable circumstances, recovery need not be de- 
 spaired of. 
 
 The hardness of the surface still persists after death, and the absence 
 of any peculiarity in the effused serum, or of any sign of active disease, 
 left writers generally in much perplexity as to its cause. The venous 
 system is usually found gorged with fluid blood, and this congestion is 
 often apparent in the cerebral vessels, as well as in those of the abdom- 
 
 1 Op. cit., pp. 124-151. See also his more recent and more extended observations 
 in his Kecherches Cliniques, &c., pp. 405-428. 
 
 2 Hervieux, Sur l'Algidite progressive des Nouveaux-Nes, in Arch. Gen. de Med., 
 Nov. 1855. Also an essay by Dr. Loschner of Prague on the same subject, in the 
 Jahrbiicher fur Kinderheilkunde, vol. i, p. 91. 
 
 3 In a paper by M. Elsasser, of Stuttgard, reprinted in the Archives de Medecine 
 for May, 1853, from the Archiv. f. physiolog. Heilkunde. are some very interesting 
 facts with reference to the loss of weight in the course of this aifection. The aver- 
 age loss of weight in 53 fatal cases, was f of a pound : the extremes each way being 
 six ounces and two pounds. 
 
INDURATION OF THE CELLULAR TISSUE. 257 
 
 inal viscera, particularly the liver. Both the thorax and abdomen also 
 frequently contain a quantity of serum, often tinged with blood — effu- 
 sions which are evidently of a passive nature, since they are unattended 
 by any trace of inflammation either of the pleura or peritoneum. None 
 of the viscera present any morbid appearances of half so much impor- 
 tance as those which are met with in the lungs, a very great part of 
 which displays, those changes to which your attention has already been 
 directed as characteristic of their deficient expansion. 1 This condition 
 of the lungs had been noticed and most carefully described many years 
 ago, as one of the most striking attendants on induration of the cellu- 
 lar tissue. It was thought by some of those who described it to be the 
 result of pneumonia ; while other observers, justly insisting on the ab- 
 sence of the other effects of inflammation of the pulmonary tissue, yet 
 drew the attention of pathologists too much away from the chest, where 
 the clue to the solution of the question as to the cause of the affection 
 was to be found, had they but known how to use it. We, however, are 
 aware that many of those appearances once thought to be the result of 
 pneumonia are in reality due to the unexpanded condition of the lung; 
 and we can understand how it may happen, if children are exposed to 
 cold immediately 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 im- 
 perfectly 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 passive effusions into the great 
 cavities of the body, and to an anasarcous swelling of the surface. I 
 w r as once disposed to look upon this state of the lungs as furnishing 
 the clue to all the phenomena of induration of the cellular tissue. But 
 the theory must, for several reasons, be given up as untenable, at least 
 in the sense of its affording a constant and sufficient explanation of the 
 causes of the affection. In the first place, changes in the pulmonary 
 tissue are not constant, but are found only in about half of the cases ; 
 secondly, in many instances they seem to be consequences rather than 
 causes ; in the third place, while the changes are distinctly not pneu- 
 monic, they are far from being constantly those of mere collapse, but 
 are at least as often those of intense congestion, sometimes even ofpul- 
 
 1 The observations of J. A. Troccon, in his dissertation " Sur la maladie connue 
 sous le nom d'endurcissement du tissu cellulaire,''' 4to., Paris, 1814, are especially- 
 remarkable, since he not only described with accuracy the physical condition of the 
 lungs, but even tried the experiment of inflating them, in order to prove that they 
 were not, as had been erroneously supposed, in a state of gangrene. He says : " J'ai 
 insuffle ensuite de Pair dans les poumons par la trachee: aussitotla couleur noire qui 
 etait a leur base s'est changed en une couleur rouge claire, laquelle s'est etendue de 
 proche en proche a mesure que je continuais ces insufflations." After removing a 
 ligature which he had applied around the veins, and allowing the escape of the 
 blood with which the heart and lungs were gorged, he resumed the inflation of the 
 lungs and " les organes de la respiration ont 6ie presque de suite dans un etat ab- 
 solument naturel, et aussi beaux que ceux que Ton voit pendus devant nos bou- 
 cheries " (pp. 37-8). 
 
 It seems strange that neither M. Troccon nor subsequent observers perceived the 
 full bearing of these experiments till similar ones were instituted by MM. Baily and 
 Legendre. 
 
 17 
 
258 TREATMENT OF INDURATION OF THE CELLULAR TISSUE. 
 
 monary apoplexy. 1 Further, one must not forget that while pulmonary 
 collapse takes place in various circumstances, induration of the cellular 
 tissue is limited, or almost limited, to large public institutions ; and 
 further, that the extraordinary depression of temperature by which it is 
 accompanied is observed in no other condition whatever, not even in 
 Asiatic cholera. 
 
 I need not add, for you will have made the reflection for yourselves, 
 that truth and knowledge are much better served by a recognition of 
 a problem as unsolved, than by straining a plausible explanation be- 
 yond the limits that it will bear. ,- -^ 
 
 The treatment of this affection implies the removal of every cause 
 likely to induce it. Hence warmth stands foremost both as a curative 
 and as a preventive measure. The warm bath may be resorted to as 
 a means of raising the child's surface to a proper temperature, provided 
 its extreme weakness do not contraindicate that measure. Gentle fric- 
 tion with warm oil is a means which has been tried for this purpose 
 with advantage. The child should be nourished with breast-milk, 
 even if it is too feeble to suck, and stimulants, of which white-wine 
 whey is a very good one, will in many instances be needed. Defective 
 respiration being the ultimate source of all the symptoms, the main 
 principles of all your treatment must be the same as have already been 
 laid down for your guidance in cases of atelectasis of the lung ; and 
 these it can hardly be necessary to recapitulate. 
 
 I should have said more about this affection, its nature and treat- 
 ment, if it were one with which you were likely to meet often ; but, in 
 consideration of its extreme rarity in this country, I may perhaps be 
 excused for passing it over with this cursory notice. 
 
 1 Koger, Kecherches, &c, p. 411 ; and a paper on Pulmonary Apoplexy in the 
 New-born Infant, read by M. Hervieux before the Paris Association of Hospital 
 Physicians, in July, 1863, and published in the J. f. Kinderkr. for 1864, vol. xlii. 
 p. 247. One must also not overlook the fact that the lungs in M. Troccon's experi- 
 ments were gorged with blood, in other words intensely congested, and that it was 
 only after the removal of a ligature, to allow the escape of the blood, that they 
 assumed a perfectly natural appearance. 
 

 INFLAMMATION OF THE RESPIRATORY MUCOUS MEMBRANE. 259 
 
 LECTURE XIX. 
 
 Inflammatory Affections of the Eespiratory Mucous Membrane. — Com- 
 parative rarity of catarrh during the first weeks of life — Coryza— Simple and 
 pseudo-membranous or malignant — Identity of latter with nasal diphtheria — 
 Catarrh, causes adding to its importance in early life — Its treatment — Danger 
 of bronchitis or pneumonia. 
 
 Post-mortem appearances of bronchitis— Kedness of the membrane — Nature of the 
 contents of the bronchi — Dilatation of their cavity — Extension of the inflam- 
 mation to the lining of the pulmonary vesicles, producing vesicular bronchitis. 
 
 State of the lungs in bronchitis — Frequency of congestion — Carnifieation of some 
 lobules — Possible extension of inflammation to the pulmonary tissue, producing 
 lobular pneumonia — Suppuration of these patches, producing vomicae. 
 
 Although two lectures have already been devoted to the pathology 
 of the respiratory organs, yet, until to-day, we have not been able to 
 commence the study of their special diseases. 
 
 They may be divided into the three grand classes — of the inflamma- 
 tory, the nervous, and those which result from morbid deposits. 
 
 We will examine these in the order in which I have enumerated 
 them. 
 
 At every age inflammatory affections of the respiratory mucous mem- 
 brane exceed all others in frequency; and even when the pulmonary 
 substance becomes eventually involved, it is often by the extension to 
 it of mischief which began in the mucous membrane. Bat in infancy 
 and childhood this is pre-eminently the case, for the delicate and highly 
 vascular lining of the respiratory organs resists but feebly the influence 
 of noxious impressions from without, while it sympathizes most acutely 
 with many morbid processes within. 
 
 This extreme susceptibility of the mucous membrane of the respira- 
 tory organs in childhood renders its disorders of very frequent occur- 
 rence, while we are compelled to study closely the signification of 
 symptoms that may betoken disturbance from such various causes. 
 Something of this sympathy with the affections of other parts exists 
 even in the adult, as we may see exemplified in the cough that attends 
 upon affections of the liver ; but in the child the sympathetic disorder 
 of the respiratory mucous membrane is vastly more frequent; and 
 nurses, taught by experience, will speak to you about a tooth-cough, a 
 stomach-cough, a worm-cough ; while you will soon find for yourselves 
 that the intestinal mucous membrane is seldom affected without that of 
 the respiratory apparatus suffering too. 
 
 It is a curious fact, however, to which Professor Jorg of Leipsic 1 
 was the first person to call attention, that this extreme susceptibility of 
 the lining of the respiratory apparatus does not exist to the same degree 
 during the first month or two of life as it does afterwards. The ex- 
 
 1 Handbuch der Kinderkrankheiten, 8vo., Leipsig, 1836, p. 531. 
 
260 INFLAMMATION OF THE RESPIRATORY MUCOUS MEMBRANE. 
 
 posure of an infant two or three weeks old to a low temperature or to 
 a vitiated air, will be followed by disturbance of the function of the 
 liver, and the occurrence of jaundice ; or, perhaps, by such depression 
 of the muscular power as to render the child incapable of taking a full 
 inspiration, so that its lungs collapse, and it dies from disorder of the 
 respiratory organs, but without the cough or bronchitic symptoms, 
 which would not fail, if it were a little older, to announce the irritation 
 of the mucous membrane of the air-tubes. Why this is so I do not 
 know, but I suppose it to be the result of the generally feeble vitality 
 which renders the lining of the bronchi less susceptible ; just as that of 
 the intestine also seems to be at the same period ; since, while consti- 
 pation is frequent, diarrhoea is comparatively rare during the first two 
 months of life. 
 
 The mucous membrane of the nares, however, has not by any means 
 this insensibility, and coryza is an affection most frequent, and most 
 important, during the first two months of life, when the other forms of 
 catarrh are comparatively rare. 
 
 This aifection, in its most frequent form, is a source of discomfort 
 rather than of danger. Its most prominent symptom has given rise to 
 its vulgar name of " the snuffles ;" for, the mucous membrane of the 
 nares being swollen, the child is no longer able to breathe through its 
 nose as it was wont to do, but is compelled to breathe likewise through 
 its mouth, and its difficult inspirations are attended by a peculiar snuf- 
 fling noise, which, during sleep, sometimes amounts to a complete 
 snore. As rn common catarrh, the secretion from the membrane is at 
 first suppressed, afterwards it flows in an increased quantity, and then 
 at length it is altered in character, and becomes thicker and puriform ; 
 when it sometimes dries and forms crusts about the nostrils, which in- 
 terfere greatly with free respiration, and cause the child much annoy- 
 ance. At the outset there is often a degree of heat of skin and febrile 
 disturbance, but these symptoms soon subside, and, with the exception 
 of the snuffling respiration the child seems quite well. If the attack 
 is more severe, however, it may occasion a good deal of suffering ; for 
 if respiration through the nose is very much impeded or altogether pre- 
 vented, the child is rendered unable to suck, and so soon as it has seized 
 the nipple and begun to draw the milk, it is compelled to leave it in a 
 state of threatening suffocation. Its distress, too, is further increased 
 by the circumstance that its mouth, being constantly kept open in order 
 to breathe, the tongue and throat become extremely dry, and degluti- 
 tion, even when the child is fed with a spoon, is often attended with 
 difficulty. Any such severity of the disease, however, is very unusual, 
 though such cases do sometimes occur, and even prove fatal ; the diffi- 
 culty of breathing and sucking together wearing out the patient. In 
 the great majority of instances indeed when this event occurs, something 
 more exists than a simple inflammation of the Schneiderian membrane, 
 since it either secretes a very tenacious mucus in extreme abundance, 
 or becomes coated with false membrane, which sometimes extends even 
 to the tonsils and palate. Cases of this kind are usually associated 
 with extreme depression of the vital powers, and have received oil this 
 account the name of coryza maligna. I have no doubt of their identity 
 
CHRONIC CORYZA AND CATARRH. 261 
 
 with diphtheria, of which they constitute the form known as nasal 
 diphtheria ; though some thirty years ago, when diphtheria was a com- 
 paratively unknown disease, their real nature did not strike me as it 
 does now. I shall therefore leave them out of consideration at present, 
 and confine my remarks to that simple coryza which, as I have stated, 
 is usually a source of discomfort rather than a cause of danger. 
 
 This simple coryza calls for but little treatment, and indeed, treat- 
 ment appears to exert but little influence over it. It is desirable, 
 however, if there is much difficulty in breathing, that the child be 
 taken from the breast, though it may still be fed with its mother's 
 milk by means of a spoon, since the fruitless efforts to suck aggravate 
 its distress, and should therefore be prevented. 
 
 If heat of skin and other indications of fever attend its onset, some 
 mild diaphoretic medicine, with a few drops of ipecacuanha wine, may 
 be given : l attention must be paid to the state of the bowels, and in 
 the course of ten days or a fortnight the infant will be found again 
 breathing quietly, and the disease w T ill have subsided. As the secre- 
 tion becomes thicker, care must be taken to prevent its accumulating 
 and drying at the opening of the nostrils, by which it would cause 
 serious discomfort to the child. 
 
 Cases are sometimes met with, in which coryza, though not of a 
 severe kiud, is troublesome by its continuance for weeks together. 
 This chronic coryza is, I believe, almost always connected with a 
 syphilitic taint. I have on several occasions met with it when there 
 were not above one or two spots of copper-colored eruption to mark its 
 character ; and a few instances of it have come under my notice in 
 which no positive evidence of< venereal taint, either past or present, 
 could be obtained, but which nevertheless got well under the use of 
 small doses of the Hydrarg. c. Creta. 
 
 With the increasing age of the infant there is a growing liability to 
 catarrh, and during the period of dentition the susceptibility of the 
 mucous membrane of the respiratory organs appears to have attained 
 its maximum. Slight variations of temperature now induce catarrhal 
 seizures ; or even, independently of any such exciting cause, the mere 
 approach of a tooth towards the surface of the gum often gives rise to 
 its symptoms, which subside when the source of irritation ceases. 
 Such attacks often alternate with attacks of diarrhoea, or the two co- 
 exist ; the symptoms of disturbance of the intestinal mucous mem- 
 brane, predominating at one time, those of disturbance of the respira- 
 tory membrane at another. The preponderance of one or the other 
 affection seems much to depend on atmospheric causes ; and children 
 who, during the months of June, July, August, and September, would 
 suffer from diarrhoea, will in precisely similar circumstances in the 
 
 * (Xo. 8.) 
 R. Liq. Am. Acet., ^j. 
 Vim Ipecac, ^xvj. 
 Pot. Xitratis, gr. viij. 
 Syr. Tolutan., ^ij. 
 Mist. Amygdala?, ad ^j. M. 
 A teaspoonful every four hours. For a child six months old. 
 
262 CATARRH — ITS IMPORTANCE IN EARLY LIFE. 
 
 earlier months of spring, or the later months of autumn, suffer from 
 catarrh. From the extreme susceptibility of these two great mucous 
 surfaces arise a large proportion of the ailments, and many even of the 
 serious diseases of infancy. Morbid as well as reparative processes go 
 on most rapidly in early life : the flux of to-day may to-morrow be 
 attended by dysenteric symptoms ; the catarrh of to-day may to-mor- 
 row have put on the grave features of acute bronchitis. 
 
 Xow these two circumstances taken together — the extreme suscepti- 
 bility of the respiratory mucous membrane, and the rapidity with 
 which its trivial disorder sometimes becomes a grave disease — give to 
 the catarrhal affections of infancy an importance such as in more ad- 
 vanced life they do not possess. This importance, too, is still further 
 increased by the tendency of the lung to become collapsed when the 
 entrance of air into its minuter cells is impeded even by a compara- 
 tively trivial cause ; while in other cases, or even in connection with 
 the collapsed condition of the lung, the inflammatory process may 
 invade the pulmonary cells and the general tissue of the lung, and 
 that which had seemed a slight cold may grow to a dangerous bron- 
 chitis, or a still more dangerous pneumonia. 
 
 Of catarrh itself and its general characters, little need be said. Al- 
 lowing for the difference between the ages of the patients, its symptoms 
 are the same as in the adult. Sneezing and running at the eyes and 
 nose, and cough, a hot skin and quickened pulse, attend it. In some 
 children the febrile disturbance with which even a common attack of 
 cold sets in is very severe for the first twenty-four hours or more, and 
 then the more threatening symptoms subside, and the true nature of 
 the affection becomes apparent. At other times, when catarrh is ex- 
 tremely prevalent — epidemic in short — this severe onset is usual ; and 
 the affection closely resembles, or is probably identical with, influenza. 
 Often, too, you will find the commencement of an epidemic of hooping- 
 cough preluded by an unusual prevalence of catarrh, the cough by 
 degrees assuming in more and more numerous cases the paroxysmal 
 character and peculiar sound of pertussis. It is unnecessary to allude 
 to the catarrhal symptoms which precede measles ; but bearing in 
 mind that that which seems to be a mere cold may turn out to be the 
 first stage of a very serious malady, you are furnished with an addi- 
 tional reason for not slighting it. Lastly, you must not forget that 
 the frequent return of attacks of catarrh is sometimes an indication of 
 that irritable state of the bronchial membrane which the abundant de- 
 posit of tubercle in the lungs occasions ; and this, again, yields another 
 argument for not neglecting an apparently trivial ailment. 
 
 While it is your duty, however, on so many grounds, to watch 
 closely every child, although its indisposition may not seem to be 
 more than a simple catarrh, yet in the way of actual medical treatment 
 very little is required. The child must be kept in one temperature ; 
 and, if the nursery is an airy room, it is desirable that it be confined to 
 that apartment. If already weaned, it may be well to withdraw some 
 of the more solid articles of diet ; if not, care must be taken that the 
 child does not, in consequence of its thirst, suck too much ; and a little 
 barley-water should therefore be given it from time to time. A warm 
 
MORBID APPEARANCES OF THE BRONCHI. 2d3 
 
 bath at night will do much to allay the heat of skin ; and, if the febrile 
 disturbance is considerable, a couple of grains of James's powder, with 
 half a grain of calomel, may be given to a child a year old, at bed- 
 time. During the day a mixture, containing a few drops of ipecacu- 
 anha and antimonial wine, with a little of the compound tincture of 
 camphor, if the cough irritates by its frequent return, may be given 
 with advantage ; and, as the fever subsides, the spirit of nitrous ether 
 may be substituted for the antimonial wine. 1 
 
 The danger, however, in these cases, is of a more grave disorder of 
 the air-passages coming on ; and this brings us to a subject which we 
 cannot pass over hurriedly, namely, the bronchitis and pneumonia of 
 infancy and childhood. 
 
 The study of these affections in childhood is beset by some difficul- 
 ties which we do not meet with in the adult. The points of difference 
 between bronchitis and pneumonia are sufficiently well marked in the 
 adult for all purposes of practical utility, although many inquiries 
 may be started with reference to the intimate nature of the morbid 
 processes, which we may be unable to answer satisfactorily. Besides, 
 whether the capillaries, or the pulmonary cells, or their parietes, be the 
 structures first attacked, it is clear that they are all involved in pneu- 
 monia from a very early stage of the disease ; and hence we find it 
 attended from the outset with peculiar symptoms, such as do not 
 occur in bronchitis. 
 
 Pneumonia similar to that of the adult is sometimes observed even 
 in early childhood ; but it often happens that, though the pulmonary 
 substance becomes eventually a partaker in the disease, yet it is not so 
 at first ; but the inflammation, beginning in the larger air-tubes, has 
 passed along them to the smaller bronchi, and then at length involving 
 the tissue of the lnng, the case comes to be one neither of pure bron- 
 chitis nor of pure pneumonia, but a mixture of the two, which has not 
 inaptly been termed bronchio-pneumonia. Another source of difficulty 
 in the study of these affections, as well as an occasion of the great peril 
 that attends them, is the tendency which we have already observed in 
 the lung during early life to become collapsed, and no longer to admit 
 that air without which the changes in the blood cannot take place, and 
 the absence of which naturally aggravates the mischief that the in- 
 flammatory disease itself tends so immediately to produce. 
 
 I must beg you, therefore, to pardon me if I enter rather more 
 minutely than is my custom into the description of the morbid appear- 
 ances produced by inflammation of the lungs and air-tubes in infancy 
 and childhood. 
 
 An increased degree of redness of the mucous membrane of the bronchi 
 
 1 (No. 9.) (No. 10.) 
 
 R. Yin. Ipecacuanhas, tt^x. R. Yin. Ipecac, tijjx. 
 
 Yin. Ant. Pot. -Tart., rr^xxx. Oxym. Scilla?, t^xl. 
 
 Tinct. Camph. co., tt^xx. Spir. zEth, Nitr., tr^xx. 
 
 Mist. Amygdala?, gvij. M. Tinct. Camph. co., ttjjxx. 
 
 Two teaspoonfuls every four hours. Aqua? Anisi, gviss. M. 
 
 Two teaspoonfuls every four hoursi 
 For children of one year old. 
 
26-i MORBID APPEARANCES OF THE BRONCHI. 
 
 is almost constantly observed in the case of children who have died 01 
 inflammation of the lungs or air-tubes. There are three sources of 
 error, however, which it is essential to guard against when examining 
 the bronchi with reference to this point. The first is the occasional 
 disappearance of redness after death, even where the presence of an 
 abundant muco-purulent secretion in the tubes bears evidence to the 
 activity of the inflammatory process ; the second is the apparent red- 
 ness of the smaller tubes in cases where the lungs are congested or 
 inflamed, and which may be due, not to the increased vascularity of 
 the bronchi themselves, but to their transparency allowing that of the 
 subjacent tissue to be seen through them. The third is the occasional 
 staining of the mucous membrane, owing to the transudation of the 
 blood through the coats of the vessels after death. With care, however, 
 none of these conditions will lead you astray. 
 
 The redness of the bronchi varies much both in degree and extent, 
 and in some cases which have approached to the character of pneu- 
 monia rather than of bronchitis, is sometimes limited to the inflamed 
 lobes. In cases, however, in which much bronchitis has existed, very 
 marked redness generally begins about an inch above the bifurcation 
 of the trachea, and pervades all the bronchi, being deeper in the sec- 
 ondary than in the primary tubes, and retaining nearly as great an 
 intensity even in the tertiary branches. It may stop here, or it may 
 extend even into the ultimate ramuscules, or into the pulmonary cells 
 themselves. 
 
 In the majority of cases no other change besides this intense redness 
 is perceptible in the mucous membrane, but sometimes it appears both 
 thickened and softened; and on one occasion, in which a fatal attack of 
 acute bronchitis supervened on a long continuance of the chronic stage 
 of the disease, the bronchial mucous membrane was intensely red, and 
 so thickened as to have an almost villous appearance, and e closely to 
 resemble red velvet. 
 
 Ulceration of the mucous membrane of the trachea and larger bron- 
 chi, which is occasionally met with in the bronchitis of adults, I never 
 observed but once. In that case, a little boy, twenty months old, who 
 had suffered from a not very severe attack of bronchitis, in the course 
 of which, however, he had had occasional difficulty in deglutition, with 
 return of fluids by the nose, died rather suddenly. The only remark- 
 able appearance besides a general redness of the bronchial tubes, con- 
 sisted in the presence of several small excavated ulcerations or erosions 
 in the upper part of the larynx, just above the chordae vocales. 
 
 Associated Avith the changes in the mucous membrane of the bronchi 
 there is an alteration in the character of their secretion. At first, no 
 doubt, this secretion is suppressed, just as we see that furnished by the 
 Schneiderian membrane to be in a common cold ; but afterwards it is 
 poured out abundantly, and next ceases to present its natural characters 
 of a glairy mucus ; becoming opaque, thick, puriform, or actually pur- 
 ulent, while in a few less common instances the secretion assumes the 
 form and consistence of false membrane, constituting a true croup 
 of the bronchi. Traces of blood are but very seldom observed in 
 the secretion, and the quantity of air-bubbles intermingled with it is 
 
MORBID APPEARANCES OF THE BRONCHI. 2G5 
 
 usually in inverse proportion to the thickness of the secretion and its 
 abundance. 
 
 But not only are the contents of the air-tubes altered in character, 
 and, for the most part, increased in quantity, but the tubes themselves 
 often undergo a marked alteration in their calibre, and become greatly 
 dilated. This dilatation is usually, observable from the secondary 
 bronchi to the minutest air-tubes; the branches often being as large as 
 the parent trunk, or even larger ; but that fusiform dilatation which is 
 met with in the adult has never come under my notice. On one occa- 
 sion, however, in addition to a general cylindrical enlargement of the 
 tubes, many of them presented a marked dilatation about half an inch 
 from their termination ; the tube expanding into a cavity big enough 
 to hold half a nut. The interior of these cavities was not perfectly 
 smooth and regular, but its thickened lining was in many parts thrown 
 into folds or wrinkles. The case in which this appearance was ob- 
 served was the one already mentioned, where the mucous membrane 
 of the bronchi presented so extraordinary a degree of thickening. 
 
 Dilatation of the bronchi was once supposed to be the purely me- 
 chanical effect of the accumulation of the secretions within them. 
 There is, however, no constant relation between the quantity of the 
 liquids within the bronchi and the degree of their dilatation, and we 
 must look to two other circumstances as being the primary causes of 
 the occurrence. The first of these is the weakening of the muscular 
 fibres of the bronchi by the inflammatory action ; the other, the loss of 
 the ciliary epithelium which lines the air-tubes when in a state of 
 health, and contributes by the incessant vibration of its cilia to keep 
 them free for the access of air. 
 
 Yriienever bronchitis has reached such an intensity as to give rise 
 to the abundant pouring out of thick fluid into the air-tubes, so 
 that the air can no longer permeate them with facility — while this 
 difficulty is still further increased by the loss of the ciliary epithelium, 
 and by the weakening of the contractile power of the bronchi, which 
 would have helped to keep them free — it often happens that the 
 feeble inspiratory power of the child becomes wholly inadequate to 
 fill the lungs, and bronchitis thus becomes the indirect cause of pul- 
 monary collapse. 
 
 In some cases, the inflammation of the respiratory mucous mem- 
 brane extends further than usual along the smaller bronchi, until it in- 
 volves their extremities and the pulmonary vesicles themselves, when 
 it produces an appearance almost peculiar to childhood, and which has 
 been described under the names of catarrhal or vesicular pneumonia, 
 or vesicular bronchitis. A lung, or a portion of a lung, thus affected, 
 no longer contains any air — it is dark in color, and feels tough, 
 though solid ; its surface is beset by a number of small, circular, 
 yellow, slightly prominent spots, of the size of a millet-seed, or 
 smaller, which, on a hasty glance, present a very great resemblance to 
 crude tubercles. A little attention, however, suffices to distinguish 
 between them ; for not only do these yellow spots differ from tubercle 
 in their favorite seat being along the lower margins of the different 
 lobes, but on puncturing any of them with the point of a scalpel a 
 
266 CONGESTION OF THE LUNG. 
 
 drop of pus will exude, and the yellow spot will disappear. Some- 
 times, too, a minute bronchus may be traced running to its termi- 
 nation in one of these little sacs. It has been suggested that this 
 appearance may be due to the secretions formed in the air-tube being 
 forced by the column of air which enters in inspiration into the smaller 
 bronchi and pulmonary vesicles, the cavities of which thus become 
 mechanically distended. The opinion that the secretions which occupy 
 these parts are produced at the spot where they are discovered, by 
 inflammation of the ultimate ramuscules of the bronchi, is however, 
 generally entertained, and is supported by very conclusive evidence. 
 Bronchitis often exists unattended with this peculiar appearance ; and 
 on the other 'hand, vesicular bronchitis is met with independent of 
 general inflammation of the air-tubes, while, though usually partial, 
 and often limited to the lower border of one or other lobe, it is some- 
 times very extensive, and occupies nearly the Avhole of the lower lobe 
 on either side, constituting the most important of the morbid appear- 
 ances discovered on examining the chest. 
 
 It may, and unquestionably often does happen, that children die 
 of bronchitis alone, and without any notable affection of the pulmonary 
 tissue. But it is much more frequent for the pulmonary substance to 
 bear a part in the morbid process ; and this share may either be 
 limited to mere congestion, or may rise in degree until it produces all 
 those consequences which we find attendant on inflammation of the 
 tissue of the lung of the adult. 
 
 Some degree of congestion of the lung is almost constant if bronchitis 
 is at all severe, for the circulation through the organ is disturbed, the 
 blood flows less freely than natural, and its changes take place more 
 slowly. It stagnates first in those depending parts whence position 
 renders its return most difficult, and the portions of the lung thus 
 affected become by degrees more and more extensive. Dark, solid, 
 non-crepitant patches may be often seen in the midst of a lung thus 
 congested; and until the results of inflation showed that a wrong in- 
 terpretation had been given to the appearance, these patches were 
 regarded as the centres whence the inflammation was extending to the 
 surrounding tissue. You do not need to be reminded that these are 
 lobules which have collapsed, and become impervious to air ; and por- 
 tions of lung in which this occurrence has taken place seem to have 
 but little disposition to become the seat of active inflammation, and to 
 pass into a state of red or gray hepatization. At the same time it 
 must be borne in mind that this indisposition to active inflammation 
 does not by any means amount to actual immunity from it, and that 
 collapsed lung may sometimes become softened, or even infiltrated 
 with pus. 
 
 It does, however, happen now and then that the lung is found in a 
 condition which may justly be called lobular pneumonia, as the result 
 of the extension to the surrounding tissue of inflammation beginning 
 in the air-tubes. Patches of lung will then be interspersed through 
 the surrounding pulmonary substance, of a vivid red color, of various 
 sizes, from that of a pea to that of an almond, irregular in shape and 
 not circumscribed exactly by the margins of lobules, as is the case with 
 
TRUE LOBULAR PNEUMONIA. 267 
 
 portions of collapsed lung. This process going on in a number of dif- 
 ferent situations, the affected parts may at length coalesce, and a pneu- 
 monia at first lobular, may thus eventually become generalized. Or, 
 though this should not occur, the inflammation may yet go on in the 
 isolated portions of lung to the infiltration of pus into its substance, or 
 the actual destruction of its tissue, when a portion of the lung will ap- 
 pear riddled with small distinct abscesses, seldom larger than a pea, 
 irregular in form, and communicating more or less evidently with a 
 minute air-tube. They may be distinguished from the vomicae pro- 
 duced by softened tubercle, partly by the absence of tubercular deposits 
 in other parts of the body, and by their being almost always limited to 
 a single lobe of one lung. Their own characters, however, are suf- 
 ficiently well marked, for they are altogether destitute of those solid 
 walls which the tubercular deposit forms around a phthisical cavity ; 
 though the yellow lymph which often lines them may be mistaken by 
 the inattentive observer for tubercle. MM. Rilliet and Barthez men- 
 tion having found the pulmonary substance healthy, except in the im- 
 mediate periphery of these abscesses ; but no instance of this kind has 
 come under my own observation, the pneumonia having in each in- 
 stance become generalized. 
 
 The appearances we have been hitherto considering are due almost, 
 exclusively to inflammation of the air-tubes ; and many of them are 
 peculiar to infancy and childhood. We might next proceed to study 
 the symptoms that betoken their existence ; but on the one hand, they 
 seldom exist quite alone, and on the other hand their symptoms pre- 
 sent so many points of resemblance to those of pneumonia strictly so 
 called, that it may be better to complete our survey of the morbid ap- 
 pearances that result from inflammation affecting either the air-tubes 
 or the parenchyma of the lung, before we pass to the study of the 
 symptoms that attend the one or the other during life. 
 
 The completion of this subject, however, must be postponed to the 
 next lecture. 
 
268 LOBAR PNEUMONIA. 
 
 LECTUEE XX. 
 
 Inflammatory Affections of the Tissue of the Lung. — Lobar Pneumonia — 
 More common in early life than has been supposed — Its general characters the 
 same as in the adult — Some morbid appearances deserving especial notice; viz., 
 subpieural ecchymoses, pneumonic abscess, and emphysema of the uninflamed 
 portions of the lung. 
 
 Frequency and causes of inflammation of the respiratory organs — Influence of age 
 — of previous attacks — of various diseases. 
 
 Bronchitis — its Symptoms and Treatment. — A more serious disease than in the 
 adult, and why — Symptoms of capillary bronchitis — Illustrative case — Results 
 of auscultation. 
 
 Treatment of bronchitis — Change in the epidemic constitution of diseases and inex- 
 pediency of very active measures — General rules for treatment — Treatment of 
 bronchitis in its chronic stage. 
 
 Influenza. — Its peculiarities and treatment in early life — Remarks on Spasmodic 
 Cough and Asthma in children. 
 
 We were occupied during the last lecture with the examination of 
 some of the results of inflammation of the respiratory organs in early 
 life, and considered more especially those changes wmich inflammation 
 produces in the air-tubes. You were told on that occasion that the 
 disease does not always remain limited to the bronchi or pulmonary 
 vesicles, but that it sometimes involves the substance of the lung, and 
 thus gives rise to the appearance of a number of small circumscribed 
 patches interspersed throughout its tissue, either red, hard, and solid, 
 or gray from the infiltration of pus ; while, if the mischief advance 
 one step farther, it may lead to the destruction of the parenchyma of 
 the organ at these points, and thus produce numerous minute abscesses 
 — a condition which has come in a few instances under my own obser- 
 vation. Cases of this kind, constituting true lobular pneumonia, 
 though somewhat less rare than in the adult, are yet of very infrequent 
 occurrence. It is almost needless to remind you that the contrary 
 opinion resulted from persons not having learned till very lately to 
 distinguish between that solidity of the lung which is produced by 
 inflammation, and that which results from the mere collapse of its air- 
 cells. 
 
 The exaggerated estimate of the frequency of lobular pneumonia, and 
 the peculiar character of the field presented at the Hospital for Chil- 
 dren at Paris, in which the most diligent and most successful students 
 of children's diseases labored, led to an underrating of the frequency 
 and importance of lobar pneumonia, such as is met with in the adult ; 
 and hence you will find but little said concerning it in many most 
 valuable works of our Continental neighbors. Lobar pneumonia, how- 
 ever, is often met with in early life both as an idiopathic and a sec- 
 ondary affection, giving rise to the same morbid appearances as in the 
 adult, and requiring a very similar treatment. 
 
NOT UNUSUAL IN CHILDHOOD. 269 
 
 Not only are the physical characters of the lung in lobar pfreumonia 
 the same in childhood as in adult age, but the three stages of engorge- 
 ment, of red and of gray hepatization, are observed with much the 
 same frequency at the one period of life as at the other. I find that 
 after rejecting all cases in which pneumonia occurred as a complication 
 of phthisis, or of acute pleurisy, and in which the results might be 
 modified by the disease to which the inflammation of the lung suc- 
 ceeded, I have a record of 94 cases in which the condition of the in- 
 flamed lung was carefully noticed. 1 
 
 In 15 of these cases the 1st and 2d stages of pneumonia coexisted. 
 
 " 4 •« » 1st and 3d " " " 
 
 " 25 " " 2d and 3d " " « 
 
 u ]4 u « a ]] 3 stages " " • " 
 
 " 13 " " lung was in the 1st stage only. 
 
 "13 " " lung was in the 2d " 
 
 " 10 " " lung was in the 3d " 
 
 94 
 
 This result does not differ very widely from that obtained by M. 
 Grisolle, 2 on an examination of 40 cases of pneumonia in the adult. 
 
 In 4 cases the 1st and 2d stages of pneumonia coexisted. 
 " 3 » 1st and 3d " " " 
 
 » 16 " 2d and 3d " " » 
 
 " 2 " all 3 stages » " " 
 
 "7 " lung was in the 2d stage only. 
 " 8 " lung was in the 3d " 
 
 40 
 
 It will be seen, on a comparison of these tables, that the third stage 
 of pneumonia occurs not very much less often in children than in 
 adults, having been met with in the former in the proportion of 56.3, 
 in the latter in the proportion of 72.5 per cent.; and the main differ- 
 ence between the two consists in the greater frequency with Avhich all 
 three stages of pneumonia coexist in the young subject. This pecu- 
 liarity of pneumonia in childhood is probably due to the tendency 
 which the disease then displays to involve a large extent of pulmonary 
 tissue ; and to the same cause we must attribute the frequency of double 
 pneumonia in early life, which, in the cases that came under my no- 
 tice, preponderated greatly over those wherein only one lung suffered. 
 The well-known law, according to which pneumonia of the right lung 
 is more common than pneumonia of the left, holds good in childhood ; 
 nor is the frequency of concomitant pleurisy much, if at all, less in the 
 child than in the adult. The contrary opinion arose from the error to 
 which reference has so often been made, of regarding cases of collapsed 
 
 1 Here, and in many other instances, I purposely abstain from swelling the num- 
 bers from which my conclusions are drawn by adding my more recent observations. 
 I do so, because as one grows older, especially in consulting practice, the field in 
 which one labors becomes more and more an exceptional one, and one but little 
 suited for the application of the numerical method. I believe, however, that the 
 conclusions to which the figures above given point are correct. 
 
 2 Traite de la Pneumonie, 8vo., 2d ed., Paris, 1864, p. 17. 
 
270 LOBAR PNEUMONIA. 
 
 lung, either with or without bronchitis, as instances of red hepatization 
 of the pulmonary substance. 
 
 Instead of inflammation of the lungs being less active in the child 
 than in the adult, there are some facts which would seem to lead to a 
 directly opposite conclusion. Such are the frequency with which, in 
 fatal pneumonia in children, ecchvmoses are found beneath the pleura 
 covering the inflamed lung, the more common occurrence of pulmonary 
 abscess in early than in adult life, and the very extensive emphysema 
 which is often observed in those parts of the lung to which the inflam- 
 mation has not extended. 
 
 The subpleural ecchi/moses appear to result from the rupture of some 
 of the minute capillaries of the lungs in consequence of the great dis- 
 turbance of the circulation through them. They are usually small, 
 like petechia?, but occasionally they attain a large size, and now and 
 then thev even extend a little wav into the tissue of the Inns constitut- 
 ing little spots of pulmonary apoplexy, about the size of a millet-seed, 
 or even a little larger. They are most numerous on the posterior sur- 
 face of the lungs, and especially in parts where the lung has become 
 hepatized, though by no means confined to those situations. 
 
 The termination of pneumonia in abscess of the lung is so rare an 
 occurrence in the adult, that Laennec did not meet with it above five 
 or six times in the course of several hundred examinations of persons 
 who had died of inflammation of the lungs. In the child, however, 
 the case is otherwise, for abscess of the lung: has come under my ob- 
 servation in four out of the ninety -four examinations of cases of pneu- 
 monia, on which my present remarks are founded. In one of these 
 cases, that of a boy, aged 20 months, who died on the fourteenth day 
 after the commencement of his illness, the following appearances were 
 observed : The upper and middle lobes of the right lung were con- 
 nected with each other, and with the walls of the chest, by adhesions 
 which were chiefly recent. Nearly the whole of the upper lobe was 
 solid, and sank in water. It was of a mottled reddish-gray color, in 
 which gray predominated ; it broke with a granular fracture, and was 
 readily reduced to a dirty putrilage. Xear the apex was a portion the 
 size of a walnut which was already soft and in a state of quagmire. 
 The upper two-thirds of the middle lobe were in the same condition 
 as the upper lobe ; the lower third was emphysematous. In the centre 
 of the middle lobe was a cavity the size of a bean, irregular in form, 
 intersected by the remains of some vessels, lined by a thin layer of 
 yellow lymph ,, and surrounded by lung in the third stage of pneumo- 
 nia ; but neither in that* lobe nor in any part of the pulmonary tissue 
 was there the least trace of tubercle. The lower lobe of the right lung 
 was in the first stage of pneumonia ; the left upper lobe was quite 
 healthy ; the left lower lobe was in a state of mingled red and gray 
 hepatization. Two cases occurred in children who had suffered for 
 some weeks from hooping-cough, and in both the lungs contained 
 numerous semi-transparent, gray, tubercular granulations. One of the 
 children was a boy five years old; the other a little girl aged two 
 years. In the case of the former, the abscess, as large as a walnut, 
 was situated at the lower border of the upper lobe, extending a little 
 
CAUSES OF PNEUMONIA. 271 
 
 into the lower lobe. In the latter it was of the size of an unshellecl 
 almond, and occupied a similar position with reference to the right 
 upper and middle lobes. The characters of the abscess were the same 
 in both instances, being situated almost immediately beneath the 
 pleura : from which a wall of lung not above two lines in thickness 
 separated it. Its cavity was partly filled with a yellowish, puriform, 
 very tenacious fluid, like very tenacious pus, and which did not bear 
 any resemblance to softened tubercle. It was not lined by any mem- 
 brane ; there was no appearance of tubercular deposit in the hepatized 
 lung in its immediate vicinity, which was generally in the second stage 
 of pneumonia, nor was it situated near to, nor in communication with, 
 any large bronchial tube. In the fourth case, that of a boy aged 
 eleven years, w r ho died of pyaemia, consequent on exposure to cold and 
 wet, the purulent deposits were not limited to the lung-substance, al- 
 though they were associated there with general pneumonia, and with 
 several patches of pulmonary apoplexy. 
 
 The emphysematous condition of the uninflamed portions of the lung, 
 in cases of fatal pneumonia in early life, seems to be connected with 
 the rapidity of the advance of the disease. It is usually most obvious 
 at the anterior part of the upper lobes of the lungs and at the margin 
 of the other lobes, and always bears a marked relation to the shortness 
 of the patient's illness, and the extent of lung which has been rendered 
 unavailable for purposes of respiration. The cases, however, which 
 terminate most rapidly are not those in which the direct results of in- 
 flammation are the most extensive, but rather those in which collapse 
 of a considerable portion of lung has taken place; and the emphysema, 
 which is met with also in many cases of vesicular bronchitis, is conse- 
 quent less on the inflammation than on the collapse by which it is ac- 
 companied. Its occurrence in those circumstances affords therefore an 
 illustration of that modification of the inspiratory theory of emphy- 
 sema so clearly propounded and so ably supported by Professor Gaird- 
 ner of Glasgow ; l and which regards the overdistension of the air- 
 vesicles of one part of the lung as a necessary compensation for their 
 collapse, and the consequent diminished bulk of another part, while 
 the enlargement and the capacity of the thorax during inspiration re- 
 main the same, or at any rate are but slightly modified. 2 
 
 The causes which give rise to inflammation of the lungs and air- 
 tubes are, to a great extent, the same at all periods of life ; so that we 
 need not devote much attention to the special study of those which 
 
 1 On the Pathological Anatomy of Bronchitis, &c, 8vo., Edinburgh, 1850; and 
 Edinburgh Monthly Journal, vol. xiv. 
 
 2 In the second and third editions of these lectures I stated that the amount of 
 emphysema bore a " marked relation to the shortness of the patient's illness, and 
 the extent of lung which had been invaded by the inflammation." A careful re- 
 examination of the accounts of my post-mortems of cases of pneumonia and bron- 
 chitis, convinces me that the statement as now modified is more correct in point of 
 fact, while at the same time it harmonizes perfectly with Dr. Gairdner's theory of 
 emphysema. That theory, however, is, I am convinced, applicable only to one 
 class of cases, while of another equally numerous, Sir W. Jenner's expiratory theory 
 (see his paper in vol. xl of the Medico'-Chirurgical Transactions) offers the true 
 solution. To this reference will be made when the subject of hooping-cough comes 
 for consideration. 
 
272 
 
 CAUSES OF PNEUMONIA. 
 
 tend to produce it in childhood. It should be borne in mind, however, 
 that the fluctuations in temperature, or the biting wind, or the cold 
 weather, which may be encountered with impunity by the robust adult, 
 may prove most deadly when they act on the feeble frame and delicate 
 organs of the child. Hence it is, in great measure, that inflammation 
 of the respiratory organs is so much more frequent, and so much more 
 fatal, in childhood than in adult age, and in infancy than in childhood. 
 The fact is well shown by the Reports of the Registrar-General for the 
 years 1842 and 1845, from which it appears that 67.1 per cent, of the 
 total mortality from inflammation of the lungs and bronchi, in the 
 metropolis, took place in persons under fifteen years of age ; 63.2 per 
 cent, under five; 57.1 under three; and 28.7 per cent, under one year. 
 But the tendency to these affections, as is shown in the following table, 
 is not greatest in the first month of life, diminishing in proportion as 
 the child advances in age and increases in strength ; but the time when 
 they are most prevalent coincides exactly with the time when the sus- 
 ceptibility of all the mucous membranes is at its highest point, namely, 
 the period of dentition. 
 
 TABLE, 
 
 Shoicing out of 299 cases of children dying from various diseases, in whom I carefully 
 examined the thoracic viscera, the number of instances in which the lungs, bronchi, 
 and pleura presenled no sign of recent inflammation, and. also those in which signs 
 of it were discovered. [The first line represents the former, the second the latter 
 class of cases.] 
 
 Under 
 1 mth. 
 
 From 
 1-6. 
 
 From 
 6-12. 
 
 17 
 
 10 
 
 From 
 
 12^18. 
 
 15 
 15 
 
 From 
 18-2 
 yrs. 
 
 From 
 2-3. 
 
 22 
 23 
 
 From 
 3-4. 
 
 From 
 4-5. 
 
 8 
 15 
 
 From 
 5-6. 
 
 From 
 6-7. 
 
 From 
 
 7-8. 
 
 From 
 .8-9. 
 
 5 
 
 11 
 
 From 
 9-10. 
 
 From 
 10-11. 
 
 3 
 4 
 
 From 
 11-12. 
 
 2 
 5 
 
 4 
 < 
 
 H 
 O 
 
 H 
 
 5 
 
 13 
 3 
 
 6 
 18 
 
 17 
 
 16 
 
 12 
 
 13 
 
 5 
 
 8 
 
 11 
 
 10 
 
 4 
 3 
 
 145 
 154 
 
 This table illustrates the fact mentioned in the last lecture, that when 
 the child is first born, the mucous membrane of the respiratory organs 
 is endowed with but little of that susceptibility which it afterwards 
 acquires, and that accordingly those diseases whose point of departure 
 is from that membrane are far less frequent during the first six months 
 of life than they become during the succeeding eighteen months ; while 
 from the completion of the second year up to the time of puberty, they 
 go on diminishing in frequency and fatality. And there are important 
 practical inferences which may be deduced from the facts we have just 
 mentioned. They teach us not only that a catarrh is a much more 
 serious thing in infancy than in adult age, but also that it is more 
 serious at one period of infancy than at another, and they warn us to 
 guard a child, during the time that the process of teething is going on, 
 with double care against all causes that are likely to excite inflamma- 
 tion of its respiratory organs. 
 
 There are some diseases which, after having occurred once, confer on 
 persons an immunity from subsequent attacks. This, however, is far 
 
SYMPTOMS OF BRONCHITIS. 273 
 
 from being the case with bronchitis or pneumonia in early life, but the 
 susceptibility of the respiratory organs appears to increase in exact pro- 
 portion to the frequency with which they have already suffered/ and a 
 child who has once been attacked by inflammation of the lungs or air- 
 tubes is more likely to have a second attack brought on by a slight 
 change of temperature than another who had never suffered from it 
 would be to experience a seizure from a much graver cause. With 
 advancing age this susceptibility seems to w T ear out — the child outgrows 
 it ; but we should act most unwisely if we were to sanction exposure 
 to the cold with the view of hardening a child against its influence. 
 
 The importance of inflammatory diseases of the respiratory organs 
 depends not merely on the frequency of their occurrence as idiopathic 
 affections, but also on their tendency to supervene in the course of other 
 maladies. This tendency, though very evident at all ages, is especially 
 remarkable in early life, as is apparent from the fact that in only 25 
 per cent, of the cases enumerated in the table was the inflammation an 
 idiopathic affection. When we come to the subject of measles, hooping- 
 cough, croup, diarrhoea, and typhoid fever, it w T ill be necessary to study 
 these secondary attacks of bronchitis and pneumonia with attention, 
 since they constitute frequent and serious complications of those diseases 
 against which it behooves us to be most anxiously on the watch. 
 
 We will now pass to the study of the symptoms of bronchitis, and 
 will commence with the examination of the most simple form of in- 
 flammation of the air-tubes — namely, that which develops itself out of 
 ordinary catarrh. In such a case the child has for some days seemed 
 to suffer from nothing more serious than a common cold ; but by de- 
 grees instead of the cold and cough subsiding, the heat of skin becomes 
 more considerable, the cough tighter, more frequent, and more painful, 
 the child sometimes crying after each cough : the pulse becomes more 
 rapid, the respiration wheezing, hurried, and often somewhat irregular. 
 These graver symptoms in many instances steal on very gradually, and 
 among the poor it by no means seldom happens that the disease has 
 already attained an advanced stage, and the condition has become one 
 of very considerable peril, before the parents, never very observant of 
 those ailments that are not attended with acute suffering, take the 
 alarm. The flush of the face and the heat of the skin become in- 
 creased, the respiration grows more labored, and the cough more trou- 
 blesome towards evening ; and the first hours of the night are usually 
 very restless, but the child then falls asleep, and often dozes tranquilly 
 for some hours ; it then generally awakes with its respiration very op- 
 pressed, for the secretions have been accumulating in the smaller bron- 
 
 1 In a tract on Pneumonia in Children, published thirty years ago in the British 
 and Foreign Medical Eeview, I mentioned that of 78 children who came under my 
 care for inflammation of the lungs, 31 were stated to have had previous attacks of 
 the disease ; 21 once ; 4 twice ; 2 four times ; and 4 were said to have had it several 
 times, though the exact number of seizures was not mentioned. Of these 31, 10 
 were under two years of age, 10 between two and three, and the remaining 11 be- 
 tween three and six. The same fact is noticed by the most recent writer on pneu- 
 monia in childhood, Ziemsen (Pleuritis und Pneumonie im Kindesalter, 8vo., Berlin, 
 1862, p. 153), though his numbers do not represent it as of quite such frequent 
 occurrence. 
 
 18 
 
274 SYMPTOMS OF CAPILLARY BRONCHITIS. 
 
 chi, and have now begun to impede the entrance of the air. An attack 
 of cough probably comes on, which very likely ends in vomiting and 
 the rejection of some mucus, and then by degrees the breathing be- 
 comes more easy, and the child may for a short time seem compara- 
 tively cheerful. The temperature of the surface, though increased, is 
 variable ; and if the disease continues for several days, perspiration 
 will be observed occasionally to break out on the body, while the pulse, 
 though quickened, is not very much accelerated, and the tongue con- 
 tinues moist throughout. The ear detects nothing in the chest besides 
 a mixture of rhonchus, sibilus, and largish crepitation ; the dry sounds 
 preponderating at the upper, the moist at the lower part of the chest, 
 and being vastly more abundant behind than in front. Xow in the 
 adult a condition such as this would excite but little apprehension, but 
 in the child it must be borne in mind that nothing more is needed than 
 a copious secretion of mucus in the bronchi, or a feeble condition of 
 the vital powers, to prevent the air from freely entering the pulmonary 
 vesicles, and thus to induce the collapse of a large portion of the lung. 
 Thus it is, at least as I apprehend, that we must explain many of the 
 instances in which urgent dyspnoea, and all the symptoms of serious 
 pulmonary disease, have developed themselves in the course of a few 
 hours out of what had seemed to be nothing more than a rather severe 
 eold, or a bronchitis of moderate intensity. This too accounts for the 
 occasional sudden supervention of dulness on percussion, and of bron- 
 chial respiration in the child ; so that you may discover them in the 
 morning in a situation where overnight the percussion was good, and 
 no sound was heard of graver import than large crepitation ; changes 
 which, unlike those dependent on solidification of the lung from in- 
 flammation, you may find, as has been remarked by Dr. Gairdner, un- 
 accompanied by any exacerbation of the febrile symptoms. This rapid 
 change in the auscultatory phenomena has been noticed by Sir W. Stokes 
 as occasionally happening in the pneumonia of the adult. 1 That dis- 
 tinguished physician offered no explanation of the occurrence ; but we 
 can now understand what is its trne import, and what the reasons are 
 for its being met with so much oftener in the child than in the adult. 
 
 But, notwithstanding this danger, which is great in proportion to 
 the youth of a child, most cases of idiopathic bronchitis that come on 
 gradually, developing themselves out of previous catarrhal symptoms, 
 have a favorable termination ; and, as a general rule, it may be stated 
 that an attack which is long in arriving at its acme is seldom very 
 dangerous in its character. Pure idiopathic bronchitis occuiVing in an 
 otherwise healthy child, usually subsides in the course of a few days, 
 leaving the patient with an increased susceptibility to the influence of 
 those causes which brought on the first attack, and perhaps with a 
 degree of debility, the recovery from which may be protracted for 
 many weeks. 
 
 There is, however, a form of acute bronchitis which is often, though 
 not always,, idiopathic, that runs its course with much rapidity, and 
 generally tends to a fatal termination. In this, the suffocative catarrh 
 
 1 On the Diseases of the Chest, 8vo., Dublin, 1837, pp. 311 and 327. 
 
SYMPTOMS OF CAPILLARY BRONCHITIS. 275 
 
 of some writers — the capillary bronchitis of others — the smaller air- 
 tubes throughout the whole or a considerable portion of the lungs are 
 attacked cither in connection with the larger bronchi, or independently 
 of them ; and the inflammation, which is very intense, usually termi- 
 nates in the abundant secretion of pus, or in the formation of false 
 membrane that nearly obliterates their cavity, or, involving the pul- 
 monary vesicles themselves, it gives rise through a considerable extent 
 of the lungs to those appearances which have been described under the 
 names of vesicular pneumonia and vesicular bronchitis. 
 
 Its attack is sometimes sudden, though in the great majority of cases 
 it is preceded for a. few days by the ordinary symptoms of catarrh, or it 
 supervenes on that condition of bronchial irritation which accompanies or 
 follows one or other of the eruptive fevers. In these latter circumstances 
 there is either a progressive though rapid increase in the severity of the 
 bronchitic symptoms, or there is a sudden outbreak of fever and dyspnoea, 
 and the cough becomes all at once frequent, short, and hacking. The 
 disease soon attains a very considerable intensity; the face becomes 
 anxious and oppressed, the eyes heavy, the manner depressed; the res- 
 piration very hurried, generally irregular, and interrupted by the cough, 
 which frequently seems to occasion pain. The restlessness is often ex- 
 treme, and the position which the child assumes very variable; but, in 
 whatever attitude it may have placed itself, it does not like to be dis- 
 turbed, and endeavors at once to return to its former posture. If 
 spoken to, the child's answers are hurried, and its manner impatient, 
 as though it were too much taken up with its suffering, or with the 
 business of respiration, to be able to reply to questions. Sometimes it 
 will say that it feels stuffed, or will complain of distress about the 
 sternum, or of pain at the epigastrium ; while pressure on the abdomen, 
 by interfering with the free descent of the diaphragm, always produces 
 much discomfort. There is no appetite; and, though at first the thirst 
 is very considerable, yet the child soon ceases to take much drink, for 
 it wants breath to swallow fluids in any quantity, and therefore does 
 little more than moisten its lips. At the same time the tongue is moist, 
 and either differs but little from its condition in health, or it has a thin 
 coating of yellowish fur ; the bowels are usually constipated, and not 
 only is nausea or vomiting seldom present, but emetic remedies often 
 fail of their ordinary effect when given in the course of this affection. 
 As the disease advances the cough becomes less hacking, though it con- 
 tinues very frequent : it sometimes puts on a paroxysmal character, 
 and returns in fits somewhat like those of hooping-cough, except that 
 each fit of coughing is shorter, does not terminate with a whoop, and 
 is seldom attended with expectoration. Even if the cough is accom- 
 panied by expectoration, it is seldom that anything is spit up more than 
 a little mucus tinged with blood, or now T and then a little pure blood, while 
 in a few instances small shreds of false membrane are intermingled with 
 the mucus. For a time the respiration grows more and more hurried and 
 paroxysms of dyspnoea continue to occur at irregular intervals almost 
 to the last. In these paroxysms the child's distress and restlessness 
 are extreme, and it sometimes throws itself wildly about the bed. 
 The breathing does not, however, go on increasing in rapidity until the 
 
276 SYMPTOMS OF CAPILLARY BRONCHITIS. 
 
 patient's death ; but, after the disease has reached its acme, the respira- 
 tion often grows less frequent, though more irregular and more variable. 
 The face loses its flush, and, instead, acquires a livid hue ; the cough 
 becomes smothered, and occurs less often ; the pulse gains in frequency 
 and fails in power ; and though there is often a diminution of the rest- 
 lessness, yet, if able to talk, the child will generally say that it is no 
 better. As death approaches, though the respiration grows more la- 
 bored and more abdominal, yet the child's suffering generally dimin- 
 ishes, or a state of somnolence gradually steals over it, in which it lies 
 till roused by an attack of cough or by a paroxysm of dyspnoea, and 
 then, after a struggle for breath, it subsides into its former drowsiness. 
 The struggles for breath grow feebler with each returning paroxysm, 
 the drowsiness becomes more profound, and the patient dies. 
 
 Though the indications afforded by auscultation and percussion are 
 often sufficiently characteristic of this disease, yet there are some cir- 
 cumstances which may occasionally render their information doubtful. 
 The child is sometimes so extremely alarmed, and the sensibility of its 
 surface so much increased, that we have much difficulty in percussing 
 the chest : but we shall usually be able to distinguish this from the 
 painfulness of the walls of the thorax which attends pleurisy by finding 
 that it is not limited to one half of the chest, but that it .is felt equally on 
 either side, and as much in front as behind. If we can succeed in 
 percussing the chest, however, it will be found to yield a natural, some- 
 times even an increased degree of resonance, while little, if any, differ- 
 ence can be discovered between the sound afforded by the upper, and 
 that given out by the lower part of the chest ; or, should such be per- 
 ceived, it is generally due to pnenmonia having supervened. The ear 
 detects a scanty transmission of air, attended at first with rhonchus and 
 sibilus, but soon with a universal subcrepitant rale, heard most distinctly 
 on the child making a deep inspiration. By the term subcrepitant rale, 
 it can hardly be necessary for me to say that a sound is meant smaller 
 in character than large mucous rale, but larger than the true small crep- 
 itation of pneumonia. As the disease advances, the only change that 
 takes place consists in this subcrepitant rale being replaced by a large 
 mucous rale, the result, not of any improvement in the child's condition, 
 but of the air scarcely penetrating beyond the larger bronchi ; for you 
 will still hear the smaller sound during the deep inspiration that fol- 
 lows the attack of cough. 
 
 This form of bronchitis is one not only very dangerous, but likewise 
 very rapid in its course to a fatal issue. One little girl in whom it came 
 on while convalescent from an attack of measles fourteen days before, 
 died within forty-eight hours ; and a boy of 7 J years old, in whom the 
 disease was idiopathic, died in less than four days from the appearance 
 of any serious symptom. These, however, are instances of a rather un- 
 usual rapidity in its course ; and from five to .eight days, which is the 
 estimate of its duration formed by M. Fauvel, who has written a very 
 valuable essay on the disease, 1 is probably not far from the true average. 
 
 1 Recherches sur la Bronchite Capillaire, &c, 4to., Paris, 1840; republished in a 
 more extended form in vol. ii of the Memoires de la Societe Medicale d'Obser- 
 1844. 
 
TREATMENT OF BRONCHITIS. 277 
 
 But we may now pass to the treatment of bronchitis, and in recon- 
 sidering the rules which I shall lay down for your guidance, I am struck 
 by the different conclusions to which more than thirty years of the 
 practice of my profession have led me from those which I adopted at the 
 outset of my career. It is, I believe, but rarely, at the present day, 
 that depletion is indicated in bronchitis or pneumonia; and tartar 
 emetic needs to be given more sparingly than in former years, and acts 
 with less certainty in cutting short at its very outset the inflammatory 
 action. And yet, when looking back on the records of cases where I 
 abstracted blood freely, and gave antimony in large doses, I cannot 
 admit that my practice then was a mistaken one, that the recoveries 
 which then took place were the result of accident, or that, in counsel- 
 ling now a different course, I am merely following the fashion or the 
 prejudice of the age. 
 
 " If any one," says M. Trousseau, with reference to this very sub- 
 ject, " reads with attention the remarks of Sydenham and of Stoll on 
 the change of the treatment of disease which the differences in the epi- 
 demic constitution of successive years rendered necessary, he will be 
 sure to arrive at two conclusions : first, that any physician must have 
 but a very narrow view of his art, who, in spite of the change of con- 
 stitution, continues still to treat all diseases in the same way ; and next, 
 that the change of epidemic constitution exerts an immense influence 
 on the action of the same remedies in a disease whose local manifesta- 
 tions continue unchanged." 
 
 You will now understand, gentlemen, why it was, when I told you 
 at the beginning of this lecture, that the necessity, nay even the utility, 
 of depletion in pneumonia did not seem to me well established, that I 
 made a point of adding;?^ at present. I did so, because it so happens 
 that now for the past several years w T e are in the midst of an epidemic 
 constitution in which diseases do not require this remedy, though for- 
 merly they did require it, and though in the course of time they will 
 no doubt stand in need of it again. 1 
 
 But besides, I believe that with advancing years all practitioners 
 become disposed to attach more importance to the hygiene of the sick- 
 room ; to the temperature of the air which the child breathes, to the 
 perfection of the ventilation, to the posture of the patient in bed, to 
 the regulation of the diet, the avoidance of all causes of irritation and 
 distress ; and the favorable issue of the case not seldom justifies the 
 apparent overcaution in these respects to w T hich experience seems to 
 lead. 
 
 The confidence sometimes expressed in nature's healing power is, 
 however, altogether misplaced, unless accompanied with every care to 
 place the patient in the most favorable conditions for that power to be 
 exercised. These conditions once secured, the severity of the attack of 
 
 1 Clinique Medicale, 2d ed., vol. i, p. 744. See also on the subject of depletion 
 generally the remarks of Sir T. Watson at vol. i, p. 241-258 of the 5th edition of 
 his Lectures. If, however, I might criticize one whom I so much respect. I should 
 express surprise that he, on whom more than on any other English physician of 
 this day Sydenham's mantle has fallen, should take so little heed of Sydenham's 
 doctrine of the varying epidemic constitution in different years, or terms of years. 
 
278 TREATMENT OF BRONCHITIS. 
 
 bronchitis must govern the further treatment. In a healthy child, at 
 the outset of a bronchitic seizure of moderate intensity, small closes of 
 calomel, antimony, and ipecacuanha, given every four hours for the 
 first twenty-four or thirty-six hours, are often extremely useful. This 
 combination usually acts on the bowels slightly as well as on the skin, 
 and often notably abates the febrile disturbance. The mercurial should 
 then be discontinued, but small doses of antimony or of ipecacuanha 
 should still be continued in a saline mixture. In addition to these 
 means, the breathing is often much relieved by the application of a 
 large warm linseed poultice to the chest, or of a large piece of spongio- 
 piline Avrung out of hot water ; either of which may be made more 
 stimulating by the addition of a third or fourth part of mustard to the 
 poultice, or by sprinkling some stimulating lininient over the spongio- 
 piline. 1 These applications should be frequently renewed, and should 
 be continued for twenty-four or thirty-six hours together, while any 
 marked increase of difficult breathing must be controlled by the appli- 
 cation of a mustard poultice between the shoulders, or to the front of 
 the chest ; a proceeding which has this great advantage over the use of 
 a blister, that it will admit of frequent repetition. After the first day 
 or two the abundance of the secretion poured out into the bronchi not 
 only increases the discomfort of the child, but is a positive source of 
 danger, inasmuch as it tends to favor the occurrence of pulmonary 
 collapse. An emetic once or tw T ice a day is the great means of reliev- 
 ing this discomfort, and warding off this danger. The emetic selected 
 should be one of ipecacuanha in preference to antimony ; or even the 
 sulphate of zinc if the ipecacuanha, as happens sometimes, while it 
 fails to vomit, should act upon the bowels. 
 
 Your attention has more than once been called to the remarkable 
 tendency of the nervous system in early life to sympathize with the 
 affections of other parts. This tendency is often very evident in in- 
 flammation of the respiratory organs ; and accordingly you must not 
 always take the degree of dyspnoea in a case of infantile bronchitis as a 
 measure of the severity of the disease, since it may be only an evidence 
 of the sympathy of the nervous system. In the majority of instances, 
 it is towards evening that this acceleration of breathing comes on, ac- 
 companied with a state of general restlessness, and usually with an 
 increase, though not to an extreme degree, of the heat of skin ; but yet 
 if you listen carefully to the chest you will find no deterioration in the 
 results of auscultation. In the infant, too, you will probably perceive 
 in the half-closed eyes, and in the thumbs drawn into the palm, indi- 
 cations of the disturbance of the nervous system. 
 
 The evening warm bath often relieves this symptom very much, 
 and if the amount of the secretion in the bronchi is not so considerable 
 
 i (No. 11.) 
 
 R. Lin. Camph. co., ^j. 
 
 Tinct. Lyttse, ^ij 
 
 Tinct. Opii., ^ij. M. ~Ft. linimentum. 
 The pungency of liniments often compel us to employ them to the posterior part 
 of the chest only, or to rub the front of the chest with a much weaker liniment 
 than that which is used for the back. 
 
TREATMENT OF BRONCHITIS. 279 
 
 as to contraindicate its use, a dose of Dover's powder given afterwards 
 will soothe the child and obtain for it a few hours of quiet sleep. The 
 emetic and the mustard poultice will in other cases be followed by the 
 same result, while it must be borne in mind that a constipated state of 
 the bowels on the one hand, or the irritation of teething on the other, 
 may give occasion to a hurry of respiration, which will at once cease 
 on the administration of a dose of castor oil, or on lancing the gums. 
 
 The combination of a direct sedative with each dose of the medicine 
 which the child takes must be had recourse to cautiously, and must 
 have reference rather to the relief of the irritating cough than to the 
 control of any very marked symptom of nervous dyspnoea, since, when- 
 ever in these cases the blood is imperfectly aerated, risk attends the 
 frequent employment of narcotics. On this account the chloric ether 
 is often so useful an adjunct to the cough mixture ; while of the more 
 direct sedatives the compound tincture of camphor is preferable to any 
 other preparation of opium, and the tincture of henbane is perhaps still 
 safer; the Dover's powder in a fuller dose being reserved for the 
 evening exacerbation of dyspnoea. 
 
 After the first few days, sometimes even very early in the attack, 
 comes the necessity for supporting the child's strength, and for watch- 
 ing carefully against that collapse of the lungs which in infancy is the 
 grand source of danger. Ammonia must now be added to the expec- 
 torant mixture which the child was previously taking, or it may be 
 given in combination with the decotion of senega 1 and tincture of 
 squills, if secretion in the bronchi is very abundant, while once or 
 twice in the twenty-four hours the attempt must be made to unload 
 the air-tubes by the administration of an emetic. 
 
 The maintenance of the child's strength by food, and often by stimu- 
 lants, becomes now, too, a matter of the greatest moment. Veal broth 
 or beef tea, given alternately with white whine whey, or brandy added 
 in a small quantity to all the food which the child takes, becomes nec- 
 essary so soon as a feebler pulse, or diminution of temperature of the 
 extremities, or a more labored respiration with an increase of mucus 
 in the air-tubes, accompanied by a diminution or suppression of the 
 cough, gives token of failing power. One troublesome symptom, very 
 apt to supervene in this condition, and which sometimes frustrates all 
 our endeavors, is an obstinate diarrhoea, that exhausts as well as 
 distresses the child. The chalk mixture with tincture of catechu 
 sometimes suffices to check it, but, should this fail, an opiate enema 
 will very generally succeed in arresting it, provided it has not been 
 allowed to continue unrestrained for more than a few hours. 
 
 During the patient's convalescence, great care is needed to avoid a 
 relapse, which is the more apt to recur and the more likely to be serious 
 
 1 (No. 12.) 
 R. Decoct. Senegas, t ^ij 3 v. 
 
 A mm on. Sesquicarb., gr. xij. 
 Tincf. Scillse, tt^xvj. 
 Syr. Tolutan., giij. M 
 A dessertspoonful every four hours. For a child from two to three years old. 
 
230 INFLUENZA, OR EPIDEMIC CATARRH. 
 
 in proportion to the tender age of the child. In the case of teething 
 children, it is by no means unusual for a fresh attack of bronchitis to 
 occur just as each tooth approaches the surface ; a circumstance which 
 renders it specially important to watch over the period of convalescence 
 with the greatest care. If the season of the year admits of it, a change 
 of air has more decided influence in removing the remains of any bron- 
 chitic attack than medicine, though for the most part the congh will 
 gradually cease, and the child regain its health, under the influence of 
 preparations either of bark or of iron. Sometimes, however, bronchitic 
 symptoms continue for a long period, the expectoration being copious 
 and puriform, while the child loses flesh, and the relatives become not 
 unnaturally apprehensive lest it should be phthisical. Their fears may 
 be well founded, but at the same time that you would recommend 
 change of climate to some warmer country in the winter, or to the sea- 
 coast during the summer, you would, as I shall hereafter point out to 
 you when speaking of phthisis, be warranted in taking a much more 
 favorable view of such cases in a child than in the adult. 
 
 Before concluding this lecture, it may be as well to say a few words 
 on the subject of influenza, or epidemic catarrh, as we observe it among 
 infants and children. Catarrhal epidemics, indeed, not infrequently 
 occur among the young at a time when there is no general prevalence 
 of the same class of ailments in the adult population, and they do so 
 especially just before the commencement of an epidemic of measles or 
 hooping-cough, and for a short period after its outbreak. Such catarrhs, 
 however, are not in general very severe, and are important chiefly as 
 forewarnings of the more serious disorder by which they are often suc- 
 ceeded. 
 
 This affection assumes, on the other hand, a more serious character 
 when influenza is generally prevalent ; and children are attacked, not 
 especially, but in common with persons of all ages. It is then often 
 very severe, and in many instances presents notable peculiarities, with 
 a description of which I prefer occupying your time to repeating over 
 again the description of how ordinary catarrh assumes by degrees the 
 graver features of bronchitis, and the bronchitis, in its turn, becomes 
 associated with pneumonia. Of course, in every epidemic of influenza, 
 there are many instances of this occurrence, and, in every case, we need 
 watch most carefully for its indications. But the anomalous forms of 
 influenza are of no less moment. Of these, one of the most remarkable 
 is characterized by the intensity of the febrile disturbance as contrasted 
 with the comparative unimportance of the chest symptoms, so that the 
 ailment sometimes runs its course more like a severe attack of ephemera 
 than like an affection in which the organs of respiration are implicated. 
 In such circumstances I have even known convulsions occur in very 
 susceptible children, and be followed by a state of intense overpowering 
 drowsiness, which, though unaccompanied by other signs of cerebral 
 disturbance, continued for twenty-four hours, and then gradually sub- 
 sided, being succeeded either by a slight feverish condition or by the 
 ordinary catarrhal symptoms, and those not always of great severity. 
 The convulsive seizures are, indeed, exceptional, and 'of decidedly rare 
 occurrence ; but the burning skin, the extremely frequent pulse, and 
 
INFLUENZA, OR EPIDEMIC CATARRH. 281 
 
 the irresistible drowsiness, are by no means unusual ; a child going to 
 bed a little ailing, sleeping heavily during the night, seeming unable 
 to get up in the morning, and continuing apparently overpowered by 
 the disorder for the ensuing twenty-four hours, but then recovering 
 with great rapidity. 
 
 It is not, however, by any means constant for the disorder of the 
 nervous system to be thus limited to the sensorium ; for, in very many 
 instances, the respiration is greatly disturbed ; and with the burning 
 skin and heavy head there are associated acceleration of breathing, and 
 imperfect aeration of the blood, such as we may often observe in hoop- 
 ing-cough. This disorder of breathing too will often be found to be 
 utterly out of proportion to the gravity of the auscultatory signs, which 
 generally consist in a large diffused rhonchus, equally audible over the 
 whole of the chest. 
 
 The danger, indeed, frequently consists less in the occurrence of 
 pneumonia or in the advance of bronchitis than in the supervention of 
 a state of collapse, such as in epidemics of influenza not infrequently 
 carries off the aged. In the influenza of 1856 many instances of this 
 kind came under my notice, by no means exclusively among infants, 
 but at least as often among children between two and three years of 
 age, in whom the attack set in with considerable nervous dyspnoea and 
 heat of skin (symptoms which on some occasions had undoubtedly been 
 treated with overactivity before the patient came under my notice), 
 but in the course of two or three days the fever suddenly disappeared, 
 and was succeeded by a state of extreme depression, with a cool, moist 
 skin, a very feeble pulse, and labored respiration. In this condition 
 the children, though quite conscious when roused, lay generally dozing, 
 while, though the somewhat livid hue of the lips and surface seemed 
 to imply the existence of some serious mischief in the lungs, there was 
 often nothing to be heard but a large moist rale. When this state was 
 well marked, the symptoms of exhaustion usually went on increasing, 
 in spite of the free employment of stimulants, and terminated fatally 
 on several occasions in the course of forty-eight hours, and within a 
 week from the commencement of the illness. 
 
 One more point deserves notice, and that is the frequent tediousness 
 of the convalescence from influenza ; an irregularly remittent febrile 
 condition, with complete loss of appetite, and much impairment of 
 strength, often remaining behind. These symptoms, however, disap- 
 pear, and sometimes rapidly, under the beneficial influence of change 
 of air and preparations of quinine. 
 
 The cautions to be borne in mind in the treatment of influenza are 
 sufficiently apparent from the remarks which have just been made. 
 The danger in these cases is oftenest that of doing too much ; of misin- 
 terpreting the nervous element, which plays so important a part in the 
 production of the symptoms ; and of regarding the dyspnoea, the hur- 
 ried breathing, and the rapid pulse, as the necessary evidence of active 
 inflammation of the lungs or air-tubes, calling for vigorous treatment 
 to subdue it. Both depletory measures and the employment of large 
 doses of antimonials are out of place, and the indications are best 
 answered by maintaining a uniformly warm temperature in the room, 
 
282 SPASMODIC COUGH. 
 
 by giving gentle diaphoretics, with small doses of ipecacuanha, and of 
 some opiate, such as the compound tincture of camphor, or Dover's 
 powder, if the cough is very troublesome or the nervous dyspnoea con- 
 siderable. Counter-irritation by large mustard poultices to the chest 
 will often relieve any great access of difficult breathing ; and the evi- 
 dence of auscultation should be very decided to justify a recourse to 
 stronger measures, while it must be borne in mind that the necessity 
 for ammonia, ether, and wine is by no means unlikely to occur, and 
 that the first appearance of those signs of exhaustion which I have just 
 described must be taken as an indication for their immediate employ- 
 ment. 
 
 There are two or three other conditions which may perhaps be best 
 briefly mentioned. here, before I close this lecture. One of them is the 
 spasmodic cough often heard in children as the result of gastric or 
 intestinal disorder. Its common character cannot be better described 
 than by its well-known name of tussis ovilla, loud, hoarse barking. 
 This character, however, is not invariable, for sometimes it is a short, 
 dry, frequent cough, of which the child seems almost unconscious, 
 ceasing for the most part during sleep, and also generally stopped by 
 taking food. Auscultation discovers nothing, but in a good many 
 instances there is slight redness of the fauces and soft palate, and the 
 long and relaxed uvula appears to have a share in keeping up the 
 irritation. It is enough to be aware of this condition in order to pro- 
 vide for its appropriate treatment, and to dissipate the anxiety of the 
 patient's friends. 
 
 Aperients, alteratives, the mineral acids as tonics, and preparations 
 of bark or quinine, with, in many instances, change of air, do more 
 for the ailment than the whole range of sedatives. Sometimes, too, 
 the cough is arrested when the uvula is long, or the soft palate re- 
 laxed by the application of the glycerin of tannin, or by the occa- 
 sional use of a solution of ten grains of nitrate of silver in an ounce of 
 distilled water. 
 
 There is also a peculiar form of paroxysmal cough which one some- 
 times meets with, though I do not know any one who has specially 
 described it, except Professor Vogel of Dorpat, who, in his very excel- 
 lent Manual on Children's Diseases, 1 speaks of it as the Night Cough 
 of Children. It is a cough which comes on exclusively at night, not 
 when the child first lies down, but after a few hours of sleep, from 
 which, indeed, it does not wake up at first, but only after coughing for 
 a time. It is a short, teasing, irritable cough — dry, not paroxysmal, 
 not accompanied by expectoration, nor occasioning dyspnoea. After 
 lasting for an hour or two it ceases, and does not recur until the next 
 night, when it comes back with just the same characters as before, and 
 thus continues, with occasional intervals of quiet for a night or two, 
 even for weeks together, not apparently seriously affecting the child ; 
 though the disturbed rest at night tells somewhat on it, and it loses 
 the look of health which it had before. 
 
 The limitation of the cough to the night-time, the absence of any 
 
 1 LehrbucTa der Kinderkrankkeiten, 4te. Auflage, 8vo., Erlangen, 1869, p. 257. 
 

 NIGHT COUGH AND ASTHMA OF CHILDREN. 283 
 
 sign of chest affection in spite of the continuance of the ailment, and 
 the patient's condition, one of ailment rather than of illness, character- 
 ize it. It is a nervous cough, and, like affections of that class, is cured 
 by change of air, by bark and quinine, by good diet with moderate 
 stimulation ; while a cure is often hastened if the habit is broken 
 through by a rather full dose of the bromide of potass and chloral at 
 bedtime for a few consecutive nights. 
 
 Dr. Salter, in his classical work on Asthma? states that in 71 out of 
 225 cases the disorder dated back to the first ten years of life, and in 
 11 of the number it came on under the age of one year. My own ob- 
 servations confirm his statements as to the frequency of the affection in 
 early life ; and recently Dr. Loschner of Prague 2 and Dr. Politzer 3 of 
 Vienna have called attention to its occurrence in infancy. The charac- 
 ters which it presents are much the same at all periods of childhood, 
 and do not differ from those of spasmodic asthma in the adult. It is 
 not an ordinary sequela of hooping-cough, even though that affection 
 should have left the child with emphysematous lungs ; but it is not 
 infrequently developed out of frequent attacks of bronchitis dating 
 back even from very early infancy. In the majority of cases, however, 
 its spasmodic character does not become so marked as to attract notice 
 until the age of five or six, or even somewhat later, while many of the 
 children in whom asthmatic symptoms then come on will be found to 
 have previously been extremely liable to attacks of a half-spasmodic 
 cough — the laryngite striduleuse of French writers, the laryngeal spasm 
 by degrees diminishing as the disposition to spasm of the air-tubes 
 comes on. In other instances the asthma has succeeded to extensive 
 eczema, and so marked is the connection between the two conditions, 
 that I have never known eczema to be very extensive and very long 
 continued without a marked liability to N asthma being associated with 
 it. It cannot, however, be said that the two conditions always alter- 
 nate, the asthma being worse when the cutaneous affection is better ; 
 but the radical cure of the eczema is usually followed, though often 
 not till after the lapse of three or four years, by the cessation of the 
 liability to asthma. 
 
 Catching cold, which in other children would produce ordinary ca- 
 tarrh, seldom fails in children with a predisposition to it to be followed 
 by an asthmatic seizure, though it often comes on independent of previ- 
 ous catarrh, constipation and indigestion being two of its most frequent 
 exciting causes. , When the asthmatic habit is once established, the at- 
 tacks are apt to recur at uncertain periods, without any exciting cause, 
 and at all seasons of the year, though undoubtedly spring and autumn 
 are the times of its greatest frequency, especially the former. If the 
 attacks are not exceptionally severe and frequent, their tendency un- 
 doubtedly is to cease about or rather before puberty — or from the age 
 of twelve to fifteen years. The probability of this being the case de- 
 
 1 On Asthma. 2d ed., 8vo., London, 1868, p 112. 
 
 2 Aus dem Franz Josef-Kinder-Spitale. 2ter Theil, 8vo., Prag, 1868, No. vii, 
 pp. 144-158. 
 
 3 Jahrb. f. Kinderheilk., 1870. 3ter Jahrg., 4 Heft, p. 377. 
 
284 SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. 
 
 pends very much on the success of the endeavors to stave off the at- 
 tacks ; but yet our prognosis may, on the whole, be a favorable one. 
 
 I do not dwell either on the symptoms of the asthmatic seizure or on 
 the treatment, for, to the best of my knowledge, neither the one nor 
 the other differs from what we observe and practice in the case of the 
 adult. We use all remedies, however, with greater hope ; while a sojourn 
 for three or four years in a climate which suits the child (and three 
 times out of four that climate will be found in a moderately sheltered 
 seaside place, with a sandy soil, such as Bournemouth) is not infre- 
 quently successful in entirely overcoming every dispositio'n to asthma 
 throughout the whole remainder of the patient's life. 
 
 LECTURE XXI. 
 
 Pxeumonia, its Symptoms and Treatment. — Symptoms of pneumonia frequently 
 present a mixed character when it supervenes on bronchitis — Idiopathic pneu- 
 monia — Approach of first stage generally gradual — Characteristic peculiarities 
 in mode of sucking and of respiration — Attack sometimes sudden. Symptoms 
 of second stage — Results of auscultation — Reasons for rarity of true pneumonic 
 crepitus. Symptoms of third stage — Convulsions often precede death — Their 
 import — Occasional imperfect recovery — Auscultatory phenomena of this stage. 
 
 Xature of modifications in symptoms produced by association with bronchitis. Di- 
 agnosis from bronchitis — Pleurisy — Hydrocephalus — Remittent fever — Intesti- 
 nal disorder during dentition. 
 
 Treatment — Expectant treatment — Depletion — Tartar emetic — Limitations as to its 
 use. Mercury — Its importance — Danger of salivation very slight. Diet — An- 
 tiphlogistic in the early stages — Caution as to sucking — Stimulants often needed 
 in advanced stage. Blisters not desirable. 
 
 It was stated in the last lecture, that the supervention of inflamma- 
 tion of the substance of the lungs constitutes one of the chief dangers of 
 infantile bronchitis. Pneumonia, however, is not to be regarded as 
 being invariably a secondary affection ; for, in some cases, while the 
 disease of the air-tubes is but trivial, the pulmonary substance is the 
 seat of serious inflammation ; and in other instances the air-tubes are 
 altogether unaffected, or at least are involved only in common with the 
 other constituents of the lung. In either case, there are peculiarities 
 enough, both in the symptoms observed and in the treatment required, 
 to render the separate study of pneumonia indispensable. 
 
 When pneumonia supervenes, as it by no means seldom does, on pre- 
 vious catarrhal symptoms, the disease often comes on insidiously, and 
 develops itself so gradually out of the preceding trivial ailments that it 
 is not possible to determine the exact date of its attack. At other times, 
 indeed, there is a sudden and well-marked increase of the fever and 
 dyspnoea, and an aggravation of all the symptoms, sufficient clearly to 
 
SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA. 285 
 
 point out the date of the supervention of the pneumonia. But, even 
 though this should be the case, yet, if there were much bronchitis pre- 
 viously, the affection of the air-tubes will often mask that of the lung 
 to some degree ; and the case not presenting the symptoms either of 
 pure bronchitis or of unmixed pneumonia, will assume some of the 
 characters of each, and merit, both by the phenomena attending it 
 during life, as well as by the appearances found after death, the name 
 of bronehio-pneumonia. Cases of this mixed character occur most fre- 
 quently during the period of teething, when the mucous membranes are 
 especially susceptible. We will return to notice some of these peculiari- 
 ties hereafter, but we will first examine the symptoms that attend a case 
 of idiopathic pneumonia, where the pulmonary substance has been 
 affected from the outset, and has not merely become involved by the 
 extension to it of mischief commencing in the bronchi. 
 
 In almost all of these unmixed cases, a condition of general feverish- 
 ness, exacerbated towards evening, with fretfulness and pain in the 
 head, precede the more marked symptoms. The child is either restless 
 at night, or^ if it sleeps, its repose is unsound ; it talks in its sleep, or 
 wakes in a state of alarm. Sometimes from the very commencement, 
 at other times, soon after the appearance of these febrile symptoms, 
 cough comes on ; at first, short and hacking, frequently not causing the 
 child any uneasiness, and so slight as scarcely to excite the notice of the 
 parents, and not at all to awaken their anxiety. Loss of appetite and 
 increase of thirst are early observable : the bowels are usually consti- 
 pated, and vomiting is not infrequent, especially in infants at the breast. 
 The tongue and lips are at the same time of a florid red ; the tongue is 
 less moist than usual, and is generally coated in the middle with a 
 thicki^sh white fur. In these symptoms, indeed, there is but little to 
 mark the real nature of the case, or to point to the organ whose disease 
 has kindled the fever in the system ; for the slight cough, if not over- 
 looked, may yet be attributed to irritation of the bronchi, sympathetic 
 with derangement of the stomach or intestines. The respiration too 
 is not always much hurried at this early period ; while, in the young 
 child, both its frequency, and that of the pulse, are much modified by 
 position ; and the results of auscultation are not uniform, and may some- 
 times afford no information at all. Even now, however, there are some 
 signs which to the attentive observer will convey much information, 
 and information all the more valuable from our being furnished with 
 it chiefly in those young infants in whom the diagnosis of the disease 
 is attended with most difficulty. The seat of the mischief is shown to 
 be in the respiratory organs by the child no longer breathing through the 
 nares, while the tongue is applied to the roof of the mouth as in health; 
 but by its breathing through the open mouth also, whence the tongue 
 early acquires an unusual degree of dryness. This same inability to 
 respire comfortably through the nares causes the child to suck by starts : 
 it seizes the breast eagerly, sucks for a few moments with greediness, 
 then suddenly drops the nipple, and in many instances begins to cry. 
 As the disease advances, these peculiarities in the mode of sucking and 
 of respiration often become more striking ; but it is at its onset that 
 
286 SYMPTOMS OF THE SECOND STAGE OF PNEUMONIA. 
 
 they are most valuable, since then we have feAver indications to lead us 
 right. 
 
 It is not, however, thus gradually that pneumonia always comes on ; 
 for sometimes a child who has gone to bed well, or merely a little 
 poorly, wakes in the night in a state of alarm, refusing to be pacified, 
 with a flushed face and burning skin, and hurried breathing and short 
 cough. This sudden supervention of pneumonia is not so often met 
 with among infants at the breast as among children from two to four 
 years old. Often, though not always, this severe onset of the disease 
 has appeared to depend on the pneumonia being associated with exten- 
 sive inflammation of the pleura ; but sometimes the symptoms which 
 at first seem so threatening soon subside, and the affection, in its subse- 
 quent stages, presents no peculiarity, and is not by any means remark- 
 able for its severity. 
 
 This first stage of pneumonia passes, for the most part, by degrees 
 into the second, in which the nature of the affection is generally obvious 
 to all. The momentary cheerfulness which before existed has now 
 passed away; infants now no longer wish to be removed from the 
 cradle, or from the recumbent posture in their nurse's arms, and older 
 children have quite lost all interest in their play ; they become drowsy, 
 ask to be put to bed, and cry if taken up. The hurry of the respira- 
 tion is now abundantly evident ; the alee nasi are dilated with each in- 
 spiration, the abdominal muscles are brought into play to assist in its 
 performance, and any change of posture renders the breathing more 
 labored and more hurried. The cough has become much more fre- 
 quent ; it is still hard, sometimes is evidently painful, so that the child 
 cries with each cough ; at other times it is an almost constant short 
 hack. The bright flush of the face, and the florid tint of the lips, are 
 gone, but the heat of skin continues ; for the persistence of an almost 
 unvarying high temperature throughout its course is, as M. Roger has 
 shown, one of the characteristics of the pneumonia of the child as well 
 as that of the adult. 1 It is a pungent heat, which becomes more sensi- 
 ble the longer the hand is kept in contact with the surface; and so 
 great is the elevation of temperature, that M. Roger found it average 
 almost 104° Fahr. in ninety-seven experiments, while in some cases it 
 greatly exceeded this degree. Though so intense, however, this heat 
 is unequal at different parts — the extremeties being cool, or even cold, 
 while the body is hot; but there is no moisture on any part of the skin. 
 The face now assumes a puffed, heavy, but anxious appearance, and 
 when the child is very young, or the pneumonia very extensive, the 
 lips put on a livid hue, which is also very evident around the mouth, 
 while the face generally is pale. The thirst usually continues very 
 urgent, but children at the breast still vomit the milk. This is appar- 
 ently owing to their thirst being so urgent as to lead them to suck too 
 greedily, and thus overload their stomach, since, while they generally 
 vomit almost immediately after leaving the breast, they do not reject 
 small quantities of fluid given them from a cup or a spoon. The dis- 
 ease of the lungs now betrays itself most strikingly in children at the 
 
 1 Op. cit., pp. 356-367. 
 
RESULTS OF AUSCULTATION. 287 
 
 breast, for as often as they attempt to suck, the respiration becomes at 
 once greatly hurried ; they drop the nipple, panting, from their mouth, 
 or, having seized it, have not breath sufficient to make the vacuum 
 necessary to bring the flow of milk. 
 
 The results of auscultation, though variable, are now sufficiently ob- 
 vious. Crepitation is now heard, often in both lungs, and generally in 
 their lower and posterior parts — seldom, however, the minute crepitus 
 such as we hear in the pneumonia of the adult, but that sound known as 
 the subcrepitant rale. The comparative rarity of true pneumonic 
 crepitus in inflammation of the lungs in infancy is a point not to be 
 lost sight of: often, however, if you keep your ear to an infant's chest, 
 and wait till it takes an unusually deep inspiration, you will hear the 
 true crepitus of pneumonia just for a moment when the air enters the 
 pulmonary vesicles'; and then again you will lose it when the child 
 breathes as it was doing before, and you will hear only the subcrepi- 
 tant rale. If the inflammation has attacked only one lung, you will 
 perhaps be struck by the loud puerile breathing in the healthy organ, 
 which is thus compelled to perform a double function. If both are in- 
 volved, you may almost overlook the disease, since you have not the 
 aid afforded by contrast ; unless, as sometimes happens, the mischief on 
 the one side is so far advanced as to cause bronchial breathing, while 
 on the other side crepitation alone is audible. This bronchial breathing 
 is sometimes heard associated with the subcrepitant rale, or w T ith large 
 crepitation, while at other times the ear detects nothing but the whiff of 
 air through the larger air-tubes ; and often this alone is audible on an 
 ordinary inspiration, while on a deep breath being taken the subcrepi- 
 tant rale will be at once perceptible. In the child we lose all the in- 
 formation 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, afford, even when 
 the child is old enough to talk well, results far too uncertain to be trust- 
 worthy. 
 
 Percussion sometimes yields a very manifest dulness on the affected 
 side ; and this dulness is usually most evident in the infrascapular 
 region. At other times, however, no such marked results are afforded, 
 but the lower parts of the chest give a somewhat duller sound than the 
 upper, and the impression communicated to the finger is that of greater 
 solidity below than above the scapula. This last sign is often very 
 valuable, since it may be perceived at a time when the ear cannot clearly 
 detect actual dulness on percussion. 
 
 Death may take place in this, the second stage of pneumonia, if a 
 very extensive portion of lung has been involved in the disease, or if it 
 is associated with much inflammation of the pleura, or if the pneumonia 
 has been grafted on severe bronchitis. The pneumonia which super- 
 venes on measles, or which comes on in a child debilitated by previous 
 illness, sometimes terminates unexpectedly in this stage, and on an 
 examination of the body after death the lung is found scarcely to have 
 passed beyond the first stage of pneumonia, except in a few portions of 
 but limited extent; though still larger tracts will probably be found 
 in the state of collapse, and to the sudden supervention of this condition 
 
288 SYMPTOMS OF THE THIRD STAGE OF PNEUMONIA. 
 
 the fatal event is probably in great measure due. It is important, too, 
 to bear in mind that in weakly children, a pneumonia of even very 
 small extent will often prove fatal : hence the great importance of 
 watching most sedulously against all those intercurrent affections of the 
 lungs which come on in the course of diarrhoea, measles, or typhoid 
 fever. 
 
 But the pneumonia may be free from any of the above-named com- 
 plications, and then, if unchecked by treatment, it will pass into the 
 third stage. The respiration now becomes more labored, and, though its 
 frequency is sometimes diminished, it will be found to have become 
 irregular ; several short and hurried inspirations being followed by one 
 or two deeper, and at longer intervals, and these again by hurried 
 breathing. The cough sometimes ceases altogether, or if not, it is less 
 frequent, and looser, since it is now produced by the child's efforts to 
 clear the larger air-tubes from the accumulating secretions. The voice 
 is often lost, the patient speaking only in a hoarse whisper ; while chil- 
 dren who were just learning to talk will frequently maintain complete 
 silence, as if conscious that they have no breath to waste in words. 
 The face looks sunken, the extremities are cold, and though the trunk re- 
 tains its high temperature almost to the last, yet the skin often loses some- 
 what of its previous dryness, and clammy sweats break out, especially 
 about the head. The pulse is extremely frequent and small, and the 
 beats so run into each other that it is almost impossible to count them. 
 The child is sometimes very restless at intervals, tossing about from 
 side to side as much as its reduced powers will permit ; but it usually 
 lies in a state of half-consciousness, though sensible when spoken to, 
 and fretful if disturbed. If raised hastily from the recumbent posture, 
 or if put to the breast, the great increase of dyspnoea which is immedi- 
 ately produced shows how seriously the respiratory organs are affected. 
 In many cases, too, the livid hue of the face and of the nails is a further 
 proof of the great impediment which exists to the decarbonization of 
 the blood ; and once I saw purpurous spots appear on the arms and 
 hands thirty-six hours before the death of a previously healthy child 
 of a year old, in whom an attack of idiopathic pneumonia terminated 
 fatally on the seventeenth day. This condition seldom lasts above two 
 or three days ; for either life becomes gradually extinct, without the 
 supervention of any new symptom, or convulsions 'occur, which are 
 followed by fatal coma, or the child recovers for a few hours only to 
 suffer a second attack of convulsions, and a return of coma, in which it 
 dies. It can scarcely be necessary to remind you of what was said 
 some time since w T ith reference to the import of convulsions, and to 
 their being in many cases merely a token of disturbance of the functions 
 of the brain, such as delirium is in the adult. The former symptoms 
 in the child, and the latter in the adult, betoken in a case of pneumonia 
 that the brain is suffering from the circulation through it of imperfectly 
 aerated blood. 
 
 The third stage, however, does not always advance thus uninterrupt- 
 edly to a fatal issue, but a kind of imperfect recovery sometimes takes 
 place. A diminution is obvious in the more alarming symptoms ; the 
 patient begins to express some desire for food as well as for drink, and 
 
RESULTS OF AUSCULTATION. 289 
 
 even has occasional gleams of cheerfulness. The cough, which in many 
 instances had almost or altogether ceased, returns, but is short and 
 hacking, although there is sometimes a good deal of mucus in the larger 
 air-tubes. The dyspnoea is no longer urgent, though the breath is ha- 
 bitually short. The skin is hot, dry, and harsh, and evening exacerba- 
 tions of fever often occur; the tongue is red, dry, and sometimes 
 chapped, or presents small aphthous ulcers at its edges ; diarrhoea is 
 not infrequent ; the child wastes daily, and dies in the course of a week 
 or two, worn out and exceedingly emaciated. 
 
 The auscultatory signs of this third stage of pneumonia are in the 
 main those of the second stage, except that the bronchial breathing 
 usually becomes both more distinct and more extensive, occupying 
 situations where either the subcrepitant rale, or even large crepitation, 
 had previously been heard. As it extends, too, it becomes audible in 
 front as well as behind, and both it, and dulness, on percussion, may 
 be perceived in the infra-mammary as well as in the infra-scapular 
 region, to which at first they are almost always limited. The bron- 
 chial breathing is generally much more extensive on one side than on 
 the other, and sometimes it is heard throughout the whole posterior 
 part of one side of the chest ; but it is exceedingly unusual to find 
 bronchial breathing confined to the upper part of one lung, except in 
 cases where there existed previous tubercular disease of the organ, and 
 then the pulmonary tissue may become solidified under the influence of 
 an amount of disease which otherwise would be inadequate to produce 
 this result. 
 
 The symptoms that attend the third stage of the disease usually are 
 the result of the lung having passed into the state of suppuration. I 
 say usually, for sometimes recovery eventually takes place even from a 
 condition apparently desperate, and in such cases the degree to which 
 disorganization of the lung had actually advanced must always remain 
 uncertain. 
 
 The results of auscultation do not help us, any more than in the 
 adult, to determine with certainty the amount of injury that the lung 
 has sustained, while we are deprived almost entirely of that informa- 
 tion which in the grown person is afforded us by the changes in the 
 appearance of the sputa. In some cases of rapidly fatal pneumonia I 
 have seen a frothy secretion collect about the mouth; but this was 
 evidently not furnished by the air-tubes, but was merely the saliva 
 which the child was unable either to spit out or to swallow. The 
 cough of pneumonia being generally short and not paroxysmal, we 
 have not so much chance of seeing the sputa as in the case of acute 
 bronchitis, and children even of five or six years old seldom spit out 
 the matters that they expectorate, fc^it almost always swallow them. 
 
 When resolution of hepatized lung takes place, the changes in the 
 physical signs of the disease are much the same as are perceived in the 
 adult. I have not, however, in any instance detected a return of true 
 pneumonic crepitation, but subcrepitant rale in most cases became 
 audible, and in a few instances large crepitation. In either case 
 mucous rale was eventually heard, and it often continued for many 
 days after the lung had in other respects recovered its natural condi- 
 
 19 
 
290 BRONCHTO-PNEUMONIA. 
 
 tion ; apparently much as, in the pneumonia of the adult, prolonged 
 expiration often persists for a long time after all the other signs of 
 disease have disappeared. 
 
 At the commencement of this lecture reference was made to cases in 
 which the symptoms of pneumonia are modified by those of the bron- 
 chitis with which it is associated. In such cases there is from the 
 very outset a marked degree of dyspnoea and distress, and the face pre- 
 sents from the first a livid hue. The cough is less short than in simple 
 pneumonia, but it comes on in paroxysms which greatly distress the 
 patient : the respiration is more hurried and more irregular, and this 
 irregularity comes on at an earlier stage of the disease. Large crepita- 
 tion and subcrepitant rale are generally heard very extensively in both 
 lungs, but true pneumonic crepitation is unusual. A preponderating 
 affection of the lower lobes is seldom perceptible ; and, since these cases 
 usually tend to a rapid termination, death sometimes takes place before 
 either dulness on percussion, or bronchial breathing, has become dis- 
 tinctly audible. 
 
 Such are the characters generally presented by pneumonia in early 
 life, and these are usually so well marked as to render it impossible 
 either to overlook the disease or to mistake its symptoms for those of 
 some other malady. This, however, is not invariably the case even 
 when the inflammation of the lungs occurs as an idiopathic affection, 
 while in those instances in which it comes on in the course of other 
 diseases, it very often remains latent, and much acuteness of perception, 
 as well as much patient observation, is necessary for its detection. We 
 will pass over for the present the consideration of secondary pneu- 
 monia, since to understand all the varieties that it presents would re- 
 quire a previous acquaintance with those diseases in the course of which 
 the inflammation of the lungs supervenes. When we come to the 
 study of hooping-cough, croup, measles, remittent fever, &c, I will 
 endeavor to point out the period at which, in each of these maladies, 
 pneumonia is most to be apprehended, and the symptoms that indicate 
 its attack ; but for the present we will confine our notice to those cases 
 in which the inflammation of the respiratory organs occurs as an idio- 
 pathic affection. 
 
 The points of difference between pneumonia and bronchitis have al- 
 ready been dwelt on so fully as to render it unnecessary to recapitulate 
 them. In many cases they are too obvious to admit of your falling 
 into error, but in others they are so shaded off that it is difficult to de- 
 termine whether the characters of one or the other predominate ; and 
 we are forced to conclude that the two exist together, the one obscuring 
 the otherwise well-marked features of the other. 
 
 In the child, as in the adult, son^e degree of pleurisy exists in a large 
 proportion of cases of pneumonia, though sometimes so slight as to be 
 scarcely noticed ; whilst in other cases, though a little friction-sound 
 may be heard for a short time, yet it is evident that the danger to life 
 is occasioned by the mischief in the lung, and not by the affection of 
 the pleura. Sometimes, however, inflammation of the pleura is the 
 chief, if not the sole cause of the patient's danger, and hence it is de- 
 
DIAGNOSIS OF BRONCHIO -PNEUMONIA. 291 
 
 sirable to know even at the outset, whether the lung or its investing 
 membrane is the part chiefly affected. 
 
 An attack of pleurisy is much oftener marked by complaint of severe 
 pain in the chest, than is an attack of pneumonia; or if the child 
 should be unable to express its feelings, the seizure is not infrequently 
 announced by violent and continued screaming. Sympathetic disturb- 
 ance of the brain is more frequent and more severe at the onset of an 
 attack of pleurisy than of pneumonia, and the attendant restlessness is 
 greater. Auscultation, too, fails to discover the crepitant or subcrepi- 
 tant rale which characterizes pneumonia, but air enters the lung on the 
 affected side much less freely than on the other, and a friction-sound 
 may perhaps be distinguished ; though this is by no means invariable, 
 and even when present it may easily be mistaken for rhonchus. It 
 may be laid down as a rule, subject to but few exceptions, that when- 
 ever a child is suddenly seized with symptoms which, while they indi- 
 cate some affection of the lungs, are yet unattended with the ausculta- 
 tory signs of pneumonia, the disease from which it is suffering is pleu- 
 risy ; and this probability is rendered almost a certainty if, while the 
 child bears percussion on one side of the chest, it cries and struggles 
 on the slightest attempt at percussion on the opposite side. 
 
 The error of taking a case of pneumonia for one of pleurisy, how- 
 ever, or the opposite, is of comparatively little moment ; but there are 
 other diseases for Avhich pneumonia may be taken, in which the error 
 of diagnosis will lead to serious, and perhaps fatal mistakes in treat- 
 ment. 
 
 These mistakes, too, may be made at almost any stage of the disease. 
 The symptoms of disorder of the brain may throw those of the lung 
 affection into the shade ; and the disease may not only begin, but may 
 even run a large portion of its course with so great an amount of 
 cerebral disturbance as to mislead the unwary practitioner. It is es- 
 pecially in pneumonia of the upper lobes that this predominance of 
 disorder of the nervous system is most remarkable, the attack even 
 setting in, as that of acute pleurisy does sometimes, with convulsions, 
 while great stupor with delirium in children old enough to present 
 this symptom, marks its subsequent progress. The cough may be 
 short, or altogether suppressed, and the hurried breathing is not un- 
 naturally referred to the supposed affection of the brain ; while a hasty 
 auscultation fails, even if resorted to, to discover the real nature of the 
 case, to which MM. Rilliet and Barthez gave the appropriate name of 
 " cerebral pneumonia." 1 If, however, we are on our guard against 
 being misled, there are two symptoms, which, even independently of 
 that careful auscultation which should never be omitted, will usually 
 preserve us from error. One is, the extremely high temperature from 
 
 1 Op. cit , 2d ed., vol. i, p. 526. More recently, too, some very valuable remarks 
 on this subject have been made by Professor Steiner in Jahrb. f. Kinderheilk., 1869, 
 p. 357. I cannot but doubt, however, whether the internal otitis to which he at- 
 taches such importance as the occasion of the head symptoms in many of these cases 
 was other than a purely accidental complication of the pneumonia, or the pneumo- 
 nia a complication of it. In many instances, undoubtedly, most marked symptoms 
 of cerebral disorder are present where yet the lungs are the exclusive seat of dis- 
 ease. 
 
292 DIAGNOSIS OF PNEUMONIA. 
 
 even the outset, and its steady continuance ; and the other, the great 
 and constant acceleration of breathing, unlike the hurried, yet irregu- 
 lar and unequally rapid respiration which attends acute affections of 
 the brain or of its membranes. But besides these exceptional cases, in 
 which a mistake is half excusable, there are others in which, especially 
 in infancy and early childhood, the inflammation of the lungs is some- 
 times overlooked, and the symptoms are regarded, until too late, as 
 those of tubercular meningitis. The vomiting, the pain in the head, 
 the restless nights, with talking in the sleep, which attend the onset of 
 almost all the acute affections of childhood, the fever, and the consti- 
 pated state of the bowels common to both diseases, lead to this error. 
 The cough in some cases of pneumonia is so slight as scarcely to be 
 noticed, while even if present it may be taken for that sympathetic 
 cough which is sometimes present in the early stages of tubercular 
 meningitis ; and the child, if questioned, may complain of his head, 
 and of nothing else. But still there are circumstances which would 
 lead the attentive observer, independently of auscultation, to detect the 
 real nature of the case. The vomiting that ushers in an attack of 
 pneumonia, though sometimes violent, seldom continues long, and is 
 unattended with that permanent nausea and irritability of the stomach 
 which are so marked in the first stage of the brain disease. The evac- 
 uations in pneumonia are natural ; the tongue is of a much more vivid 
 red ; the pulse is much more frequent, its beats are not irregular, the 
 heat of the skin is far greater, far more constant, and more remarkable 
 on the trunk than about the head, and the thirst is generally urgent. 
 If these indications, however, are overlooked at the commencement of 
 the attack, and if auscultation, by which the error might still be set 
 right, is neglected, it is probable that each subsequent occurrence will 
 be misinterpreted, and that the real nature of the disease will not be 
 understood until it is revealed by the post-mortem examination. More 
 or less sympathetic affection of the head is seldom wanting in pneumo- 
 nia to confirm the preconceived erroneous notion ; while, as the child 
 grows worse, the difficulties in the way of making a careful ausculta- 
 tion increase. Convulsions sometimes occur even several days before 
 the patient's death, and the head symptoms may appear, especially to 
 a prejudiced observer, to be much more striking than any which indi- 
 cate affection of the lungs. 
 
 It sometimes happens that the sympathetic disturbance of the stom- 
 ach and bowels is so considerable as to obscure the chest symptoms, and 
 the case is taken for one of enteritis ; or perhaps, if the heat of skin 
 and sensorial disturbance are considerable, for what is loosely termed 
 remittent fever ; and this latter error is especially likely to be com- 
 mitted if the upper lobes of the lung are the seat of the inflammation. 
 The vomiting at the outset of the disease, the pain referred to the ab- 
 domen, with the evident increase of discomfort on pressure, the red 
 tongue, with its disposition to dryness, and the diarrhoea that exists in 
 these rather exceptional cases of pneumonia, are the symptoms which 
 tend to lead into error ; and this error may be confirmed on the prac- 
 titioner finding that at least temporary relief follows the application of 
 leeches and poultices to. the abdomen. With reference to the complaint 
 
TREATMENT OF PNEUMONIA. 293 
 
 * 
 
 of pain in the belly, which seems often to have a large share in induc- 
 ing this error, it must be remembered that the statements of children 
 with reference to the seat of pain are very vague, and that they fre- 
 quently speak of the belly when they mean the chest ; while the im- 
 pediment to the descent of the diaphragm occasioned by pressure on 
 the abdomen, especially if this pressure is either sudden or considerable, 
 will almost always excite expressions of uneasiness when the organs of 
 respiration are in any way affected. It is in careful auscultation that 
 your chief safeguard against these mistakes will consist ; but you will 
 find besides, that by accustoming yourselves to look not at one or two 
 prominent symptoms only, but at the relation which each bears to the 
 other, many of the chief difficulties in the way of forming a correct 
 diagnosis will disappear. 
 
 It may perhaps seem to you that much of this is very dry and 
 rather needless detail ; but unfortunately my own case-books would 
 enable me to illustrate each of these errors of diagnosis against which 
 it is my endeavor to guard you. One more caution I would offer you, 
 and that is, not to overlook the pneumonia which sometimes comes on 
 in children while teething. Unless you are on the watch for it, its early 
 symptoms will probably fail to excite your apprehension, since they 
 will be regarded as the result of that sympathetic irritation of the air- 
 tubes which so often accompanies dentition, and the time for action 
 will thus be allowed to pass unemployed. The disease comes on most 
 frequently in weakly children, is unattended by much constitutional 
 reaction, and often runs a somewhat chronic course : while its nature 
 is further obscured by the tendency to diarrhoea which exists during 
 dentition, and which is now excited by the thoracic affection. The 
 purging often becomes the most striking symptom, and all means are 
 employed to suppress it, and to check the vomiting which generally 
 attends it. These efforts, however, are unavailing ; the child wastes 
 daily, and its skin hangs in wrinkles about its attenuated limbs, while 
 the abdomen becomes tumid from the collection of flatus in the large 
 intestines, and tender on pressure, and the tongue grow r s red, dry, and 
 chapped, or covered with aphthous ulcers. The cough now T perhaps 
 attracts notice ; but both it and the bronchial breathing in the lungs 
 are probably looked on as indications of phthisis, and the doctor con- 
 soles himself with the belief that -he has failed to cure the disease be- 
 cause it was irremediable. At last the child is worn out, and dies, and 
 great is the surprise to find no tubercle in any part of the body, no 
 disease in the intestines, but pneumonia, with purulent infiltration in 
 both lungs— a disease which ought to have been detected, and which 
 probably might have been cured. 
 
 When speaking of the treatment of bronchitis in early life, I felt it 
 to be my duty to explain to how large a degree changes in the character 
 of disease had led to a modification of my practice. But in the case of 
 the treatment of pneumonia we have to consider even more than this, 
 and to decide whether the adage "Optima est medicina, medicinam 
 non facere," does not include, as some have contended, all that we need 
 know w r ith reference to it. This allegation has been made : it has been 
 asserted that in the young the tendency to recovery from uncompli- 
 
294 TREATMENT OF PNEUMONIA. 
 
 % 
 
 cated pneumonia is so invariable, that the physician has nothing more 
 to do, after having established his diagnosis, than to watch how nature 
 brings about the cure, and to abstain from disturbing processes which 
 his interference can only mar. 1 
 
 Dr. Barthez 2 — a name which we cannot mention without stopping 
 for a moment to pay the tribute due to the memory of his worthy 
 fellow-laborer, Rilliet, who passed away so suddenly, so prematurely 
 for science, if not for his own fame — addressed a communication to the 
 Academy of Medicine of Paris in April, 1862, the object of which was 
 to vindicate the expectant treatment of pneumonia in early life. In 
 this paper he states, that of 212 cases of lobar pneumonia occurring 
 between the ages of two and fifteen, in the course of seven years, at the 
 Hopital Ste. Eugenie, two only had a fatal termination, although no 
 approach to active treatment was adopted in more than a sixth of the 
 number. M. Grisolle, so deservedly high an authority on the subject, 
 seems inclined to accept the conclusions of M. Barthez for children 
 above the age of four, and. for young persons up to the age of five and 
 twenty, but demurs to its applicability at a more advanced age : or, in 
 other words, where his own largest experience commences, and his own 
 personal responsibility weighs upon him most heavily, he hesitates to 
 stand by a mere spectator of the combat between disease and nature for 
 the mastery. M. Barthez sums up his conclusions very decidedly, 
 though with just moderation, and it is fairest to state them in his own 
 words : " The only positive rule which I am anxious to lay down is 
 this : that it is scarcely ever useful, and still less is it necessary, to em- 
 ploy very active treatment in the idiopathic pneumonia of children, and 
 that it is especially important to abstain as much as possible from the 
 repeated abstraction of blood, since its evident effect is to weaken the 
 children uselessly, and to protract their convalescence considerably." 
 
 Now I have no statistical data to oppose to the statements of M. 
 Barthez. I meet with idiopathic pneumonia in an early stage much 
 more rarely now than I did formerly, when I was physician to the 
 Children's Dispensary in Lambeth, or when I had charge of some of 
 the out-patients of the Children's Hospital ; and in the case of most of 
 the patients who are admitted with pneumonia, the disease has long 
 since passed the stage in which active treatment would have been ad- 
 missible. The same/ too, applies to the cases that have come under 
 my notice in private consultation ; though at the same time it must be 
 allowed that the very rarity with which idiopathic pneumonia has 
 fallen under my observation in private, says much for its tendency to 
 spontaneous subsidence when the patient is placed in favorable hy- 
 gienic conditions. 
 
 But I confess that I cannot forget the good results which I saw 
 years ago from the abstraction of blood at the outset of an attack of 
 pneumonia in previously healthy children, in whom fever, short cough, 
 
 1 For the history of opinion with reference to the expectant treatment of pneu- 
 monia, see Grisolle, La Pneumonie, 2d ed , Paris, pp. 558—578 
 
 2 Reported in the Bulletin de Therapeutique, 8vo., Paris, 1862, vol. 62, pp. 368- 
 374. 
 
 \ 
 
DEPLETION AND USE OF ANTIMONY. 295 
 
 and hurried breathing had come on suddenly, and unpreceded by ca- 
 tarrhal or bronchitic symptoms. It is conceded, by writers even at 
 the present day, that depletion employed at an early period lessens heat 
 of skin, abates hurry "of breathing, and relieves distress; and to these 
 admissions I should be disposed to add that, in some instances, it cuts 
 short the disease. I do not, however, think that after the first twenty- 
 four or thirty-six hours this result will be obtained, and should not 
 advise depletion at a time when small crepitation has become generally 
 diffused, still less when dulness or bronchial breathing is perceptible ; 
 nor should I advocate a repetition of bleeding in any case when the 
 good which it appeared to have effected had passed away. 
 
 But if I cannot admit that the abstraction of blood in the early 
 stage of pneumonia is never indicated, still less can I allow that anti- 
 mony is in no case to be employed, even though the symptoms do not 
 seem to justify depletion, or though the time for having recourse to it 
 may have passed way. So long as the breathing has not become bron- 
 chial, or the heat of skin and hurry of respiration continue, and the 
 vital powers of the child are manifestly unimpaired, even though the 
 diffusion of small crepitation through the lungs proves the inflamma- 
 tion to be very general, I believe that antimony is likely to prove of 
 essential service. I mean here antimony employed for its own specific 
 action, and not merely given as an adjunct to other treatment. Given 
 in a dose of gr. J every ten minutes till vomiting is produced, in the 
 case of a child of two years old, and continued afterwards every two 
 hours for a period of twenty -four or thirty-six hours, it subdues the 
 fever and abates the dyspnoea in a most remarkable manner ; the minute 
 crepitation becomes larger, and, as M. Trousseau says, " there is no 
 stage of convalescen.ee ;" the child dangerously ill yesterday is all but 
 well to-day ; and nothing but our experience of the real importance of 
 the previous symptoms would satisfy us that we had not misread their 
 meaning, nor overestimated their gravity. But I must add that an- 
 timony thus employed usually accomplishes its purpose in twenty-four, 
 or at the most in thirty-six hours ; and that with the establishment of 
 its complete tolerance comes the signal for its discontinuance, or at 
 least for a change in the mode of its administration, and the results of 
 auscultation must now in great measure determine our subsequent con- 
 duct. Should that inform us that the physical condition of the lung 
 has greatly improved, as well as the general state of the patient, the 
 use of the remedy may be persevered in at longer intervals, as every 
 four or every six hours. If the signs of inflammation are advancing, 
 and have become perceptible in portions of lung previously free from 
 disease, mercury must be employed, which may be combined with 
 small doses of antimony, while large doses of that remedy may still be 
 given to combat any sudden increase of fever or dyspnoea that may 
 chance to supervene. If, notwithstanding a manifest diminution of 
 the fever and reduction of the dyspnoea, bronchial breathing should 
 have become distinctly audible, mercurials must at once be substituted 
 for the antimony; and the existence in any case of extensive or well- 
 marked bronchial respiration should be regarded as of itself contra- 
 indicating the antimonial plan of treatment. It is not my intention to 
 
296 EMPLOYMENT OF MERCURIALS. 
 
 say, that after the supervention of bronchial respiration antimony ought 
 never to be given, but only that it should not be employed except in 
 small doses, and in combination with other remedies. 
 
 In cases where the symptoms do not set in with such violence as to 
 indicate the necessity for very large doses of antimony, or in which 
 the disease has passed that stage where antimony so given is likely to 
 be beneficial, mercurials may be used with great advantage. In cases 
 of the former kind, from two-thirds of a grain to a grain of calomel, 
 combined with two grains of James's powder, may be given every six 
 hours to a child two years old. If the case is of a graver kind, and 
 bronchial breathing has become perceptible notwithstanding depletion 
 and the administration of tartar emetic, the calomel must be given more 
 frequently — as every four or three hours, combined with small doses of 
 Dover's powder and tartar emetic, if the child is not so depressed as to 
 render the use of the latter medicine inexpedient. Sometimes the combi- 
 nation of antimony with the mercurial is at first well borne, but afterwards 
 it becomes desirable to discontinue it on account of the sickness that it 
 produces, or on account of the debility of the patient. The diarrhoea 
 which the calomel excites may usually be checked by increasing the 
 quantity of the Dover's powder, or by an occasional dose of chalk 
 mixture. There are some troublesome cases, however, in which the 
 stomach and bowels are so irritable that scarcely any medicine can be 
 borne ; and in them, as well as in cases of neglected pneumonia, where 
 the proper, time for active treatment has been allowed to pass by, and 
 the child has become exhausted while a large extent of lung is imper- 
 vious to air, much benefit sometimes follows the persevering use of 
 mercurial inunction, or the employment of that convenient substitute 
 for inunction, the mercurial belt, on which the ointment should be re- 
 newed every twelve hours. In infants and children under five years of 
 age, the gums hardly ever become affected by mercury, even though 
 most energetically employed ; and it has only once occurred to me to 
 meet with an instance of profuse salivation, or of dangerous ulceration 
 of the gums, as the result of the employment of mercury in pneumonia. 
 Such accidents, however, do now and then occur, and have been known 
 to terminate in fatal gangrene of the cheek, or in necrosis of the jaw. 
 On this account, therefore, you must watch the condition of the gums 
 in infants and children to whom you are administering mercury, just 
 as you would do in the case of the adult, and diminish or discontinue 
 the remedy on the first indication of their being affected. 
 
 The diet of children in the early stages of pneumonia should be spar- 
 ing ; and infants not weaned should have some less nutritious food than 
 the mother's milk, which their thirst will otherwise lead them to take 
 more abundantly even than when they are well. If the pneumonia is 
 severe, it is better to give even the mother's milk with a spoon, rather 
 than to allow the infant to suck, since the very act of sucking is inju- 
 rious, and taxes to the utmost the respiratory function, the organs of 
 which it is desirable to keep in as unexcited a state as possible. 
 
 But though the treatment of inflammation of the lungs requires a 
 strict antiphlogistic regimen in the early stages of the disease, yet in 
 many, perhaps in most cases, there arrives a period in which a spare 
 
DIET — STIMULANTS — BLISTERS. 297 
 
 diet is no longer suitable — in which your main efforts must be directed 
 to support the constitutional powers, rather than to subdue the inflam- 
 mation. If you forget this, it may happen to you to overcome the mis- 
 chief in the chest, but to lose your patient from carrying too far, or 
 from continuing too long, the very treatment which, within proper 
 limits, was most salutary. No point in the management of the disease 
 is more difficult than the seizing the exact moment when the employ- 
 ment of stimulants becomes necessary; and no general rule can be laid 
 down for regulating their use. If, however, the patient were beginning 
 to be much purged, if the respiration were growing more labored and 
 irregular, though diminished in frequency, and if the pulse were be- 
 coming more frequent, and above all, smaller and smaller, it is high 
 time to resort to their use. Wine is as indispensable in such cases in 
 the pneumonia of the child as in that of the adult ; and it may be nec- 
 essary to give it even to infants at the breast. Ammonia may also be ad- 
 vantageously administered in this stage of the disease, either in a mixture 
 with the decoction of senega, 1 or dissolved in milk, which conceals its 
 disagreeable pungency better than any other vehicle. If diarrhoea does 
 not exist, strong beef tea or veal broth is the best form in which nutri- 
 ment can be given; but if the bowels are relaxed, arrowroot, or the 
 decoction blanche 2 of the French hospitals, should be substituted for it. 
 
 In conclusion, it may be well to offer a caution with reference to the 
 employment of blisters — a measure to which we often have recourse 
 with advantage during the resolution of pneumonia in the adult, but 
 which is not advisable in young children whose lungs have been solidi- 
 fied by the disease. The sores which blisters form are very apt in 
 weakly children to take on an unhealthy character ; and the disposition 
 to this accident appears to be greater after inflammation of the lungs 
 than after almost any other disease ; and especially in those cases of 
 secondary pneumonia that supervene on measles. For any such counter- 
 irritation, I am accustomed to substitute the constant application of 
 warm linseed-meal poultices. These afford great relief to the patient. 
 and I imagine answer by their soothing influence, the chief purpose 
 aimed at by the use of cold compresses to the chest, which appear to me 
 objectionable, not only on account of the child's repugnance to their use, 
 but also on account of the necessity for frequently disturbing the patient 
 in order to renew them. 
 
 I am bound, however, to add that these objections are not based on 
 personal observation ; and that many German physicians 3 of deservedly 
 high reputation advocate this mode of treatment, though rather as a 
 means of abating fever than of importantly modifying the course of 
 the disease. I must further say, that the evidence in favor of the use 
 of cold for this purpose, and also for its soothing influence when steadily 
 applied, is so strong, that I do not consider myself altogether free from 
 blame for never having given it a trial. 
 
 1 Soe Formula No. xii, p. 279. 2 See Note, p. 57. 
 
 3 Especially Ziemmsen, Pleuritis und Pneumonie im Kindesalter, 8vo., Berlin, 
 ]862, pp. 273-281. 
 
298 (EDEMA OF THE LlTNGS. 
 
 LECTURE XXII. 
 
 (Edema of the Lungs. — Occasionally comes on in the course of scarlatinal dropsy 
 — Severity of the symptoms, and their sudden accession — Difference between 
 characters of oedematous and hepatized lung — Treatment — Importance of vene- 
 section — Occasional exceptions to its use — Chronic oedema, or carnification. 
 
 Gangrene of the Lung. — Case illustrative of the disease — Is not the result of 
 mere intensity of inflammation — Unattended by any pathognomonic symptom. 
 
 Pleurisy — Its symptoms and morbid appearances similar to those observed in the 
 adult — Auscultatory signs of it, and their changes # as recovery advances — It 
 occasionally simulates other diseases, as affections of the head and of the abdo- 
 men — Evidences of auscultation less conclusive than in the adult, and why. 
 
 Latent pleurisy — Occasional sudden death in these cases — Various modes in which 
 pleurisy proves fatal — Other terminations of the disease — Empyema — Deformity 
 of the chest from pleurisy — Spontaneous opening in chest — Its tendency to re- 
 main fistulous. 
 
 Treatment in the acute stage — Importance of depletion and antiphlogistic measures 
 —Management in subsequent stages — Question of paracentesis considered — 
 Minute rules laid down for its performance and for after treatment — Its dan- 
 gers — Seasons against leaving cases to nature — Deformity of chest after pleurisy. 
 
 Before we proceed to the examination of some other forms of in- 
 flammatory disease of the respiratory organs, it may be convenient to 
 notice two conditions of the pulmonary tissue, which, though not the 
 direct results of inflammation, yet are closely connected with it. One 
 of these conditions is acute oedema of the lung ; the other is gangrene 
 of its substance. 
 
 It is unnecessary to occupy your time with any detailed account of 
 that anasarcous state of the lungs which is sometimes met with in con- 
 nection with general dropsy of long standing, or with some old disease 
 of the heart and great vessels. In such cases, the oedema of the lungs 
 %s a secondary affection, and has very little share in producing the 
 patient's death. But it occasionally happens that children are attacked 
 by intense dyspnoea, and other symptom? of disorder of the respiratory 
 organs, which terminate rapidly in death; while it is discovered, on an 
 examination of the bo^y, that the thoracic viscera generally are free 
 from disease, but that the tissue of the lungs is loaded with serous fluid. 
 Laennec 1 refers to such an accident as probably accounting for the occa- 
 sional sudden supervention of extreme dyspnoea in children recovering 
 from measles ; but the late much-lamented M. Legendre 2 was, to the 
 best of my knowledge, the first person who clearly proved the connec- 
 tion between the symptoms observed during life, and the state of ex- 
 treme oedema of the pulmonary tissue after death. 
 
 This oedema of the lungs, though it sometimes destroys life very 
 speedily, is seldom, if ever, a purely idiopathic affection, but occurs 
 generally as one of the complications of that acute anasarca which not 
 
 1 On the Diseases of the Chest, translated by Dr. Forbes, 4th edition, p. 164. 
 London, 1834. 
 
 2 Eecherches sur quelques Maladies de L'Enfance, 8vo., pp. 324-352. Paris, 1846. 
 
 I 
 
CHARACTER OF (EDEMATOUS LUNG. 299 
 
 infrequently succeeds to scarlatina ; and even then it is not of very 
 common occurrence. M. Legend re records only four cases, all of which 
 were observed in children who were suffering from anasarca after scar- 
 latina ; but several instances of it have come under my notice since the 
 publication of his observations, in all of which it supervened during 
 scarlatinal dropsy. In some of these cases it came on while the children 
 were laboring under a great degree of anasarca ; while in others the 
 dropsy had greatly abated before the thoracic symptoms appeared. In- 
 dications of slight mischief in the chest, such as frequent dry cough, 
 some degree of dyspnoea, with rhonchus and sibilus, or scanty crepita- 
 tion, preceded the more serious symptoms for two or three days. The 
 patient, in short, had seemed to be suffering from a bronchitis of mod- 
 erate intensity, when suddenly extreme difficulty of respiration super- 
 vened, attended with very hurried breathing, orthopnoea, and most 
 tumultuous and violent action of the heart, though with a feeble pulse. 
 The cough continued, being still short, and quite unaccompanied by 
 expectoration. Auscultation in such circumstances does not seem to 
 give account of mischief sufficiently serious to explain the alarming 
 nature of the symptoms. It may be thought that air enters the lungs 
 less freely than it should do ; but the crepitation heard is scanty, bron- 
 chial respiration is not perceptible, neither is the resonance of the chest 
 on percussion diminished unless fluid has at the same time been effused 
 into the pleura. Nevertheless, if relief is not soon afforded, the child's 
 sufferings in a few hours amount to perfect agony ; the difficulty of 
 respiration and the tumultuous action of the heart continue ; the lips 
 and face become perfectly livid, but the intellect remains clear, and the 
 child complains of great distress, referred to the heart or epigastrium ; 
 till at length death takes place suddenly, which it sometimes does 
 within twenty-four hours from the appearance of these alarming symp- 
 toms. At other times the approach of the disease is more gradual, 
 dyspnoea being augmented in paroxysms, but on the whole increasing 
 with the increase of the general anasarca, and proving fatal in the 
 course of five or six days. 
 
 On examining after death the bodies of children who have died of 
 this acute oedema of the lungs, some transparent serum is usually found 
 in the chest, and a few deposits of lymph on the surface of the lung 
 sometimes betoken the existence of slight inflammation of the pleura. 
 The lungs themselves are of a deep red color, firm, and destitute of air 
 through a great extent of their substance, not breaking down so easily 
 as lung in a state of true hepatization would do, but giving exit when 
 cut into to a most abundant quantity of reddish serum, mixed with 
 very few air-bubbles. If the lung is punctured, the fluid will by degrees 
 drain out, and the organ will recover much of its natural flaccidity, 
 while, if air is blown into the bronchi, the pulmonary tissue will com- 
 pletely resume its light color, and will crepitate as in a state of health. 
 These experiments show T that the fluid is not actually incorporated with 
 the substance of the lung; and M. Legendre explains the sudden occur- 
 rence of alarming dyspnoea in some instances by the assumption that it 
 is due to compression of the air-vesicles by the rapid pouring out of 
 fluid into the cellular tissue by which they are surrounded. The sup- 
 
300 TREATMENT OF (EDEMA OF THE LUNG. 
 
 position, however, that the fluid is in these 'cases entirely external to 
 the pulmonary vesicles does not appear to be well founded, for watery 
 fluids 1 will pass by endosmosis from one part of the lung to another, 
 and will even transude through the pleura. The general effect, how- 
 ever, is the same, whether the chief accumulation of fluid be within the 
 air-cells or external to them, for in either case the free entrance of air 
 is impeded; while the severity of the symptoms depends upon the 
 rapidity with which the oedema has taken place almost as much as upon 
 its degree. In cases where it comes on towards the close of some chronic 
 affection, there is often no dyspnoea nor any aggravation of the patient's 
 sufferings to mark its occurrence, while, when it takes place suddenly, 
 not only are the symptoms most urgent, but the right auricle and ven- 
 tricle are found after death enormously distended with coagulated 
 blood — a token of the difficulty with which the heart had discharged 
 the functions to the performance of which it at length became wholly 
 unequal. 
 
 In every case of anasarca after scarlatina, the possibility of the super- 
 vention of this condition must be borne in mind, and every endeavor 
 must be made, by the employment of diaphoretics and antimonials, and 
 by the use of the hot-air bath, to maintain the action of the skin, and to 
 relieve thereby the congested kidneys. If in spite of care, or, as far 
 oftener happens, from want of it, these symptoms should occur, your 
 course of treatment must be governed by the child's general condition. 
 If its employment is not absolutely contraindicated, free venesection 
 will be found to bring the same remarkable and immediate relief which 
 it affords to those most urgent symptoms that follow the escape of air 
 into the pleura; and the relief is probably in both cases brought 
 about in the same manner. After depletion, large doses of tartar 
 emetic should be given, since there is no other remedy that so speedily 
 or so effectually reduces the urgent dyspnoea. In the subsequent man- 
 agement of the case, just such remedies are required as would be best 
 calculated to relieve the general dropsy ; and, as that decreases, the 
 oedema of the lungs will likewise diminish and disappear. 
 
 Very often, however, especially among the poor, the oedema of the 
 lung comes on after long neglect of the patient's symptoms, or after 
 some course of treatment altogether inefficient has been adopted ; and 
 the cold extremities, the livid surface, and the feeble pulse forbid all 
 depletory measures, and render the use of any depressing remedy, such 
 as antimony, altogether inappropriate. In such circumstances, a di- 
 rectly opposite plan must be adopted : a large mustard poultice must 
 be applied to the chest ; stimulants must be given abundantly, such as 
 the nitrous or sulphuric ether, wine, or brandy ; and sometimes it is 
 necessary to continue these measures for several days, while some mild 
 diuretic, such as the tartrate or citrate of potass, or the benzoic acid, is 
 the only medicine Avhich we can venture to employ. On one or two 
 occasions I have found reaction speedily follow the use of stimulants, 
 and have even been able in six or eight hours not only to discontinue 
 
 1 See the remarks and experiments of M. Barthez, in a note at p. 188 of vol. ii of 
 his and M. Rilliet's work on Diseases of Children. 
 
CHRONIC (EDEMA — GANGRENE OF THE LUNG. 301 
 
 them, but have even ventured to take blood from the arm ; and the relief 
 which followed justified the wisdom of the course. These, however, are 
 exceptional cases, and care is often needed, on the other hand, lest the 
 child should sink from the too early withdrawal of the stimulants. 
 
 It would be wrong, perhaps, to leave this subject without some no- 
 tice of the views of M. Baron 1 with reference to certain alterations in 
 the lungs, and in other parenchymatous viscera, which he believes to 
 be due to chronic oedema of their tissue. He describes a state of car- 
 nification in which the substance of the organ becomes dark, firm, and 
 compact, as if from compression ; but instead of these changes being 
 attended by any diminution of its bulk, its size is actually increased. 
 This alteration, though observable both in the liver and spleen, is 
 naturally most striking when it exists in the lung, and was found by 
 M. Baron, in all instances, either coexisting with dropsical effusions, 
 or present in cases where such effusions had previously existed. He 
 believes it to be due to long-standing oedema, and to depend on changes 
 in the tissue which the infiltration of fluid brings about in the course 
 of time. The tendency of this condition, when the lung is the part 
 affected by it, is to compress the air-cells, and interfere with the en- 
 trance of air ; but nevertheless in many cases there were no symptoms 
 announcing its existence during life, and air was found in the pulmo- 
 nary vesicles after death — a fact which goes far to substantiate the cor- 
 rectness of Dr. Gairdner's opinion, that positive obstruction of the 
 bronchial tubes is necessary to prevent the entrance of air into the 
 lung ; that the mere elasticity of its tissue, or congestion of its vessels, 
 is not adequate to occasion this result. I will not, however, dwell fur- 
 ther on these opinions, which involve questions of morbid anatomy 
 more than of practical medicine, and the rather since I have no obser- 
 vations of my own bearing on the subject. 
 
 My experience of gangrene of the lung in childhood is extremely 
 limited, for only one case of it has come under my notice. The par- 
 ticulars of it, however, may be worth relating, since they illustrate 
 very well the symptoms w T hich the disease usually presents, and the 
 circumstances in which it generally occurs. 
 
 A little girl, three years old, the child of healthy parents, who had 
 previously had good health, with the exception of a severe attack of 
 inflammation of the lungs when two years old, began to droop in 
 health, to cough, and to have shortness of breath, on February 11, 
 1843. No treatment was adopted until the child was brought to me 
 on the 15th. Her breathing was then more oppressed, her general 
 condition more east down, and her strength more reduced than is usual 
 in so short a time from the commencement of an attack of pneumonia, 
 which had not set in with very severe symptoms. Four leeches were 
 applied beneath the right scapula, and half-grain doses of calomel and 
 Dover's powder were given every three hours. Slight relief succeeded 
 to the bleeding, but this was of but short duration ; and the child did 
 not seem to be either better or seriously worse until the 19th, when 
 she appeared to be losing strength. The mercury was now discon- 
 
 1 In the Gazette M6dicale for 1851 ; and republished in the Journal fiir Kinder- 
 krankheiten, vol. xviii, March, 1852. 
 
302 GANGRENE OF THE LUNG. 
 
 tinned, and ammonia and nourishing diet were freely given. /On the 
 20th, the gums both of the upper and lower jaw began to swell ; by 
 the next day they were ulcerated ; the breath became very fetid, and 
 a discolored, stinking fluid ran from the mouth. The thoracic symp- 
 toms continued much the same, not at all increasing in intensity, and 
 the cough growing looser than before ; but the child became paler and 
 more exsanguine, and continued to lose power. The ulceration of the 
 gums extended to the fold of the lower lip, and three of the incisor 
 teeth fell out before the disease was finally checked, on February 26, 
 by the application of pure nitric acid. The child did not appear to 
 suifer pain, but was very restless, and continually harassed by efforts 
 to vomit, during which she rejected nothing but an offensive mucus. 
 She was extremely indisposed to take either wine or any nourishment 
 for four days before her death, which took place, apparently from ex- 
 haustion, on March 1, nineteen days after the commencement of her 
 illness. 
 
 On an examination of the body after death, the left lung was found 
 perfectly healthy, with the exception of some emphysema of its upper, 
 and considerable congestion of its lower lobe. 
 
 The right lung, which consisted of only two lobes, was universally 
 solid and non-crepitant, with the exception of about a fourth of the 
 upper and inner edge of the lower 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 grayish-red 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 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 w r as in a 
 state of far advanced purulent infiltration, and other parts of the lobe 
 were in an earlier state of the same condition ; besides which, small 
 collections of puriform fluid, not bigger than a split pea, were found 
 in various parts of its substance. The state of the lower lobe on the 
 whole resembled that of the upper, but the cavity in it 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. 
 
 Although there w r as in this instance a larger amount of inflammatory 
 disorganization of the lung than is usually met with in connection with 
 gangrene of its substance, yet the symptoms noticed during the patient's 
 lifetime were precisely such as are generally observed in cases of this 
 
PLEURISY. 303 
 
 description. The child was attacked with symptoms of pneumonia, 
 which, however, were far from being severe ; but, nevertheless, by the 
 fifth day from their commencement, the greater part of the right 
 lung had become impervious to air, and percussion over the right side 
 of the chest, on February 15, yielded an almost entirely dull sound. 
 Even then the child's strength seemed much reduced, and in the course 
 of a few days more she sank into a state of great weakness. Throughout 
 the whole course of the disease, there was the same absence of striking 
 indications of the extent to which the respiratory organs had suffered, 
 and this even after a large portion of the lung was completely disor- 
 ganized. The most remarkable phenomena were those which betokened 
 the general loss of power in the system, while the appearance of gan- 
 grenous ulceration about the gums tended to prove the correctness of 
 the opinion which refers the disease to some peculiar alteration of the 
 circulating fluid rather than to the violence of the inflammatory action. 
 Another circumstance which tends to support this opinion is, that gan- 
 grene of the lung much more frequently supervenes on the pneumonia 
 that comes on in the course of the exanthematous fevers, than on idio- 
 pathic inflammation of the lungs. The disease, too, occurs far more 
 rarely in children who are well fed, and who live in pure air, than in 
 those who are surrounded by unfavorable hygienic conditions. Hence 
 it results that this, as well as other forms of gangrene, are met with in 
 the Children's Hospital at Paris with far greater frequency than else- 
 where, and that they sometimes show a tendency to become epidemic 
 in that institution. 
 
 There is no symptom that can be mentioned as of constant occurrence 
 in gangrene of the lung in children, and as pathognomonic of the dis- 
 ease. That peculiar fetor of the breath on which so much reliance is 
 placed in cases of gangrene of the lung in the adult, sometimes loses its 
 value in the child, as it did in the case just related, by the coexistence 
 with it of gangrene of the mouth. It happens, too, not infrequently, 
 that the characteristic odor of the breath is altogether absent in cases 
 of gangrene of the lung — a circumstance for which it is not easy to 
 account ; though of the fact there can be no doubt, since it rests on the 
 authority of MM. Rilliet and Barthez. 
 
 Should you meet with any case in which you apprehend that this con- 
 dition of the lung is present, you would adopt a tonic and stimulant 
 plan of treatment, as affording the only chance, and that a very slender 
 one, of saving the patient's life. Sir W. Stokes's suggestion, too, 1 for 
 the administration of chlorine, in the form of the chloride of lime or 
 soda, should not be forgotten, since if the remedy did nothing else, it 
 might diminish that fetor of the breath, which is a source of very great 
 suffering to the patient. 2 
 
 Pleurisy, or inflammation of the investing membrane of the lungs, is 
 a disease which received until comparatively lately much less attention 
 
 1 Op. cit., p. 359. ^ ' 
 
 2 For the fullest account of pulmonary gangrene in children, the reader is referred 
 to vol. ii of '2d edit, of Rilliet and Barthez, pp. 404-421 ; and to the most elabo- 
 rate work of Dr. Steffen, Klinik der Kinderkrankheiten, 8vo. Berlin, 1869, vol. 
 ii, pp. 47-94. 
 
304 POST-MORTEM APPEARANCES. 
 
 than its importance deserves. Some writers on the diseases of children, 
 indeed, have left it altogether unnoticed on account of its supposed ex- 
 treme rarity in early life ; though this opinion is certainly erroneous so 
 far as regards that secondary pleurisy which comes on in the course of 
 pneumonia, and which is almost, if not quite, as frequent in child- 
 hood as in adult age. It is true that acute idiopathic pleurisy, uncon- 
 nected with pneumonia, or in which the inflammation of the lung bears 
 but a very small proportion to that of the pleura, is an uncommon affec- 
 tion during the first years of childhood ; and that as a cause of death its 
 rarity is extreme. According to the Reports of the Registrar-General, 
 of 202 fatal cases of pleurisy that occurred in London in the years 
 1842 and 1845, only 14, or, 6.3 per cent., took place in children under 
 five years old ; while you will not have forgotten that 63.2 per cent, of 
 all fatal cases of pneumonia are alleged on the same authority to have be- 
 fallen children aged less than five years. It may be doubted whether this 
 statement, which rests only to a comparatively small extent on the 
 results of post-mortem examination, does not underestimate the fre- 
 quency of idiopathic pleurisy in early life. But, be this as it may, the 
 rarity of the disease unquestionably diminishes after the first years of 
 infancy are passed; while its importance as an occasional complication 
 or sequela of other affections, and more particularly of scarlet fever, 
 and the frequent obscurity of its symptoms, are reasons for devoting to 
 it more than a passing notice. 
 
 In fatal cases of pleurisy in childhood, the appearances found after 
 death are precisely- the same as are met with in the adult. Adhesions 
 between the costal and pulmonary pleura, and between the different 
 lobes of one or other lung, associated sometimes with very intense 
 redness of parts of the membrane, are hardly ever wanting, and in 
 connection with them a small quantity of transparent serum, often of 
 a reddish tint, is sometimes effused into the cavity of the chest. In 
 other cases the effused matters are entirely solid, and both the surface 
 of the lung and the interior of the thorax are coated with a distinct in- 
 vestment of lymph ; or, in addition to the deposit of lymph on the 
 lung, fluid is poured out into the chest — no longer transparent serum, 
 but either a sero-purulent fluid in which flakes of lymph are floating, 
 or more rarely healthy pus. The most frequent complication of pleu- 
 risy is with inflammation of the lungs ; besides which, it occasionally 
 happens, when the left pleura has been the seat of inflammation, that 
 the disease extends from it to the pericardium, which on four such oc- 
 casions I have found lined with lymph, partially adhering to the heart, 
 and containing a sero-purulent fluid. 1 
 
 1 In 118 cases in which the above-mentioned consequences of recent inflamma- 
 tion of the pleura were observed after death in non-phthisical subjects, they existed 
 in the following combinations : 
 
 Kecent adhesions and deposit of lymph, ..... 30 
 
 Serous effusion existed alone, . .... 22 . 
 
 " " " with adhesions, or deposits of lymph, . 18 
 
 Sero-purulent effusion, or effusion of pus, 48 
 
 118 
 In 39 of the above 118 cases, the affection of the pleura, though sometimes con- 
 
SYMPTOMS OF ACUTE PLEURISY. 305 
 
 The main symptoms that attend the disease, as well as the physical 
 signs of its existence, are the same at all ages. There are, however, 
 some circumstances peculiar to early life, which, unless you are on your 
 guard, may serve to obscure the real nature of the affection. The 
 history of a case of acute pleurisy in childhood is generally something 
 to this eifect : A child previously in perfect health is suddenly attacked 
 by pain referred to the chest or to the upper part of the abdomen, so 
 severe as to occasion it to cry aloud ; perhaps attended at first by vom- 
 iting, accompanied with fever, a rapid pulse, and hurried respiration 
 interrupted by frequent short cough, which evidently occasions pain, 
 and which the child labors, though in vain, to suppress. After a few 
 hours the severity of the pain subsides ; but the fever, hurried respira- 
 tion, and cough continue, and the child, though usually it looks heavy 
 and seems drowsy, yet becomes extremely restless at intervals — cries 
 and struggles, as if in pain, and violently resists any attempt to alter 
 its position, since every movement brings on an exacerbation pf its 
 sufferings. The posture which it selects varies much : sometimes its 
 breath seems disturbed in any other than an upright position ; at other 
 times it lies on its back, or on one side ; but whatever be the posture, 
 any alteration of it appears to cause much distress^ and is sure to be 
 resisted by the patient. 
 
 The probabilities are that, if you auscultate the chest of a child in 
 whom these symptoms exist, you will hear good breathing through the 
 whole of one lung. On the other side, the motion of which in breath- 
 ing will be seen to be less extensive, and performed in a slightly jerking 
 manner, the air will be found to enter less freely, though unaccom- 
 panied by any moist sound, perhaps unattended by any morbid sound 
 at all ; or, possibly, a rough sound like a rhonchus may be audible on 
 this side, and for this you may very likely at first take it, though with 
 more attention it will be discovered to be a friction-sound. A day or 
 two later you will detect a sound like that of bronchial breathing, 1 as 
 
 siderable, appeared to be secondary, and subsidiary to that of the lung itself. In the 
 remaining 79, the pleura was the chief seat of the mischief, the lung being either 
 simply compressed by the quantity of the effused fluid, or its' inflammation being 
 secondary in extent and importance to that of which the pleura bore evidence. 
 
 The following were the circumstances in which the affection of the pleura came 
 on in the latfpr 79 instances : 
 
 Idiopathic, ......... in 21 
 
 After Scarlatina, ........ 32 
 
 u Measles, 1 
 
 " Typhus, 1 
 
 " Typhoid, 1 
 
 " Diphtheria, . .3 
 
 " Pygemia, ......... 1 
 
 " Pericarditis and endocarditis, . . . . .10 
 
 " Peritonitis, ........ 3 
 
 " Ascites with diseased liver, ..... 2 
 
 " General dropsy, diseased kidneys, . . . .3 
 
 " Disease of cervical vertebra, ..... 1 
 
 79 
 
 1 Killiet and Barthez were the first to insist on the constant occurrence of bron- 
 chial breathing as one of the earliest auscultatory signs of the existence of pleurisy 
 in childhood. See vol. i, p. 554, of the 2d edition of their work. 
 
 20 
 
306 DIAGNOSIS OF PLEURISY. 
 
 you pass your ear from above downwards along the posterior part of 
 the chest, w T hile the friction-sound, if it had previously been audible, 
 will have disappeared ; and still lower there will be an utter absence 
 of all sound. In most instances, however, no friction-sound is to be 
 heard at the commencement of the attack, though it becomes percep- 
 tible on its decline, but a bronchial character of the respiration 
 will be perceived as one of the earliest auscultatory signs of the disease. 
 The walls of this side of the chest, if their tenderness do not prevent 
 your trying percussion, will yield a much less resonant sound than 
 usual ; while, at the same time, a distinct sense of solidity will be 
 communicated to the finger, and the vocal fremitus will either be 
 indistinct or altogether absent. 
 
 The first auscultatory evidence of improvement is often furnished 
 by the reappearance of friction-sound, or by its beginning to be heard 
 for the first time. It is usually perceived first about the upper and 
 back .part of the affected side, and descends by degrees in proportion 
 as the air enters with more freedom, and as the thin layer of fluid 
 which has been poured out becomes absorbed. This process of ab- 
 sorption obeys no rule as to the time which it occupies; so that a fric- 
 tion-sound may be, heard in some cases only for a few days, in others 
 for several weeks. The very long persistence of a friction-sound, how- 
 ever, always raises the suspicion that tubercular deposit has taken 
 place on the surface of the pleura. It is very rare for a friction-sound 
 not to be heard over at least some small extent of surface, but in some 
 instances, when very little fluid has been poured out, the costal and 
 pulmonary pleura speedily become adherent, and in such cases little 
 or no friction-sound may be heard. With the gradual return of the 
 pleura to a healthy state the rubbing-sound passes away ; but for some 
 time after all other traces of the attack have disappeared, a somewhat 
 harsher character of the breathing, and a marked dulness on percussion, 
 continue. The dulness on percussion, too, far exceeds that which the 
 disparity between the amount of air admitted into the two lungs would 
 seem to account for, and has, to the best of my knowledge, never yet 
 received a thoroughly satisfactory explanation. 
 
 The symptoms by which an attack of acute pleurisy is ushered in, 
 point sometimes rather to the head than to the chest. The child is 
 seized with vomiting, attended by fever and intense headache : it either 
 cries aloud, or is delirious at night, or screams much in its sleep, and, 
 when* morning comes, complains much of its head, but denies having 
 any pain whatever in its chest, while the short cough and the hurried 
 breathing may be thought to be merely the result of the cerebral dis- 
 turbance. Sometimes, too, the cough is altogether absent, and the 
 acceleration of the breathing so slight as not to suggest the idea that 
 serious mischief is going on in the chest. Under the impression that 
 the child is suffering from cerebral disease, auscultation is omitted, or 
 at least practiced hastily and superficially, and consequently serves but 
 to confirm the erroneous diagnosis. It often happens, indeed, that in 
 these cases no friction-sound is perceptible, and that you have no other 
 indication to guide you aright besides the feebleness of the respiratory 
 murmur on the affected side. The child, too, fearful of taking a deep 
 
DIAGNOSIS OF PLEURISY. 307 
 
 inspiration, fills neither lung completely, so that the information usu- 
 ally gained by comparison of the breathing in one lung with that in 
 the other is in great measure lost. Still, the presence of feeble respira- 
 tory murmur at the lower part of one lung, when coupled with the 
 sudden accession of acute febrile symptoms in a previously healthy 
 child, points almost invariably to the existence of acute pleurisy ; while 
 a careful consideration of the patient's history and general condition 
 will, even irrespective of the results of auscultation, go far towards 
 preventing you from falling into error. The onset of the illness has 
 been far too acute, attended with far too much febrile disturbance, for 
 a case of tubercular meningitis, while many of the signs of cerebral 
 mischief which might be expected in a case of simple encephalitis have 
 not presented themselves. The heat of head is not greater than that 
 of the rest of the surface : the cries with which the disease set in have 
 not ended in coma. It happens but seldom that convulsions mark the 
 commencement of the disease ; but if they had occurred at the onset, 
 they have not since returned ; neither twitching of the muscles, nor 
 strabismus, nor retraction of the head, is present ; and though the child 
 may cry (as children when ill and fretful often do) at the curtain being 
 undrawn and the candle brought near it, yet there is no real intoler- 
 ance of light, while in spite of its fretful ness, the intelligence is not 
 otherwise perverted. Error indeed is easy, but to avoid it requires in 
 this, as in most instances, not so much great acuteness as great care and 
 great patience. 
 
 The pain with which pleurisy sets in is sometimes referred not to the 
 chest, but to the abdomen ; and its commencement may be attended 
 with vomiting and purging. This mode of onset of the disease is 
 especially likely to be observed in cases of diaphragmatic pleurisy, and 
 more particularly if the inflammation is seated on the right side ; and 
 in this latter case, bilious vomiting is often one of the most marked of 
 the early symptoms. Pressure on the abdomen, too, not only in these, 
 but frequently also in other cases, occasions a considerable increase of 
 suffering ; and you may thus be led to overlook the existence of the 
 pleurisy, and to allow your attention to be entirely directed to the ab- 
 dominal symptoms. Some years since a boy seven years of age was 
 admitted into the Children's Hospital in the sixth week of a pleurisy 
 of the right side, which had terminated in empyema, for which para- 
 centesis was afterwards successfully performed. He was reported to 
 have had inflammation of the bowels, and the marks of recent leech- 
 bites in his right iliac region bore witness to the diagnostic error which 
 auscultation would have avoided. In any such doubtful case, it is 
 well to bear in mind that children, long after they can talk, describe. 
 the nature and seat of their sufferings very inaccurately ; and if, as 
 often happens in these cases, they refer the pain to the right hypo- 
 chondrium, you should not forget that pain in that situation is at all 
 ages much oftener connected with inflammation of the pleura than of 
 the peritoneum ; and lastly, that the increase of discomfort produced 
 by pressure on the abdomen may be due to the additional impediment 
 thereby offered to the already laboring respiration. The careful aus- 
 cultation, which I need not say should never be neglected, will gener- 
 
308 DIAGNOSIS OF PLEURISY FROM PNEUMONIA. 
 
 ally save you from error, but in a case of diaphragmatic pleurisy you 
 are rather left to infer the nature of the disease, from the non-corre- 
 spondence of its symptoms with those of any other ailment, than ena- 
 bled to decide upon its character from any positive sign of mischief 
 in the chest with which your ear makes you acquainted. The heat of 
 skin, the frequency of the pulse, and the hurry of the breathing, are 
 such as to exclude the suspicion of almost all affections of the abdo- 
 men, while not only do not the general characters of the attack tally 
 with those of acute peritonitis, but there is no such tenderness upon even 
 slight pressure, no such tension of the abdominal walls, no such dread 
 of the slightest movement, as characterize that disease. Your great 
 safeguard will be found, in such a case, in the right interpretation of 
 the general symptoms, and in the recognition of the fact that, when 
 attended with acute febrile symptoms, the mere imperfect entrance of 
 air into the lung is itself a valuable indication of inflammation of the 
 pleura. The danger, in cases of pleurisy in early life, is, however, not 
 simply that of overlooking the existence of mischief in the chest, but 
 also of referring that mischief to a wrong cause. The fever, and cough, 
 and dyspnoea, may be so marked as to render the former mistake im- 
 possible ; but auscultation, unless you rightly interpret the information 
 it affords, may not guarantee you against the latter. It is not by 
 any means a matter of indifference whether you take a case of pleu- 
 risy for one of pneumonia, or whether, in a case of bronchitis, which 
 may for some time have been under your care, you recognize the in- 
 flammation of the pleura which may have supervened, or see in the 
 increased urgency of the chest symptoms merely an exacerbation of the 
 previous ailment. The error, indeed, is one not so likely to be com- 
 mitted in a case of idiopathic pleurisy that you may have watched 
 from the commencement, but it is one into which you may very prob- 
 ably fall in those instances where pleurisy succeeds to the exanthem- 
 ata, especially to scarlet fever, and less often to measles. Cough and 
 hurried breathing, and rhonchus, with some crepitant rale, may have 
 already existed for some time, and in these circumstances a friction- 
 sound, even if it should become audible, is very likely to be unnoticed. 
 But, besides this, the unequal breathing so characteristic of early life, 
 as the result of which air may seem one hour to enter one lung imper- 
 fectly, while a few hours subsequently the deficient respiration may 
 appear to be on the opposite side, naturally leads you to undervalue 
 the importance of mere deficient respiration. But, if the bronchial 
 character of the breathing forces itself on your attention, the proba- 
 bility is that, without any further consideration, you may put that 
 down as an unequivocal proof of the advance of pneumonia, and alto- 
 gether overlook the pleurisy of which, in this instance, it is an indica- 
 tion. 
 
 It is the more important to bear in mind the possibility of error, 
 since some of the means of distinguishing between pleurisy and pneu- 
 monia on which we rely much in the adult are less available in the 
 child. It is so difficult to induce children to speak several words con- 
 secutively in the same tone, and their voice is often so feeble, as to 
 deprive us in great measure of the information which the different 
 
LATENT PLEURISY. 309 
 
 resonance of the two sides of the chest would otherwise afford. For 
 the same reason, too, the difference of vocal vibration, as perceived on 
 applying the hands to either side of the chest, is often by no means so 
 manifest in children as in grown persons. The experiment, however, 
 is one which should never be omitted, since the information which it 
 yields, provided it do not fail altogether, is as valuable in the one 
 case as in the other. Two more hints may perhaps be of service in 
 helping to keep you from error; first, that the limitation of the physi- 
 cal signs of affection of the chest to one side, of itself raises a presump- 
 tion that that affection is inflammation of the pleura, not of the lung; 
 and second, that the bronchial breathing which is perceived at an early 
 period of an attack of acute pleurisy is attended by diminished reso- 
 nance on percussion rather than by that absolute dulness which is per- 
 ceived when the substance of the lung itself has passed into a state of 
 hepatization. 
 
 But there are also cases of latent pleurisy in the child as well as in 
 the adult; cases in which there are vague symptoms of feverish ness, 
 with perhaps a little cough, and nothing more ; nothing to call special 
 attention to the chest, nor even to suggest the existence of grave ailment 
 anywhere. In young children the symptoms are attributed to teething, 
 in those who are older to worms, or to gastric fever ; terms which cover 
 a large amount of carelessness, ignorance, and indolence. I know of 
 no means infallibly to preserve from error, besides those simple rules 
 which have grown almost wearisome by frequent repetition. Bear in 
 mind, with reference to teething, that there are pauses in the evolution 
 of the teeth ; that it does not follow because a child has not yet cut all 
 its teeth, that dentition must therefore at any particular moment be in 
 active progress. Next, that how much soever the presence of worms 
 may interfere with a state of perfect health, febrile symptoms are not 
 indicative of their presence ; and in the third place, that, with the ex- 
 ception of the exanthemata and of ague, and very rarely of typhus, 
 typhoid fever is the only essential fever to which children are liable. 
 In other words, fever is symptomatic of disturbance somewhere ; it be- 
 hooves you by careful examination to make out where ; and in order 
 that you may not fail to discover the seat of the disturbance, you must 
 never omit auscultation. 
 
 A little girl, two years and two months old, had slight cold and a 
 cough, which seemed so trivial that medical care was not sought for ; 
 and when at the end of a fortnight a purulent discharge took place 
 from the right ear, that was looked on but as another evidence of the 
 dependence of the ailment on dentition. At the end of three weeks, as 
 she did not recover her. customary health, a doctor was called in, who 
 found her breathing quietly, with no cough, but looking worn and ill. 
 She slept well during the night, and the following day seemed much 
 the same, except that she was rather more fretful, so that she would 
 not allow of any attempt at auscultation, and her pulse had suddenly 
 fallen from 120 to ,7 2 beats in the minute. She slept pretty well dur- 
 ing the night, but the next morning, when taken up, as was her wont, 
 she laid her head on one side against the nurse's bosom, and died with- 
 out a struggle or convulsion. 
 
310 SUDDEN DEATH IN PLEURISY. 
 
 I was present at the post-mortem examination, which disclosed no 
 morbid appearances whatever in the brain. There were, however, 
 nearly six ounces of reddish serum in the cavity of each pleura, though 
 without any deposit of false membrane on their surface. Some portions 
 of the lung were in a state of collapse; there were some white clots on 
 the right side of the heart, while the left side was empty and contracted. 
 
 Few symptoms had here called attention to the condition of the child, 
 who at length died suddenly in consequence of the effusion into its chest, 
 and probably from the sudden change of posture on assuming the sitting 
 position. 
 
 This ca£e has a twofold interest, partly from the latency of its symp- 
 toms, partly from the suddenness of its termination ; and the possible 
 sudden termination of a case of pleuritic effusion is perhaps less borne 
 in mind than it should be. 
 
 A little boy, not quite three years old, whose health had never been 
 very robust, was brought as an out-patient to the Children's Dispensary 
 in Lambeth on June 11, 1847, on account of a chronic impetiginous 
 eruption on his scalp. On the night of June 12 he suddenly became 
 hot, and his chest was much oppressed, but on the following day he 
 was well enough to be out at play in the garden, and on the 15th was 
 drawn a mile and a half in a perambulator to and from the dispensary 
 when I saw him for the first time. He looked pale and ill, was fever- 
 ish, and breathed with a wheezing noise, but there was nothing about 
 him indicative of serious mischief; and in the hurry of prescribing for 
 a large number of patients, I regarded him as probably a phthisical 
 child, who had caught cold recently. I ordered some simple medicine 
 for him, and at one p.m. he returned home. At three o'clock the same 
 afternoon he suddenly became much worse, was very faint, breathed 
 with extreme difficulty, and died at eight o'clock the next morning. 
 Some serous fluid was present in the abdomen, and about six ounces in 
 either pleura, by which the lower lobes of both lungs were so compressed 
 as to be almost destitute of air. 
 
 But again, death may, as in the first case, be almost immediate ; and 
 this sudden death, be it observed, takes place chiefly in instances where 
 the inflammatory action has not been intense, and where the effusion is 
 simple serum. A little boy, aged eight years, was attacked by moder- 
 ately severe scarlatina. Slight anasarca appeared on the 19th day, 
 which had somewhat increased, but was accompanied by no urgent 
 symptom on the 22d day, when he walked a distance of two miles with- 
 out suffering serious fatigue. After a rather restless night he rose to 
 relieve his bowels, and there was so little suggestive of danger in his 
 condition that his mother left him for a few minutes alone. On her 
 return, his bowels had acted scantily, and he seemed faint. He was 
 replaced in bed, when he immediately began to struggle feebly, and in 
 a few minutes was dead. 
 
 The lungs were compressed by abundant serous effusion in each 
 pleura, and the pericardium also contained four ounces of fluid, but 
 there were no other morbid appearances except some congestion of the 
 kidneys. 
 
 This very sudden, death is unquestionably a rare result of pleurisy, 
 
TERMINATION OF PLEURISY IN EMPYEMA. 311 
 
 but nevertheless, the disease in early life is by no means unattended 
 with danger ; and my own impression is that a fatal termination of 
 acute idiopathic pleurisy is by no means of such rare occurrence in early 
 as in adult life. In most of those cases, however, which I have seen 
 terminate fatally, the disease though it began in the pleura, did not 
 continue limited to it, but extended either to the pulmonary substance 
 or to the pericardium. I have, indeed, in these circumstances known 
 a case of pleurisy prove fatal within four days from the first appearance 
 of its symptoms. 
 
 Besides these cases, others require notice in which the pleurisy neither 
 proves immediately fatal, nor terminates on the other hand by speedy 
 recovery. Here the effusion which takes place produces an even greater 
 degree of deformity of the chest in the child than in the adult, since 
 its more yielding walls give place more readily. The immediate con- 
 sequence of the effusion is of course to produce an .enlargement of that 
 side of the chest into which the fluid is poured out, while at the same 
 time the respiratory movements on that side are almost entirely abolished, 
 and the intercostal spaces are bulged outwards, or at least are raised to 
 a level with the surface of the ribs ; though in the child the amount of 
 fat beneath the integuments renders this less obvious than in the adult. 
 The heart's apex, too, will be displaced from its natural position, and 
 will be felt beating either outside the left nipple, or far to the right of 
 the mesial line, according as the one or the other pleura is the seat of 
 the effusion; while, if fluid is poured out abundantly in the right 
 pleura, the liver may often be felt forced down far below its ordinary 
 situation ; or if into the left, a similar change may be discovered in the 
 relations of the spleen. As the one side, however, is expanded by the 
 effusion of fluid, the other also increases very appreciably in the course 
 of ten days or a fortnight, as the result of the extra work thrown ou the 
 healthy lung, which has to perform its functions not for itself only but 
 also for the other, whose action is impaired, or it may be almost com- 
 pletely arrested. With the commencement of the absorption of the 
 fluid the affected side begins to shrink ; and in the course of time from 
 being half an inch to an inch larger than the healthy side it becomes 
 at least as much smaller ; it grows flatter in the infra-clavicular region ; 
 the spine itself , yields, its upper convexity being directed towards the 
 healthy, its lower convexity towards the contracted side. The hyper- 
 trophy of the healthy lung produces a bulging of the corresponding 
 side, the shoulder of which is thrown up, while the other is proportion- 
 ately depressed, and a very remarkable degree of deformity is thus 
 produced. Gradually with the lapse of time, a sort of restorative pro- 
 cess seems to be set on foot, the steps of which have not been sufficiently 
 studied ; but by it the spinal curvature and the flattening of the upper 
 and front part of the chest are lessened, in proportion as air permeates 
 the lung more freely ; and in many instances, a comparatively slight de- 
 gree of deformity remains the only evidence of what had seemed to be 
 almost irremediable mischief. 
 
 This, however, is a result which it does not seem possible to calcu- 
 late on with any certainty, for there can be no doubt but that in the large 
 majority of cases of acute pleurisy in early life in which effusion takes 
 
612 TERMINATION OF PLEURISY IN EMPYEMA. 
 
 place, either pus is poured out at once, or the fluid very speedily be- 
 comes purulent, and consequently inapt for absorption, though by no 
 means incapable, as was once imagined, of being absorbed. 1 In these 
 circumstances, we usually find the chain of occurrences to be somewhat 
 as follows. After the first acute attack which has terminated in the 
 effusion of fluid, the more active symptoms abate, the fever subsides, 
 and the child enters on a state of semi-convalescence. This, hoAvever, 
 does not las# above a week or ten days, when, without any fresh acces- 
 sion of acute symptoms, the child begins to suffer from notable dysp- 
 noea, grows unable to lie at all except on the affected side, while the 
 superficial veins on that side become greatly enlarged, the integuments 
 somewhat oedematous, and the whole surface so tender that even the 
 gentlest p3rcussion cannot be tolerated. These symptoms indicate that 
 the matter is about making its way outwardly, which it does usually 
 by perforating the* chest- wall, though the empyema now and then 
 empties itself into a bronchus, of which I have seen four instances ; and 
 has been known to burst through the diaphragm into the abdominal 
 cavity, and thus to produce fatal peritonitis. In by far the majority 
 of cases the matter is discharged externally through the chest-wall, 
 almost invariably through the anterior wall of the chest, and mostly in 
 the fourth or fifth interspace and a little outside the nipple. Increase 
 of the tenderness of the chest- wall, and then bulging of the integuments 
 in one or other intercostal space, precede the distinct pointing of the 
 abscess, which, whether opened or allowed to burst of itself, will almost 
 invariably continue fistulous for a great length of time ; the profuse 
 discharge exhausting the patient, and the rapid contraction of the side 
 producing great and often remediless deformity. This external open- 
 ing, too, is not infrequently an indirect one, the matter having burrowed 
 between the pleura and the chest-wall for some distance before it 
 escaped externally. 
 
 Thus, in the case of a boy, aged eight years, who died eighteen 
 months after the first symptoms of pleurisy on the left side, and four- 
 teen months after the formation of a pleural fistula between the first 
 and second bones of the sternum, which remained open till his death, 
 and another between the sixth and seventh rib, which ceased to dis- 
 charge nine months before that event, a post-mortem examination dis- 
 closed the following state of* things : 
 
 The old sinus between the sixth and seventh rib did not extend for 
 more than a quarter of an inch, and terminated without entering the 
 chest. That between the bones of the sternum opened at once into a 
 number of sinuses which led for at least an inch upwards and down- 
 wards in several directions, and then pierced the chest-wall to run 
 along in a similar manner in the substance of the costal pleura, which 
 was like cartilage in appearance, and at least three-fourths of an inch 
 in thickness ; and all these sinuses were filled with pus. 
 
 1 In Mr. Hilton's work, already referred to, will be found many instances of the 
 absorption of the contents of abscesses. Perhaps the most interesting is that related 
 at p. 375, in which the small amount of solid residuum found on the patient's death 
 after the lapse of some months, was ascertained by chemical examination to be ab- 
 solutely identical with the constituents of pus. 
 
TREATMENT OF ACUTE PLEURISY. 313 
 
 To sum up then. Speedy recovery when little fluid has been poured 
 out; tardy recovery when it has been more abundant ; and followed 
 in most instances by deformity, which time tends gradually and im- 
 perfectly to remove ; occasional sudden death when serous fluid has 
 been poured out rapidly and in large quantity ; escape of the fluid in 
 most instances when purulent through the chest-walls, in obedience to 
 the laws which govern the course of an abscess, wherever situated : 
 such are the different issues of pleurisy in early life. How these facts 
 bear upon our treatment of the disease is the question that we have 
 next to consider. Before doing so, however, I must just add one w T ord 
 of caution with reference to the diagnosis of pleurisy and empyema in 
 childhood. This caution, too, concerns not the difficulty of discovering 
 the condition, but the culpable carelessness with which it is often over- 
 looked by practitioners, who satisfy themselves with determining that 
 their patient has inflammation of the chest as they term i^ and never 
 take the trouble to inquire further into its nature ; and at last are taken 
 by surprise, either by their patient's unexpected death, or by the un- 
 looked-for escape of the matter with which one side of the chest was 
 filled, through some external opening. There are no cases in which it 
 happens to me to have to screen the mistakes of others so often as in 
 cases of pleurisy and empyema ; and I venture to use one of the priv- 
 ileges of age, in order to entreat the younger members of my profession 
 never to allow themselves to fall into habits of inaccuracy. The limits 
 of our knowledge are narrow enough ; we need not circumscribe them 
 still further by our own indolence. 
 
 The causes which have already been referred to as modifying in very 
 important respects the treatment of bronchitis and pneumonia, have also 
 exercised their influence over the treatment of pleurisy. But, never- 
 theless, I am fully convinced that considerable activity in the early stage 
 of the disease best averts danger, and most economizes the patient's 
 strength. In almost every instance, indeed, that has come under my 
 observation, where the issue of acute pleurisy has been unfortunate, 
 either all treatment had been neglected until the children were past 
 hope, or the nature of the complaint had been mistaken, or the treat- 
 ment followed had not been sufficiently active. The same statement, 
 too, may be made with reference to those cases in which paracentesis 
 of the chest became necessary. By active treatment, I imply depletion 
 in all cases in which the child's previous health has been good, in which 
 pleurisy is idiopathic, the symptoms are at all urgent, and the patient 
 is seen before the occurrence of effusion. In children of five or six 
 years old, general depletion is to be preferred, and the relief to the 
 breathing may be taken as the indication for stopping the flow of blood. 
 If after the lapse of four or six hours the pain and dyspnoea return, 
 leeches should be applied to the affected side, and four or six leeches 
 will seldom fail to give permanent relief. In the case of younger chil- 
 dren local depletion alone will suffice, but that should not be practiced 
 too timorously, since the most relief is procured when the abstraction 
 of blood answers to some degree the purpose of a general bleeding. 
 After depletion our chief reliance is to be placed on calomel, which 
 should be freely given in combination with opium or Dover's powder, 
 
314 TREATMENT OF PLEURISY. 
 
 while a warm poultice is constantly applied to the affected side ; and 
 an attack of pleurisy thus treated will often be cut short in thirty-six 
 or forty-eight hours. 
 
 In many instances, however, the child's previous health does not 
 warrant, or the severity of the symptoms is not such as to indicate, 
 these very active proceedings. In these circumstances a mustard poul- 
 tice to the chest will often give immediate ease ; and on its removal a 
 linseed poultice may be applied, and renewed every four hours, so as to 
 maintain the effect of a gentle counter-irritant. At the same time the 
 iodide of potassium may be given in combination with a saline and di- 
 uretic, 1 and continued steadily for several days ; while its action may 
 be seconded by a small dose of mercury, given once or twice a day, as 
 one grain of calomel, or three of gray powder, for a child of six years 
 old. The mercurial may be discontinued at the end of a week, but the 
 iodide of potass may be persevered with for two or three weeks ; the 
 abatement of all febrile action, and the diminution of the effusion, in- 
 dicating the time when it may be given with less frequency. Often, 
 however, after the symptoms have subsided, the affected side remains 
 dull, and the respiration scanty for several weeks together • and now 
 is the time when the use of blisters, or still better the painting the side 
 with tincture of iodine, seems to be of much service in promoting the 
 absorption of the fluid ; while cod-liver oil given twice a day, is a 
 useful means of maintaining the nutrition of the child, and of counter- 
 acting that tendency to the development of tubercular disease which is 
 so apt to manifest itself in cases where pleurisy has passed into a 
 chronic stage. 
 
 Sometimes, indeed, in spite of remedies perseveringly employed, one 
 side of the chest continues full of fluid ; and the question then comes 
 before us whether it will not be expedient to let out that fluid by me- 
 chanical means. I believe that so long as the child's health is improv- 
 ing, or at least not deteriorating, as the temperature, which falls after 
 the first onset of acute pleurisy, has not begun to rise again, as the res- 
 piration is not growing more hurried, nor the cough more troublesome, 
 as the chest-walls have not become tender, nor the superficial veins 
 notably enlarged, and there is no sign of pointing anywhere, while 
 careful measurement of the chest proves the effused fluid not to be on 
 the increase, we may persevere in the employment of the means already 
 indicated. I believe, however, also, that we shall best consult the in- 
 terests of our patient by evacuating the contents of the pleura, so soon 
 as any of the above-mentioned favorable conditions cease, and that we 
 shall err if we delay until the supervention of intense dyspnoea leaves 
 
 i (No. 13.) 
 ]£. Potassii Iodidi, gr. xij. 
 Potassse Nitratis, gr. xxx. 
 Spt. Mth. Nitr., gj. 
 Liq. Taraxaci, ^iij. 
 Tinct. Scillse, t^xxx. 
 Tinct. Digitalis, Trj?xxiv. 
 
 Aquse, ad giv. Syr. Aurantii, t ^iv. M. ft. Mist. 
 A tablespoonful every four hours. For a child six years old. 
 
QUESTION ON PARACENTESIS — ITS RESULTS. 315 
 
 us no choice, or until the pointing of the empyema externally allows 
 us to do no more than anticipate, by a very few days, the completion 
 of the process which nature herself has undertaken. 
 
 In 48 out of 88 post-mortem examinations, in which fluid was found 
 in the pleural sac, that fluid was purulent ; and if the cases were ex- 
 cluded in which either the fluid was very inconsiderable in quantity, or 
 in which its effusion was secondary to scarlatinal dropsy, we should 
 find that in almost every instance the pleura contained pus. In 34 out 
 of 38 of my cases in which paracentesis of the chest was performed 
 the fluid was purulent. In one of the four exceptional cases the effu- 
 sion followed scarlatinal dropsy, in a second it succeeded to measles, in 
 the other two the pleurisy was idiopathic, but paracentesis was in one 
 instance had recourse to on the 8th, in the other on the 14th clay from 
 the commencement of the child's illness. In the latter of these two 
 cases, it became necessary to repeat the puncture 18 days later, and the 
 fluid was then becoming turbid. It is indeed my belief that in almost 
 every instance of idiopathic pleurisy in which fluid is poured out in 
 considerable quantity, that fluid either is originally purulent or becomes 
 so very speedily. The possibility of the absorption of pus is indeed no 
 longer disputed, but at the same time pus is inapt to be absorbed, and 
 its absorption is sure to be tedious ; while the longer the lung continues 
 compressed by it, the more likely is it to become bound down perma- 
 nently by lymph, to become altered in texture, and incapable of being 
 again permeated by air. If to this we add the constitutional symp- 
 toms which never fail to be excited by the presence of a large abscess ; 
 the risk of pya3mia inseparable from it ; and the great probability, nay 
 the almost certainty, that in the course of time nature herself will de- 
 cide the point, and make an opening in an undesirable situation which 
 will empty the pleura but imperfectly, while it will remain fistulous for 
 months or years, difficult to close, aggravating the deformity of the 
 chest, wearing the strength by the constant drain of matter ; we have, 
 I think, a number of reasons more than sufficient to justify the com- 
 paratively early performance of paracentesis. 
 
 While these reasons tell very strongly in favor of paracentesis, I 
 know of no valid arguments against it ; and I believe there are now 
 very few dissentients from its performance. 1 It is true that we cannot 
 regard each case of successful tapping, as one in which a life has been 
 saved that would otherwise have been lost ; since the frequency with 
 which we meet with pleural fistula, shows the extent of nature's re- 
 sources ; while at the same time it points out the proceeding which art 
 can anticipate with so much advantage. Still more rarely — in the 
 child, I believe, very rarely — and usually only after much and pro- 
 longed suffering, the matter finds its way into an air-tube, the empyema 
 is spit up, and the patient recovers. But if each successful paracentesis 
 
 1 It seems strange, however, to find a man of the large experience which Pro- 
 fessor Vogel, of Dorpat, undoubtedly possesses, saying in his Lehrbuch der Kinder- 
 krankheiten, 4th ed., 8vo., Erlangen, 1869, p. 263, " 1 have not met with any instance 
 where paracentesis was urgently required, and have therefore never had recourse 
 to it." 
 
316 INDICATIONS FOR PARACENTESIS. 
 
 does not represent a life saved, still less does each failure represent a life 
 destroyed; and the common, and I believe, on the whole, correct esti- 
 mate of one death in every four cases of tapping of the chest 1 in child- 
 hood, tells usually of too tardy an interference, or of some inevitable 
 complication, and very rarely indeed of any added risk which the 
 operation brought with it. This fact receives one of its best illustra- 
 tions in the difference between the results of tapping in private and in 
 hospital practice. Of six cases in which the chest was tapped under 
 my direction in private, all recovered ; and the only one who did not 
 regain health was a little boy, from whose right pleura I removed six 
 ounces of pus when he was only seven months old, and who died of 
 general tuberculosis three months later. In hospital practice, on the 
 other hand, fifteen out of thirty-four cases died, or very nearly half. 
 But one of these patients died of intercurrent scarlatina ; in two the 
 pleurisy was consequent on scarlatina ; in two others on measles ; three 
 died from caries of the ribs or sternum, consequent on undue delay in 
 the performance of the tapping ; and four died of tuberculosis. If I 
 were to state, indeed, in as few words as possible, my experience of 
 paracentesis of the chest in pleurisy, I should say that I have in no 
 single instance ever regretted its performance, but have often been sorry 
 that I did not have recourse to it sooner. 
 
 What, then, may- we lay down as the indications for tapping the 
 chest? First, it ought to be had recourse to in every case of urgent 
 dyspnoea, accompanied with effusion into the chest, where there is rea- 
 son for believing that great, even though only temporary, relief would 
 be obtained by the evacuation of the fluid. It is not often, however, 
 that we meet in children with any considerable amount of passive effu- 
 sion in the cavity of the chest, except in cases of dropsy succeeding to 
 scarlatina. In those cases, too, the pleuritic effusion is usually asso- 
 ciated with so considerable an amount of previous oedema of the pulmo- 
 nary tissue, that we are very likely to be disappointed in obtaining the 
 relief that we anticipated. Even here, however, I do not believe that 
 the mere fact of tapping the chest makes any appreciable addition to 
 the gravity of the patient's condition. 
 
 In the next place : in any case of acute pleurisy, in which, however 
 early it may be in the disease, there is fluid in quantity sufficient to 
 modify,the form of the chest, or to produce displacement of the viscera, 
 the child at the same time suffering from cough, distress, or dyspnoea, 
 the fluid should be at once let out. The chest ought also to be tapped 
 even independent of those symptoms of constitutional disturbance, if 
 the effused fluid should remain stationary for three or four days in spite 
 of treatment; and I believe that, even though nature might eventually 
 .have accomplished the absorption of the fluid without this intervention, 
 recovery will take place more speedily as well as more surely in conse- 
 quence of the tapping. 
 
 1 The latest statistic?, those of Steffen, in vol. ii of his Clinic der Kinderkrank- 
 heiten, p. 598, yield this result. They are founded, indeed, on only 59 cases; but I 
 doubt whether a comparison of larger numbers would lead to any very different 
 conclusion. 
 
RULES FOR ITS PERFORMANCE. 317 
 
 In these cases, or in any others in which there is a possible question 
 as to the presence of fluid, or as to its exact situation, it is well to punc- 
 ture the chest, in the first instance with a hypodermic syringe, by which, 
 even if the lung should be pricked, no harm can be done ; and to be 
 guided in our subsequent proceedings by the information thus ob- 
 tained. The presence of fluid having been ascertained, the trocar may 
 be introduced in the fourth or fifth interspace, and about two inches 
 outside the nipple, unless there should be some special reason for 
 choosing some other position. On the whole, I prefer a Thompson's 
 syringe, with a tube of vulcanized india-rubber attached to it, by which 
 the fluid may be evacuated under water, to any more elaborate con- 
 trivance, such as the aspirator, or Bowditch's syringe. I do so for 
 several reasons; of which one of the chief is the great importance of 
 simplicity in the instruments, and in the performance of an operation 
 which is even more likely to be required at the hands of a country 
 practitioner than at those of a hospital surgeon. In the next place, a 
 certain degree of practice is needed in the use of the aspirator, while 
 there is always risk when Bowditch's syringe is employed, lest the 
 process of exhaustion be carried too far, and blood be drawn after the 
 pleura has been emptied of its contents ; an accident which I have wit- 
 nessed more than once. 
 
 I do not think that the complete emptying of the pleura is by any 
 means essential to the success of the operation ; neither has my experi- 
 ence led me to believe that in cases where the fluid is serous, the accr- 
 dental entrance of air leads to its becoming purulent, or that it produces 
 any of those formidable consequences which have been attributed to it. 
 Inasmuch, however, as our object is to place the patient in the best possi- 
 ble condition for obtaining the complete absorption of any fluid that may 
 still be left behind, for avoiding its re-collection and for facilitating the 
 expansion of the compressed lung, I avoid, as far as possible, the entrance 
 of air into the chest, and close the wound. Supposing the fluid let out 
 to be serum — which, however, it rarely is in idiopathic pleurisy in child- 
 hood — a single tapping may suffice, and recovery maybe both uninter- 
 rupted and speedy. Even though the fluid should be purulent, it yet does 
 not follow of necessity that a second tapping will be required, for some- 
 times the operation is followed by steady, though more gradual im- 
 provement. In many cases, however, where the fluid was originally 
 serous, and in most where it was purulent, a second, and even a third tap- 
 ping is necessary ; while the smaller the quantity of fluid evacuated, and 
 the longer the interval between each successive tapping, the better the 
 prospect of the patient's recovery. The indications for each tapping 
 are in the main the same as those which guided us in its first perform- 
 ance, though, as a rule, in spite of the presence of even a larger quan- 
 tity of fluid, the dyspnoea is less urgent, the cough less troublesome, 
 and the symptoms altogether less grave than they were on the first oc- 
 casion. The heart often fails to regain its natural position immediately 
 on the evacuation of the fluid, so that the evidence afforded by displace- 
 ment of the viscera ceases to guide us ; while, if the lung did not rise 
 immediately on the first performance of paracentesis, the affected side 
 speedily falls in. In consequence of this, instead of the affected side 
 
318 RULES FOR PARACENTESIS 
 
 bulging as it did before the first tapping, it may be a quarter to half an 
 inch smaller than the healthy side, even though the quantity of fluid 
 which has -re-collected may be as great as was present in the first in- 
 stance. I dwell on this point because, for want of its general recogni- 
 tion, I have known practitioners who had resorted to timely paracentesis 
 at first, overlook the subsequent re-collection of the fluid, and be made 
 aware of their oversight only when a spontaneous discharge of matter 
 took place through the chest-wall. Such an error is avoided by a few 
 simple precautions ; as by taking the outline of the chest with a piece 
 of soft wire just before the first tapping, immediately after it and then 
 at intervals of a few days, so as to be made aware of all changes in its 
 contour. If now 7 the chest, which shrank so soon as the fluid was let 
 out, should again begin to enlarge ever so little ; or if, though its girth 
 remains stationary, the results of auscultation do not improve, it is al- 
 most certain that fluid is re-collecting. Again, if the relief at first 
 experienced does not altogether maintain itself, while the febrile symp- 
 toms in some measure return, the temperature, which had fallen, steadily 
 rising again, there can be no doubt, provided the opposite side of the 
 chest has not been attacked by inflammation, but that a re-collection of 
 fluid has taken place. Any remaining uncertainty may be set at rest 
 by the use of the hypodermic syringe and a very fine trocar. 
 
 On the second puncture the fluid, even though serous before, will 
 very generally be found to have become purulent, how great soever 
 may have been the precautions taken to secure the complete exclusion of 
 air. And now arises the question whether again to close the opening, or 
 to allow of the constant outflow 7 of the matter through the wound. My 
 belief is, that in all tolerably recent cases the repetition of the tapping 
 is the better expedient, and that the patient is less exhausted thereby, 
 than by the constant drain of the secretion from the chest. This rule, 
 however, has its limits, and tapping repeated every second or third day 
 has seemed to me an unsafe proceeding, and more likely to be followed 
 by the excitement of acute mischief than the keeping the wound open. 
 Various forms of tubes or canulse have been employed with the view 
 of providing for the ready exit of the fluid. I have often used a curved 
 tube fitted with a movable shield, after the pattern of Luer's trache- 
 otomy tube, so as to avoid the constant friction of a fixed tube against 
 the rib. Caries of the rib has sometimes seemed to be a consequence 
 of neglect of this precaution. Such tubes should either be made of 
 vulcanite, or be electro-gilt; and, ow 7 ing to the narrow space between 
 the ribs, a silver canula gilt is generally the better. A drainage-tube 
 has for this same reason sometimes been employed, but if the space 
 between the ribs is very narrow 7 , the tube is apt to be so compressed as 
 not to allow r the ready escape of the fluid. 
 
 The gold-wire tube is not open to this objection, and has sometimes 
 seemed to answ 7 er very well ; while now 7 and then, following a hint 
 from my colleage, Dr. Gee, I have contented myself with the introduc- 
 tion of a T-shaped piece of double silver wire, the stem of which is 
 bent within the chest, while the crosspiece rests outside, and the w T ound 
 is thus effectually kept from closing. Sometimes, however, the granu- 
 lations from the edge of the opening sprout so as to interfere with the 
 
AND SUBSEQUENT MANAGEMENT. 319 
 
 free exit of the pus ; and in such circumstances a canula must be sub- 
 stituted for the wire. I have not found it desirable to attempt any 
 plan of drainage by means of a distant counter-opening kept patulous 
 by a tube or other contrivance introduced into it. I tried it, indeed, 
 on two occasions, but the proceeding appeared to be a severe one, and 
 the opening at the back of the chest became unhealthy, and it was nec- 
 essary to close it. Even without any such counter-opening, in all 
 cases where the operation has not been too long delayed, the fluid les- 
 sens by degrees, and finally ceases to be secreted as the lung gradually 
 expands on the one side, and the yielding chest-wall falls in to meet it 
 on the other. The only instances in which it has seemed to me to be 
 desirable to make a second opening have been cases of neglected em- 
 pyema, in which there is a circuitous sinus leading to a fistulous aper- 
 ture into the chest. In these circumstances it is sometimes useful to 
 make and to maintain a second direct opening into the chest at a dis- 
 tance of two or three inches from the first ; and the free escape of the 
 matter being thus provided for, the fistula will close in time, and no 
 great difficulty will in general be experienced in the closing of the 
 second aperture. I do not, as a general rule, wash out the chest ; 
 for if the opening is free, the pleural cavity in general remains 
 tolerably empty ; while I have not found that those iodine injections 
 which greatly modify the secretion from a simple serous cyst have any 
 influence on that poured out by a pyogenic membrane. But when- 
 ever the discharge is specially offensive, I always wash out the pleural 
 cavity first with warm water, and afterwards with a weak solution of 
 iodine, or of carbolic acid, either of which greatly lessens any bad 
 odor. 
 
 There still remain tw T o questions with reference to these cases : the 
 one of which concerns the causes of death in chronic empyema, and 
 the other the reason why it is inexpedient to leave the evacuation of 
 the fluid to nature. 
 
 The causes of death are generally one or other of the following : 
 
 1. The supervention of inflammation either on the side originally 
 affected, or still more frequently on the opposite side ; an accident 
 which may occur at any time, though rare when the disease has passed 
 completely into a chronic state. 
 
 2. The occurrence of ulceration of the pleura and the extension of 
 the mischief to the ribs or sternum, producing necrosis ; an accident 
 far from being very uncommon. 
 
 3. The failure of constitutional power, in consequence of the con- 
 tinued drain on the system, though this occurs far less often than 
 might have been expected. 
 
 4. The development of general tuberculosis, which I believe to be 
 the most frequent of all causes of death from chronic pleurisy. 
 
 The reasons why it is inexpedient to leave the evacuation of an em- 
 pyema to nature have already been indicated in what I have said, but 
 they may perhaps be summed up under the following heads : 
 
 1. The needlessly protracted suffering, as well as the additional 
 risk, to which the patient is exposed. 
 
 2. The extreme probability that the opening which nature makes 
 
320 croup. 
 
 will be in a situation unfavorable for its eventual closure, and the 
 further likelihood that it will be circuitous, and not direct. 
 
 3, The risk that the ulceration of the pleura, which precedes the 
 formation of the opening, will not be limited to one spot, but will 
 occur at several ; that it will extend to the periosteum, denuding the 
 ribs or sternum at different parts, and thus leading to their caries. 
 
 4. The certainty that the false membrane lining the chest and cover- 
 ing the lung will be more extensive and thicker than if the fluid had 
 been let out ; that the discharge is therefore more likely to persist ; 
 that the lung, long compressed and firmly bound down, will be less 
 capable of expansion ; and that the resulting deformity will be far 
 more considerable. 
 
 In all cases of effusion into the chest, whether it has been tapped or 
 not, some deformity is sure to take place ; due in part to the falling in 
 of the wall of the affected side, partly to the expansion of the opposite 
 side, owing to the increased development of the sound lung, which has 
 a double duty to perform. I was accustomed once in all cases to 
 resort to mechanical contrivances almost from the first, in order to 
 control this deformity, and to prevent as far as possible the occurrence 
 of great spinal curvature. I am now, however, convinced that in the 
 great majority of cases this precaution is needless; for even when the 
 contraction has at first been most marked, a disposition to its spon- 
 taneous removal almost invariably becomes apparent in a few months, 
 and at the end of a year or two all traces of it have almost always dis- 
 appeared. To this rule, indeed, one must make an exception in most 
 cases where the opening remains fistulous, though even here we meet 
 with instances where the lung gradually rises, and a small circum- 
 scribed collection of matter remains shut off from the general chest 
 cavity ; an inconvenience rather than a grave trouble. Still these are 
 happy exceptions ; and an opening which communicates Avith the gen- 
 eral cavity of the chest leads almost always to deformities which tax 
 all the skill of the orthopaedic mechanician, and too often vainly, to 
 rectify. 
 
 LECTUEE XXIII. 
 
 Croup. — Keasons for not studying it earlier in the course — Discrepancy of opinion 
 with reference to it — Two distinct though allied diseases included under the 
 name. 
 
 Laryngeal Croup; or Cynanche Laryngea. — Causes of the disease — Its fre- 
 quency in childhood, in the male subject, in northern climates, in rural districts. 
 
 Post-mortem appearances — Variations in the extent of false membrane in the air- 
 passages — Changes associated with it — Affection of the fauces and soft palate. 
 
 Symptoms — Occasional sudden onset — Catarrhal stage — General course of a fatal 
 case — Occasional delusive appearances of amendment — Evidences of ausculta- 
 tion — Changes in tracheal sound. 
 
 Duration — Prognosis. 
 
croup. 321 
 
 Treatment — Importance of abstraction of blood — Directions for its performance, and 
 for the administration of tartar emetic — When and how mercurials are to be 
 employed — Modifications in treatment produced by alterations in epidemic con- 
 stitution — Importance of not exaggerating them, and of not confounding in 
 their treatment croup and diphtheria. 
 
 In strict propriety the very important disease which we are now 
 about to investigate, ought to have engaged our attention immediately 
 after we had completed our study of infantile bronchitis. Two reasons, 
 however, independent of mere convenience, have led me to postpone till 
 now the consideration of the subject of croup. One of these reasons is, 
 that its gravity is often greatly increased by the association with it of 
 inflammation of the lungs — a complication the importance of which it 
 was essential that you should thoroughly understand ; the other is, that 
 croup, though an inflammatory disease, is not without a very evident 
 spasmodic element in every case : so that it may very appropriately 
 form a sort of transition between the inflammatory and the spasmodic 
 diseases of the respiratory organs. 
 
 It can scarcely be necessary to tell any of you that croup is the 
 English name for the disease designated by scientific writers cynanche 
 traehealis, or cynanche laryngea. It consists in inflammation, generally 
 of a highly acute character, of the larynx or trachea, or of both, which 
 terminates in the majority of cases in the exudation of false membrane 
 more or less abundantly upon the affected surface. 
 
 The formidable nature of the symptoms by which it is attended, and 
 the rapidity with which it tends to a fatal issue, have led many of the 
 ablest physicians to devote much time and attention to the study of 
 croup. It might, therefore, be anticipated that our knowledge of a 
 disease which betrays itself by very manifest and highly characteristic 
 symptoms, and which gives rise, when fatal, to changes easily appreci- 
 able after death, should, by this time, be very definite and settled. 
 With reference to many of the more important points in the history of 
 the malady, writers are now, indeed, pretty well agreed; but croup, 
 like many other diseases that depend to a great extent on atmospheric 
 and telluric causes, is modified in many of its symptoms by peculiarities 
 of air, water, and situation. The affection assumes one character among 
 the poor of a crowded city, and another among the children of the 
 laborer in some rural district ; or varies in both in accordance with 
 what Sydenham calls the epidemic constitution of the year. 1 
 
 1 I have preserved a record of 23 cases of croup that came under my notice at the 
 Royal Infirmary for Children between May, 1839 and April, 1819. Of these 23 cases 
 11 were idiopathic, 12 secondary ; five of the former and two of the latter recovered. 
 In two of the idiopathic cases that recovered, a scanty formation of false membrane 
 was observed upon the velum and tonsils, but no such appearance existed in the 
 other idiopathic cases. Three of the six fatal idiopathic cases were examined after 
 death : in two the false membrane was confined to the larynx; and there was but 
 little injection of the trachea or bronchi: in the third case there was great redness 
 both of the trachea and bronchi, and a large quantity of purulent secretion in both, 
 and ulceration of the mucous membrane of the larynx, but no false membrane. Of 
 the twelve secondary cases, one supervened in the course of pneumonia ; in the other 
 eleven, croup appeared as the sequela or concomitant of measles, and ten of the 
 twelve terminated fatally. In the cases which recovered, and in three of those 
 which terminated fatally, there was no false membrane on the velum or fauces, but 
 
 21 
 
322 
 
 TWO DISEASES UNDER COMMON NAME OF CROUP, 
 
 If, therefore, you find that my account of the disease varies in any 
 respect from the description given by some other writers, or from the 
 results of your own observation hereafter, do not too hastily assume 
 either that your teacher has been mistaken, or that your own observa- 
 tion has been incorrect. The difference may be nothing more than a 
 fresh exemplification of the old story of the shield, silver on the one 
 side and golden on the other, about which the knights in the fable 
 quarrelled. 
 
 There are, indeed, two diseases which have often been included under 
 
 in the other seven, false membrane was present in those situations as well as in the 
 larynx, and twice this false membrane extended into the oesophagus. Six of the 
 fatal cases were examined after death : in one there was no false membrane any- 
 where, but intense redness of the larynx, trachea, and bronchi, with an uneven 
 granular appearance of the larynx, and ulceration about the epiglottis. In the 
 other five cases the larynx contained more or less false membrane, and its surface 
 was ulcerated; and in four of the cases the palate and tonsils were inflamed and 
 coated with false membrane In all these live cases, pneumonia existed in both 
 lungs, and four times it was found to have reached in some parts the stage of puru- 
 lent infiltration. 
 
 These results, which differ in so many respects from the conclusions of many most 
 excellent observers in this country, approach much more nearly to those obtained in 
 the Hopital des Enfans Malades at Paris. The district in which my observations 
 were made is low, with defective sewerage, open drains running close to many of 
 the houses ; and most of the patients were the children of poor parents, who occupied 
 only one room, and who consequently were placed in most unfavorable hygienic 
 conditions. 
 
 I may further add, that with the change of my field for observation since the 
 opening of the Children's Hospital in 1852, a more sthenic form of the disease came 
 under my notice ; and in some of the fatal cases which occurred in that institution 
 under my care, a complete false membrane not only lined the trachea, but extended 
 even into the tertiary bronchi. This state of things continued for some five years, 
 and then once more the disease assumed an asthenic character as it increased in fre- 
 quency ; and became associated with diphtheria, in which latter disease it for a time 
 almost completely merged. The following abstract from the tables of the Children's 
 Hospital is not without interest as illustrative of these changes in the epidemic con- 
 stitution of # the time since it was opened. I need not say that it is not to be taken 
 as illustrative of any other fact : 
 
 
 
 
 Total Admissions 
 
 Cases of 
 
 Cases of 
 
 Date. of In-Patients. 
 
 Croup. 
 
 Diphtheria. 
 
 In the vear 1852, . . . .143 
 
 
 
 
 
 1853, 
 
 
 
 . 187 
 
 4 
 
 
 
 1854, 
 
 
 
 . 251 
 
 2 
 
 
 
 1855, 
 
 
 
 . 263 
 
 8 
 
 
 
 1856, 
 
 
 
 . 309 
 
 15 
 
 
 
 1857, 
 
 
 
 . 325 
 
 11 
 
 5 
 
 1858, 
 
 
 
 . 380 
 
 4 
 
 6 
 
 1859, 
 
 
 
 . 411 
 
 4 
 
 5 
 
 1860, 
 
 
 
 . 384 
 
 
 
 3 
 
 1861, 
 
 
 
 . 577 
 
 10 
 
 15 
 
 1862, 
 
 
 
 . 543 
 
 7 
 
 17 
 
 1863, 
 
 
 
 . 571 
 
 2 
 
 23 
 
 1864, 
 
 
 
 . 581 
 
 7 
 
 11 
 
 1865, 
 
 
 
 . 658 
 
 6 
 
 7 
 
 1866, 
 
 
 
 . 786 
 
 3 
 
 10 
 
 1867, 
 
 
 
 . 618 
 
 5 
 
 7 
 
 1868, 
 
 
 
 . 719 
 
 7 
 
 12 
 
 1869, 
 
 
 
 . 709 
 
 5 
 
 3 
 
 1*70, , 
 
 
 
 . 691 
 
 4 
 
 1 
 
 1871, 
 
 
 
 . 678 
 
 2 
 
 3 
 
 Total, 
 
 9804 
 
 106 
 
 128 
 
DIFFERENCES OF CROUP AND DIPHTHERIA. 323 
 
 the common name of croup, though the points of difference between 
 them are at least as numerous and as important as are those in which 
 they resemble each other. Of these two diseases, the one is almost always 
 idiopathic, the other is often secondary ; the one attacks persons in 
 perfect health, is sthenic in its character, acute in its course, and usually 
 proves amenable to antiphlogistic treatment; the other attacks by prefer- 
 ence those who are out of health or who are surrounded by unfavorable 
 hygienic conditions, and is remarkable for the asthenic character of the 
 symptoms which attend it. The one selects its victims almost exclu- 
 sively from among children, is incapable of being diffused by contagion, 
 is governed in its prevalence by the influence of season, temperature, 
 and climate, but rarely becomes, in the usual acceptation of the term, 
 an epidemic ; while the other attacks adults as well as children, is 
 propagated by contagion, and though it occasionally occurs in a sporadic 
 form, is susceptible of widespread epidemic prevalence. The one is 
 developed out of catarrh, and the amount of disease of the respiratory 
 organs is the exact measure of the danger which attends it; while the 
 other affects the organs of respiration secondarily, its peril is often alto- 
 gether out of proportion to the degree in which they are involved, and 
 death itself may take place although they are altogether unaffected. 
 In this latter ailment, too, a long train of sequela? not infrequently 
 remains after the local symptoms have been dissipated : the evidence 
 of its affinity to the class of blood diseases rather than to that of simple 
 inflammations. Cynanche Trachealis, Cynanche Laryngea, are the 
 appellations of the former ; Home 1 and Cheyne 2 and Albers, 3 its his- 
 torians ; Angina Maligna, the Garotillo, Morbus Strangulatorius, Diph- 
 therite or Diphtheria, the synonyms of the latter ; Severinus, 4 Ghisi, 5 
 Bard, 6 Starr, 7 Rumsey, 8 Bretonneau, 9 Trousseau, 10 and Jenner, 11 some 
 of the writers who have most carefully described it. 
 
 Different, however, as the two diseases are, there are yet between 
 them points of similarity no less striking — 
 
 Facies non una, nee diversa tamen, 
 
 and the diagnostic difficulties which are thus almost inevitable, are still 
 further enhanced by the not infrequent simultaneous prevalence of both 
 affections. 
 
 1 An Inquiry into the Nature, Cause, and Cure of the Croup. 8vo., Edinburgh, 
 1765. 
 
 2 On the Pathology of the Larynx and Bronchia. 8vo., Edinburgh, 1809. 
 
 3 De Tracheitide Infantum. 4to., Lipsise, 1816. 
 
 4 De psedanchone maligna, &c., in De recondita abscessuum natura, p. 513. 4to., 
 Lugd. Bat., 1724. 
 
 5 Lettere mediohe; la seconda contiene l'istoria delle anghine epidemiche degli 
 anni 1747 e 1748. Cremina, 1749, 4to. 
 
 6 An Inquiry into the Nature, &c., of the Angina Suffocativa, in Transactions of 
 American Philosophical Society. 4to., vol. i, 2d ed., Philadelphia, 1789, p. 388. 
 
 7 An account of the Morbus Strangulatorius, in Philosophical Transactions, vol. 
 xliv. 4to., London, 1752, p. 435. 
 
 8 Transactions of a Society for the Improvement of Medical and Surgical Knowl- 
 edge, vol. ii. 
 
 9 De la Diphthe>ite. 8vo., Paris, 1826. 
 
 10 Clinique Medicale, &c, vol. i, pp 312-450. 
 
 11 Diphtheria, its Symptoms and Treatment. 12mo., London, 1861. 
 
324 CAUSES OF CROUP. 
 
 It will be my endeavor to describe, first, that disease which used at 
 least to be the more frequent in this country, and then to give the best 
 account in my power of that other malady, which is a yet more for- 
 midable visitant, and one less within the power of medicine to control. 
 
 Croup, or Cynanche Laryngea, in the form which it usually assumes 
 in this country is essentially a disease of early life ; for it appears from 
 the Fifth Report of the Registrar-General, that while 1022 out of 
 98,391 deaths in the metropolis and twenty-four town districts, took 
 place from croup, 1013, or 99.9 per cent., of those deaths occurred be- 
 fore the age of fifteen ; and 879, or 87.9 per cent., before the age of five 
 years. Of 100 cases of croup occurring among the in-patients of the 
 Children's Hospital, 84 took place in children under five years of age, 
 and only 16 in children between the ages of five and ten. 58 of the 
 patients were males, 42 females. It has been attempted to explain this 
 great frequency of croup in early life by the imperfect development of 
 the organ of the voice before puberty. This, however, can scarcely be 
 admitted as a valid explanation, since it does not at all account for the 
 extreme rarity of the disease after five years of age. The preponder- 
 ance of male over female children among those who are attacked by 
 croup, is another fact which, though confirmed by the experience of all 
 observers, has never received any adequate explanation. 1 
 
 Croup appears to be influenced by peculiarities of elimate and locality 
 much more than most diseases of the respiratory organs. Though not 
 entirely confined to northern climates, it prevails but seldom in the 
 southern parts of Europe, and is even less frequent in the southern 
 than in the northern counties of England. In Kent, Surrey, and Sus- 
 sex, the deaths from croup are to the deaths from all causes in the pro- 
 portion of .9 per cent. ; while in the four northern counties, Durham, 
 Northumberland, Cumberland, and Westmoreland, which contain an 
 equal population, the deaths from this cause are in the proportion of 
 1.6 per cent. It is endemic in particular localities; and residence near 
 the sea, proximity to the mouths of large rivers, a moist soil and a 
 damp atmosphere, have been enumerated as greatly predisposing to the 
 disease. The influence of these local peculiarities has probably, in some 
 
 i From the Fifth Keport of the Registrar-General, it appears that, while the deaths 
 of males under 15 from all causes, are to the deaths of females from all causes as 11 
 to 10, the deaths from croup are as 15 to 10. Of 249 cases that came under Golis's 
 observation at Vienna, 144 occurred in males, 105 in females ; at Geneva, under 
 Jurine's observation, 54 males and 37 females died of croup, between the years 1791 
 and 1808 ; and the relation of the sexes at Berlin among the deaths from croup be- 
 tween 1838 and 1849, was. as nearly as possible, as 5 to 4; the actual numbers being 
 545 male to 459 female children. See Honerkopff iiber die Anwendung des schwefel- 
 sauren Kupferoxyd's gegen Croup. 8vo , Leipzig, 1852. 
 
 It may be noticed as a point of difference between croup and diphtheria that no 
 such special liability of the male subject to its attacks is observed in the case of the 
 latter disease. The proportion, indeed, would seem from the 24th Report of the 
 Registrar-General to be almost reversed, since while 2321 male deaths, and only 
 2076 deaths of females, took place from croup in 1861 throughout England; 2453 
 female deaths, and only 2064 male deaths, occurred from diphtheria. M. Roger, 
 in his valuable essay on diphtheritic paralysis, notices the same fact, of the equal 
 liability of both sexes to diphtheria, or that if any difference exists between the lia- 
 bility of the two sexes to diphtheria, it is the female sex which suffers the most; in 
 the proportion of about 5 to 4. See p. 462 of vol. i of the Archives de Medecine 
 for 1862. 
 
MORBID APPEARANCES IN CROUP. 325 
 
 instance-, been overrated ; but still it cannot be denied, for a most 
 striking illustration of it is afforded by the comparative rarity of croup 
 in towns, and its frequency in rural districts. In the county of Surrey, 
 exclusive of the metropolitan districts, the mortality, from all causes, 
 under live years of age, is little more than a third of the mortality in 
 Liverpool, and little more than half the mortality in London. But 
 the total mortality, under five years of age, f) om croup in the county 
 of Surrey is to that in Liverpool nearly as 3 to 2, and to that in Lon- 
 don as 2 to 1 ; so that out of 100 children dying under five years of 
 age from all causes, more than four times as many will have died from 
 croup in Surrey as in Liverpool, and exactly four times as many as in 
 London. 
 
 Variations in the condition of the atmosphere, and peculiarities of 
 situation, not only influence the frequency of the occurrence of croup, 
 but they likewise greatly modify its character, and determine to a con- 
 siderable extent the nature of the lesions which it produces. The 
 chief morbid appearances, however, are always discovered in the larynx, 
 trachea, and air-tubes. They consist of redness of the mucous mem- 
 brane, which is often thickened, sometimes abraded or ulcerated, and 
 very generally covered with a more or less abundant exudation of false 
 membrane. This exudation, however, though so generally met with 
 as to have suggested to medical writers the terms angina polyposa, 
 angina membranacea, as appropriate designations of croup, is neither 
 invariable in its occurrence, nor of a uniform extent in all cases. It is 
 found in the larynx oftener than in the trachea, and in both more fre- 
 quently than in the bronchi. Nevertheless, in many instances, the 
 secretion of false membrane is so extensive as not only to line the 
 larynx and trachea, but even to reach into the minuter air-tubes, form- 
 ing a complete cast of many of their ramifications. There appears to 
 be some connection between the circumstances in which children be- 
 come attacked by croup, and the extent of false membrane in the air- 
 passages, which a post-mortem examination reveals. In rural districts, 
 where the disease wears throughout a sthenic character, false mem- 
 brane is deposited in greater abundance and over a greater extent of 
 surface than is usually observed in the case of the poor in this metrop- 
 olis : while, on the other hand, we find in London a condition of 
 unhealthy ulceration about the larynx ; ulceration, and the deposit of 
 false membrane about the tonsils and palate in many instances, appear- 
 ances which are seldom met with in children placed in circumstances 
 more favorable to health. 1 
 
 In cases of croup that have come under my own observation, the 
 formation of false membrane in the larynx has seemed almost invari- 
 ably to precede its deposit in the trachea ; and not infrequently it has 
 been found constituting a tough, continuous membrane in the former 
 situation, but growing less tenacious in the upper part of the trachea, 
 and passing gradually into a thick, puriform mucus, interspersed with 
 
 1 It is open to question how far one is justified in classing such cases with true 
 croup ; whether they do not approach more nearly to diphtheria, or whether at 
 least they do not form a sort of connecting link between the two diseases. 
 
326 MORBID APPEARANCES IN CROUP. 
 
 shreds of lymph. I have usually observed the false membrane lining 
 the whole of the larynx, and reaching down to the lower edge of the 
 thyroid cartilage, while the trachea contained nothing else than a puri- 
 form matter, or glairy mucus, sometimes of a reddish color. In some 
 instances the false membrane has been confined to the upper part of the 
 larynx, lining the lower surface of the epiglottis, blocking up the 
 opening of the sacculus laryngis, and covering the chordae vocales, but 
 not extending any further. When first secreted, the false membrane is 
 firmly adherent to the mucous lining of the air-passages, but after a 
 time a secretion of a puriform character is generally poured out, which 
 detaches the membrane from its connections ; and it is after this occur- 
 rence has taken place that tubular pieces of false membrane have some- 
 times been expectorated. This detachment of the false membrane 
 from the subjacent surface takes place more frequently and more com- 
 pletely from the interior of the trachea than from that of the larynx. On 
 removing the false membrane from the trachea, the lining of the tube 
 is seldom found to present any change other than an increase of its 
 vascularity, which, though sometimes very considerable, does not bear 
 any certain relation to the amount of false membrane present. The 
 greater difficulty in removing the false membrane from the larynx 
 depends upon the more extensive alterations which the lining of that 
 part of the air-tubes is usually found to have undergone. It is gener- 
 ally red and swollen, especially about the edges of the rima glottidis 
 and the arytenoid cartilages, and the opening of the sacculus laryngis. 
 Small aphthous ulcerations are also frequent in the two former situa- 
 tions ; and occasionally, the ulceration being more extensive, the whole 
 of the larynx, on detaching the false membrane that lined it, presents 
 a worm-eaten appearance. 
 
 It seldom happens that the bronchi are perfectly free from disease ; 
 but even if the trachea should contain no false membrane, and should 
 present but few signs of inflammation, they are almost always much 
 congested, and contain a muco-purulent or purulent secretion : though 
 false membrane is seldom found in them, except when it is continuous 
 with a similar adventitious structure in the trachea. 
 
 Pneumonia, in all its stages, is far from being unusual, and is a com- 
 plication especially to be feared in those cases where croup occurs as a 
 secondary affection in the course of measles. 
 
 The cavity of the mouth and the fauces do not present any invariable 
 alteration in cases of croup. Congestion about the fauces and soft palate 
 is of frequent occurrence, sometimes coupled with a scanty deposit of false 
 membrane in those situations, or the tonsils are found in a state of ulcer- 
 ation. In that form of croup which succeeds to measles, there is more- 
 over in many instances a condition of unhealthy inflammation, and 
 aphthous ulceration of the mouth and gums ; a slight speck of ash- 
 colored false membrane covering each little ulcer. In many of these 
 cases I apprehend that the laryngeal affection does not come on in conse- 
 quence of extension to the air-passages of disease beginning in the 
 mouth, but that the disease is the same in both situations ; though the 
 accident of the locality renders that a serious disorder when seated in 
 the larynx, which is but a trivial ailment when affecting the mouth. 
 
SYMPTOMS OF CROUP. 327 
 
 Cases of this last kind have been called cases of ulcerative laryngitis : 
 they have always come under my notice associated with the exudation 
 of false membrane, and I suspect their affinities are with diphtheria 
 rather than with true croup. 
 
 Whatever be the circumstances in which croup comes on, the symp- 
 toms resulting from disease obstructing the channel of the larynx and 
 trachea by false membrane, or inducing a spasmodic closure of their 
 aperture, must always be to a great extent the same. Its mode of 
 onset, however, is very variable. Sometimes, especially in those forms 
 of croup that prevail among healthy children living in the country, 
 the disease is announced by few, if any, premonitory symptoms ; but 
 the affection of the larynx is apparent from the very outset, and attains, 
 in the course of a few hours, to a high degree of intensity. Some years 
 since I saw a little boy, about seven years old, living at some distance 
 from London. He had overheated himself at play during the after- 
 noon of a hot day in August, but went to bed apparently well at eight 
 o'clock, and soon fell asleep. At ten, he began to breathe with the 
 peculiar noise characteristic of croup, and presented all the symptoms 
 of the disease before midnight. 
 
 In his treatise on croup, Professor Golis, of Vienna, 1 relates the case 
 of a little boy, four years old, previously in perfect health, who having 
 gone out of an overheated room into the open air, during an extremely 
 cold winter's day, was seized while walking with all the symptoms of 
 most violent croup, which proved fatal in fourteen hours. 
 
 This sudden onset and rapid course of the disease, however, are of 
 rare occurrence, and croup generally comes on gradually, attended in 
 its first stage by but few symptoms that could distinguish it from 
 ordinary catarrh. Slight fever, drowsiness, suffusion of the eyes, and 
 defluxion from the nares, attend it. The respiration is not perceptibly 
 disturbed, and the cough, though frequent, presents no peculiar char- 
 acter. There is, besides, occasional complaint of slight sore throat, or 
 of uneasy sensation about the larynx, but so slight as scarcely to attract 
 attention, and not sufficient to cause any alarm. 
 
 The duration of this stage is very variable : nor is there any reg- 
 ularity in the mode of its transition into the second stage. In the ma- 
 jority of cases, indeed, the transition takes place gradually; but thirty- 
 six hours seldom pass without the supervention of some symptom 
 which, to the well-schooled observer, would betray the nature of the 
 coming danger. Most symptoms may continue unchanged, perhaps 
 scarcely aggravated, but a slight modification takes place in the char- 
 acter of the cough, which now becomes attended with a peculiar ring- 
 ing sound, difficult to describe, but when once heard not easily for- 
 gotten. This peculiarity in the cough very often precedes any change 
 in the respiration, and may sometimes be so slight as scarcely to attract 
 the parent's notice at the time, and to be remembered only when the 
 full development of the disease leads to inquiries as to how the attack 
 came on. Soon after this modification of the cough has become per- 
 
 1 De rite cognoscenda et sananda Angina Membranacea r 8vo.. Yiennse.. Observ.. 
 iv, p. 141. 
 
328 SYMPTOMS OF CROUP. 
 
 ceptible, or even simultaneously with it, the respiration undergoes a 
 change no less remarkable. The act of inspiration becomes prolonged, 
 and attended with a stridor as difficult to describe, but as characteristic 
 of the disease, as the tone of the cough. It often happens that these 
 two pathognomonic symptoms first come on, or at least first excite 
 attention, in the night, and that a child who at bedtime was supposed 
 to ail nothing, or at most to have a slight cold, awakes suddenly with 
 ringing cough and stridulous breathing, frequently in a state of alarm, 
 and with marked dyspnoea. Through the whole course of the disease, 
 indeed, an obvious tendency exists to nocturnal exacerbations, and to 
 remissions as the morning approaches. In whatever manner these 
 symptoms may have come on, they will not continue for many hours 
 without being attended by increase of fever, by acceleration, and soon 
 by difficulty of respiration. The skin becomes hot and dry, the face 
 flushed, the breathing hurried, the cough frequent, the pulse full and 
 quick, the child dull, fretful, and passionate. For a few minutes, 
 indeed, it may appear cheerful, may turn to its playthings, and breathe 
 more naturally, though the peculiar respiratory sound never ceases 
 altogether. Soon, however, the dyspnoea returns with increased in- 
 tensity ; the whole chest heaves with the inspiratory effort, which is 
 more prolonged, and attended with great stridor. During it perspi- 
 ration breaks oat at every pore, and the veins of the neck and face 
 become greatly distended. Short and forcible expiration follows, and 
 after this state of dyspnoea has lasted for some minutes, an interval of 
 comparative ease succeeds. The child now often falls asleep exhausted; 
 but during sleep, the sound attending respiration is heard in an exag- 
 gerated degree. Though the drowsiness is great, sleep is uneasy, and 
 frequently interrupted by violent startings, in spite of which the child 
 may still sleep on. After some minutes he awakes in a state of terror, 
 to pass through another paroxysm similar to the preceding one, though 
 more severe. The cough does not increase in severity in proportion as 
 the disease advances; it is unattended by expectoration, or at most a 
 little mucus is spit up, but without any relief. Although the par- 
 oxysms of dyspnoea are not dependent on the cough, they are some- 
 times provoked by it, and the two or three inspirations next following 
 an effort of coughing are often attended with increased stridor. From 
 the first appearance of the more marked symptoms, the voice is hoarse, 
 cracked, and whispering, or in young children is either totally sup- 
 pressed, or, if their voice is not actually extinct, at least their disin- 
 clination to speak is so great that they will reply to questions only by 
 signs, and cannot be induced by any persuasion to utter a w T ord. 
 
 There is almost always much eagerness for drink, and deglutition is 
 generally well performed. The fauces are often red, though their red- 
 ness bears no direct proportion to the intensity of the croupal symptoms ; 
 and there is frequently considerable tenderness of the larynx. The 
 tongue is red at the tip and edges, but coated in the centre and at the 
 back with thick white fur ; the bowels are rather constipated, and the 
 appetite for food is entirely lost. 
 
 As the disease advances, the paroxysms become less marked, or rather, 
 the intermissions grow less distinct, and the child is constantly engaged 
 
RESULTS OF AUSCULTATION IN CROUP. 329 
 
 with the effort to respire. The cough now sometimes ceases altogether, 
 and the breathing frequently becomes sibilant rather than stridulous. The 
 child throws its head back as far as possible, in order to increase the 
 capacity of the trachea ; the chest is heaved violently at each effort to 
 inspire, during which its lateral region becomes flattened, and all the 
 soft parts of its parietes recede, indicating the inadequacy of the attempt 
 to fill them ; and the larynx is depressed forcibly towards the sternum, 
 while the abdominal muscles co-operate energetically in expiration. 
 The face is heavy and anxious, the eyes are dull, the lips livid, the skin 
 dry, and the extremities cold; or clammy sweats bedew the surface. 
 The respiration is hurried, unequal, and irregular, and the pulse is very 
 frequent and very feeble. Though no remissions now occur, there are 
 frequent exacerbations, in which the child throws itself about, and puts 
 its hand to its throat, as though to tear away some obstacle to the 
 admission of air, while helpless, hopeless agony is depicted on its counte- 
 nance. In the midst of these sufferings the patient dies, or coma or 
 convulsions come on, and close the scene. 
 
 It is not always, however, that the last stage of croup is attended by 
 such distressing symptoms. The treatment employed may seem to have 
 mitigated the severity of the disease; the restlessness may give place to 
 ease, the burning skin may grow moist, the respiration may become 
 tranquil, the cough loose with but little clangor; expectoration may 
 be easy, and a wheezing, attended with a very slight croupy sound, 
 may be the only indication of the dangerous disease under which the 
 patient is suffering. This apparent amendment may continue for a few 
 hours, and then be succeeded, without any assignable cause, by the 
 return of all the former symptoms, and soon be followed by death; or, 
 the mitigation of the disease may be accompanied with great drowsi- 
 ness, which, however, does not excite alarm, since it is very naturally 
 attributed to the exhaustion produced partly by the disease, partly by 
 the remedies. During sleep, the respiration is deep and tranquil, like 
 that of a person in a sound slumber ; it is, indeed, attended by a kind 
 of w T heeze, but presents little of the croupy stridor ; and when awake 
 the child is quite sensible, and even cheerful. After a time, however, 
 it becomes difficult thoroughly to- rouse him ; his pulse grows more 
 rapid, the moisture on his skin changes almost imperceptibly to a cold 
 clammy sweat, and convulsive twitchings of the angles of the mouth 
 occasionally disturb the repose of his features. Silently, but surely, 
 the exudation has been making progress, and when the alarm is taken, 
 it is too late; the stupor deepens, and the child dies comatose, or rouses 
 only to spend its last hours in the vain struggle for breath, and embit- 
 tered by all the painful circumstances which ordinarily attend the 
 suffocative stage of croup. 
 
 Auscultation yields us information in cases of croup with reference to 
 two important points ; namely, the amount of obstruction to the entrance 
 of air into the lungs, and the extent of disease of the air-tubes or sub- 
 stance of the lungs which accompanies it. At first, air is heard entering 
 the chest freely, and unattended by any morbid sound other than that 
 stridor which is produced in the larynx. If the lungs should continue 
 unaffected, no other morbid sound will be heard ; but as the disease 
 
330 DURATION OF CROUP. 
 
 advances, the same negative results will be obtained from auscultation 
 as are yielded by it in cases of emphysema — a feeble respiratory murmur 
 belying the loud resonance on percussion. Often, however, respiration 
 is attended from the commencement with the sonorous rhonchus of the 
 first stage of bronchitis, though masked to some extent by the croupy 
 noise in the trachea. Even in cases where the disease was originally con- 
 fined to the larynx or trachea, inflammation almost always extends to 
 the bronchi ; often, also, to the substance of the lungs, so that mucous 
 or subcrepitant rale generally becomes perceptible during its course, 
 often attended by impaired resonance on percussion over the lower part 
 of the chest. Air, however, may enter so imperfectly as not to fill the 
 smaller bronchi ; and these sounds may be quite unperceived, unless 
 the auscultator listens at the moment when the child makes an unusually 
 deep inspiration, such as often follows a fit of coughing. The pneu- 
 monia, too, in all cases that I have observed, was double, and the 
 resonance consequently nearly equally diminished on both sides of the 
 chest. Hence the importance of comparing the sound elicited by per- 
 cussion of the upper with that given out by the lower part of the chest — 
 a point to which you will remember that your attention has already been 
 called on several occasions. 
 
 The changes in the tracheal sound which attend the progress of the 
 disease may be traced with great distinctness by applying a stethoscope 
 to the larynx. Some writers have thought that they recognized in its 
 variations the indications of the formation of false membrane, and that 
 these changes also afford a means whereby to judge of its extent. I 
 believe that usually, when false membrane has been extensively formed 
 in the larynx, the tracheal sound becomes less stridulous and more 
 sibilant ; but I noticed on one occasion those alterations in the tracheal 
 sound which are supposed to indicate the presence of a very extensive 
 deposit of false membrane, although no false membrane was either 
 expectoratecl*during the patient's lifetime, or discovered in the inflamed 
 larynx and trachea after her death. We must conclude, therefore, that the 
 changes in the tracheal sound do not afford absolutely certain evidence 
 of the existence of false membrane, and that still less can they be 
 regarded as safe criterions of its extent. 
 
 It is difficult to state with precision the duration of a disease such as 
 croup, since its premonitory symptoms vary greatly, and its fatal termi- 
 nation is often in great measure due to the concomitant or consecutive 
 bronchitis or pneumonia. When the laryngeal affection goes on to 
 destroy life, it is seldom that more than forty-eight, or at the most 
 seventy-two hours elapse from the full development of the croupal symp- 
 toms to the fatal event; and, allowing the ordinary duration of the 
 premonitory stage to be about thirty-six hours, the disease will be found 
 to run its course in from four to six days. Twice I knew death take 
 place within thirty -six hours from the occurrence of the first croupal 
 symptoms ; and on a third occasion within thirty-seven hours ; but 
 these are instances of unusually rapid termination of the disease. Treat- 
 ment sometimes partially subdues it ; but it returns, and the relapse, 
 in the course of a few hours, proves fatal. Now and then the acute 
 symptoms subside, and the disease assumes a chronic character; but 
 
PROGNOSIS — DANGER OF RELAPSES IN CROUP. 331 
 
 this has very rarely come under my notice in idiopathic croup, though 
 it is more common in that form of the disease which we shall have here- 
 after to notice as constituting a serious complication of measles. 
 
 The prognosis of croup must always be guarded, and is generally 
 unfavorable, since the disease is unquestionably one of the most dan- 
 gerous to which childhood is liable. Much depends upon the patient 
 being seen at an early stage of the disease ; and the prospect of recovery 
 is generally very small if no treatment should have been adopted 
 until after the full development of the symptoms. The presence ot 
 bronchitis, and, still more of pueumonia, adds greatly to the dangers 
 of the affection, and would induce us to form a very unfavorable 
 opinion of the chances of recovery. A second attack of croup is gener- 
 ally less serious than the first ; and cases in which catarrhal symptoms 
 have preceded the seizure for several days are more amenable to treat- 
 ment than those in which the premonitory stage has been short, or 
 altogether absent. Diminution of the dyspnoea in the intervals of the 
 cough — a louder and looser cough, attended with expectoration or 
 vomiting of muco-purulent matter, intermingled with shreds of false 
 membrane — a less suppressed voice, less anxiety, and less restlessness 
 — all indicate that the disease is abating. Much caution, however, 
 must be exercised in drawing a favorable conclusion from a diminution 
 of the severity of the symptoms, until such improvement has continued 
 for twenty-four hours at least. In all but the most acute cases of 
 croup the remittent character of the disease is very apparent ; and it is 
 well to bear in mind that the fatal termination usually takes place 
 with extreme rapidity, when an exacerbation of the symptoms follows 
 soon after a manifest remission of their intensity. 1 It can scarcely be 
 necessary to remind you that extinction of the voice, suppression of the 
 cough, the change from stridulous to sibilant breathing, and increased 
 difficulty of respiration, all show death to be surely and speedily ap- 
 proaching. 
 
 The danger of being lulled into security by the apparent improve- 
 ment of a child w T ho has been attacked by croup, is so serious, that 
 before proceeding to consider the treatment of the disease I will relate 
 to you a case by way of caution. On the 25th of June, a little girl, 
 four years old, became hoarse and lost her appetite, though she did 
 not appear otherwise ill. On the 27th she seemed less well, and in 
 the night was very restless, and had difficulty of breathing. On the 
 28th respiration was more difficult, and though she had but little 
 cough, she seemed sometimes in danger of choking. In the night a 
 croupy sound accompanied her breathing, and violent attacks of dysp- 
 noea were of frequent occurrence. 
 
 On the 29th she was taken to a surgeon, who gave her some medi- 
 cine, after each dose of which she was sick, and this sickness was fol- 
 lowed by much relief, and by an almost complete cessation of the 
 croupy sound. This improvement was thought to have continued 
 during the 30th ; the child slept quietly during the night, and was 
 
 1 " Mox post symptomatum remissionem recidivantes, brevi ac certa morte de- 
 muntur." Golis, lib. cit., p. 164. 
 
332 TREATMENT OF CROUP. 
 
 considered so much better by her parents that she was brought by 
 them to the Children's Hospital at 9 a.m. on July 1st. As she lay 
 in the lap in a sitting posture, her countenance was pale and livid, her 
 respiration was sibilant, her surface cool, her pulse very frequent and 
 feeble, but there did not appear to be any of the distress usual in 
 the advanced stages of croup. At 9 a.m. she was admitted; at 6 
 P.M. she died ; though no great distress nor violent struggle for breath 
 preceded her death. The extensive deposit of false membrane in the 
 trachea and bronchi showed that, in spite of her apparent amendment 
 for a season, disease must all the time have been advancing, unsus- 
 pected by her friends, overlooked even by her medical attendant. 
 
 In no disease is the prompt employment of appropriate treatment 
 more important than in croup, since in none does the use of remedies 
 sooner become unavailing. Even in cases where the attack is merely 
 apprehended, but where catarrh exists, attended with a slight ringing 
 cough, such as often indicates the commencement of croup, the patient 
 should be watched most sedulously, and visited not merely by day- 
 time, but also late in the evening ; and attention should be particularly 
 directed to the character of the respiration during sleep as well as in 
 the waking state. The child should at once be placed in a warm 
 bath, be confined to bed, be placed on a spare diet, and should take an 
 emetic of ipecacuanha and antimony, to be followed by some mild 
 saline medicine, containing slightly nauseating doses of antimonial 
 wine. 1 At the same time the air which the child breathes should be 
 both warm and moist, the temperature of the room being steadily kept 
 up at 65°, while the moisture of the air is easily maintained, by a 
 kettle boiling on the fire, with a long roll of paper, or, still better, a 
 tin tube attached to its spout, which serves to direct the steam into the 
 apartment. These simple precautions, useful in diminishing the irri- 
 tability of the air-tubes when croup is merely threatened, are, I need 
 scarcely say, of still greater moment when the disease is fully devel- 
 oped. 2 By these measures, which should be observed with especial 
 care if the premonitory symptoms of croup appear in a child who has 
 previously suffered from the disease, or in whose family a liability to 
 it exists, you may often succeed in warding off the attack. 
 
 A far more energetic plan must be resorted to if the disease sets in 
 with violence, or if, the indications of its approach having been either 
 
 1 (No. 14.) 
 R. Potassae Bicarbonatis, gr. xl. 
 Acicli. Citrici, gr. xx. 
 Vin. Ant. Pot.-Tart., £iss. 
 Yin Ipecac, ff^xx. 
 Syr. Limonum, ^iiss. 
 Aqua?, Jiiss. M. ft. Mist. 
 A dessertspoonful every 3 or 4 hours. For a child two years old. 
 
 2 At the Children's Hospital, so much importance is attached to the mainte- 
 nance of a warm and moist atmosphere around the croup patient, that we are ac- 
 customed to inclose the bed with curtains, and to introduce within them the steam 
 from boiling water, so as to maintain uniformity of moisture and temperature if 
 necessary for days together. Many contrivances have been employed for this pur- 
 pose. My colleague, Dr. Gee, has devised a very ingenious one, which we always 
 . use at the Children's Hospital. 
 
DEPLETION. 333 
 
 overlooked or unchecked, the symptoms should have attained their full 
 development before the patient came under your notice. The abstraction 
 of blood, and the administration of tartar emetic, are the two measures 
 on which your main reliance must be placed ; remembering that if relief 
 do not come soon it will not come at all — that there is not danger only, 
 but death, in delay. I have never met with an exception to the rule 
 which prescribes the free abstraction of blood in every case of severe 
 idiopathic croup, when seen at an early period, and before the purple 
 lips and livid countenance, and failing pulse, announce the long-con- 
 tinuance of a serious obstacle to the free admission of air into the lungs. 
 Even in very young children local depletion forms in these cases but a 
 poor substitute for general bleeding, for it is not merely the abstraction 
 of a certain quantity of blood that is needed, but its removal in such a 
 manner as most speedily to produce an effect on the system. Bleeding 
 from the jugular vein is preferable in these circumstances to venesec- 
 tion in the arm, since the latter often fails in children under three years 
 old; and the blood never flows so freely as when taken from the jugu- 
 lar vein. It is not easy to state in figures the exact quantity to be 
 abstracted, since the child's previous health, the intensity of the symp- 
 toms, and the effect produced by the flow of the blood, must all be 
 taken into account in determining when to stop. Dr. Cheyne says, 
 " The removal of three ounces of blood from a child between one and 
 two years of age, or of six ounces from a child from eight till ten, gen- 
 erally appears to make a sufficient impression on the disease; and this 
 is a sufficiently near approach to a correct estimate of what is usually 
 needed. The effect of free venesection is often very striking, and as 
 the blood flows, the respiration may be seen to become notably easier. 
 But though the relief thus afforded is very great, it proves but tempo- 
 rary; and unless followed by other remedies, the symptoms will often 
 regain their former intensity in the course of four or six hours. I 
 have not seen any instance in which the repetition of general bleeding 
 appeared indicated, but I have occasionally employed local depletion 
 with advantage a few hours after the general bleeding; though, if you 
 follow up the first loss of blood by the free employment of tartar emetic, 
 you will generally be spared the necessity for further depletion. It 
 has been recommended that leeches should be applied to the top of the 
 sternum rather than to the windpipe, since difficulty may be experienced 
 in arresting the bleeding if applied in the latter situation, as children 
 are very intolerant of pressure in that neighborhood. The caution is 
 worth bearing in mind; but if you superintend the application of the 
 leeches yourselves, which in such a case you certainly ought to do, the 
 advantage of drawing the blood as nearly as possible from the affected 
 part will more than make up for the risk of some slight difficulty in 
 stopping its flow. 
 
 To accomplish any real good by means of the tartar emetic it must 
 be given in doses of an eighth, a quarter, or half a grain every ten 
 minutes until vomiting is produced; and the same doses should after- 
 wards be continued every half-hour, until decided and permanent relief 
 has been afforded. The dose that at first caused vomiting may, after it 
 has been repeated a few times, cease to excite it, in which case we must 
 
334: EMPLOYMENT OP ANTIMONY IN CROUP. 
 
 increase it, and not rest satisfied with tolerance of the medicine having 
 been established, since its utility appears to be closely connected with 
 its emetic power. Nauseating doses of antimony have not seemed to 
 me to check the disease so surely, while they cause a greater depression 
 of the system, and thus mask the approach of the fatal event, A 
 striking illustration of the superiority of emetic over nauseating doses 
 of medicine is given by M. Valleix, 1 who states that, in thirty-one out 
 of fifty-three cases of true croup, ipecacuanha and antimony were em- 
 ployed in full doses as emetics, and of these thirty-one cases fifteen re- 
 covered ; while of the twenty-two cases in which their use was but 
 sparingly resorted to, only one survived. 
 
 If, after antimony has been thus administered for four or six hours, 
 no satisfactory measure of improvement should have appeared, local 
 depletion may be resorted to. If the croupal symptoms, on the other 
 hand, should have begun to abate, the antimony may be given at longer 
 intervals ; but you cannot be too much on your guard against being 
 misled by temporary improvement, and abandoning the medicine too 
 soon. Its use likewise is not to be relinquished by gradually dimin- 
 ishing the dose and substituting a quantity sufficient only to induce 
 nausea for that which caused vomiting, but a full dose should be given 
 every hour or two hours, instead of every half-hour, and if amendment 
 continues, the interval may be prolonged to three, four, or six hours. 
 It is now, after the severity of the disease has been subdued by anti- 
 mony, that the time has come for the administration of calomel. From 
 the very commencement of the attack, mercurial inunction may be had 
 recourse to every two or three hours ; or a flannel bandage, on which 
 two drachms of mercurial ointment have been spread, may be swathed 
 around the abdomen of the patient; but the action of mercurials is far 
 too slow to overtake at its outset a disease which tends so rapidly to a 
 fatal issue. At this period, however, calomel seems to have a twofold 
 utility ; it counteracts the tendency to the formation of false membrane 
 in the air-passages, and prevents or subdues that inflammation of the 
 lungs which is so frequent and so fatal a complication of the disease. 
 I usually employ it in doses of half a grain or a grain in children from 
 two to five years old every hour or tAVO hours, in combination with 
 minute doses of ipecacuanha, but interrupting its use at intervals in 
 order to give an antimonial emetic. The appearance of any exacerba- 
 tion of the croupal symptoms, however, would lead me at once to dis- 
 continue the calomel, and to return to the emetic employment of 
 antimony. 
 
 It is not unintentionally, nor from any oversight, that I have allowed 
 my observations on the treatment of true croup to remain unaltered ; 
 expressing the opinions which I formed, and the practice which I 
 adopted, thirty years ago. Both indeed have been modified, just as 
 the treatment of bronchitis ^and pneumonia has been modified, by the 
 changes in the epidemic constitution of disease which recent years have 
 brought with them, and which have been especially marked since the 
 second epidemic prevalence of cholera in this country in 1848 and 
 
 1 Bulletin General de Therapeutique, Oct. 1843, p. 246. 
 
CROUP AND DIPHTHERIA. 335 
 
 1849. Bat with every allowance made for these changes, I still be- 
 lieve that a decided antiphlogistic treatment (by which 1 mean the 
 employment of antimony in emetic doses, the subsequent administra- 
 tion of calomel, and if the case be seen at the very outset, the recourse 
 to actual depletion) is indicated in almost all cases of acute idiopathic 
 croup. 
 
 I have full notes of 114 cases of croup or diphtheria, though very 
 many more have come under my observation in consultation, when I have 
 seen them one, two, or three times. The earliest date borne by these 
 notes is July, 1840, and for the first ten subsequent years all cases, 
 with the exception of those secondary to measles, were treated by me 
 with uniform activity, in accordance with the principles laid down by 
 Dr. Cheyne, and to which reference has already been made. 1 
 
 About this time, however, I find from my notes evidence of a grad- 
 ual falling off in the activity of my treatment, and this in spite of my 
 field of observation having shifted to a district in which disease gener- 
 ally, and croup among the rest, presented a more sthenic character than 
 it wore in the low-lying district to the south of the Thames. I notice 
 less frequent employment of depletion, and at the same time recourse 
 to cauterization of the throat, a proceeding to which I was led in a 
 measure by Dr. Horace Green's remarks on cauterization of the larynx 
 in croup, and which therefore had by no means constant reference to 
 the presence of false membrane about the fauces. 
 
 For some years past I have given up . the charge of out-patients at 
 the Children's Hospital, and almost all the cases of croup which I see 
 in private I see in consultation, and consequently when some symptom 
 of special gravity has already arisen. It may perhaps be due in part 
 to these circumstances that I have met with no occasion for deple- 
 tion during the past ten years. I have, however, met with not a few 
 instances of idiopathic laryngeal croup, which, in the hands of younger 
 practitioners who thought of nothing but diphtheria, were being plied 
 with stimulants and perchloride of iron, and were saved by antimony, 
 by emetics, and the use of mercurials. 
 
 In Germany, in spite of the prevalence of diphtheria there as well 
 as here, the old form of inflammatory croup still prevails ; and some 
 of the older practitioners 2 have raised their voice against the tendency 
 to ignore its existence, to assume that diphtheria is the one only form 
 of croup, that the observers of five-and-twenty or fifty years ago com- 
 mitted a mistake in supposing that antiphlogistic treatment was ever 
 called for, or that stimulants could possibly be out of place. 
 
 My object is to warn against the same errors, to insist on the differ- 
 ence in character between cynanche trachealis and diphtheria, and, as a 
 consequence, on the necessary difference between their treatment. 
 
 There is, however, one point which it is important to remember in 
 
 1 The peculiarities of this form of secondary croup, and its relation to the then 
 so-called diphtheritis, were noticed by me, and illustrated by cases, in the Medical 
 Gazette, Aug 25, 1843. 
 
 2 Among them is especially deserving of notice a short paper by Dr. Clemens, 
 of Frankfort, in J. f. Kinderkrankh., vol. xxxvi, June, 1861, p. 359. 
 
836 TREATMENT OF CROUP. 
 
 the management of the severe cases of croup, lest you fall into the error 
 of overtreating your patient; an error not less hazardous than the 
 opposite one of too great inertness. The disease, as you know, has a 
 marked tendency to exacerbations and remissions, even independently 
 of any physical change in the condition of the respiratory organs. You 
 must not, therefore, allow the return of more difficult breathing, after a 
 period of comparative tranquillity, to lead you at once to the inference 
 that the child is worse, and that necessity exists for renewed and increased 
 activity of treatment. It is very possible that the increased dyspnoea 
 may be merely spasmodic ; that immersing the child in a hot bath will 
 give immediate and most signal relief; and that if you ausculate the 
 chest afterwards you will lind the air entering the lungs in as large a 
 quantity as before, and unattended by an increase of morbid sounds. 
 
 The administration of calomel is not necessary in every case of croup, 
 for when seen early, and treated with due activity, its symptoms are 
 sometimes completely removed in the course of a few hours. Bat though 
 we may sometimes be warranted in suspending all active treatment for 
 a season, yet we must watch our patient with most untiring care for some 
 days after the decline of the acute croupal symptoms, and at each visit 
 our attention must be directed to the condition of the lungs, in order 
 that we may at once put a stop at its very commencement to that inflam- 
 mation of the smaller bronchi and of the pulmonary substance which 
 so often disappoints the fairest prospects of recovery. Its treatment 
 does not differ from that of ordinary bronchitis or pneumonia, except 
 that depletion is not generally indicated, and that it not infrequently 
 becomes necessary to support the patient's strength even from a very 
 early period. 
 
 Your own good sense will suggest to you the care and watching which 
 are required during convalescence from croup; the necessity of with- 
 drawing your remedies cautiously, and of awaiting the complete dis- 
 appearance of all hoarseness, and the cessation of all cough, before you 
 allow the child to breathe the external air. In cases where the peculiar 
 croupal sound continues with slight cough, long after every other sign 
 of mischief about the larynx has subsided, you will often find it of 
 service to paint the neighborhood of the larynx every day with the 
 tincture of iodine ; a mild, but in the circumstances a very efficacious 
 form of counter-irritation. 
 
 It still remains for us to inquire into the treatment of cases in which 
 we have not the good fortune to encounter the disease at its outset, but 
 in which we have to combat it when it has already reached the second 
 stage. 
 
 This subject, however, must be reserved for our next lecture. 
 
TREATMENT OF SECOND STAGE OF CROUP. 337 
 
 LECTURE XXIV. 
 
 CROur continued. — Treatment of the more advanced stages of the disease — Trache- 
 otomy — The difference between the results obtained by it in England and in 
 France, and its probahle cause — Objections to its performance — Reasons for not 
 regarding them as conclusive — Inquiry into the object of the operation — Indi- 
 cations for its performance — Its dangers — And how they are to be obviated. 
 
 In the last lecture we were occupied with the consideration of the 
 management of those cases of croup in which the patient is seen early, 
 and in which his condition warrants the employment of powerful anti- 
 phlogistic measures. He may, however, be seen too late for such means 
 to be allowable or they may have been tried in vain. If antimony 
 ceases to vomit, or if it is rejected immediately and without effort, the 
 fluid thrown up being unmixed with phlegm or false membrane, while 
 the temperature sinks, the lips grow more livid, the pulse becomes more 
 frequent and feeble, and the paroxysms of dyspnoea are undiminished 
 in severity ; or if the respiration, though less laborious, is attended with 
 a sibilant instead of a stridulous sound, it is evident that by continuing 
 the medicine we may destroy the patient, but shall fail to cure the dis- 
 ease. A totally different plan of treatment must at once be adopted, 
 though with but slender hope of success. 
 
 An attempt should be made to arouse the child from the state of col- 
 lapse into which it is sinking, by placing it for a few minutes in a hot 
 mustard bath, and emetics of the sulphate of copper should at once be 
 administered. The sulphate of copper has been considered by some 
 writers to be possessed of a specific' influence over croup. I cannot, 
 however, take this view of its action. It has seemed to me to be 
 nothing more than an emetic of great power, and therefore especially 
 applicable in cases where considerable depression exists, where the 
 stomach has consequently lost much of its irritability, and where tartar 
 emetic would probably not act at all, or if it did, would be injurious 
 from its depressing action. Alum has been recommended in similar 
 circumstances, and I dare say^would answer equally well, though per- 
 haps there is some advantage in the smaller bulk of the sulphate of 
 copper. 1 I am accustomed to give it dissolved in water in quarter or 
 half-grain doses every quarter of an hour till free vomiting has been 
 produced, but have never trusted to it alone, in the same way as in an 
 earlier stage of the disease I am used to rely on tartar emetic. I em- 
 ploy it with a twofold purpose : first, to obtain the stimulant action of 
 an emetic ; second, to prevent, if possible, the accumulation of false 
 
 1 Alum has been used and strenuously recommended in these circumstances by 
 Dr. Meigs, of Philadelphia; and the experience of his son, Dr. J. Meigs, as recorded 
 in his work on Diseases of Children, seems fully to bear out his father's recom- 
 mendation. He gives a teaspoonful in honey or syrup, every 10 or 15 minutes, tilL 
 free vomiting is produced. See Meigs and Pepper, op. cit., 4th ed., 1870, p. 99.. 
 
 22 
 
338 COUNTER-IRRITATION IN CROUP. 
 
 membrane in the larynx. Hence, if the child seems again sinking into 
 a state of collapse, or if coma appears coming on, or if the dyspnoea 
 becomes much aggravated, the sulphate of copper may again be em- 
 ployed to induce vomiting. If, however, in these cases, or in others in 
 which, though some degree of improvement has followed the previous 
 treatment, yet the child has been much reduced by it, emetics should 
 not act, I would not advise you to attempt to compel vomiting by irri- 
 tating the fauces, or by other similar proceedings. On one occasion 
 I saw these endeavors succeeded, not by the vomiting, which they were 
 intended to excite, but by general convulsions, followed by a comatose 
 condition, in which death took place an hour and a half afterwards. 
 Examination of the body discovered some congestion of the brain, but 
 showed at the same time that the affection of the air-passages had not 
 reached such a degree as to have precluded the possibility of recovery, 
 and that the patient's death had been caused not by the disease, but 
 rather by the ill-judged employment of the remedy. 
 
 In this stage of croup the decoction of senega is a medicine of great 
 value, and may be given in combination with the carbonate of ammonia 
 and tincture of squills, every two hours. 1 The pungency of the am- 
 monia is best concealed by sweetening the medicine with treacle or with 
 coarse sugar, and mixing it with about a third of milk ; and in this 
 form children will seldom refuse it. No other remedy or combination 
 of remedies has appeared to me to be so useful as a stimulant expecto- 
 rant in the advanced stages of croup or bronchitis. The patient's 
 strength must be supported by beef tea and a generally nutritious diet ; 
 and even wine may be indicated ; though small, indeed, are the hopes 
 that remain when the vital powers have sunk so low as to require its 
 employment. While by these means you try to keep your patient 
 alive, there is still one remedy that you may use, and use actively, 
 though I fear it must be admitted with no great prospect of success. 
 You employ mercury, or you increase the dose in which you have 
 previously prescribed it. A grain of calomel may be given every hour 
 to a child from two to three years old, unless the existence of profuse 
 diarrhoea should contraindicate its use ; while, at the same time, a 
 drachm of strong mercurial ointment may be rubbed into the thighs 
 every two hours. If diarrhoea is present, the calomel must be given 
 more sparingly, or must even be altogether omitted. 
 
 Much difference of opinion prevails among writers of high repute as to 
 the proper time for employing counter-irritation in cases of croup, and 
 still more as to the part to which this counter-irritation should be applied. 
 I believe that when the disease has been checked by antiphlogistic 
 measures, and the symptoms have lost something of their severity, much 
 good is done by the application of blisters to the upper part of the ster- 
 num. But, on the other hand, if croup has reached an advanced stage, 
 unchecked by previous remedies, blisters to the sternum have seemed 
 to me nearly, if not altogether, useless ; while, from the application of 
 a large blister to the throat, covering the larynx and reaching down 
 nearly to the sternum, I have often observed the paroxysms of dyspnoea 
 
 1 See Formula No. 12, p. 279. 
 
BRONCHOTOMY IN CROUP. 839 
 
 to be much alleviated, the respiration to be rendered far more easy, and 
 expectoration for the first time to accompany the cough. In any case, 
 if very manifest relief were not observed within six hours after the 
 abstraction of blood and the administration of antimony, while further 
 depletion did not appear justifiable, I should apply a blister to the 
 throat. 1 
 
 It was to be expected that the probable utility of bronchotomy in 
 cases of croup should suggest itself to the earliest observers of the dis- 
 ease. For many years, however, after it was first advocated on theo- 
 retical grounds by Dr. Honie, the value of the operation was not put 
 to the test ; and even for a long time after it had been tried, but one 
 instance was recorded of any other than an unsuccessful result. 2 In 
 the year 1825, M. Bretonneau, of Tours, saved the life of a little girl 
 when in the last stage of croup by performing tracheotomy. Eight 
 years afterwards a second operation was performed and a second success 
 obtained by M. Trousseau, and in the subsequent five-and-twenty years 
 the operation was had recourse to in France nearly 500 times, and 
 about a fourth of the patients on whom it was performed recovered. 8 
 This proportion, too, may be taken as representing very nearly the 
 present rate of recoveries after the operation of tracheotomy in early 
 life, when had recourse to either for croup or diphtheria. 
 
 The results of the operation in this country are, however, far less 
 favorable than those which have been obtained in France, and many 
 attempts, though none to the best of my judgment altogether satisfac- 
 tory, have been made to account for this difference. I once thought 
 that the difference between the characters of the disease in the two coun- 
 tries might account for the different results of tracheotomy ; that the 
 diphtheritic form of croup which prevailed in France might be more 
 amenable to mechanical relief than the sthenic variety, associated with 
 bronchitis or pneumonia almost from the outset, which was more fre- 
 quent in this country. Recently, however, the character of the disease 
 in the two countries has become more closely assimilated, without in- 
 fluencing the great, preponderance of successes on the other side of the 
 Channel. Sir W. Jenner 4 suggests that the greater frequency of rickets 
 
 1 This opinion being opposed to that of men such as Sir W. Stokes and Mr. Por- 
 ter, I feel it necessary to appeal in support of it to the authority of Golis, lib. cit., p. 
 118; and Albers, De Tracheitide Infantum, p. 127 ; and not to rest it solely on the 
 results of my own experience. 
 
 2 In this case the operation was performed in the year 1782 by M. Andre, of 
 London, on a little girl, five years old. The particulars are related in a dissertation 
 published at Lcyden in 1786, by Mr. T. White, whence they are extracted by Dr. 
 Farre, and appended as a note to a paper of his on Croup, at p. 338 of vol. iii of the 
 Medico-Chirurgical Transactions. 
 
 3 The most recent statements with which I am acquainted of the results of 
 tracheotomy in France, are those of MM. H. Roger and See, which yield 126 
 recoveries to 446 operations, or 27 per cent, during the last seven years. Gaz. 
 Hebdom , Nov. 12, 1858, p. 789. The somewhat more recent estimate given by M. 
 Roger, in his paper on Diphtheria already referred to, does but confirm on the whole 
 the accuracy of his previous conclusions. M. Trousseau, in his Clinique de l'Hotel 
 Dieu, 2d ed., vol. i, p. 438, which was published in 1865, states that down to that 
 time he had performed tracheotomy more than 200 times, and more than a fourth 
 of the cases had had a successful result. 
 
 4 Op. cit., p. 80. 
 
340 ARGUMENTS AGAINST AND IN FAVOR 
 
 in this country, and the consequent greater flexibility of the chest-walls, 
 as the result of which mechanical power is wanting to draw air beyond 
 the fluid which from any cause finds its way into the bronchial tubes, 
 has much to do with the different results obtained in the two countries. 
 Something, too, is unquestionably due to the earlier stage of the disease 
 in which the operation is resorted to on the Continent 1 than in England, 
 so that while in this country a successful tracheotomy represents a child 
 snatched from inevitable death, in not a few of the instances of its 
 performance in France other means might have been tried, and would 
 probably have controlled the disease. Still, if these facts detract some- 
 thing from the apparent value of the operation, they at least show that 
 in itself it is not attended by serious dangers ; and statistics prove that, 
 in as far at least as the diphtheritic form of croup is concerned, 2 there 
 is no sort of connection between an increase of frequency in the per- 
 formance of tracheotomy and a higher mortality from the disease. 
 Further, it must be conceded that the somewhat premature performance 
 of tracheotomy is not without some compensating advantage, by the 
 relief it affords to that spasmodic action of. the muscles of the glottis 
 which endangers the patient's life, independently of the extent of false 
 membrane in the glottis. My own personal experience of the results 
 of tracheotomy is exceptionally unfavorable, inasmuch as .1 have to 
 record but seven recoveries out of thirty operations. In most of these 
 cases the disease had already reached an advanced stage w T hen the 
 patients came under my care, and the operation was resorted to as a 
 doubtful remedy, holding out a chance of recovery when otherwise 
 none appeared. 3 I suspect indeed that it will be found that the date 
 of performance of the operation has more than anything else to do with 
 its result. In New York tracheotomy appears to have been performed 
 in general at an early stage of croup, and 213 4 cases yielded 50 recov- 
 eries, a proportion as high as that obtained in Paris. My own expe- 
 rience too points in the same direction ; the first 16 of my cases yielded 
 but 1 recovery, the second 14 gave 6. 
 
 In spite, however, of the unfavorable issue of many of my cases, I 
 am so far from being opposed to tracheotomy, that the euthanasia 
 which it secures, even when all hope of cure is gone, seems to me 
 cheaply purchased by its performance. As a remedial measure, my 
 chief anxiety is to make out the indications that may justify me in 
 having more timely recourse to it in future. The discrepancies of 
 
 1 In illustration of this fact two cases may be noticed, recorded in the Journal de 
 la Societe Medicale d'Indre et Loire, extracted and commented on in the Bull. Gen. 
 de Therapeutique, Octobre, 1842. 
 
 2 Koger and See, loc. cit. 
 
 3 The thesis of M. Millard, De la Tracheotomie dans le cas de Croup, 4to., Paris, 
 1858, illustrates extremely well the almost invariable fatality of tracheotom} 7 when 
 performed on young children. Of 124 cases in which the operation was performed at 
 the Hopital des Enfans between January, 1857 and July, 1858, 29, or 24 per cent., 
 had a favorable issue. But of twenty children under two years old who were oper- 
 ated on none survived ; and of 36 between two and three only 5: the remaining 24 
 recoveries having been obtained in children between the ages of three and nine. 
 
 4 As stated by Dr. Jacobi, of New York, in 1868, in a paper referred to by Meigs 
 and Pepper, op., cit.,. 4th ed,, 1870, p. 106. 
 
OF TRACHEOTOMY. 341 
 
 opinion which have prevailed with reference to it are, I think, partly 
 due to an overestimate, on the part both of its advocates and oppo- 
 nents, of the ends which it is proposed to attain by it. In itself, tra- 
 cheotomy in croup is not a curative proceeding, nor can its perform- 
 ance warrant the discontinuance of those measures previously resorted 
 to, whose object was to overcome the disease of the larynx and trachea. 
 It professes to remove in some cases the danger of immediate death 
 from suffocation, and thus to give time for nature and art to do their 
 best in overcoming the inflammation of the air-passages, or in obviat- 
 ing its results. That it should prove inefficacious to accomplish this 
 in cases where false membrane has extended to the extreme bronchi, is 
 no argument against its performance in the present state of our knowl- 
 edge, though it furnishes a cogent reason for the endeavor to perfect 
 our diagnosis, so that our failures may be lessened by our less often 
 attempting the impossible, or at least by our performing the operation 
 with the avowed object of mitigating suffering, not of prolonging life. 
 
 The questions that call for determination in any endeavors to esti- 
 mate the value of tracheotomy are, first, whether the danger arises 
 from causes which in certain instances tracheotomy, and that alone, 
 can remove; and secondly, whether the dangers attendant or consequent 
 on the operation are themselves of such a kind as to outweigh its ad- 
 vantages. If these inquiries should be answered in favor of the opera- 
 tion, we may then endeavor to determine by what means its danger 
 can be most effectually lessened, and those cases be best discriminated 
 in which the benefits of the proceeding are likely to be most signal. 
 
 It has been objected by no less an authority than Dr. Cheyne, that 
 inasmuch as three-eighths of the aperture of the larynx have been 
 found free in fatal cases of croup, there must have existed during life 
 room enough for the entrance of air ; or that, in other words, the suffo- 
 cative symptoms of croup do not depend on a cause which tracheotomy 
 can remove. The operation, however, is not performed merely oil the 
 mechanical principle of removing from the windpipe a quantity of mat- 
 ter which prevents the entrance of air into the lung ; but it is done 
 rather to obviate the dangers of that spasm of the glottis which the 
 inflammation or the deposit of false membrane occasions, and which 
 will not cease until either the inflammation is subdued, or the spasm 
 relaxes with the approach of death. Even the narrow opening made 
 into the trachea — often much narrower than the aperture of the 
 larynx, though diminished by swelling or encroached on by false 
 membrane — suffices, for a time at least, to admit all the air which the 
 patient needs, and the dyspnoea is relieved. The larynx is now at 
 rest, while the air entering continuously, and without effort, duly oxy- 
 genates the blood ; and the child is thus placed in a condition in which 
 all remedial agents would seem much more likely to tell upon it, than 
 when it was in a state of impending suffocation. 
 
 Tracheotomy, then, in cases of croup, answers a twofold end, and 
 one not by other means attainable. 1 It removes in some instances, a 
 
 1 I purposely pass with this slight notice the proposition of M. Bouehut (origi- 
 nally suggested, indeed, by the famous Dessault) for the so-calied " tubage de la 
 
342 TRACHEOTOMY: 
 
 positive mechanical obstacle to the entrance of air into the lungs, 
 while in all it puts a stop to that spasm of the glottis which interferes 
 with respiration as much as the actual deposit of false membrane, 
 though not so constantly nor with equal peril. 
 
 Now, it may be asked, what evils are there attendant on the opera- 
 tion that counterpoise these indisputable benefits? To this inquiry 
 it does not seem to me that the opponents of tracheotomy give any 
 sufficient answer. It is admitted on all hands that in itself the opera- 
 tion is not attended by serious hazard ; while the uncertainty as to its 
 issue depends, not on any defect in the proceeding, but on an imper- 
 fect knowledge of what cases are within the power of art to succor, and 
 what are beyond the help, not of tracheotomy only, but of all other 
 measures likewise. The shock of the operation is seldom serious ex- 
 cept in cases where it has been delayed to the very last moment ; seri- 
 ous hemorrhage is a very rare accident, and is generally due to the 
 unskilfulness of the operator, while the dysphagia which occasionally 
 follows is a troublesome rather than a dangerous occurrence ; one, too, 
 which is not encountered until the canula has been worn some days, 
 and which is a result of the disease rather than of the operation ; or, 
 in other words, is due to the paralysis of the soft palate which follows 
 diphtheria, and has no relation whatever to the laryngeal affection for 
 which tracheotomy was resorted to, any more than to the tracheotomy 
 itself. The gravest charge against it is that it is apt to induce serious 
 bronchitis, or, at any rate, to aggravate any previously existing in- 
 flammation of the lungs or air-tubes. I am not altogether certain that 
 there is not some ground for this accusation, but on the other hand it 
 must be borne in mind that these very diseases are the ordinary, almost 
 invariable, complications of croup, however treated ; and further, that 
 they are not ordinary sequelae of tracheotomy when resorted to in 
 other circumstances, as in cases of acute laryngitis, or of oedema of the 
 glottis. 
 
 But if we come to the conclusion that in cases of croup which have 
 not yielded to ordinary medical treatment, and in which there seems 
 reason to anticipate a speedy death unless the inability to fill the lungs 
 with air can be soon relieved, the operation of tracheotomy does not 
 superadd some peculiar danger of its own more certain and more des- 
 
 glotte" or introduction of a tube within the canal of the larynx, in order to keep a 
 passage permanently free lor the entrance of air, and thus to do away with the ne- 
 cessity for the performance of tracheotomy in croup. M. Trousseau's Report on 
 the subject to the Academy of Medicine at Paris, most temperately, but at the 
 same time most conclusively, exposes the fallacies of M. Bouchut, and shows the 
 small practical value of the suggestion, as well as its almost complete inapplica- 
 bility to the treatment of croup. Of seven cases in which this proceeding was 
 resorted to five terminated fatally, and in the only two patients who recovered 
 tracheotomy was performed. The proceeding is very difficult to accomplish, while 
 in some instances the presence of the tube within the glottis could not be tolerated 
 by the patients, and its removal was necessary ; and though M Trousseau admits 
 its possible utility in cases of cedema of the glottis, and of simple laryngitis, I should 
 doubt whether even in these instances the presence of a foreign body within the 
 opening of the larynx would not be likely to produce a most mischievous irritation 
 of the diseased organ, and such as would far exceed that which would be excited by 
 a tube in the trachea. 
 
CAUTIONS AS TO ITS PERFORMANCE. 343 
 
 perate than those by which the patient is already surround ed, it then 
 becomes our duty to resort to it; and this not at the last moment, but 
 so soon as ever we feel that our remedies are too tardy to overtake the 
 disease. In such circumstances, to gain time is to gain everything, 
 and it is just this which tracheotomy places within our reach. It is 
 not possible to fix absolutely what rate of mortality may be fairly 
 expected to follow an operation performed in circumstances such as 
 those which call for tracheotomy; for that, unlike most surgical pro- 
 ceedings, does not remove the disease for which it is had recourse to, 
 it does but give the constitution another chance of battling with it ; . 
 and many of the deaths after tracheotomy are, strictly speaking, far 
 from being instances of failure of the operation. The operation may 
 have done all that it could do, but false membrane may have extended 
 far beyond the opening in the trachea, or the bronchitis may have 
 reached the capillary air-tubes, or the pneumonia may have involved 
 the pulmonary substance too extensively for recovery to be possible. 
 We may hence deduce a limitation to the performance of tracheotomy 
 which I cannot state better than in the words of its great advocate, 
 M. Trousseau, 1 who " forbids the performance of the operation in any 
 cases where the danger to the child appears to depend on disease of 
 the general system rather than on the affection of the larynx or 
 trachea." But in cases where no such contraindication exists, it is 
 yet evident that the issue of the operation must be in a great measure 
 controlled by the age of the patient, by the fact of the disease being 
 idiopathic or secondary, by the extent of the disease of the respiratory 
 organs .generally, and that this influence must be of a kind which no 
 surgical dexterity or medical skill can do much to control or to modify. 
 
 Some circumstances may, however, be borne in mind as influencing 
 the result of tracheotomy, while- at the same time they are not beyond 
 the control of the medical attendant. 
 
 The first of these concerns the size of the tracheal tube, a point the 
 importance of which was first insisted on by M. Trousseau. He ex- 
 plains the occasional speedy and apparently causeless disappearance of 
 the amendment that at first succeeds the operation of tracheotomy, by 
 the inadequate size of the canula which is frequently employed and 
 which does not provide for the permanent admission of a sufficient 
 quantity of air. The air admitted through even a small canula is 
 enough to afford temporary relief, but not enough for the continued 
 discharge of the functions of the organism ; and the return Of hurried 
 breathing, and the reappearance of the livid hue of the surface, be- 
 token the imperfect depuration of the blood. " Take/' says he in 
 illustration of this fact, u a quill, and, closing your nostrils, endeavor 
 to breathe entirely through it : at first you breathe easily enough, but 
 soon your respiration becomes laborious ; and at length you are fain to 
 throw aw r ay the quill, and with open mouth once more to fill your 
 lungs completely. Now precisely this. is what happens when an open- 
 ing of inadequate size is made into the trachea ; air enters readily, and 
 without the interruption which the spasm of the glottis occasioned ; 
 
 1 Archives Gen. de Medecine, Mars, 1855, "p. 257. 
 
344 tracheotomy: 
 
 but it does not enter in sufficient quantity, and hence the return of the 
 symptoms and the patient's death." Acting on this principle, M. 
 Trousseau used to make a larger opening into the trachea, and to in- 
 troduce a larger canula than had previously been customary ; and this 
 practice I believe to be now gaining ground among persons who have 
 omitted to acknowledge their obligation to M. Trousseau for the sug- 
 gestion. One word, moreover, must be added against the needless ex- 
 aggeration of M. Trousseau's wise caution. Tt is, as Mr. Marsh has 
 pointed out in his admirable paper on Tracheotomy in Children, 1 the 
 size of the aperture of the glottis, not that of the trachea, which regu- 
 lates the quantity of air inspired. 
 
 The second of these precautions has reference to the necessity of sur- 
 rounding the child after the operation with a warm, moist atmosphere, 
 such as alone it ought to be allowed to respire ; though, unfortunately, 
 this is very much neglected, not in hospitals only, but also in private 
 practice. The importance of attention to this point, and also to keep- 
 ing the canula free, cannot be overstated ; and yet these little things 
 are overlooked or intrusted to unskilful hands, because they seem too 
 trivial for such large issues to be dependent on them. 
 
 The third caution which I would urge is, that medical treatment 
 must not be suspended, nor necessarily modified, after tracheotomy has 
 been performed. The operation, indeed, seems so heroic a measure, 
 and when it yields relief, the relief is so speedy and so striking as to 
 occasion some risk of its being forgotten that the disease has not been 
 removed by it, that its danger has only been postponed, and that the 
 indications for treatment continue the same after tracheotomy as they 
 were before. 
 
 A word or two with reference to the after-management of cases of 
 tracheotomy will comprise all that I have to say on this subject. My 
 own patients have rarely lived long enough after the operation for me 
 to become practically familiar with many of the difficulties which arise 
 some few days after its performance. These, however, apart from such 
 as are the consequences of the supervention or increase of the disease 
 of the respiratory organs, are twofold, and arise from the condition of 
 the wound, and from the occasional supervention of difficulty of swal- 
 lowing. 
 
 One of the reasons for seeking to remove the canula as early as pos- 
 sible is supplied by the irritation of the edges of the wound which its 
 long-continued presence is apt to produce. I saw the death of a child 
 take place from this cause on the 11th day after the otherwise success- 
 ful performance of tracheotomy by my colleague, Mr. Athol Johnson ; 
 and it was ascertained after death that, in addition to the destruction of 
 several rings of the trachea, an abscess had formed in the anterior 
 mediastinum which communicated with the external wound by sinuses 
 that burrowed between the trachea and oesophagus. In fat children 
 the unhealthy state of the edges of the wound is partly produced by 
 the canula remaining deeply sunk in the flesh ; an evil which would 
 perhaps be lessened by the use of a long canula with a very broad 
 
 1 St. Bartholomew's Hospital Reports, vol. iii, 1867, p. 331. 
 
CAUTIONS AS TO PERFORMANCE. 345 
 
 shield ; or else by the employment of one " a lorgnette" as it has been 
 termed by its inventor, M. Paul Guersant; that is to say, capable of 
 being lengthened by pulling it out, like a telescope or an opera-glass. 
 Besides this, the covering the wound with lint thickly spread with 
 spermaceti ointment, and placing over that a piece of oiled silk so as 
 to defend it as far as may be from irritation, and from the external air, 
 as well as the touching its edges daily with the nitrate of silver, are 
 the most important means of maintaining its healthy condition. 
 
 Another of the dangers of the operation depends on the abrasion of 
 the mucous membrane of the trachea by the end of the canula, and its 
 consequent ulceration. This danger, however, is almost, although per- 
 haps not quite invariably, prevented by M. Liter's modification of the 
 canula, which was introduced to general notice by M. Roger. This 
 modification consists in the canula being movable on the shield, so that 
 its position shifts with the varying attitudes of the child. 
 
 The difficulty of deglutition is an inconvenience which usually comes 
 on about the fifth or sixth day after the operation ; that is to say, at the 
 time when the larynx, though now free from the false membrane which 
 before occluded it, has not completely recovered from the effects of the 
 disease, but a state of partial paralysis of its muscles remains, which 
 allows food, and especially liquids, to enter the air-tubes. This accident, 
 which is by no means invariable in its occurrence, has probably little 
 or no relation to the operation. It is a result of that paralysis of the 
 soft palate and muscles of the pharynx which sometimes succeeds to 
 diphtheria, and which, from being a troublesome accident, is converted 
 by the previous tracheotomy into a dangerous complication. If the 
 patient is sufficiently intelligent to admit of M. Archambault's sugges- 
 tion 1 being adopted, and will place the finger on the opening of the 
 tube, and endeavor to breathe quietly though the larynx when swallow- 
 ing, it is very likely that the want of harmony between respiration and 
 deglutition will be overcome in many instances, though, according to 
 M. Trousseau's experience, by no means in all. In the majority of 
 cases, however, we are compelled, by the tender age of our patients, to 
 confine ourselves to feeding them as far as possible on solid, or at least 
 on pultaceous food; rejecting all drink as far as possible, and giving it, 
 when absolutely necessary, in small quantities, and either immediately 
 before or a considerable time after food. 2 In some instances, M. Guer- 
 sant 3 has found the use of the stomach-pump, or of a tube introduced 
 through the nares, necessary to convey food safely into the stomach ; 
 though happily such are exceptional cases ; while generally the larynx 
 recovers itself in three or four days, and deglutition is then no longer 
 attended with difficulty or danger. 
 
 It happens, now and then that, after apparent recovery from croup 
 or diphtheria, difficulty is experienced in the withdrawal of the canula, 
 and that we are compelled to allow it to remain for an almost indefinite 
 time. The cause of this difficulty is not always very obvious. At first 
 
 1 L'Union Medicale, Juillet, 1854. 
 
 2 Archives Gen. de Medecine, Mars, 1855. 
 
 3 Notices sur la Chirurgie des Enfants, 8vo. Paris, 1864, pp. 34-48. 
 
346 AFTER-MANAGEMENT OF TRACHEOTOMY. 
 
 it seems to be owing to some impaired action of the laryngeal muscles; 
 which having been thrown out of gear as it were by the operation, and 
 in diphtheria partly also by the subsequent paralysis, are long in re- 
 gaining their power of harmonious action. It is in inspiration that 
 this condition is most marked ; and while air passes out readily by the 
 mouth ; and inspiration too goes on fairly well for a short time, the 
 ability to inspire continuously through the larynx is wanting. In some 
 cases the child may even be able to breathe tolerably by the month 
 during the daytime, and when quite quiet, but can no longer do so if 
 hurried or excited; and no sooner falls asleep than it is seized with 
 urgent dyspnoea; which subsides only on the rei introduction of the tube. 
 
 It is therefore a wise precaution, before attempting the final removal 
 of the tube, to try how far the child is able to breathe with the orifice 
 of the canula closed by a plug, and then to withdraw it at first in the 
 daytime only ; a competent person being at hand to replace the tube 
 immediately if the respiration begins to be more hurried, and not to 
 await the occurrence of severe dyspnoea, 
 
 But besides these cases, where the difficulty is but temporary, and is 
 overcome by a little time and patience, there are some instances in 
 which a distinct mechanical obstacle exists to the entrance of air. M. 
 Guersant speaks of having met with perfect occlusion of the larynx 
 after tracheotomy by the adhesion of false membrane to the vocal cords, 
 and recommends that the larynx should be swept out by a little piece 
 of lint introduced through the canula, and carried from below upwards 
 so as to detach any adherent deposits. 
 
 He confesses, however, that the proceeding has not always been suc- 
 cessful, and instances are on record in which the larynx has remained 
 permanently obstructed, so that it was altogether impossible to remove 
 the canula. In a patient of my own, operated on for diphtheritic 
 croup, it was not until after the lapse of fourteen months, and after a 
 variety of means had been resorted to by my colleague, Mr. Thomas 
 Smith, to widen the canal, and to keep it pervious, that she was able 
 entirely to lay aside the canula. Now, seven years after, she continues 
 perfectly well, though her voice is gruff and low. 
 
 To Mr. T. Smith's most interesting paper 1 I must refer for a further 
 detail of this case; and of all the difficulties he encountered, and how 
 he overcame them ; as well as for the particulars of other similar cases 
 which may be found scattered through our medical literature. 
 
 1 Medico-Chirurgical Transactions, vol. xlviii, 1865, p. 227. 
 
347 
 
 LECTUEE XXV. 
 
 Diphtheria, or Angina Maligna. — Not a new disease — Its anatomical charac- 
 ters — Mode of extension of the disease — Its relation to true croup — Charac- 
 teristic peculiarities of each disease. 
 
 Symptoms of diphtheria. — In its milder form, insidious supervention of croupal 
 symptoms — In its severer forms, frequently associated with albuminuria — Pe- 
 culiar depression which attends it — Evidence of its affinity to the class of 
 blood diseases — Paralytic symptoms which, follow it — Relation between it and 
 scarlatina examined — Evidence on both sides of the question stated — That in 
 favor of their non-identity considered to preponderate. 
 
 Treatment. — Local applications — Constitutional measures — Necessity for tonics 
 and stimulants. 
 
 Modified form of the disease. — Usually a complication of measles — Its symptoms 
 and treatment. 
 
 Laryngitis Stridula, or croup with predominance of spasmodic symptoms. — 
 Not a distinct disease, but results from constitutional peculiarity — Illustrative 
 case. 
 
 Instances of spasmodic cough and affection of larynx, from irritation in lungs. — 
 Intestines — Brain — Note on thymic asthma. 
 
 Reference was made in the last lecture to a second form of disease, 
 resembling croup in some respects though differing in others, alike but 
 not the same, and calling therefore for a separate notice. This other 
 disease, Angina Maligna, Diphtheritis, or more correctly Diphtheria, 
 is no new malady, 1 but one which, though always prevalent, forces 
 itself occasionally upon general notice by the formidable symptoms 
 that sometimes attend it, by the rapidity with which it then runs 
 its course, and by its selection of several victims from one town, 
 one village, or one family. At such seasons it wears a character which 
 seems so different from that which it assumes in its milder forms as to 
 render it almost impossible to believe that the slight sore throat which 
 caused only a trivial inconvenience, and hardly required any medical 
 treatment, is one with the malignant disease, whose local symptoms 
 are often cast into the shade by the grave constitutional disorder that 
 attends them. 
 
 In each case, however, its essential anatomical characteristic is the 
 same, and consists of redness, and swelling involving the tonsils and 
 soft palate, and accompanied within a few hours by the exudation on 
 their surface of a dense white false membrane, appearing in little points 
 or spots, which speedily coalesce, and form a uniform investment to the 
 
 1 Starr's unpretending account of the disease at Liskeard, a century ago, details 
 all the most characteristic features of diphtheria . the false membrane on the fauces, 
 its extension to the air-passages, its appearance on blistered surfaces and upon the 
 skin behind the ears, leave scarcel}'- a symptom wanting to prove the identity of the 
 two affections. Those who wish to pursue the question will find all necessary infor- 
 mation in Euchs's Historische Untersuchungen iiber Angina Maligna, 8vo., Wiirz- 
 buroj, 1828. 
 
348 CHARACTERISTIC SYMPTOMS OF 
 
 part where swelling and redness were first apparent. The white color 
 of the original deposit is speedily lost as fresh exudation is produced ; 
 and the membrane becomes gray or blackish as the air acts upon it, or 
 as blood from the congested mucous surface beneath stains it. Speedily 
 too it splits up into shreds, which, hanging down at the back of the 
 fauces, produce that appearance of a sloughing tissue which imposed 
 upon the early observers, and obtained for the disease the name of 
 Angina Gangrenosa. 
 
 If detached from its connections, a number of minute bloody points 
 on the subjacent tissue attest the firmness with Avhich the false mem- 
 brane adhered to it ; but beyond increase of their vascularity the parts 
 do not in general displa}*. any marked alteration. I doubt, however, 
 whether that rigid classification which would refer to a separate category 
 all those instances in which there exists distinct erosion or ulceration 
 of the mucous membrane beneath the exudation is either practically 
 useful or pathologically tenable ; for while the surface of the tonsils is 
 not invariably free from ulceration, I believe that in a very large pro- 
 portion of the instances in which the exudation extends into the air- 
 passages the mucous lining of the larynx is distinctly eroded, and small 
 specks of ulceration are discernible about the edges of the glottis. 
 
 Coupled with the condition of the fauces there is usually a swelling 
 of the submaxillary glands, and of the adjacent cellular tissue, as well 
 as to some extent also of the parotids. This swelling, however, though 
 very rapid in its formation, and equally so in its disappearance, is sel- 
 dom so considerable as that which often attends upon scarlatina; it 
 has but little tendency to terminate in abscess, and still less to assume 
 the brawny hardness, and the extremely indolent character, which often 
 add so much both to the suffering and the danger of that disease. 
 
 Although the soft palate and tonsils are the parts on which the 
 deposit is first observable, it often does not remain limited to those 
 situations, but its tendency is to extend by mere continuity of tissue to 
 the mouth, the pharynx and oesophagus ; to the larynx and trachea, and 
 also occasionally upwards to the nares. Affection of the mucous mem- 
 brane of the mouth, and the deposit of exudation on the tongue or on 
 the inside of the cheeks or on the surface of the gums, are exceptional 
 occurrences. I have met with such deposit only on four occasions, and 
 I believe that at all times it is far more frequently absent than present. 
 In two instances, though the mouth was free from false membrane, the 
 oesophagus was lined by it for two-thirds of its length ; the subjacent 
 mucous surface showing but very slight increase of vascularity /and the 
 exudation being but very loosely connected with it. In one case, 
 although the oesophagus was perfectly normal, the stomach was lined 
 by a thick false membrane, intimately adherent but terminating abruply 
 both at the cardiac and pyloric orifice. False membrane was in this 
 case deposited also on the tonsils, velum, upper surface of the epiglottis, 
 pharynx, root of tongue, in the nasal fossse, and in the larynx as low 
 as the cricoid cartilage. The disposition of the false membrane to affect 
 the nares seems to vary much in different epidemics. It has very rarely 
 come under my notice in this country in its most characteristic form as 
 a distinct false membrane, though a discharge from the nostrils similar 
 
DIPHTHERIA, OR ANGINA MALIGNA. 349 
 
 to the scarlatinal eoryza is present in almost all cases of severe diphtheria. 
 M. Bretonneau 1 gives a caution with reference to these cases which must 
 not be forgotten, to the effect that in some few instances the disease 
 begins at the nares, and extends thence in a manner so insidious as to 
 escape the notice of all who are not forewarned and on the lookout for 
 the occurrence. 
 
 The relation between the amount of deposit on the fauces and the 
 extension of false membrane to the air-passages is by no means constant. 
 A very slight deposit on the soft palate and tonsils, soon disappearing, 
 may yet be succeeded by a very abundant exudation in the larynx and 
 trachea, while, on the other hand, most extensive, formations of false 
 membrane at the back of the throat may yet never involve the air- 
 passages. The appearances produced by the extension of the diphtheritic 
 deposit to the air-passages are precisely the same as those observed in 
 cynanche trachealis, in which, without any previous affection of the 
 fauces, the inflammation has attacked the larynx and trachea. It has 
 indeed been suggested by M. Isambert, 2 in a very valuable paper, that 
 the condition of the subjacent mucous membrane furnishes a ground of 
 distinction between the affections; and that while in diphtheria the 
 surface beneath the exudation is often ulcerated, no such erosion of the 
 mucous membrane is met with in genuine croup. My own observation 
 does not, however, altogether bear out this difference ; for ulceration of 
 the mucous membrane has come under my notice in primary croup, 
 though less frequently than in cases of the diphtheritic kind ; and its 
 presence or absence seems to me mainly dependent on the rate of prog- 
 ress of the disease towards a fatal termination. When false membrane 
 is deposited very extensively, and when death takes place in conse- 
 quence most speedily, the mucous surfaces have appeared least altered ; 
 when the course of the disease is slower and the false membrane limited 
 almost or altogether to the larynx, ulceration has seemed to me most 
 frequent and has in some of these cases amounted to an almost complete 
 erosion of the lining of the larynx. In conformity with this I may add 
 that it is in the diphtheritic croup that succeeds to measles, which is 
 usually the least rapid in its course, that we commonly find the altera- 
 tion of the mucous membrane the most considerable. 3 
 
 I have come indeed to the conclusion, which I long hesitated to 
 adopt, that what differences soever exist between croup and diphtheria, 
 they must be sought elsewhere than in the pathological changes observ- 
 able in the respiratory organs. The mere extent of false membrane in 
 the air-passages certainly affords no ground for a distinction between 
 the two affections, though I think it is more common to find the false 
 membrane reaching to the tertiary bronchi in diphtheria than in 
 primary croup. A distinction between the two diseases founded on the 
 greater frequency of bronchitis and pneumonia in primary croup be- 
 comes to my mind with every year's added experience less and less 
 
 L 
 
 1 Archives Gen. de Medecine, Jan. and Sept. 1855. 
 
 2 Ibid, March and April, 1857. 
 
 3 The results of microscopic examination seem at present scarcely definite enough 
 to furnish a solution of this question. See the observations and remarks on the sub- 
 ject in Uhle and Wagner, Allgemeine Pathologie, 5th ed., 1872, pp. 285-289. 
 
350 
 
 DIFFERENCES BETWEEN DIPHTHERIA AND CROUP. 
 
 tenable ; and when once it Las invaded the air-passages, diphtheria 
 seems to produce precisely the same changes, to the same extent, and 
 with at least the same rapidity, as primary croup. 
 
 But even though this be so, the sameness of the anatomical changes 
 produced by two diseases does not suffice to establish their identitv. 
 The practitioner of midwifery knows that simple puerperal metritis and 
 puerperal fever are diseases which differ widely in their symptoms, 
 their course, their danger, and the degree in which they are amenable 
 to remedies, though in both, when they terminate fatally, precisely the 
 same alterations in the womb are discovered. In the same way, if we 
 extend our inquiry beyond the mere changes wrought in the respiratory 
 organs, the differences between croup and diphtheria at once become 
 apparent ; and the affinities of the latter disease are seen to be to the 
 class of blood diseases, rather than to that of purely local inflammations 
 to which croup belongs. 
 
 Though probably not embracing all points of difference, nor perhaps 
 always holding absolutely true in every detail, the subjoined table may 
 be of use as embodying the main points of difference between croup 
 and diphtheria. 
 
 Croup 
 
 Is influenced by climate and season, is 
 endemic in some localities, but not epi- 
 demic nor contagious. 
 
 Is apt to recur, though with diminish- 
 ing severity, in the same patient. 
 
 Is almost limited to childhood ; of very 
 rare occurrence indeed in the adult. 
 
 Usually begins with catarrh and fever, 
 which latter is always proportionate to 
 the severity of the local symptoms. Dys- 
 phagia rare, slight, always secondary, and 
 subordinate to the larj-ngeal affection. 
 
 Glandular swelling and coryza always 
 absent. False membrane on fauces very 
 rare, and not extensive. 
 
 Constitutional disorder always in pro- 
 portion to gravity of local mischief. No 
 albumen in urine, nor any sign of general 
 blood disorder. 
 
 Death always from apnoea. 
 
 Has no sequelae, complete recovery fol- 
 lowing cure of local affection. 
 
 Diphtheria 
 
 Is independent of climate or season, 
 contagious, and often epidemic. 
 
 Has no special tendency to recur, 
 though an attack confers no absolute 
 immunity. 
 
 Though specially frequent in childhood, 
 adult age has no exemption from it. 
 
 Catarrh rare. Symptoms of constitu- 
 tional disorder often severe from the very 
 outset. Sore throat and difficult deglu- 
 tition precede laryngeal affection, which 
 is often slight, and sometimes altogether 
 absent. 
 
 Glandular swelling always, coryza often 
 present ; deposit of false membrane on 
 tonsils always occurs at some period, often 
 very extensive. 
 
 Constitutional disorder often quite out 
 of proportion to local mischief. Albumen 
 present in the urine, and various eviden- 
 ces of blood disorder. 
 
 Death often from asthenia, and various 
 disorders of nervous system. 
 
 Has many sequela;, and specially a 
 peculiar form of paralysis, which may 
 continue for months after the disappear- 
 ance of every sign of local ailment. 
 
 Diphtheria presents itself in two forms, — either as a primary or as a 
 secondary disease. In the former case it is often sporadic, ^md is then 
 generally mild in character ; but occasionally it is epidemic, and then 
 conforms to the general laws of epidemic disease, and manifests on its 
 first attack a degree of severity which passes off as its prevalence de- 
 clines. When it occurs as a secondary affection, it is as a sequela to 
 

 SYMPTOMS OF DIPHTHERIA. 351 
 
 one or other of those diseases (especially measles and scarlatina), which 
 are distinguished by the alterations that they bring about in the circu- 
 lating fluid. With scarlet fever too its relations seem to be peculiarly 
 intimate, for while there is no evidence that the one furnishes any pro- 
 tection from the other, both not infrequently prevail together ; and it 
 does occasionally happen that even in the same household some indi- 
 viduals will be attacked by diphtheria, and others by well-marked 
 scarlet fever. 
 
 Until within the past few years, diphtheria had not been observed 
 in London or its vicinity, within the memory of the present generation, 
 except either as a sequela of measles, or else in that sporadic form 
 Avhich derives all its importance from the extension of false membrane 
 to the larynx and trachea, and the consequent production of croupal 
 symptoms. Recently, however, the disease has assumed a more for- 
 midable type, and its symptoms have resembled those which it often 
 displays in France, though to the best of my knowledge that disposi- 
 tion to the formation of exudation on abraded surfaces, and at the outlet 
 of all mucous canals, which is by no means unusual there, has occurred 
 much more rarely in this country. 
 
 In its less severe forms the disease is ushered in by mild febrile 
 symptoms accompanied with slight sore throat — the most remarkable 
 feature of the case being generally that the depression of the patient 
 is out of proportion to the severity of the local ailment. Examination 
 of the throat shows a slight degree of swelling, and redness not usually 
 very vivid, and at first confined to one tonsil. In the course of a few 
 hours white specks are observed on the tonsil, chiefly on its inner sur- 
 face, and before long the other tonsil becomes similarly affected, while, 
 in some instances, though by no means constantly, a slight deposit ap- 
 pears on the velum and uvula. One or two applications of caustics or 
 astringents to the part are usually sufficient' to clear away the deposit, 
 or it may disappear spontaneously, and not be reproduced, and in two 
 or three days the patient is pretty well again, though strength is in 
 general regained less quickly than might have been expected from the 
 comparative mildness of the attack. 
 
 In cases so slight it is no easy matter to recognize the features of a 
 highly dangerous disease ; for there is no coryza, no swelling of the 
 submaxillary glands, no increased secretion of saliva, no offensive odor 
 of the breath, nor any disorder of the respiratory functions. Still, out 
 of forerunners as trivial as these, croupal symptoms may be developed, 
 and as the deposit on the fauces, when slight, is often not persistent, no 
 trace of it may be perceptible when the signs of the affection of the 
 larynx first attract attention. Whether croup comes on as a primary 
 or as a secondary disease, its signs are always much the same, and I 
 need not therefore occupy your tiihe in repeating the description of 
 them ; but it must not be forgotten that its advances are often most in- 
 sidious when it succeeds to diphtheritic deposit on the fauces. The 
 cough, in these circumstances, may present but little of the loud clangor 
 of ordinary croup, and the respiration may have little of the character- 
 istic stridor ; but grave apprehensions may be all at once excited (and 
 this especially in infants and young children) by the breathing suddenly 
 
352 SYMPTOMS OF DIPHTHERIA. 
 
 becoming sibilant and interrupted by paroxysms of urgent dyspnoea, 
 the evidence of the already complete formation of false membrane, and 
 the herald of death, which may not delay four-and-twenty hours from 
 the first sign of serious danger. 
 
 But, much though it imports us to be on the lookout for this train 
 of symptoms, they are not the expression of the special severity of the 
 disease, but rather of the accidental extension of its consequences to 
 the air-passages. It is true that to this accident much of the danger 
 of diphtheria is due, and true too that in the worst forms of the disease 
 it is more frequent than in its slighter manifestations ; but while we 
 must be always on the lookout for croupal symptoms, they do not con- 
 stitute the disease : they are by no means the only source of its dangers, 
 nor is it in their occurrence that the most characterisiic features of 
 diphtheria are to be sought. 
 
 Even in the more serious cases, the course of the disease, in its early 
 stages, is usually slow and often insidious. For a day or two there is 
 perhaps much febrile disturbance and a heat of skin which raises the 
 suspicion that scarlatina is about to appear, of which the painful swell- 
 ing of the submaxillary glands seems to be a still further indication. 
 No rash, however, makes its appearance ; the heat of skin often sub- 
 sides completely, so that the surface becomes even cooler than natural ; 
 while the absence of the red and prominent papillae which beset the 
 tongue in scarlatina, belies the evidence of the sore throat. The fauces 
 are red and swollen, sometimes very much so, but the redness is not 
 vivid, and there is not in general that difficulty in opening the mouth 
 which is experienced in scarlet fever when the sore throat is at all se- 
 vere. The false membrane appears almost simultaneously on both ton- 
 sils ; and soon after on the soft palate and uvula, and the latter is 
 generally much swollen, and contributes a good deal to obstruct the 
 channel of the fauces. Accompanying this state of the throat, there 
 is often a discharge from the nares, resembling the coryza of scarlet 
 fever, and as has already been mentioned, false membrane is occasion- 
 ally deposited there, whence it may travel to the posterior nares, and 
 so to the throat and air-passages. When the deposit is considerable 
 the appearance of the tongue is peculiar. It is usually red at the tip, 
 but thickly coated with white fur, which on the dorsum and towards 
 the root of the tongue is almost membraniform. It is not usual for 
 the inside of the mouth to be affected, but now and then the gums are 
 red, soft, and spongy, and covered here and there, as well as the inside 
 of the cheek, with patches of false membrane, beneath which the tissue 
 appears red and shining. When the mouth is thus affected the secre- 
 tion of saliva is considerably increased ; but I have never seen that 
 profuse dribbling of it which takes place in stomatitis, nor have I ob- 
 served that complication of stomatitis with diphtheria of which M. 
 Bretonneau speaks, and which led him to regard the two diseases as 
 closely related to each other. It is after the false membrane has been 
 formed somewhat abundantly for two or three days that it undergoes 
 those changes Avhich impart to the breath its peculiarly offensive odor, 
 and give to the fauces that appearance of being the seat of a sloughing 
 ulceration, whence arose the old names of angina maligna, angina gan- 
 
VARIOUS MODES IN WHICH DIPHTHERIA PROVES FATAL. 353 
 
 grsenosa. Even when the affection of the throat is most considerable, 
 deglutition can still almost always be performed, not easily indeed, but 
 yet in general without that extreme difficulty which one often observes 
 in the sore throat of scarlet fever, and of common quinsy. 
 
 The voice is often hoarse and indistinct, independently of actual 
 affection of the larynx ; and a short spasmodic, slightly ringing cough, 
 is frequently heard, due to the irritation of the larynx by the mischief 
 in its vicinity. But, though these symptoms do not necessarily imply 
 that the air-passages are actually involved in the disease, they should 
 keep us most anxiously on the watch, since very few tokens indicate 
 this event, and they are often of a kind to escape the notice of the 
 unobservant. 
 
 In proportion to the severity of the case is usually the shortness of 
 the premonitory fever, which sometimes does not exceed twelve hours 
 in its duration, and at other times scarcely occurs at all, the child being 
 struck down at once by the disease ; false membrane being deposited 
 extensively on the fauces in the course of a few hours, and the coryza, 
 which usually does not appear before the third day, showing itself 
 almost from the first. The mode in which such cases tend to a fatal 
 issue is very various. As a general rule it may, I think, be said that 
 the laryngeal affection, which is so grave a source of peril, does not so 
 frequently occur in cases where the constitutional symptoms of diph- 
 theria are most severe, as in those in which they wear a milder form. 
 At the same time, however, no guarantee is furnished against its super- 
 vention by the gravity of the disease in other respects, while, when the 
 larynx becomes involved in severe diphtheria, the case must be regarded 
 as at once utterly hopeless. 
 
 Setting aside these cases, we find that the evidence of general consti- 
 tutional disorder becomes more marked day by day, and this even with- 
 out an invariable aggravation of the local malady. Of these evidences 
 one of the most important is furnished by the presence of albumen in 
 the urine. I believe that albumen is rarely absent in cases of other 
 than the very mildest diphtheria; though the amount is strangely fluc- 
 tuating, varying even on successive days ; and these fluctuations are by 
 no means constantly associated with any corresponding modifications in 
 the other symptoms of the disease. When the albumen, however, is 
 very abundant, the urine is invariably scanty, and there is perhaps no 
 single symptom of worse omen than the extremely scanty secretion of 
 urine. In cases of average severity the albumen seldom makes its 
 appearance within the first four or five days ; and then, according to 
 the subsequent progress, it either goes on increasing, or lessens with the 
 gradual improvement in the patient's condition. The complete sup- 
 pression of urine is an almost invariably fatal symptom, and I do not 
 know of any instance in which the patient has recovered after the 
 urinary secretion has been suspended for twenty -four hours. In these 
 circumstances, and even in cases where the urinary secretion, though 
 not absolutely suspended, is unusually scanty, ursemic convulsions are 
 likely to occur and suddenly to carry off the patient. 
 
 But even where the urinary secretion continues in tolerable quantity, 
 and the albumen is not excessive, the symptoms that attend the progress 
 
 23 
 
354 RELATION OF DIPHTHERIA 
 
 of the disease are invariably those of depression, and of depression which, 
 like that attendant on the worst forms of puerperal fever, is by no means 
 constantly proportionate to the apparent local mischief. The child, 
 feeble yesterday, becomes still feebler to-day, and often, without any 
 actual increase of deposit, sometimes even in spite of its diminution, 
 and of the absence of any apparent cause for difficult deglutition, his 
 repugnance to take food goes on increasing, until at length he positively 
 refuses all nourishment. This refusal of food, whether in childhood 
 or in adult age, is a very unfavorable occurrence. It is sometimes 
 associated with vomiting, and may then be dependent on the presence 
 of false membrane in the stomach, though this is by no means always 
 the case ; but whether it be so or not it tends to reduce the patient's 
 strength very much, and if persistent for any considerable time almost 
 invariably occasions fatal depression. It is not always easy to realize 
 the degree of peril, for the intellect is generally clear, and the muscular 
 powers are not inconsiderable, while at the same time the extremities 
 are cold, and the pulse is either extremely frequent or else very feeble 
 or irregular in its beat. For two or three days together, this condition 
 may continue, the pulse growing feebler, the signs of failing power 
 more manifest, and this in spite of stimulants being administered lav- 
 ishly, and taken readily, until at length either the signs of the last 
 stage of croup suddenly appear, showing that the local mischief has 
 been extending silently and unperceived, or else an attack of syncope 
 follows on some sudden and violent action of the bowels, or causeless 
 convulsions come on, and in the subsequent coma the patient dies. 
 This depression too, as already mentioned, is by no means constantly 
 proportionate to the extent of the false membrane, nor is the danger of 
 it past even when the local mischief, as far at least as the eye can 
 reach, has altogether disappeared ; for I have known frequently recur- 
 ring syncope take place even when no traces of false membrane re- 
 mained on the fauces ; and fatal convulsions come on when the local 
 mischief was so slight that nothing but the previous death of a member 
 of the family from well-marked diphtheria had called attention to the 
 throat, and had led me to watch with painful solicitude a local ailment 
 which owed all its importance to its being an evidence of grave consti- 
 tutional disease. 
 
 The simultaneous or successive affection of different and distant 
 parts, is one of the great evidences on which we are wont to rely, in 
 proof that a disease belongs to that great class of blood diseases whose 
 importance and whose distinctive characters modern pathology has 
 done so much to elucidate. The more closely we study diphtheria, 
 the stronger will its claims appear to be referred to this category. 
 The false membrane, whose most usual seat is on the fauces, whence it 
 extends into the air-passages, is not limited to those situations, but oc- 
 casionally invades other parts, and is deposited behind the ears, upon 
 the vulva, or on abraded surfaces ; while, in the albuminuria which 
 generally accompanies its severer forms, another point of resemblance 
 exists 1 between diphtheria and other maladies which result from puru- 
 
 1 Bouchut and Empis, Gaz. Hebdora., Nov. 12, 1858. 
 
TO BLOOD DISEASES. 355 
 
 lent infection. In some epidemics of diphtheria the formation of false 
 membrane on different parts has been a frequent occurrence. Thus 
 Bard, 1 describing the disease as it prevailed nearly a century ago in 
 America, speaks of the formation of ulcers behind the ears, covered in 
 some places with sloughs resembling those on-the tonsils ; and Starr, 
 in his description of the epidemic at Liskeard, 2 notices "a rotten mem- 
 branous body, or slough, generated on the skin of a patient, on the 
 neck and arm, where blisters had been applied ;" and says that the 
 part presented " a white surface which had the aspect of an oversoaked 
 membrane." Such a deposit I saw take place on the neck of a little 
 girl, around whose throat, before the diphtheritic deposit had been 
 recognized on the fauces, a stimulating liniment had been applied to re- 
 lieve her swollen glands. But besides the formation of false membrane 
 on abraded surfaces, the mucous membrane of the vulva seems often to 
 be the seat of a similar deposit ; and in some rare cases the prepuce is 
 affected in the same manner, or small superficial ulcers break out on 
 different parts of the body, and become speedily covered with false 
 membrane. Once, too, I saw in consultation with Mr. Alford, of 
 Haverstock Hill, twin boys, eight months old, in each of whom a 
 small abrasion formed on the raphe of the perineum, and became cov- 
 ered with false membrane. This membrane extended, though un- 
 accompanied with other local symptoms of diphtheria, to the margin 
 of the anus, and to just within the external sphincter. Both children 
 died within a week from the commencement of their illness, sinking as 
 under some grave constitutional disease, with troublesome diarrhoea and 
 exhaustion, which stimulants failed to remove. The identity of the 
 disease in these circumstances with ordinary diphtheria is established 
 beyond doubt by facts such as those observed by M. Trousseau 3 in a 
 village in the neighborhood of Orleans, where diphtheria prevailed, 
 presenting in some persons its ordinary features; manifesting itself in 
 others by deposits of false membrane on the vulva, on the mamma, on 
 blistered surfaces, or on ulcers, and proving fatal in some cases without 
 the throat being at all involved in the disease. 
 
 Among the sequela? of diphtheria we shall presently have to notice 
 peculiar paralytic symptoms, which sometimes affect the extremities ; 
 or the pharynx, soft palate, and other parts that have been more im- 
 mediately involved in the disease. But besides these, which belong 
 rather to the remote phenomena of diphtheria, we sometimes meet with 
 even a graver form of disordered innervation, occurring in its earliest 
 stage, and leading, by affection of the vital centres, to a speedily and 
 often to a suddenly fatal issue. Disordered innervation of the heart 
 is perhaps the most frequent, and betrays itself by a remarkable dimi- 
 nution, sometimes for two or three days, in the frequency of the pulse, 
 which may even sink, as in the case of a little girl, related by Sir W. 
 Jenner, to sixteen beats in the minute. This occurrence indeed is by 
 no means constant, and death may take place by sudden failure of the 
 heart without this forewarning. AVhen observed, however, its import 
 
 1 Loc. cit., p. 392. 2 Idem, p. 440. 
 
 3 De la Diphtherite cutanee, in Arch, de Med., Juillet, 1830, p. 383. 
 
356 
 
 DURATION OF DIPHTHERIA. 
 
 is always serious, and you may augur ill of any case in which, be the 
 local symptoms what they may, the heart's pulsations fall much below 
 their natural standard. 
 
 But there are other cases in which the disordered innervation seems 
 to affect the muscles of respiration rather than the heart itself; the 
 breathing, without any extension of the false membrane to the larynx, 
 and without any notable mischief in the lungs, becoming by degrees 
 more and more labored, and the patient dying at the end of some four- 
 and-twenty hours from asphyxia, for which a post-mortem examina- 
 tion discovers no adequate cause. 
 
 It seems then that death may take place in the acute stage of diph- 
 theria, either — 
 
 1st. From blood-poisoning, as in cases of malignant fever. 
 
 2d. From extension of the local mischief to the larynx. 
 
 3d. From progressive exhaustion aggravated by the difficulty in 
 deglutition. 
 
 4th. From uraemia and uraemic convulsions. 
 
 5th. From various forms of affection of the nervous system, as— 
 
 a. Sudden syncope. 
 
 b. Disordered innervation of the heart. 
 
 c. Disordered innervation of the organs of respiration. 
 
 d. General disorder of innervation, accompanied with affection of the 
 stomach, and uncontrollable vomiting. 
 
 It is not easy to fix the duration 1 of a malady whose course is not 
 infrequently so anomalous, and which, as we shall see hereafter, not 
 seldom leaves sequelae in its train such as are themselves only fresh 
 manifestations of the workings of the original morbid poison. Of 53 
 fatal cases, 27 terminated within the first 7 clays ; and after the termi- 
 nation of the second week death may be regarded as a decidedly un- 
 usual and exceptional occurrence ; though it is not easy, perhaps even 
 not possible, to fix any date before convalescence is perfectly established 
 at which some of the remote sequelae of diphtheria may not unexpect- 
 
 1 In 26 cases in which death took 
 place from causes other than the affec- 
 
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SEQUELS OF DIPHTHERIA. 357 
 
 edly come on and endanger life. The most rapidly fatal cases are those 
 in which death depends on affection of the larynx, and in them death 
 sometimes takes place in from twenty-four to thirty-six hours from the 
 apparent commencement of the attack ; the local symptoms throwing 
 the signs of constitutional disorder completely into the shade, some- 
 times rendering it almost impossible to determine whether a case should 
 be classed with diphtheria or with simple cynanche trachealis. 
 
 Reference has already been made to the occasional death of patients 
 in whom the local affection had throughout been so inconsiderable as 
 to produce but few symptoms, or has even altogether disappeared before 
 the fatal issue took place. But other cases are sometimes observed 
 where long-continued illness remains, or where even death takes place 
 not from the disease itself nor from any of its immediate effects, but 
 from its remote sequela?, from a sort of accidental consequences. These 
 remote results of diphtheria have been noticed both by Bretonneau and 
 Trousseau, and some of them have probably come under the observa- 
 tion of most persons who have had even a very limited experience of 
 the disease. Thus, for instance, I saw a child, between three and four 
 years old, whose infant brother had died of diphtheria, and who her- 
 self had had very slight deposit of false membrane on her fauces, at- 
 tacked by causeless convulsions when apparently convalescent, and 
 when more than a week had elapsed since the throat presented any un- 
 natural condition ; and these convulsions terminated in fatal coma within 
 less than twenty-four hours. A lady whose child (aged three years) 
 had died of diphtheria extending to the air-passages, and who herself 
 had suffered from very slight sore throat with a trace of false membrane 
 on the tonsils, was attacked by sudden faintness, almost amounting to 
 syncope, with extreme feebleness of pulse and a sense of impending dis- 
 solution, which for more than twenty-four hours was scarcely kept in 
 check by the almost incessant administration of stimulants. Cases of a 
 similar kind might no doubt be multiplied ; but besides these earlier 
 sequela? there is a peculiar form of temporary paralysis, which occurs 
 by no means rarely as a remote consequence of the disease, and which 
 is yet both important in itself and also as furnishing an additional dis- 
 tinction between diphtheria and any simply inflammatory affection. 
 
 Both MM. Bretonneau and Trousseau have referred to this peculiar 
 condition ; and incidental mention of it is to be found a century ago 
 in the writings of physicians who have noticed the so-called malignant 
 sore throat, by which name diphtheria was then described. 1 It is to 
 M. Faure, 2 however, that we are indebted for the first complete account 
 of it, derived partly from his own observation, partly from facts detailed 
 by others. He describes it as " a state characterized by a gradually 
 increasing loss of power, showing itself especially in all functions con- 
 nected with muscular movement. In some instances, several sets of 
 organs are affected, in others only one; while, again, in others the 
 whole system is involved in the general debility. But, whatever are the 
 
 1 M. Maingault's valuable essay, De la Paralysie Diphtherique, 8vo., Paris, 1860, 
 contains an interesting historical sketch of the early notices of this affection. 
 
 2 L'Union Medicale de Paris, Fevrier, 1857 : and J. f. Kinderkr.. Jan. 1858. 
 
358 SEQUELS OF DIPHTHERIA. 
 
 variations in this respect, there is no definite relation between the severity 
 of the primary symptoms of diphtheria and that of the sequelae. The 
 primary symptoms, though very formidable, yet by no means of neces- 
 sity prove fatal ; while, on the other hand, the comparative mildness 
 of the attack will not justify an absolutely favorable prognosis, since 
 death sometimes follows where everything had seemed to warrant the 
 most confident expectation of recovery/' 
 
 Several cases are related by M. Faure, in illustration of the different 
 phases of this condition, and he then proceeds to sum up the general 
 results as follows : " Some time after an attack of diphtheria, from 
 which the patient had so completely recovered that no trace of false 
 membrane is left behind, the skin grows causelessly more and more 
 colorless, so that at length it assumes an almost livid pallor. Severe 
 pains begin at the same time to be felt in the joints, the patient loses 
 power over his limbs, and soon sinks into a state of indescribable weak- 
 ness. At the same time, the disorders that appear in different functions 
 show that the various organs which should minister to them are involved, 
 so far as they are dependent upon muscular power. In this respect, how- 
 ever, the phenomena are not constant, for sometimes it is one set of 
 organs, and sometimes another, which suffers most from this weakness. 
 
 " Very generally, in consequence of the want of muscular power, or, 
 more strictly speaking, in consequence of its complete abolition, the 
 patient becomes unable to sit upright, or does so with great difficulty ; 
 while the legs cannot bear the weight of the body, the arms become 
 nerveless and cease to obey the will, and all the movements grow uncer- 
 tain, tottering, hesitating, and apparently purposeless. Very remarkable 
 disorders show themselves also within the throat; for the velum is 
 completely paralyzed, and hangs down like a flaccid lifeless curtain, 
 which interferes with speech and deglutition. All the muscles of the 
 jaw, those too of the neck and chest, are partially paralyzed, in conse- 
 quence of which mastication is rendered difficult, and the food can 
 neither be easily moved about in the mouth nor readily swallowed. 
 From the same cause too it is not infrequently regurgitated, and the 
 laborious deglutition often induces spasm of the respiratory apparatus. 
 Vision is impaired, one or other pupil often remains widely dilated, 
 even in the strongest light, and squinting is not unusual. The sensi- 
 bility of the skin is much diminished ; in the limbs it is sometimes 
 completely lost, though morbid sensations — such, for instance, as formi- 
 cation — are sometimes experienced. (Edema of various parts often 
 occurs, while, though less commonly, parts here and there lose their 
 vitality, and become gangrenous. No general reaction occurs, fever is 
 rare. The skin usually has a certain degree of moisture. The features 
 grow duller and more and more expressionless, though a foolish smile 
 sometimes crosses them, or now and then a ray of intelligence appears. 
 Some patients have frequent fainting fits. As the condition goes on 
 from bad to worse, the weakness becomes extreme ; and death at length 
 either follows some fainting fit, or takes place when exhaustion has 
 reached its uttermost — life as it were quietly, almost imperceptibly, 
 passing away." 
 
 This fatal termination is, however, an exceptional occurrence, and, 
 
DIPHTHERITIC PARALYSIS. 359 
 
 indeed, the symptoms of diphtheritic paralysis are not usually by any 
 means so severe as the above description implies. My own impression 
 too (though I have not statistical data sufficient to warrant a positive 
 statement on the subject) is that diphtheritic paralysis is far rarer in 
 this country than on the Continent, or at least than in Paris. I have 
 not seen in the Children's Hospital any of the graver forms of the 
 affection succeed to diphtheria for which the patient was admitted 
 when in its acute stage ; and, further, the number of children received 
 on account of paralytic symptoms at all has been but small, and the 
 cases not severe. Even in private practice, while, a large number of 
 diphtheritic patients have come under my observation, the instances of 
 paralysis succeeding have been so few, that I may, I think, feel sure 
 that in London, paralysis does not follow diphtheria with anything 
 like the frequency w T ith which it is stated on the best authority to 
 occur in Paris. 1 
 
 The form in which diphtheritic paralysis most frequently shows 
 itself, is that in which the soft palate is affected, producing nasal voice 
 and occasional difficulty in deglutition. Next in frequency, I have ob- 
 served impaired power over the limbs, the lower being affected oftener 
 and to a greater degree than the upper ; and with this there was as- 
 sociated, in many instances, indistinct articulation, with strabismus, 
 dilated pupils, and imperfect vision. Once I saw a child on whom 
 tracheotomy had been successfully performed on account of diphtheria 
 affecting the larynx, and from whose windpipe the canula had been re- 
 moved early, attacked some days after the wound had healed completely, 
 by such difficulty in breathing from paralysis of the muscles of the 
 larynx, as to raise in the mind of the medical attendant the question 
 whether fresh disease had not come on. I have also seen death occur 
 in two children three years old — in the one ten and in the other seven 
 weeks after the invasion of diphtheria — and who had both appeared to 
 have completely recovered from the disease. The paralytic symptoms 
 supervened in both these cases on slight catarrh, which, however, was 
 unattended by bronchitis. In both cases the little patients objected 
 to take food ; and in one, any attempt at deglutition, especially of fluids, 
 brought on most distressing cough. No rales were heard in the chest, 
 but mucus collected in the windpipe, which the children made fruitless 
 efforts to expectorate ; while the pupils became dilated, the lips livid, 
 and the surface cold and clammy, during the attempt to get rid of the 
 obstacle to the entrance of air. At length the power of coughing 
 
 1 M. Roger, in his valuable paper on this subject, estimates the frequency of paral- 
 ysis at a third of the cases in which life was prolonged sufficiently to allow of its 
 occurrence. See his " Recherehes sur la Paralysie Piphtheritique," in Archives de 
 Medecine, 1862, vol. i, p. 1. It ca^ scarcely be necessary to observe that as the 
 characters of the same disease vary at different periods in the same country, so may 
 they also differ in different countries at one time ; and that discrepancies between 
 the statements of observers in France and England do not of necessity imply error 
 on the part of either. It so chances that in the whole course of my practice I have 
 only four times met with cutaneous diphtheria — once affecting the vulva, twice the 
 anus, and once attacking an abraded surface. Judging by the statements of French 
 physicians, my experience would have been widely different if the scene of my ob- 
 servations had been on the other side of the Channel instead of in England. 
 
360 DIPHTHERITIC PARALYSIS. 
 
 ceased, and then the children died — one seven days, the other five 
 days, from the first interruption of their convalescence. 
 
 These paralytic symptoms vary in the date of their occurrence as 
 well as in their severity. I have already referred to the failure of the 
 power of the heart, and to the paralysis of the respiratory muscles, as 
 sometimes carrying off patients during the acute stage of diphtheria. 
 The more remote results, however — with the exception of the paralysis 
 of the soft palate, which sometimes persists from the first attack of the 
 disease — do not come on until after a distinct interval of apparent 
 convalescence, marked by nothing but that state of general weakness 
 which might be expected to succeed to the previous illness. They 
 bear no necessary relation to the severity of the previous attack, nor to 
 the quantity of albumen which had been present in the urine; and I 
 remember to have seen them in a very marked form in a little boy, in 
 whom the previous diphtheria was so light as to have been unrecog- 
 nized, and who was supposed to have suffered only from influenza with 
 a little sore throat. I do not know after how long a period from the 
 attack paralytic symptoms may come on, and to the best of my belief 
 we are not as yet furnished with data sufficient to form a positive 
 opinion on the subject, though the two cases I have related above 
 prove that a lapse even of several weeks furnishes no positive guar- 
 antee against their occurrence. 
 
 It has been alleged 1 that these paralytic affections have in them 
 nothing of a specific character — that, so far from belonging exclusively 
 to diphtheria, they are occasionally met with, presenting the same 
 essential features, after many acute diseases ; or that, in other words, 
 diphtheritic paralyses are but a particular example of a very general 
 rule. 
 
 Now I do not believe this ; for though, as I have already stated, 
 diphtheritic paralysis has appeared to me to be of far less frequent 
 occurrence in this country than on the Continent, I yet have met with 
 paralysis after diphtheria far more frequently than after any other acute 
 affection of early life. In some very rare instances, indeed, I have 
 known paralytic symptoms succeed to measles and typhoid fever; but 
 even in these cases it has assumed a form similar to that of the so-called 
 essential paralysis of childhood, has affected the same parts from the 
 outset, and has presented nothing of that progressive character which 
 one observes in diphtheritic paralysis. In France — where this paral- 
 ysis, as I have already mentioned, has occurred in as many as a third 
 of all cases of diphtheria in which the patients have survived the 
 urgent dangers of the acute stage of the disease — there is even stronger 
 ground than my own experience would furnish for regarding it as one 
 of the ordinary sequelae of the disease, and for looking on it as having 
 as much of a special character as belongs to that form of dropsy which 
 we look upon as one of the peculiar incidents of the desquamative stage 
 of scarlatina. 
 
 1 See the most elaborate series of papers by Dr. G-ubler, devoted to the support 
 of this paradox, in the Archives de Medecine, 1860. Vol. i, pp. 257, 402, 534, 693 ; 
 vol. di, pp. 187, 718; and 1861, vol. i, p. 306. 
 
DIPHTHERIA AND SCARLATINA. 361 
 
 This disposition to the occurrence of paralysis as its most frequent 
 sequela, is also not without interest as bearing on a question more 
 debated a few years since than it is at the present day — namely, that of 
 the exact relation subsisting between diphtheria and scarlatina. Of late, 
 indeed, the question seems to have been nearly set at rest by the unani- 
 mous recognition of the essential differences between the two diseases. 
 
 It may, however, be worth while to sum up briefly the majority of 
 those differences, which I think justify us in the assertion that diph- 
 theria and scarlatina, however allied in some of their characters, are 
 yet diseases essentially distinct from each other: 
 
 1st. In all epidemics of scarlatina the anomalous cases, in which the 
 characteristic rash is absent, form but a very small minority. In epi- 
 demics of diphtheria, however, the existence of a rash, even though 
 most partial and evanescent, is but rarely noticed, and in the majority 
 of epidemics is not at all observed. 
 
 2d. In cases of malignant scarlet fever terminating fatally, and 
 without the appearance of any rash, death usually occurs very early, 
 and is preceded by very marked cerebral disturbance, by violent de- 
 lirium, or by profound insensibility ; while, on the other hand, the 
 fatal issue in diphtheria is generally far less speedy in its approach, 
 and the disease, even in its worst forms, is usually remarkable for the 
 perfect clearness of the intellect almost to the very last. 
 
 3d. The characters of the tongue in diphtheria differ entirely from 
 those which it presents in scarlatina ; and even the rash, on the occa- 
 sional appearance of which so much stress has been laid, is in many 
 respects dissimilar from the scarlatinoid eruption. It is for the most 
 part a uniform blush of erythematous redness, unattended by the pecu- 
 liar punctated appearance which marks the scarlatinoid rash. It ap- 
 pears suddenly in patches, is vivid from the very first, not deepening 
 gradually in intensity like the rash of scarlet fever; while its sudden 
 and speedy disappearance is not followed by any change in the other 
 symptoms, nor by any increase in their severity. I may add, still 
 further, that the appearance of any rash at all is a purely exceptional 
 occurrence. 
 
 4th. The oedema of the surface, which is occasionally present, comes 
 on during the acute stage of diphtheria, not during its decline ; it is in- 
 considerable in degree, is unaccompanied by serous effusion into the cav- 
 ities of the chest or abdomen, and is by no means of necessity associated 
 with albuminuria. The presence of albumen in the urine is not accom- 
 panied with any other change in its character, such as would be obvious 
 on a cursory examination ; for, though lessened in quantity, it still con- 
 tinues pale in color and acid in its reaction, and I have not met with 
 any instance in which blood was present in it. The albumen seems 
 also often to disappear at a very early period of the disease — its disap- 
 pearance takes place suddenly; and though its presence is almost in- 
 variably observed in cases where the disease is severe, yet there does not 
 seem to be any necessary connection between the urine becoming non- 
 albuminous and the disease assuming a milder type. 
 
 5th. The whole train of the sequela? of the two affections is entirely 
 different ; and while, on the one hand, the convalescence from diph- 
 
362 TREATMENT OF DIPHTHERIA. 
 
 theria presents none of the formidable dropsical symptoms which so 
 often succeed to scarlet fever, the peculiar loss of nervous power, and 
 the temporary muscular paralysis which frequently follow diphtheria, 
 have no analogy to any of the sequelae of scarlet fever. 
 
 6th. Scarlet fever does not protect from diphtheria, nor, on the 
 other hand, does diphtheria defend from scarlet fever. To both of 
 these facts universal experience bears testimony, and it would scarcely 
 be justifiable to assume that every instance, or even the majority of 
 instances, of the succession of diphtheria to scarlet fever, or the oppo- 
 site, are illustrations of a secondary attack of scarlet fever. An ex- 
 ample which puts this in a very strong light was recently commu- 
 nicated to me. In a school in the neighborhood of London diphtheria 
 broke out ; many of the lads were affected by it, and one or two died. 
 Several of those who were convalescent from the disease were sent to 
 the seacoast for the more speedy recovery of their strength, and while 
 there some were attacked by scarlet fever ; and this also, in one or two 
 cases, proved fatal. Still stronger, however, is the evidence supplied 
 by cases in the Children's Hospital, where patients recovering from 
 scarlatina have been attacked by diphtheria ; and the reverse, in which 
 children convalescent from diphtheria have been attacked by scarla- 
 tina • showing that the one disease exerts no more preservative influence 
 from the other than does measles or typhoid fever, each of which may 
 follow diphtheria, or be followed by it. 
 
 Two main points are involved in the treatment of this disease, — the 
 one the control of the local mischief, the other the support of the con- 
 stitutional powers. All the various measures which have been em- 
 ployed are directed to one or other of these objects ■ and there is at the 
 present day a degree of unanimity as to the means to be resorted to, 
 such as is of rare occurrence in questions of therapeutics. Depletion, 
 antiphlogistics of all kinds, blisters, and all counter-irritants by which 
 the surface may be abraded, though used at one time, under what are 
 believed to have been mistaken views as to the nature of this affection, 
 are now by common consent altogether discontinued ; and the only 
 points debated among practitioners regard the comparative merit of 
 this or that local application, or of this or that tonic medicine. 
 
 I do not believe that there is any remedy, either local or general, 
 which exercises a specific influence over diphtheria — such, for instance, 
 as the chlorate of potass seems to possess in controlling stomatitis, or 
 as quinine displays in cutting short an attack of ague. There is, how- 
 ever, usually a very marked connection between the early arrest of the 
 deposit, however affected, and the speedy recovery of the patient, 
 although it sometimes happens that the constitutional symptoms of the 
 disease have a fatal issue after all trace of false membrane has disap- 
 peared from the fauces. In illustration of the connection between the 
 arrest of the deposit and the cutting short of the disease, M. Trousseau 
 relates the story of the epidemic prevalence of diphtheria in a village, 
 where all the cases treated by the medical men, who confined them- 
 selves to the employment of constitutional remedies, proved fatal; 
 while the only cures were wrought by an old woman, who despised the 
 
TREATMENT OF DIPHTHERIA. 363 
 
 doctors and their remedies, and applied indiscriminately to everybody's 
 throat a rough and rather violent escharotic. 
 
 The practice, however, which this story seems to inculcate — and 
 which I, in common with many others, was at one time accustomed to 
 adopt — has come of late years to be regarded as of more than doubtful 
 expediency. The application of a strong solution of nitrate of silver, 
 as two scruples to an ounce of distilled water, or of equal parts of 
 hydrochloric acid and honey, by means of a soft camel's-hair brush, on 
 the first discovery of the deposit, sometimes seems to arrest its exten- 
 sion. At the same time I am fully satisfied that often-repeated cau- 
 terization, in the hope of thereby overtaking the spread of the disease, 
 not merely fails of this result, but often produces an increase of swell- 
 ing and greater difficulty of deglutition. 
 
 But, though the repetition of the stronger caustics is injurious, 
 benefit may often be derived from some of the milder local applica- 
 tions. Thus, for instance, a gargle of half an ounce of the solution of 
 chloride of soda to six ounces of water, or a similar application made 
 to the back of the throat with a soft camel's-hair brush, or the syring- 
 ing the mouth with it every three or four hours, often relieves the 
 local mischief, and at the same time promotes the patient's comfort, by 
 freeing the mouth from the ropy mucus and the other secretions which 
 are apt to accumulate in it. The ingenious apparatus too, now so 
 generally used in one form or other for the diffusion of spray, either 
 for producing local anaesthesia, for applying lotions to the eye, or for 
 perfuming a room — and the idea of which, I believe, we owe to Dr. 
 B. Richardson — is extremely useful in these cases. By means of it 
 we can apply a solution of tannin in glycerin, and mixed with water; 
 or a solution of carbolic acid ; or the sulphurous acid diluted with 
 eight times the quantity of water, with much relief and with much 
 real benefit. The mere gargling with iced water, or the frequent 
 swallowing of small pieces of ice, is also of much service in many 
 instances, when the swelling and the difficulty in deglutition are con- 
 siderable ; but, unfortunately, it is almost impossible to induce children 
 to carry out any of these measures with perseverance. 
 
 The discharge from the nostrils, which is a very frequent and very 
 troublesome complication, may generally be checked by the injection, 
 twice in the twenty-four hours, of a solution of one or two grains of 
 nitrate of silver to an ounce of water ; and the swelling of the sub- 
 maxillary glands may often be diminished by warm fomentations, or 
 by the application of spongio-piline, or of a linseed-meal poultice to 
 the neck. 
 
 Something too may be done to promote the patient's comfort, and to 
 lessen the danger of affection of the air-passages, by providing (as was 
 suggested when I spoke of croup) for the presence of a warm and moist 
 atmosphere in the room ; and, in the early stage of the affection, by 
 the inhalation, if the child is old enough to employ it, of the steam of 
 warm water, or of warm vinegar and water. 
 
 While the above local measures are had recourse to, the constitu- 
 tional treatment must be pursued no less diligently. In this it is im- 
 portant to bear in mind that the feverish condition, which is often 
 
364 TREATMENT OF DIPHTHERIA. 
 
 observed at the outset of diphtheria, must not mislead us into with- 
 holding nourishment, or into resorting to any strenuously antiphlogistic 
 treatment. If, indeed, there is much heat of skin at the onset of the 
 attack, if the tongue is coated, and the bowels are constipated, an 
 ipecacuanha emetic may be given, followed by a few grains of gray 
 powder, and a mild saline aperient, as the sulphate of magnesia, or its 
 effervescing citrate. A simple saline, as the citrate of potass, may 
 afterwards be continued every three or four hours, to each dose of 
 which four or five grains of the chlorate of potass should be added. 
 All this time, too, the child should be kept in bed, since it is of the 
 greatest moment to avoid all needless expenditure of the strength ; 
 while, though wine may at first be unnecessary, beef tea must be given 
 from the very first, and stimulants can seldom be long delayed. The 
 softness and feebleness of the pulse, indeed, almost always give, in 
 spite of the temporary heat of surface, plain intimation of the course 
 which we shall have to pursue ; and very often a shorter time than 
 twenty-four hours suffices to dissipate entirely the febrile symptoms 
 with which the disease set in, and to show it in its real characters. 
 
 I have already expressed my disbelief in the existence of any specific 
 remedy for diphtheria, though I have given, and am accustomed to 
 give, the tincture of the perchloride of iron in a large proportion of 
 cases. It has seemed to me to be a valuable medicine, but no more ; 
 and in my hands it has never vindicated its claims to those special 
 virtues for which some practitioners give it credit. I generally employ 
 it in combination with the chlorate of potass, giving about four grains 
 of that salt and eight minims of the tincture every four hours, to a 
 child five years old. I have never seen reason for believing that where 
 ordinary doses of a remedy fail, extraordinary doses will succeed ; and 
 when one physician talks of giving fifteen minims every quarter of an 
 hour, day and night, for seventy -two hours, I do not know whether to 
 marvel more at the endurance of the patient or the hardihood of the 
 doctor. 1 Iron has seemed to me in some instances to indispose the 
 patient for taking food, or to incapacitate the stomach for bearing it ; 
 and sometimes on this account, sometimes simply from its failing to 
 produce any good effect, I have discontinued it and had recourse in- 
 stead to quinine, with hydrochloric acid and tincture of bark ; and this 
 again has succeeded in some instances, and not succeeded in others. 
 
 In the great majority of instances, it must be confessed that the 
 employment of medicine has seemed of importance altogether subordi- 
 nate to the administration of food and stimulants; and children of 
 four years old have taken six ounces of port wine and one or two 
 ounces of brandy, for several days together, not only with manifest 
 advantage, but apparently as the only means by which life could be 
 maintained. When deglutition has been very difficult, or when, with- 
 out any absolute difficulty in swallowing, the patient has refused 
 nourishment, or the stomach has rejected it, I have had recourse to 
 
 1 Dr. Aubrun, in a communication to the Academie des Sciences at Paris, Nov. 
 20, 1860: reported, in the Journal f. Kinderkrankheiten, Jan. 1861, vol. xxxvi, 
 p. 141. 
 
TREATMENT OF DIPHTHERIA. 365 
 
 beef tea enemata with temporary advantage ; though in no instance 
 did a patient ultimately recover in whom vomiting, or indisposition to 
 take food, was other than a very transitory symptom. 
 
 Mention has been made of the scanty secretion of urine in some 
 cases of diphtheria, and of the excessive quantity of albumen which it 
 is then found to contain, as one of the gravest symptoms of the disease. 
 Dr. Wade 1 of Birmingham' — to whom we are indebted for pointing 
 out the structural changes in the kidneys which are found associated 
 with this condition of the urine, and which are in many instances ap- 
 parent even within the first three or four days from the commencement 
 of diphtheria — insists on the employment of the iodide and chlorate 
 of potass almost from the first, and on the administration of large 
 quantities of fluid, as infallible preventives of this danger, and indeed 
 of every other. There can be no doubt but that the quantity of the 
 urinary secretion may be greatly increased by drinking large quantities 
 of water, and that, in many instances, the absolute (not the merely 
 proportionate) quantity of albumen is simultaneously diminished to a 
 very considerable extent. It is, however, a very different thing to in- 
 duce a child of three years old, suffering from scarlatinal dropsy, to 
 drink a quart of water daily, from what it is to force upon it large 
 quantities of fluid, at a time when every attempt at deglutition pro- 
 duces intense pain, and when it taxes the attendants to the utmost to 
 induce the patient to swallow enough to maintain the flagging powers 
 of life. It is during the early stage of the disease, when deglutition is 
 commonly most difficult, and dangers from other sources are most 
 pressing, that the troubles of the urinary secretion are commonly en- 
 countered in their gravest forms. I have given the iodide of potassium 
 in these cases, just as I have given it in combination with other salines 
 in scarlatinal dropsy. I believe the remedy to be a serviceable one : 
 but I must at the same time add, that there seem to me to be few 
 things more injurious to the advancement of medical knowledge, than 
 the aphoristic dogmatism which enunciates a certain mode of treatment 
 as one in which "no instance of a fatal termination" is met with 
 "where it has been carried out." 
 
 Now and then a single dose of ipecacuanha, in the earlier stages of 
 the disease, has relieved the difficulty of deglutition where that was 
 troublesome ; but I have not observed any internal remedy check the 
 advance of croupal symptoms coming on in the course of diphtheria for 
 which tonic and stimulant measures had already been necessary. In 
 those instances in which the disease has announced itself almost from 
 the outset by croupal symptoms, I believe that the presence of false 
 membrane on the fauces should not betray us into any wide deviation 
 from that course of treatment which we should adopt in cases of primary 
 cynanche trachealis ; and the administration of emetics (though not of 
 antimonials) and the steady employment of mercurials, though the 
 patient may at the same time stand in need of support and stimulants, 
 have seemed to me of great moment. In these cases, however, even 
 
 1 In his essay, "Observations on Diphtheria," 8vo., London, 1858; and a sub- 
 sequent paper " On Diphtheria," piinted at Birmingham in 1863. 
 
366 DIPHTHERITIC CROUP 
 
 more than in those of inflammatory croup, the early performance of 
 tracheotomy has appeared to me to be indicated, so soon as remedies 
 ceased to tell on the symptoms of disordered respiration. 
 
 I do not know that there is any specific treatment which we can 
 recommend for the removal of the paralytic symptoms that succeed to 
 diphtheria. First of all, it is to be borne in mind that they have a ten- 
 dency to spontaneous subsidence with the lapse of time ; in the next 
 2)lace, the longer the interval between the acute stage of diphtheria and 
 the supervention of the paralytic symptoms, the less is in general their 
 gravity ; and thirdly, so long as the impaired power is limited to the 
 extremities, and to the mnscles of deglutition, we are warranted in 
 entertaining a favorable view of the case, which, however, is no longer 
 justified when either the muscles of respiration are involved, or the 
 action of the heart is disturbed. As a general rule, tonic remedies are 
 indicated ; and I have been accustomed to employ preparations of iron, 
 in combination with nux vomica, or strychnine. I have frequently 
 observed recovery to take place, slowly but steadily, under the use of 
 these means : I do not, however, know of any case in which the improve- 
 ment was so marked as to justify me in saying, that the remedies, inde- 
 pendent of the influence of time and of general hygienic measures, had 
 had an important share in producing it. 
 
 There is another form of disease, allied to diphtheria by many of its 
 characters, allied to cynanche laryngea by others, which presents itself 
 to us as a most dangerous complication of some other affection, almost 
 ahcays of measles. I was familiar with this, and described l it, at a time 
 when my acquaintance with genuine idiopathic diphtheria w r as very 
 slight and imperfect; and I reproduce my account of it here, because 
 in a few respects — as for instance in the ulcerative stomatitis, with 
 which it was associated — it differed from those forms of diphtheria with 
 which I have since become conversant. 
 
 This variety of croup seldom begins until the eruption of measles is 
 on the decline, or till the process of desquamation has commenced. Its 
 occurrence is most frequent from the third to the sixth day from the ap- 
 pearance of the eruption, but it oftener occurs at a later than at an earlier 
 period. It is sometimes attended with well-marked symptoms from the 
 very first; but it often happens that the character of the disease is masked 
 and its course insidious, and that the degree of suffering during life af- 
 fords no correct index to the amount of mischief which may be revealed by 
 a dissection after death. Of itself it is highly dangerous, and its hazard 
 is increased by the frequent coexistence with it of inflammation of the 
 lungs, which serves moreover to throw the symptoms of croup into the 
 shade. ^Yhen the laryngeal affection comes on three or four days after 
 the appearance of measles, its presence is usually betokened by much 
 more obvious symptoms than when it occurs after the lapse of a longer 
 period from the febrile attack. Sometimes, however, it develops itself 
 unnoticed simultaneously with the measles, and causes a fatal issue when 
 the medical attendant is least prepared to expect it. The child in such 
 cases is evidently more seriously ill than can be accounted for by the 
 
 1 Medical Gazette, Aug. 25, 1843. 
 
COMPLICATING MEASLES. 367 
 
 mere existence of measles; but he makes no definite complaint, neither 
 are there any obvious indications of the special suffering of any par- 
 ticular organ. There are considerable drowsiness, disinclination to 
 swallow, and reluctance to speak ; but the cough may be very slight, 
 and the respiration free from distinct croupy stridor, while the child 
 speaks in so low a tone that it is almost impossible to appreciate any 
 alteration of the voice. In such circumstances, the most careful obser- 
 vation is needed to avoid error. The loss of voice should of itself direct 
 attention to the state of the larynx ; the cry should be listened to atten- 
 tively, pressure should be made on the larynx, to ascertain whether 
 much tenderness exists, and examination of the fauces should never be 
 neglected. 
 
 But little less obscure, and of much more frequent occurrence, are 
 those instances in which the laryngeal affection attends the process of 
 desquamation. Recovery up to a certain point has probably gone on 
 well, when sometimes with, sometimes without an increase of the cough 
 and morbillous catarrh, the febrile symptoms become exacerbated and 
 the child droops again apparently without any adequate cause. Some- 
 times a loud sonorous cough, succeeded or accompanied by alteration of 
 the respiratory sounds, betrays the nature of the disease ; but at other 
 times there are no symptoms besides unusual drowsiness, reluctance to 
 speak, or alteration in the tone of the voice, with disinclination to swal- 
 low, or difficulty in the act of deglutition. In many instances deglu- 
 tition is scarcely at all impeded ; and I remember only one case in 
 which the difficulty of swallowing was so great that fluids returned by 
 the nose. But even though these symptoms be but slight, it will 
 usually be observed, on examining the mouth, that the gums have a 
 spongy appearance, or are actually ulcerated, that the tongue is preter- 
 naturally red and raw, and that small aphthous ulcers have formed 
 upon its edges and on the lining membrane of the mouth. The soft 
 palate will usually be seen to be red and swollen, and specks of false 
 membrane will be observed on the velum or tonsils. In such a case, if 
 it terminates fatally, the duration of life is very variable ; though the 
 disease, for the most part, runs a somewhat chronic course. The child's 
 strength declines daily, and emaciation makes rapid progress ; yet no 
 acute symptoms appear. There is great restlessness, and no posture 
 seems easy to the child ; or else it sits constantly upright in bed, dis- 
 tress and dyspnoea following any attempt to place it in the recumbent 
 position. The alteration of the voice is succeeded by complete aphonia; 
 the frequent hacking cough, which had previously caused much annoy- 
 ance, ceases altogether; and, although evidently thirsty, the child often 
 refuses drink, or swallows with difficulty. Diarrhoea, or pneumonia, 
 usually supervenes, and hastens death ; though in some instances exac- 
 erbation of the croupal symptoms, coupled with the increasing weak- 
 ness of the child, are the only causes of the fatal termination. 
 
 On examining after death the bodies of children who have died of 
 this affection, not only is the mucous membrane of the mouth found 
 inflamed and ulcerated, but the soft palate, fauces, epiglottis, and the 
 upper part of the pharynx are seen to be more or less intensely con- 
 
368 LARYNGITIS STRIDULA. 
 
 gested, and coated more or less extensively with false membrane. The 
 epiglottis is often ulcerated on both its surfaces, and partially coated 
 with false membrane; and the mucous membrane of the larynx is 
 generally eroded by numerous small ulcerations, as well as covered 
 with a similar deposit. I have in no instance observed false membrane 
 extending below the larynx; and although the trachea is usually con- 
 gested, sometimes intensely so, yet this is by no means of invariable 
 occurrence. Bronchitis and pneumonia, especially the latter, are fre- 
 quent complications of this affection. 
 
 The peculiar sound that characterizes the cough of croup, the stridor 
 of the respiration, and the urgent dyspnoea which attend the progress 
 of the disease, result, as I scarcely need remind you almost entirely 
 from the spasmodic action of the muscles of the larynx, and not from 
 the mechanical obstacle which the presence of false membrane offers to 
 the free admission or exit of air. We have seen that these symptoms 
 are, on the whole, less marked in cases where croup appears as a secon- 
 dary affection, and the larynx becomes involved by the extension to it 
 of disease beginning in the throat, than in those where the air-passages 
 themselves are primarily affected. Still they vary much, both in the 
 period of their occurrence and the degree of their severity, even in those 
 cases that most resemble each other ; and they bear no certain relation 
 to the intensity of the inflammation any more than to the amount of 
 the deposit of false membrane. The diversities in this respect depend 
 on constitutional peculiarity rather than on any essential differences in 
 the nature of the disease. 
 
 This view, indeed, is not taken by all writers, but some observers 
 of deservedly high repute — such, for instance, as M. Guersant 1 — have 
 conceived that there are differences" sufficient to warrant our placing in 
 a separate category those cases of croup which are marked by the pre- 
 dominance of spasmodic symptoms. They have proposed to designate 
 this form of the disease by the name of laryngitis stridula, to distinguish 
 it from ordinary croup, the laryngitis pseudo-membranacea. It was 
 doubtless the observation of some cases of this kind that led Dr. Millar, 2 
 more than a century ago, to describe under the name of the " acute 
 asthma' 7 a disease resembling croup in many respects, but presenting 
 a mixture of spasmodic and inflammatory symptoms — the former pre- 
 dominating at the commencement of the disease, the latter towards its 
 close. Dr. Millar appears, indeed, in some measure to have confounded 
 two very different affections, — the true spasmodic croup, or laryngismus 
 stridulus, with the inflammatory croup, or cynanche trachealis, under 
 the idea that they constituted the two stages of one disease. But never- 
 theless, cases are sometimes observed that bear a very close resemblance 
 to Millar's description, though no advantage seems to me likely to 
 arise from constituting a new species of croup out of a modification in 
 its symptoms produced by the idiosyncrasy of the patient. 
 
 In some children there is a greater tendency to spasmodic affections 
 
 1 In the article " Croup," in vol. ix of the 2d edition of the Dictionnaire de Mede- 
 cine, &c. Paris, 1835. 
 
 2 Observations on the Asthma and on the Hooping-cough, 8vo., London, 1769. 
 
SPASMODIC AFFECTIONS OF THE LARYNX. 369 
 
 than in others : in such the laryngeal nerves will take the alarm at the 
 very outset of the disease, and the paroxysms of dyspnoea will conse- 
 quently commence at an early stage, and will soon attain great inten- 
 sity, but may become masked by the permanent distress of breathing 
 to which the disease in its progress gives rise. In other instances, the 
 symptoms of inflammatory disease, and those of spasmodic disturbance, 
 may be so commingled, or may so alternate with each other, as to render 
 it hard to tell from which the child suffers most. This was the case 
 with a little boy, ten months old, who some years since came under my 
 care, suffering from what seemed at first to be Ordinary inflammatory 
 croup. The symptoms, though not very urgent, were plainly marked, 
 and the active employment of antimony soon dissipated them. During 
 the whole course of the disease, however, the child, who seemed highly 
 nervous and excitable, suffered from fits of dyspnoea far more severe 
 than could have been anticipated from the general mildness of the 
 attack, or than would have been supposed to exist by any one who had 
 seen the child only in the intervals of the paroxysm. The cough and 
 respiration had for forty-eight hours entirely lost all croupy character, 
 and nothing but catarrh seemed left behind ; wdien the child was sud- 
 denly seized with extreme difficulty of breathing, attended w T ith slight 
 croupy noise, and lay stiff in his nurse's arms with his thumbs draw T n 
 into the palms of his hands, and his great toe separated from the others. 
 Four-and-twenty hours had elapsed from the supervention of these new 
 symptoms before I was able to visit the child. He was then extremely 
 restless ; his face was flushed, his thumbs were drawn into the palms 
 of his hands and his feet w 7 ere forcibly extended ; his breathing was 
 labored, and attended with a hoarse croupy sound, which became still 
 more distinct whenever the child coughed. The bowels had not acted 
 for a couple of days ; but an hour after my visit some purgative medi- 
 cine, of which large doses had been given during the previous six or 
 eight hours, began to act, and produced three very copious evacuations, 
 with perfect relief to all his symptoms. The carpopedal contractions 
 disappeared, the respiration became easy, and the face ceased to be 
 flushed or anxious. The child slept well through the night, was cheer- 
 ful on the following day, and slight hoarseness attending his occasional 
 cough was the only remaining symptom. In a day or two that also 
 disappeared, and the child perfectly recovered. 
 
 The influence of that spasmodic element which enters so largely into 
 the production of the symptoms of cynanche trachealis, is seen in many 
 cases in the long persistence of a croupy sound with the cough, and in 
 its subsequent recurrence when a patient who has once had croup catches 
 cold. In these cases the nerves have doubtless not thoroughly recov- 
 ered from the effects of the previous inflammation. 
 
 Before closing this lecture, one or two additional illustrations may 
 be adduced of spasmodic affection of the larynx in connection with dis- 
 ease seated elsewhere j 1 though the remarks made at an early period of 
 the course, on spasm of the glottis as a frequent attendant on the con- 
 
 1 See Lecture xiii, p. 163. 
 24 
 
370 SPASMODIC AFFECTIONS OF THE LARYNX. 
 
 vulsive affections of infancy, must have made you thoroughly familiar 
 with its occurrence. 1 
 
 MM. Billiet and Barthez have described a spasmodic cough that 
 returns .in paroxysms, is loud, attended with an imperfect hoop, and 
 may be easily taken for hooping-cough by the inattentive observer. 
 It is, however, a symptom of bronchial phthisis, due to the extension 
 to the larynx of irritation seated in a distant part of the respiratory 
 organs. 
 
 Intestinal irritation is a frequent cause of nervous cough in child- 
 hood. It is sometimes a loud, solitary, ringing cough — the tussis 
 ovilla, tussis ferina of medical writers ; at other times it is a short dry 
 cough, attended with no particular inconvenience, but teasing from its 
 frequency. Both of these forms appear to result in many instances 
 from the presence of worms, and speedily cease under the judicious 
 employment of purgative medicines. 
 
 Lastly, I may once more remind you of the cough which is occasion- 
 ally heard in the early stage of inflammatory affections of the' brain. 
 It is a very short, hoarse cough, which sometimes continues for a few 
 minutes almost incessantly, then ceases for a time, and then, after a 
 pause, returns again. The disturbance of the brain is sympathized 
 with by the larynx, and the depletion which relieves the former organ 
 removes the irritation of the latter. 
 
 1 There is a form of spasmodic affection of the larynx, which, under the name of 
 Thymic Asthma, has attracted considerahle attention among Continental writers, 
 though my own experience concerning it is confined to a single case which I observed 
 many years ago. The spasm of the glottis, which is the most prominent symptom 
 in this affection, is supposed to be due to the pressure of the hypertrophied thymus 
 on the larynx, and the consequent irritation of its nerves. 
 
 The essay of Haugsted — Thymi in homine, etc. : descriptio anatomica, pathologica 
 et physiologica, 8vo., Hafnise, 1832 — may be consulted with advantage by any one 
 desirous of becoming thoroughly acquainted with the subject. I owe to Professor 
 Gairdner, of Glasgow, the obligation of his having directed my attention, in a note 
 at p. 263 of his Lectures on Clinical Medicine, by which he has left all members of 
 our profession largely his debtors ; to the memoir by Dr. Hood, of Kilmarnock, on 
 Spasm of the Glottis from enlarged Thymus, published in the Edinburgh Medical 
 Journal for January, 1827. He "who proves, discovers," is an old adage, but a 
 true one ; I am glad that it should find a fresh verification, as in Dr. Hood's case, 
 among our northern countrymen. 
 
SYMPTOMS OF HOOPING-COUGH. 371 
 
 LECTURE XXVI. 
 
 Hoopixg-Cough. — Course of the disease in its simplest form — Subject to great 
 variations in its mode of onset and degree of severity — Signification of the 
 hoop — Course of the disease when declining — Its danger depends on its com- 
 plications — Complication with bronchitis — At its outset, or when it has con- 
 tinued for some time — Complication with disorder of the nervous system — 
 Sometimes exists from the first, and causes death even before characters of dis- 
 ease are fully developed — But ma}' come on at any period — Various forms 
 assumed by disorder of nervous system — Great danger when paroxysms of 
 cough terminate in convulsions — Caution as to nervous character of dyspnoea in 
 many cases, and as to danger of overtreating it — Tubercular meningitis rare as 
 a complication. 
 
 We pass next to the study of one of the most common disorders of 
 childhood. Few persons attain to adult age without having experi- 
 enced an attack of hooping-cough, and still fewer of those who escape 
 it when children suffer from it in after-life. 
 
 Hooping-cough, then, claims our notice as being essentially a dis- 
 ease of early life ; bat as it is one which almost every old woman pro- 
 fesses to cure, we might fairly expect not to be detained long with its 
 study. We find, however, that in this metropolis it ranks fourth 
 among the causes of death under five years of age ; inflammation of the 
 lungs, convulsions, and tubercular meningitis being the only more 
 fatal ailments. Nor do these facts adequately represent its importance ; 
 for it is alleged to be the most fatal of all the diseases of early infancy ; 
 while 68 per cent, of the total deaths which it occasions take place in 
 children under the age of two years. 1 A cursory inquiry will not 
 suffice to make us thoroughly acquainted with all points of importance 
 in the history of a disease that has so many victims. 
 
 The affection in its simplest form consists of a cough of spasmodic 
 character, that usually succeeds to catarrhal symptoms, and having re- 
 curred at intervals for a few weeks, ceases without having occasioned any 
 serious disturbance of the general health, or having required any active 
 medical treatment. In its graver forms it is one of the most fearful 
 diseases that we ever have to encounter, often keeping the life of the 
 patient for days or weeks together in almost constant jeopardy, liable 
 to be exaggerated by the most trivial cause, or rendered fatal by the 
 slightest error in treatment ; while the highest effort of our art is 
 limited to mitigating the severity and warding off the urgent danger 
 of symptoms which we are unable wholly to subdue, and which we 
 must trust to time and nature thoroughly to cure. 
 
 Such great differences in the course of the disease in different cases 
 have given rise to many ingenious theories as to its nature and seat, 
 framed with the view of explaining that which cannot but strike all 
 
 1 Dr. E. Smith, in Keynolds's System of Medicine, vol. i, 2d ed., 1870, p. 53. 
 
372 COURSE OF THE DISEASE IN ITS SIMPLEST FORM. 
 
 observers as so enigmatical in its character. None of these speculations, 
 however, have led to any useful practical result, and we shall be better 
 employed than in their study, if we confine ourselves to the simple 
 observation of the phenomena of the disease. In doing this, we w T ill 
 begin with those cases in which it is most simple and least perilous, and 
 will then examine in succession the different modes in which its course 
 becomes complicated and dangerous. 
 
 An attack of hooping-cough usually begins with catarrh, and pre- 
 sents at first little or nothing to distinguish it from a common cold, 
 except that at sometimes the cough is attended almost from the outset 
 with a peculiar ringing sound. By degrees the catarrhal symptoms 
 abate, and the slight disturbance of the child's health altogether ceases, 
 but nevertheless the cough continues ; it grows louder and lasts longer 
 than before, and assumes something of a suffocative character, in all of 
 which respects a tendency to exacerbation towards night becomes early 
 apparent. As the cough grows severer, its peculiarities become more 
 and more manifest; during each paroxysm the child turns red in the 
 face, and its whole frame is shaken with the violence of the cough. 
 Each fit of coughing is now made up of a number of short, hurried 
 expirations, so forcible, and succeeding each other with such rapidity, 
 that the lungs are emptied, to a great degree, of air, and the child is 
 brought by their continuance into a condition of impending suffocation. 
 At length the child draws breath with a long, loud, sonorous inspira- 
 tion — the hoop from which the disease derives its name — and the attack 
 sometimes terminates. More often, however, the hoop is followed by 
 but a momentary pause, and the hurried expiratory efforts begin again, 
 and are again arrested by the loud inspiration — perhaps only to recom- 
 mence; until, after the abundant expectoration of glairy mucus, or 
 retching, or actual vomiting, free inspiration takes place, and quiet- 
 breathing by degrees returns. If you listen to the chest during a fit of 
 hooping-cough you will hear no sound whatever in the lungs ; but when 
 the hoop occurs, you will once more perceive air entering, though not 
 penetrating into the minuter bronchi. It is not till the fit is over, and 
 respiration once more goes on quietly, that the air reaches the pulmonary 
 cells again ; but then you will hear vesicular murmur as clear as if 
 nothing ailed the child, or at most interrupted only by a little rhonchus, 
 or by slight mucous rale. If the cough is severe, quiet breathing does 
 not return, nor the vesicular murmur become audible, till some time 
 after the paroxysm is over ; and occasionally, short and laborious respi- 
 ration ushers in each fit of coughing. The child then seems to have a 
 presentiment of the coming seizure ; its face grows anxious, it looks up 
 at its mother, and clings more closely to her ; or, if old enough to run 
 about, you may observe it, even before its breathing has become mani- 
 festly affected, throw down its playthings, and hasten to seize hold of a 
 chair, or of some article of furniture, for support during the approach- 
 ing fit of coughing. 
 
 If the case is uncomplicated, even though the attack be severe, the 
 child's health continues good, and little or nothing ails it during the 
 intervals of the cough. Its appetite is" not impaired, but after throw- 
 ing up the contents of the stomach in a fit of coughing, it asks for food 
 
DURATION OF THE CATARRHAL STAGE OP HOOPING-COUGH. 373 
 
 almost immediately. It sleeps soundly, except when roused by the 
 cough ; the bowels act regularly, or are perhaps a little constipated, and 
 slight complaint of headache or languor, with loss of the usual cheerful- 
 ness, are often all the permanent ill effects to be discerned between the 
 seizures. 
 
 After the hoop has been heard, the disease goes on for about a week 
 to increase in severity, the cough becoming more frequent, its paroxysms 
 severer and more suffocating, and attended with more frequent hoop. 
 After remaining stationary for ten days or a fortnight, it begins to 
 decline ; and one of the first indications of this is usually afforded by a 
 diminution in the severity of the nocturnal exacerbations. We next 
 find, either that the fits of coughing are less frequent, or, though they 
 should occur as often as before, yet they are less severe and sometimes 
 cease without the occurrence of a hoop. When on the decline, however, 
 exposure to cold, neglect of the state of the bowels, or mental excite- 
 ment, will suffice in many cases to bring back the hoop, and to increase 
 the previously diminished severity of the attack. For the most part, 
 the cough loses its spasmodic character for many days before it ceases 
 altogether ; and you may even find a child, otherwise in good health, 
 who, some six weeks after an attack of hooping-cough, still has occa- 
 sional returns of cough, which a slight cause would once more convert 
 into an ailment with all the characters of fully developed pertussis. 
 
 Such is the ordinary course of the disease in those cases in which 
 it is unattended by any complication, and does not give rise to any 
 formidable symptom, but issues in the complete recovery of the patient. 
 But even in favorable cases its course is often variously modified, while 
 these modifications derive additional importance from frequently be- 
 tokening or accompanying some of those serious complications to which 
 the danger of the disease is almost exclusively due. 
 
 The average duration of the catarrhal stage of hooping-cough, as 
 deduced from a comparison of fifty-five' cases, in which the date of the 
 occurrence of the first distinct hoop was ascertained, was 12.7 days. 
 In nineteen of these cases the first hoop was heard within seven days 
 from the commencement of the catarrhal symptoms, and in nineteen 
 more cases during the succeeding seven days ; but the extreme limits 
 of the duration of the premonitory stage are very wide apart, since on 
 one occasion it lasted only tw T o days, and on another thirty-five days. 
 
 But there are many other respects in w T hich the mode of onset of 
 hooping-cough varies, as is clearly shown by the following facts : 
 
 In fifty-five cases the average duration of the catarrhal stage was 
 12.7 days; the extremes being 2 and 35 days. In eighteen cases the 
 catarrhal stage lasted on the average only 8.3 days, when the cough 
 assumed a distinctly paroxysmal character ; but no hoop occurred till 
 the fifteenth day. In four cases, after the catarrhal stage had lasted on 
 the average 11.5 days, the cough became paroxysmal, but no hoop 
 occurred during the whole course of the affection. In one case the 
 cough had a distinctly paroxysmal character from the first, but no hoop 
 occurred during the whole course of the affection. In six cases the 
 cough was paroxysmal from the outset, and continued so on the aver- 
 age 9.3 days, at the end of which time distinct hoop accompanied it.. 
 
374 VARIATIONS IN THE MODE OF ONSET OF HOOPING-COUGH. 
 
 In three cases a distinct hoop attended the cough from the very com- 
 mencement. 
 
 Some of these may be merely accidental differences, but I believe 
 that most of them are by no means unimportant, and that they depend 
 on causes with which a little observation will make you acquainted. 
 My excuse, indeed, for bringing before you such dry detail with refer- 
 ence to hooping-cough, is, that there is scarcely any other disease of 
 early life concerning which we are so much in want of definite facts. 
 Its general features are so obvious, that persons have not observed with 
 equal care those less striking characters which yet are of much mo- 
 ment, as affording sure grounds for prognosis, and trustworthy indica- 
 tions for the guidance of treatment. 
 
 Unusual protraction of the catarrhal stage of hooping-cough is, I 
 believe, usually met with either at the commencement of an epidemic 
 of the disease, or towards its close. Epidemic hooping-cough very fre- 
 quently succeeds to epidemic catarrh ; the former disease becoming 
 gradually developed out of the latter, and the pesistence of cough in 
 several cases, long after the decline of all other indications of catarrh, 
 is often one of the first signs of the commencement of an epidemic of 
 hooping-cough. The characters of hooping-cough, like those of other 
 epidemic diseases, often become less marked towards the decline of its 
 prevalence, and we then meet with cases in which catarrhal symptoms 
 continue long, while the paroxysms of cough are slight, and the hoop 
 occurs very seldom and not severely. It may be laid down as a general 
 rule, that those cases in which the catarrhal stage is of long continu- 
 ance seldom become severe during their subsequent progress, and the 
 same holds good with reference to the majority of those cases in which 
 the hoop does -not come on until after the cough has for some time 
 assumed a paroxysmal character. There are, however, some instances, 
 which we shall hereafter have to notice, where the long duration of the 
 paroxysmal and suffocative character of the cough, unattended by any 
 hoop, is a sign of the peculiar intensity of the disease, rather than of 
 its mildness ; on the other hand, the preternatural shortness of the 
 catarrhal stage, or its total absence, is not of itself any proof that the 
 disease will be more than usually severe. It is usually observed in 
 very young children, who, as I have already told you, are but little 
 liable to catarrhal affections, and who are not so often attacked by 
 hooping-cough as those who are older. Sometimes, however, when 
 other children in the same family are suffering from it, they contract 
 the disease apparently by contagion, and in that case it frequently 
 happens that no purely catarrhal symptoms precede it, but that the 
 cough from the first presents a paroxysmal character, and soon becomes 
 attended with a distinct hoop. 
 
 Instead of coming on with catarrh of moderate intensity, hooping- 
 cough sometimes sets in with great fever, dyspnoea, and many symp- 
 toms of severe bronchitis ; though the results of auscultation do not 
 indicate such serious disease as, judging from the amount of constitu- 
 tional disturbance, we should expect to discover. In such cases, it is 
 only on the subsidence of the acute symptoms, which usually give way 
 speedily under treatment, that the real nature of the disease becomes 
 
PROGRESS OF AN ATTACK. 375 
 
 apparent. We then observe, however, that while the child in all other 
 respects improves, the cough continues unabated, that it soon grows 
 more severe, returning in paroxysms, and being attended before long 
 by the characteristic hoop. Besides these cases there are others, though 
 much less common, in which, though the catarrhal symptoms are not 
 unusually severe, the child yet has paroxysms of dyspnoea, which gen- 
 erally come on at night, and may excite much apprehension on the 
 part of the parents. The attacks do not appear to be induced by any 
 previous fit of coughing, and after lasting from half an hour to an 
 hour they pass off of their own accord, leaving the child free for many 
 hours together, and probably not returning until the following night. 
 While the child continues subject to them, auscultation discovers no 
 sign of serious mischief in the lungs ; but in proportion as the parox- 
 ysms of the cough increase in distinctness, and the hoop becomes 
 established, the fits of dyspnoea diminish, and in the course of a few 
 days entirely disappear. 
 
 Some days usually elapse after the general characters of the disease 
 have become well marked, before it reaches its acme, and during this 
 time its nocturnal paroxysms generally increase in a greater ratio, both 
 as to frequency and severity, than those which occur by day. Such, at 
 least, was the course of the disease in thirty-eight out of forty-seven 
 cases in which this point was especially noticed. The nocturnal ex- 
 acerbation is sometimes so marked, that the fits of coughing are not 
 only severer, but are actually more numerous by night-time than by 
 day. In very mild cases of hooping-cough there is but little difference 
 between the frequency and severity of the paroxysms at night-time and 
 by day ; and in other instances, while the child rests quietly through 
 the greater part of the night; there is yet a marked aggravation of the 
 cough on first lying down at night, and on first waking in the morning. 
 When the exacerbations occur at those two periods, the evening ex- 
 acerbation is often induced by the child being removed to a bed-room 
 less warm than the apartment in which it spends the day, while the 
 morning attack results from the accumulation of mucus in the bronchi 
 during the hours of sleep. 
 
 Neither of these causes, however, is the sole occasion of the increased 
 severity of the disease at night, nor is the occurrence peculiar to hoop- 
 ing-cough, but is observed also in asthma, and in many other affections 
 of the respiratory organs in adults. The severity of the nocturnal 
 paroxysms is often a very good criterion of the general severity of the 
 disease ; and any exacerbation of the disease is usually attended with 
 special increase of the nocturnal paroxysms, and not merely by more 
 frequent coughing and hooping, but likewise by a marked increase of 
 dyspnoea. On the other hand, a diminution of the nocturnal exacerba- 
 tions is one of the most frequent indications that the disease has begun 
 to lose something of its previous severity, and the cough often ceases- 
 entirely at night for some time before it disappears completely during 
 the daytime. 
 
 Cough, preceded by catarrhal symptoms, aggravated in paroxysms, 
 assuming a suffocative character, and attended with a peculiar sonorous 
 inspiration called a hoop, were said to be the characteristics of this dis- 
 
376 CAUSE OF THE HOOP WHICH ATTENDS FITS OF COUGHING. 
 
 ease. The last two of these phenomena are the special results of the 
 nervous element which goes to make up the very compound character of 
 hooping-cough. Hence, in those cases which are very mild, there is so 
 little spasm of the glottis, that air enters freely when the child draws 
 breath after a fit of coughing, and the hoop is occasional and faint, 
 while it is still more seldom that the cough displays that suffocative 
 character which, when severe, constitutes one of its most formidable 
 peculiarities. 
 
 None of the phenomena of this disease call for such close observation, 
 as the hoop from which it derives its name. Its occurrence indicates 
 on the one hand the existence of spasm of the glottis ; and hence in 
 those cases which are very slight it takes place but seldom, while it 
 hardly ever comes on until the disease has lasted a certain time, and 
 acquired a certain degree of intensity. It shows, however, on the other 
 hand, that air* does enter when the child endeavors to inspire, and, 
 therefore, in cases of severe hooping-cough, a loud, long-drawn, sonor- 
 ous hoop, instead of adding to our apprehension, tends rather to quiet 
 it, for it assures us that the spasm does not amount to actual closure of 
 the glottis, and that, for this time at least, the child will not choke in 
 the fit of coughing. I have already mentioned to you that the noc- 
 turnal dyspnoea which excites anxiety in some cases while hooping- 
 cough is coming on, may disappear altogether when the disease has 
 assumed its regular type, and the hoop has become loud and distinct. 
 Just in the same way, the violent suffocative character of the paroxysm 
 often abates, the fits of coughing become fewer, and the dyspnoea grows 
 less urgent, after the hoop has become developed. 
 
 But, if the disease should increase in severity, cough comes on more 
 frequently, and the paroxysms are of longer continuance, so that the 
 face grows quite livid before they pass away, the lips become purple, 
 the eyes seem starting from their sockets, as in a person who is being 
 strangled. Some of the small vessels give way, and ecchymosis more 
 or less extensive takes place beneath the conjunctivae; or blood bursts 
 forth from the back of the throat, or tinges the mucus which at last is 
 expectorated from the air-tubes, or is rejected by vomiting from the 
 stomach. The pauses in the fit are now no longer marked by the so- 
 norous hoop, but after a momentary cessation, the cough recommences ; 
 and though when at length the attack passes off a hoop is heard, it is 
 t more striclulous than it used to be, though not so loud. Each paroxysm 
 of cough is now preceded and followed by marked dyspnoea, and the 
 child has scarcely recovered from one attack before another comes on. 
 The hoop now sometimes disappears altogether, or is very occasional, 
 very short, and suppressed ; and then the cough itself loses its former 
 character ; the child dreads its approach much and tries to suppress it, 
 but in vain ; the whole frame labors with the convulsive efforts, but no 
 sound is produced ; the larynx is now completely closed ; violent, but 
 fruitless, expiratory efforts are made, as in some of the worst cases of 
 spasmodic croup, till general convulsions come on ; or at length the 
 spasmodic constriction yields, and the attempt at expiration is success- 
 ful. The spasm over, the child once more draws breath, but it seems 
 quite exhausted by the violence of the struggle ; while sometimes before 
 
VARIATIONS IN THE DISTINCTNESS OF THE HOOP. 377 
 
 it has recovered from this seizure, another, and then another, succeeds, 
 till one at length proves fatal. 
 
 "When the disease has approached to this degree of intensity, we 
 should rejoice to hear the loud, long hoop again, which would be a 
 sure token of some diminution in the suffocative character of the cough. 
 We should next find that as the hoop regained its former character, 
 those more numerous but less distinct efforts, which the child had made 
 before, would be merged in the single prolonged inspiration. The 
 dyspnoea would next diminish, and then the severity of each paroxysm 
 would grow less ; and then they would not recur so often, and the hoop 
 would be less loud and the night attacks less frequent. If amendment 
 were to continue, the attacks would become more brief, and they would 
 sometimes pass off without any hoop, while the mucous expectoration 
 would become more copious ; next the hoop would altogether cease, but 
 the cough would continue to recur in paroxysms, and to* present some- 
 thing of its old suffocative character ; and then this too would cease, 
 though cough might still continue for a time longer. 
 
 The variations in the course of hooping-cough which I have now 
 described, depend for the most part either'on the greater or less inten- 
 sity of the disease, or on some idiosyncrasy of the patient, or on some 
 peculiarity in the epidemic constitution of the year. There are, how- 
 ever, other, and some of them much more important changes in its 
 symptoms and its course, which result from hooping-cough becoming 
 complicated with another disease. Of these complications, by far the 
 most frequent and most perilous are those which it presents with bron- 
 chitis and pneumonia on the one hand ; and with convulsions, con- 
 gestion of the brain, or tubercular meningitis, on the other. Their 
 importance, too, is greatly increased by there being no period of the 
 disease to which w T e can look as bringing with it any immunity from 
 either; but, from the commencement of the cough to its complete dis- 
 appearance, we are at any moment exposed to the risk of disease, either 
 of the lungs or of the brain, converting a trivial into a most formidable 
 affection. 1 
 
 1 Of 35 children who died of hooping-cough under my care, 17 perished in conse- 
 quence of the supervention of bronchitis or pneumonia ; 18 from congestion of the 
 brain, from convulsions coming on in a fit of coughing, or from tubercular menin- 
 gitis. 
 
 -Reckoning the commencement of the disease from the first distinct hoop, or first 
 appearance of a well-marked paroxysmal character of the cough, it appears that of 
 31 cases in which this point was noted — 
 
 ying throi 
 
 gh 
 
 Dying through 
 
 
 the lungs 
 
 
 the brain. 
 
 Total. 
 
 
 
 
 1 
 
 1 
 
 2 
 
 . 
 
 4 
 
 6 
 
 2 
 
 
 3 
 
 5 
 
 
 
 , 
 
 2 
 
 2 
 
 1 
 
 . 
 
 1 
 
 2 
 
 2 
 
 . 
 
 
 
 2 
 
 3 
 
 
 3 
 
 6 
 
 1 
 
 
 1 
 
 2 
 
 4 
 
 . 
 
 1 
 
 5 
 
 Dying within 
 
 7 da} r s. 
 
 14 " 
 
 21 « 
 
 28 " 
 
 5 weeks. 
 
 6 " 
 
 7 " 
 
 8 " 
 
 from 8 weeks 
 
 to 3 months. 
 
 15 16 % ' 31 
 
378 COMPLICATIONS OF HOOPING-COUGH: 
 
 The circumstances in which hooping-cough becomes associated with 
 other affections of the respiratory organs are very various. Sometimes, 
 as I have already mentioned, rather severe bronchitic symptoms, fre- 
 quent short cough, and considerable dyspnoea, precede the full develop- 
 ment of the disease. This occurrence is oftenest met with at the com- 
 mencement of epidemics of hooping-cough, or in children the mucous 
 membrane of whose air-tubes may be supposed to have acquired a 
 peculiar susceptibility from many previous bronchitic seizures. On the 
 whole, however, these are not the cases which need excite our greatest 
 solicitude, for the constitutional symptoms, which are generally out of 
 all proportion to the amount of the local mischief, usually subside in 
 the course of a few days, just as we often observe to be the case with 
 epidemic influenza in the adult; and as the characteristic cough and 
 hoop come on, all cause for anxiety disappears. 
 
 Those cases are in general much more serious in which the symp- 
 toms of bronchitis or pneumonia come on after the cough has assumed 
 the characters of hooping-cough. This complication sometimes occurs 
 very early in the course of the disease, and then the bronchitis and hoop- 
 ing-cough appear to be developed almost simultaneously. For a day or 
 two, perhaps, a hoop has been heard accompanying the cough at inter- 
 vals, and nothing has appeared to indicate that the attack will be 
 unusually severe, when all the symptoms suddenly become very much 
 aggravated ; the skin grows hot ; the respiration and pulse become 
 very much hurried, and this increase in their frequency is permanent, 
 though much greater at one time than at another. The cough at the 
 same time becomes more frequent and more severe, and the hoop is 
 more violent, but the cough is almost entirely unattended with expecto- 
 ration, or if a little mucus is spit up it is almost always streaked with 
 blood. Though very violent, the fits of coughing are not very long, 
 and they seldom or never end with vomiting. The ear detects mucous 
 rale through nearly the whole of both lungs : on a deep inspiration still 
 smaller sounds are heard, for inflammation has attacked the minuter 
 air-tubes ; and the case is one of hoopiug-cough complicated with 
 capillary bronchitis. 
 
 Supposing the disease to continue, the cough will often in a day or 
 two lose its characteristic hoop, an occurrence which you will likewise 
 observe in the course of many other intercurrent febrile or inflamma- 
 tory affections that may supervene during an attack of hooping-cough. 
 The cough, too, may become less frequent, or may lose its paroxysmal 
 character, though it will still appear to cause much suffering. The 
 respiration will increase in frequency, the child constantly laboring for 
 breath, and being distressed by the slightest movement, since that 
 adds to its dyspnoea. In one little child two years old, the inspira- 
 tions two days before her death were 130 in the minute, and then on 
 the following clay they sank to 80 : but her feet were now cold, her 
 face was livid, and her pulse very feeble. It was she of whose lungs 
 I showed the drawing some days since, illustrative of vesicular bron- 
 chitis : and her case might be taken as a type of those in which acute 
 bronchitis comes on at an early stage of hooping-cough. 
 
 Death takes place more speedily in* cases of this kind than under 
 
BRONCHITIS — PNEUMONIA. 379 
 
 any other form of affection of the lungs which comes on in the course 
 of hooping-cough. I have seen a child die on the sixth day from the 
 first appearance of any indication that the disease was other than a 
 very mild attack of hooping-congh. It will not surprise you that the 
 fatal event should take place so speedily, if you bear in mind that 
 after death we discover either intense injection, even of the smaller 
 bronchi, with copious effusion of pus into their cavities, or very exten- 
 sive vesicular bronchitis, or both conditions together. 
 
 But it is not only at the outset of an attack of hooping-cough that 
 we encounter the danger of its becoming complicated with other disease 
 of the lungs. Exposure to cold, or damp, may at almost any time 
 induce an exacerbation of the cough, or a distinct attack of bronchitis. 
 If, however, the disease has already lasted for some ten days or a fort- 
 night, without having presented any grave features, such intercurrent 
 bronchitic seizures are usually very tractable. 
 
 As a general rule, those cases have appeared to me to be far more 
 serious in which bronchitic symptoms become developed of their own 
 accord out of severe hooping-cough. In such cases there has usually 
 been a gradual increase in the child's sufferings ; the cough growing- 
 more frequent, and, though not more violent, yet evidently occasioning 
 the child greater suffering while the hoop is unchanged in its character. 
 At the same time the child seems overwhelmed by the disease ; its face 
 is anxious and puffed, the eyes are much suffused, the skin usually dry 
 and hot ; dyspnoea is no longer confined to the periods just before and 
 just after a fit of coughing, but the respiration is habitually wheezing, 
 hurried, and rather irregular. The ear, at the same time, detects 
 mucous or subcrepitant rale through the whole of both lungs. Such 
 cases are seldom very rapid in their course. The symptoms, after ex- 
 citing our solicitude for a week, ten days, or a fortnight, may gradually 
 abate in severity, and the disease may run the remainder of its course 
 slowly, but safely. If the case should have an unfavorable issue, 
 this sometimes takes place speedily, owing to the supervention of cere- 
 bral symptoms ; and the child then dies during a paroxysm of cough- 
 ing. Or the minute bronchi may become involved in the inflammatory 
 mischief; the case may assume the characters of pneumonia, and bron- 
 chial breathing and dulness on percussion may reveal during the pa- 
 tient's lifetime the nature of the mischief which will be disclosed on an 
 examination after death. 
 
 In a still more numerous class of cases, the disease retains its chronic 
 character to the last, and presents little or no variation from day to 
 day. The violence of the cough, and the frequency of its return, some- 
 times continue unabated, though often they undergo a marked diminu- 
 tion. The respiration grows more hurried than before, the fever 
 becomes exacerbated, and the emaciation extreme; while the child's 
 strength is still more enfeebled by the supervention of a troublesome 
 diarrhoea, which no remedies are adequate to restrain. Death at length 
 takes place, sometimes from pure exhaustion ; and the transition from 
 sleep to death is so gentle as to be almost imperceptible. At other 
 times an increase of the symptoms of bronchitis or pneumonia becomes 
 apparent £or two or three days previously ; or in other cases the child 
 
380 COMPLICATIONS OF HOOPING-COUGH 
 
 dies exhausted in a fit of coughing, or convulsions take place a few 
 hours before death, and the patient dies convulsed or comatose. 
 
 The complication of hooping-cough with serious disorder of the nervous 
 system is almost as frequent as its association with grave mischief in 
 the lungs and air-tubes, and even more dangerous and perplexing. 
 Hazard from this source attends alike the onset of the disease, its acme, 
 and decline; aDd the mode in which the danger presents itself is no 
 less variable than are the seasons of its occurrence. The nervous sys- 
 tem sometimes suffers so severely from the very first, that death takes 
 place almost before the disease has had time to assume its usual char- 
 acters. At other times hooping-cough comes on naturally; its two 
 elements, the bronchitic and the nervous (if I may be allowed the ex- 
 pression), 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. 
 
 Danger from this cause sometimes assumes the form of simple con- 
 gestion of the brain ; drowsiness is followed by convulsions, and these 
 are succeeded by fatal coma. In other instances the spinal system of 
 nerves becomes excited to more tumultuous reaction ; and carpopedal 
 contractions, and attacks of spasm of the glottis, are superadded to fre- 
 quently recurring general convulsions ; while in some cases the long 
 continuance of hooping-cough gives rise to the development of tuber- 
 cular meningitis. The time will not be lost that we may spend in the 
 examination of each of these various modes in which hooping-cough 
 becomes complicated with disorder of the nervous system. 
 
 In very young children, and in those in whom the process of denti- 
 tion is still going on at the time of their becoming aiFected with hoop- 
 ing-cough, the symptoms of disturbance of the nervous system are 
 sometimes formidable even from the outset. In such cases the prelimi- 
 nary catarrh is usually of short duration, and the cough, though not very 
 frequent, yet assumes a paroxysmal character almost from the first. Each 
 fit of coughing is extremely violent and suffocative ; it lasts for several 
 minutes, is not attended by any distinct hoop, nor folloAved by vomiting, 
 but ceases apparently from the child being too exhausted to make any 
 further effort. In the intervals of the cough the face is flushed, the 
 eyes are suffused, and the child is very drowsy, and averse to being 
 disturbed — a condition which is manifestly increased by each paroxysm 
 of coughing. When the cough comes on, the flush of the face deepens 
 to a livid hue, the pupils become dilated, convulsions seem impending 
 and at length come on, and though but of short continuance, yet they 
 often leave the child in a state of profound stupor. This condition 
 seldom lasts long : sometimes the effort at coughing brings on a fatal 
 convulsive seizure, at other times the cough does not return, but con- 
 vulsions recur independently of it, and in twenty-four or thirty-six 
 hours from their first occurrence the child dies. 
 
WITH DISORDERS OF THE NERVOUS SYSTEM. 381 
 
 No cases of hooping-cough run so surely or so speedily as these to a 
 fatal termination, which even the most judicious treatment will often 
 fail to prevent. I«have seen death take place in less than a week from 
 the commencement of the cough, and have known several instances of 
 its occurrence long before the lapse of a fortnight. 
 
 The fact that the cough has run its course naturally up to a certain 
 point affords, however, no guarantee against the supervention of a dan- 
 ger similar to that which we have just been contemplating. It is in- 
 deed but seldom that any case which for the first ten days or fortnight 
 has been mild in character, afterwards presents these alarming symp- 
 toms of cerebral disturbance ; for in most instances the cough will have 
 been severe from the commencement, the paroxysms frequent and of 
 long continuance, the hoop loud, each attack terminating with vomit- 
 ing, and the return of each being much dreaded by the child. In all 
 this, however, there is nothing to direct special attention to the head, 
 and the approach of the new danger is not always very obvious. Some- 
 times the first indication that the head suffers is afforded by the increased 
 irritability of the stomach, which becomes almost unable to retain food 
 or drink. And here let me urge upon you the importance of duly 
 estimating the signification of this symptom. Vomiting, independent 
 of the fits of coughing, if it persists for above twenty-four hours, and 
 is not referable to the remedies you are employing, nor connected with 
 obvious gastric disorder, should always excite your solicitude, and 
 direct your attention most anxiously to the head. 
 
 At other times, either in connection with this irritability of the 
 stomach, or even independently of it, the child is observed to become 
 daily more heavy and drowsy, and averse to movement ; complaining 
 of headache if able to talk, and appearing overwhelmed by the disease 
 to a greater degree than can be accounted for either by the severity of 
 the paroxysms or by the frequency of their recurrence. This condi- 
 tion is generally succeeded by aggravation of the dyspnoea both before 
 and after each fit of coughing, the respiration sometimes not regaining 
 its proper frequency during the interval between their return, though 
 auscultation fails to detect any adequate cause for this hurried breath- 
 ing. In some instances the hoop still continues as loud as before ; but 
 if that be the case, the cough grows harder, and hardly any mucus is 
 expectorated ; while streaks of blood are seen in the matters rejected 
 by vomiting. It happens more frequently, however, that these symp- 
 toms are associated with a more or less complete suppression of the 
 hoop ; the cough losing something of its distinctly paroxysmal char- 
 acter, but becoming more suffocative ; the child, on each occasion of 
 its return, vainly striying to suppress it. A convulsive seizure now, 
 in some cases, supervenes on an erfort to cough, and in this the child 
 expires; or the fatal convulsion may come on to all appearance cause- 
 lessly ; or, more frequently, the first convulsion does not occasion 
 death, but it leaves the child in a comatose condition, Avhich is inter- 
 rupted by the frequent return of convulsions, one of which at length 
 proves fatal. 
 
 It happens sometimes that children who are laboring under severe 
 
382 COMPLICATIONS OF HOOPING-COUGH 
 
 hooping-cough are suddenly seized, during a paroxysm of coughing, 
 with a fit of convulsions ; and they may die in this fit, even though 
 they had not previously seemed to suffer from any serious disorder of 
 the nervous system. Death in such cases takes place as the result of 
 spasmodic closure of the larynx, and consequent congestion of the 
 brain ; you watch for a few moments the fruitless expiratory efforts of 
 the child, and then all is over, just as in many fatal cases of spasmodic 
 croup. The relation between hooping-cough and spasmodic croup, 
 indeed, is sometimes very apparent ; and you may observe, after some 
 unusually violent fit of coughing, the thumbs drawn into the palms, the 
 hand flexed upon the wrist, or the great toe drawn apart from the others. 
 At first, probably, the symptoms will be slight, and will soon pass away ; 
 but their import is most serious. You will expect soon to see other and 
 graver indications of the disturbance of the nervous system — if, indeed, 
 they are not already present. It is especially in cases of this sort that 
 you will observe a degree of dyspnoea which you cannot explain ; and 
 that the child will seem to make the most violent efforts to suppress 
 the cough — efforts which are really involuntary, and are the result of 
 the spasmodic closure of the glottis, which is sure, if complete and long 
 continued, to be followed by an attack of convulsions. If treatment 
 fail, the carpopedal contractions will become permanent, the eyes will 
 close but partially, the breathing will grow extremely unequal and 
 irregular, as well as hurried, the hoop will no longer be heard, and the 
 cough itself will yield only a kind of smothered sound. The surface 
 will grow quite livid, in consequence of the extremely imperfect per- 
 formance of the respiratory function ; the child will sink into a state 
 of stupor, in which it will lie with dilated pupils and constant twitch- 
 ing of the muscles of its face, till a great effort to cough comes on, and 
 passes almost at once into a convulsive paroxysm. The fits at length 
 occur independent of any attempt at coughing, and once I saw a con- 
 siderable degree of stiffness of the whole spinal column precede for 
 twelve hours the death of a little boy, who fell a victim to hooping- 
 cough thus sadly complicated with disorder of the nervous system. 
 
 It would be only by the recital of cases that I could bring before 
 your notice each minute variation in the characters of these formidable 
 complications of hooping-cough ; and for such details our time is insuffi- 
 cient. There are two points, however, bearing on this subject, which 
 I am most anxious to impress on your memory. One is, that the 
 supervention of dyspnoea, or the sudden aggravation of difficulty of 
 breathing which had existed previously, is often one of the earliest 
 indications of serious affection of the nervous system. The other point, 
 on which I shall have to dwell at our next lecture, is, that if, mistak- 
 ing the import of this nervous dyspnoea, you direct your treatment 
 to some imagined mischief in the chest, and make free use of anti- 
 mony and other depressing medicines, you will aggravate, instead of 
 relieving the difficulty of breathing ; and — the irritability of the nerv- 
 ous system increasing in proportion as the respiration becomes im- 
 paired — you will hasten the occurrence of convulsions, and of that for- 
 midable train of symptoms which we have just been contemplating. 
 
 I mentioned that tubercular meningitis is now and then met with as 
 

 WITH TUBERCULAR MENINGITIS. 383 
 
 a complication of hooping-cough. Fortunately it is not of frequent 
 occurrence, though the clanger of its supervention should never be for- 
 gotten in the case of weakly children who have long suffered from severe 
 hooping-cough. A few instances of it have come under my observa- 
 tion ; and I have notes of two cases of it. In one of these cases the 
 cerebral disease was associated with such a large amount of mischief in 
 the chest as would of itself have sufficed to destroy the child. The 
 other case was of much importance, as showing the insidious manner in 
 which fatal disease may steal on, presenting little to excite serious 
 apprehension till long after the possibility of doing good has passed 
 away. The patient, a boy five years old, of a phthisical family on his 
 mother's side, was attacked by hooping-cough, from which he suffered 
 severely. The disease was attended by great dyspnoea, with general 
 oedema and great lividity of the surface. No auscultatory signs of serious 
 mischief in the lungs existed at any time ; but the oppression of breath- 
 ing was so considerable, and the child seemed so completely over- 
 whelmed by the disorder, that I feared he would not recover. After 
 he had suffered from the cough for about five weeks, and three weeks 
 before his death, matters seemed to take a more favorable turn ; his 
 cough diminished greatly both in frequency and severity, and his strength 
 returned under a tonic plan of treatment. He still, however, continued 
 low-spirited, and very much disposed to sleep ; and this condition of 
 depression progressively increased, until, about a week before his death, 
 he sank into a state of complete stupor ; but no convulsions occurred 
 either as precursors of the stupor or during its continuance. He lay 
 on his back, either sleeping, or in a state of stupor, from which, how- 
 ever, he could be partially roused, when his pupils, before contracted, 
 would become suddenly dilated to the full, and he would stare wildly 
 about for a few moments ; the pupils would then oscillate for a short 
 time between dilatation and contraction, but soon revert to their former 
 contracted condition. The bowels were not constipated at any time, 
 neither did vomiting occur, and the pulse continued frequent till within 
 a day or two of his death. Strabismus came on in a day or two before 
 he died, and two days before his death deglutition became difficult, and 
 he began to make slight automatic movements with his hands and arms. 
 Paroxysms of cough continued to recur to the very last; they were 
 suffocative in character, but unattended by hoop. At the end of the 
 eighth week from the commencement of his cough, the child, who was 
 extremely emaciated, died quietly. 
 
 After death, the membranes of the brain were found much congested ; 
 there was a large quantity of fluid in the ventricles ; the central parts of 
 the brain were diffluent, and its lower parts were likewise considerably 
 softened. The membranes at the base of the brain presented an opalescent 
 appearance, and were bestudded with numerous minute granules, while 
 about the optic nerves they were greatly thickened and infiltrated with 
 that hyaline matter to w T hich I have often called your attention. 
 
 There was much congestion of the bronchi and pulmonary substance. 
 The lungs contained a good deal of tubercle, mostly in the state of gray 
 granulations, and a small cavity occupied the lower part of the left 
 lower lobe. 
 
d84: COMPLICATIONS OF HOOPING-COUGH: 
 
 Many points of importance connected with the history of hooping- 
 cough remain for our examination before we can proceed to consider 
 its treatment : but all of these must be reserved till our next meeting. 
 
 LECTURE XXVII. 
 
 Hooping-Cough continued. — Complications with diarrhoea and intestinal dis- 
 order — With great irritability of the stomach — With measles and varicella — 
 Duration of the disease — Relapses — Influence of age, sex, season, &c, in its 
 production — Post-mortem appearances. 
 
 Treatment. — No real specific for hooping-cough — Treatment of first and second 
 stages — Utility of hydrocyanic acid — Of counter-irritation — Of attention to 
 temperature — Danger of overtreating the bronchitis of hooping-cough — Treat- 
 ment of third stage of disease. 
 
 It is a peculiarity of the affection which we are now studying, that 
 much of the suffering, and almost all the danger that attend it, are the 
 result, not of the disorder itself, but of some complication that super- 
 venes during its course. We have already examined the two most 
 frequent and most formidable sources of danger to patients laboring 
 under hooping-cough, but others remain, against which it behooves us 
 to be no less sedulously* on our guard. 
 
 Some days ago I mentioned to you that a state of extreme irritability 
 of the lining of the air-tubes is one of the characteristics of early child- 
 hood. To this are due the attacks of catarrh which children often 
 experience while teething, and the cough which, wholly independent 
 of exposure to cold, comes on as the result of sympathy with irritation 
 in some distant viscus. This high degree of susceptibility, however, 
 is not confined to the bronchi, but is possessed in the young subject by 
 the whole tract of mucous membranes : diarrhoea often accompanies 
 catarrh, or alternates with it, and in the course of inflammation of the 
 lungs, the patient's life is sometimes jeopardized, or his death hastened, 
 by the supervention of an intractable looseness of the bowels. 
 
 Diarrhoea, though comparatively seldom fatal, is frequently a very 
 troublesome complication of hooping-cough, and if it continues, iff 
 greatly reduces the strength of a child, and interferes with the employ- 
 ment of some of those means to which otherwise we might have 
 recourse. It sometimes sets in with the preliminary catarrh, and 
 abates as that subsides, but in other cases it harasses the patient at 
 intervals during the whole course of the affection. It is, however, 
 when it .comes on in the course of an attack of hooping-cough which 
 has already attained considerable severity, that it should excite our 
 chief solicitude. It does not, indeed, in the majority of instances, 
 betoken the supervention of disease in the intestines, but it is one of 
 
WITH MEASLES AND VARICELLA. 385 
 
 the forms of constitutional disturbance that attend upon a congested 
 state of the brain, or it indicates the advance of serious mischief in the 
 lungs. I have, indeed, seen diarrhoea become the most prominent 
 symptom in a case of severe hooping-cough, the bowels being for days 
 so irritable that their action was excited by the slightest article of food 
 or drink, while the abdomen was exquisitely tender; and yet, when 
 death at length took place, unusual redness and prominence of the 
 Peyerian glands were the only morbid appearances in the intestines, 
 while the signs of intense bronchitis, and inflammation, which in some 
 parts had advanced to suppuration, were discovered in the lungs. 
 
 An irritable state of the stomach, with occasional vomiting, are symp- 
 toms almost constantly observed at some period or other in the course 
 of hooping-cough. In cases of a mild character, they usually occur 
 only when the cough has reached its acme, and vomiting succeeds to 
 none but the severest fits of coughing, while it is one of the earliest 
 symptoms to cease as the severity of the disease declines. Sometimes, 
 however, very distressing nausea harasses the patient, and efforts to 
 vomit not only follow the paroxysms of coughing, but are excited by 
 food or by the blandest fluid. I have already warned you of the seri- 
 ous import of this symptom in many instances, and have called your 
 attention to it as being frequently one of the earliest indications of 
 cerebral mischief. In some few instances I have observed it come on 
 very early in the disease, and subside by degrees as the cough assumed 
 a distinctly paroxysmal character ; just as is the case sometimes with 
 that nervous dyspnoea of which I spoke in my last lecture. Sometimes 
 it continues to be a troublesome though almost a solitary symptom of 
 disturbance of the nervous system, the cough not being severe, nor the 
 child's health at all seriously impaired; and in two instances that I 
 met with, it appeared to be the result of a state of extreme irritability 
 about the fauces, so that the cough, which hardly ever occurred at other 
 times, was immediately excited "by any attempt at deglutition, and the 
 effort to cough terminated almost directly in vomiting. Nausea and 
 vomiting are sometimes associated with general intestinal disorder and 
 diarrhoea; at other times there is equal evidence of disorder of the 
 digestive organs in a constipated state of the bowels, a red tongue, with 
 perhaps numerous small aphthous ulcers about the mouth, or in the 
 large quantity of frothy mucus rejected by the stomach at each effort 
 to vomit. 
 
 Before leaving the subject of the complications of hooping-cough, I 
 must notice the relation that appears to exist between it and two of the 
 eruptive fevers, namely, measles and chicken-pox. It has been thought, 
 indeed, by some writers, that there is no connection between these dis- 
 eases other than that of their accidental association ; but my own experi- 
 ence would lead me to incline to an opposite opinion, which is likewise 
 entertained by several high authorities. I am not, indeed, able to ad- 
 duce a number of observations bearing on this point sufficient to estab- 
 lish the fact beyond doubt; but my belief is, that the occurrence of any 
 one of these diseases during the epidemic prevalence of another, in- 
 creases the liability of the child to become affected by that which is 
 epidemic, and that an exacerbation of the fever of hooping-cough, and 
 
 25 
 
386 DURATION OF HOOPING-COUGH. 
 
 the appearance of more serious illness than the local symptoms account 
 for, is very likely to be due to the approach either of measles or of 
 varicella. Like other intercurrent febrile and inflammatory affections, 
 both measles and chicken-pox often produce some temporary abatement 
 of the paroxysms of hooping-cough, and sometimes cure the disease 
 altogether. In this, however, there is nothing constant, for hooping- 
 cough often appears not to be in the least modified in its character by 
 the supervention of the other malady; while in some cases the compli- 
 cation adds to the mischief in the chest, and increases the patient's suf- 
 fering and danger. 
 
 Although there are many important points of analogy between hoop- 
 ing-cough and some of the exanthemata, yet in nothing is the difference 
 between these affections more apparent than in the uncertain duration 
 of the former, in the exacerbations which take place during its course, 
 either causelessly or from very slight occasions, and in the actual re- 
 lapses that sometimes occur after apparent cure. It is a matter of con- 
 siderable difficulty, in the case of a disease so protracted in its course 
 as hooping-cough, to make even an approximation to a correct estimate 
 of its duration. In twenty-five cases, however, I had the opportunity 
 of watching the patients from the time when the cough first assumed a 
 paroxysmal character, or the hoop first became audible, until the final 
 cessation of all cough. From this small number of observations I 
 should be disposed to estimate the average duration of hooping-cough 
 at ten weeks ; of which period nearly two weeks 1 would be occupied by 
 the preliminary catarrh, for four weeks the cough would present the 
 characteristic hoop, and the cough would continue for about the same 
 period to occur occasionally, gradually losing its paroxysmal character ; 
 though exposure to cold, or any trivial cause, would suffice to bring 
 back the hoop, and to restore to the paroxysms of the cough all their 
 former intensity. So long as any cough continues, even though very 
 occasional in its occurrence, and though the hoop have entirely ceased 
 for many weeks, the patient cannot be regarded as well ; while the 
 neglect of proper hygienic precautions may protract the duration of the 
 cough for between three and four months — an occurrence by no means 
 unusual among the poor. I have on several occasions treated children 
 for hooping-cough during the spring, in whom the hoop has disappeared, 
 and the cough almost ceased, in the warm months of summer; but on 
 the approach of autumn has returned with nearly its former intensity. 
 In other cases, hooping-cough contracted in the early part of autumn 
 has returned during the prevalence of cold March winds ; or a casual 
 catarrhal seizure has been followed by a recurrence of all the signs of 
 the disease in a severe form. These relapses of hooping-cough fre- 
 quently set in with considerable severity, the paroxysms of cough being 
 very frequent, and the hoop loud and often repeated ; but, if treated 
 
 1 The estimate of the duration of the catarrhal stage is deduced from the ohser- 
 vations of 55 cases, and the exact period of its continuance was 12.7 days. Of the 
 25 in which the total duration of the cough from the occurrence of the first hoop 
 was noted, 11, or nearly half, showed a duration of eight weeks; and the duration 
 of the remaining 14 cases varied from four to twelve weeks. 
 
CONDITIONS PREDISPOSING TO HOOPING-COUGH. 387 
 
 judiciously, they are much more amenable to remedies than is the first 
 attack of the disease. 
 
 A true recurrence of hooping-cough, after the disease has been per- 
 fectly cured, is at least as unusual as the occurrence of measles or small- 
 pox twice in the same subject. Only one instance of hooping-cough 
 affecting the same patient more than once has come under my notice. 
 In that case the patient was a girl aged seven years, who, when three 
 years old, had very severe hooping-cough, which lasted for several 
 weeks, the paroxysms of cough being frequent and the hoop loud and 
 often repeated. In March, 1845, hooping-cough being then epidemic, 
 she experienced a return of the disease in a very severe form, and con- 
 tinued to suffer from it until the end of June. 
 
 But little more remains to complete the history of the disease, except 
 that we notice briefly the circumstances in ivhich it comes on. It is 
 essentially an affection of childhood, few children escaping from it, while 
 more than half the cases of it occur before the completion of the third 
 year. After the age of five years its frequency rapidly diminishes, and 
 after ten it becomes so extremely rare that, out of 1367 cases in which 
 I noticed the patient's age, I find but eleven in wdiich it exceeded 
 ten years. 1 The occurrence of the disease appears to be influenced 
 to a considerable degree by sex as well as age ; and, as is the case 
 with a' large number of the non-inflammatory disorders of the nerv- 
 ous system, females suffer from it in a considerably larger propor- 
 tion than males. Of 100 cases of hooping-cough at the Children's In- 
 firmary, 55.3 per cent, occurred in females, only 44.7 per cent, in 
 males ; although the total number of female children to the total num- 
 ber of males among my patients at that institution was only as 50.2 
 to 49.8. 
 
 Age and sex exert an evident influence on the mortality of the dis- 
 ease as well as on its prevalence, both being greatest in early childhood, 
 though hooping-cough does not seem to be so formidable before the 
 commencement of dentition as it is while that process is going on. 
 
 1 Of the above 1367 cases — 
 
 41.2 per cent, occurred during the first 2 years of life. 
 56.7 '" " " 3 " 
 
 82 9 » " " 5 " 
 
 98.4 " " « 10 " 
 
 The subjoined table shows the proportion borne by these hooping-cough cases to 
 14,440 cases of all diseases at the same ages, which occurred during the same period 
 at the Children's Infirmary. Cases of hooping-cough constituted — 
 
 8.4 per cent, of all cases occurring under the age of 6 months. 
 " " from 6 months to 12 months. 
 
 10 4 
 
 u 
 
 10.3 
 
 u 
 
 9.3 
 
 a 
 
 12.2 
 
 u 
 
 14.6 
 
 << 
 
 13.2 
 
 it 
 
 11.2 
 
 it 
 
 7.2 
 
 n 
 
 .8 
 
 u 
 
 " 12 
 
 " 
 
 
 18 
 
 " 18 
 
 t< 
 
 
 2 years. 
 
 « 2 
 
 years 
 
 to 
 
 3 " 
 
 " 3 
 
 a 
 
 
 4 " 
 
 " 4 
 
 << 
 
 
 5 " 
 
 under 
 
 
 
 5 " 
 
 from 5 
 
 
 
 10 " 
 
 " 10 
 
 u 
 
 
 15 " 
 
388 CONDITIONS PREDISPOSING TO HOOPING-COUGH. 
 
 Female children are not only more liable to the affection, but it proves 
 more fatal to them than to boys in the proportion of about 3 to 2. 1 
 
 Hooping-cough is a disease of all climates, and though more frequent 
 in the cold than in the warm months of the year, yet its epidemics 
 break out at almost all seasons. The epidemic of 1841-2 reached its 
 acme in the months of December and January; while in 1845, cases of 
 hooping-cough were by far more numerous in the months of June and 
 July than during any other part of the year. Though little influenced 
 by the season of the year, the outbreak of an epidemic of hooping-cough 
 seldom, if ever, takes place suddenly, and altogether without warning. 
 Sometimes, as already mentioned, it succeeds to an epidemic of measles, 
 but still more frequently it follows an unusual prevalence of catarrh, in 
 which the cough gradually becomes paroxysmal, and at length puts on 
 the characters of hooping-cough. In a similar way, epidemic hooping- 
 cough sometimes resolves itself into simple catarrh : the signs of disturb- 
 ance of the nervous system by degrees disappearing, and the cases 
 presenting the indications of mere bronchial irritation. 
 
 The question whether hooping-cough is a contagious disease, has long 
 since been set at rest by a general answer in the affirmative. How 
 long it retains this character is an inquiry to which it is not possible to 
 return any very precise reply ; but so long as a child who has suffered 
 from hooping-cough continues to cough at all, even though only once 
 or twice a day, I should be unwilling to restore him to the society of 
 children who have not already had the disease. All children are not 
 equally susceptible of the contagion, and infants under six months old 
 appear to be especially indisposed to receive it, either by association 
 with other children, or as the result of atmospheric influence. If care- 
 fully kept from contact with other children, infants of tender age will 
 very often escape during the general prevalence of hooping-cough ; and 
 in nearly half of the cases of hooping-cough that I have met with in 
 infants under six months old, other children in the family had suffered 
 from it for a week or ten days before the infants showed any symptom 
 of it. 
 
 You may expect, perhaps, that before I pass to the consideration 
 
 1 The subjoined table shows the age at which death took place in 35 fatal cases of 
 hooping-cough : 
 
 under 6 months. 
 
 5 between 6 months and.l year. 
 
 6 " 1 year and 2 years. 
 8 "2 " 3 " 
 4 "3 " 4 " 
 
 This result tallies very closely with that afforded by the Fifth Report of the 
 Eegistrar-G-eneral, from which it appears that the deaths from hooping-cough in 
 London were to the deaths from all causes in the proportion of — 
 
 5.6 per cent, under 1 year old. 
 10.6 " between 1 and 3 vears. 
 
 10.2 " " 3 " 5 * " 
 
 Of the 35 cases that came under my notice, 21 occurred in female, and only 14 in 
 male children ; and the mortality under ten years of age from hooping-cough is to 
 the total mortality at that age in London in the proportion of 8.9 per cent, among 
 female and 6.1 per cent, among male children. 
 
 6 between 4 
 
 vears i 
 
 md 5 years 
 
 1 " 
 
 5 
 
 u 
 
 6 » 
 
 3 » 
 
 6 
 
 (C 
 
 7 " 
 
 rH 
 
 7 
 
 tt 
 
 8 « 
 
 1 " 
 
 10 
 
 tt 
 
 i— i 
 
 5.0 per cent, between 5 and 10 years. 
 .8 " " 10 " 15 " 
 
MORBID APPEARANCES IN HOOPING-COUGH. 6tiy 
 
 of the treatment of hooping-cough, I should say something about the 
 morbid appearances to which it gives rise, and about the essential nature 
 of the affection. I know, however, of no morbid appearances peculiar 
 to this disease, nor do I think that much would be gained by a dis- 
 quisition on its seat, or on the occult cause of its symptoms. It is 
 through the medium of the lungs or of the brain, that death takes place 
 in nearly every instance of fatal hooping-cough; and almost all the 
 structural lesions of importance are found in one or other of those organs. 
 The vessels of the brain and its membranes are often found overfilled 
 with blood, though even in cases where death has taken place in con- 
 vulsions, or has been preceded by a comatose condition, these appear- 
 ances are sometimes much less marked than might have been expected, 
 and occasionally are altogether absent. Softening of the cerebral sub- 
 stance, or other indications of inflammatory action, are very seldom 
 met with ; increased vascularity of the organ, with perhaps a small 
 quantity of fluid in the ventricles, being almost the only morbid ap- 
 pearances in the encephalon. 
 
 It is but seldom that the lungs are found free from disease, though 
 they present no structural changes that can be regarded as character- 
 istic of hooping-cough. The mucous membrane of the bronchi is gener- 
 ally injected ; sometimes it is intensely red ; while an abundant secre- 
 tion of thick mucus occupies the cavities of the air-tubes, and their 
 calibre is much increased. This dilatation of the bronchi, which some- 
 times is very remarkable, arises from inflammation of the air-tubes, 
 just as it does in ordinary bronchitis, and is not due, as has been 
 erroneously supposed, to the violence of the child's inspiratory efforts. 
 The emphysematous condition of the lung, which is likewise observed 
 in many cases of fatal hooping-cough, has also been referred to the 
 same forcible attempts at inspiration. MM. Rilliet and Barthez, 1 
 however, have observed, that the supposed violence of the inspiratory 
 efforts during hooping-cough is altogether a mistaken assumption ; for 
 the efforts made during a paroxysm of coughing are expiratory, the 
 lungs during a severe seizure being almost emptied of air ; while in 
 the inspiratory efforts that succeed, the air at first does not penetrate 
 beyond the larger bronchi, and is long before it again freely permeates 
 the pulmonary vesicles. The objection raised by these gentlemen to 
 the inspiratory theory as explaining the production of emphysema in 
 cases of uncomplicated hooping-cough, is, I believe, quite unanswera- 
 ble. The fact, however, still remains that the condition is met with, 
 and sometimes in an extreme degree, in the lungs of children who 
 have died of hooping-cough unassociated with other diseases of the 
 respiratory organs. To such cases the expiratory theory 2 applies pre- 
 eminently ; for, during the violent expiratory efforts with a closed 
 glottis which characterize a paroxysm of the cough, the air is driven 
 forcibly towards the upper part, and the circumference of the lungs ; 
 in other words, towards just those parts. which are the least compressed, 
 
 1 Lib. nit , vol. ii, 2d ed., p. 631. 
 
 2 See Sir W. Jenner's exposition of it in vol. xl of the Medico-Chirurgical Trans- 
 actions. 
 
390 STATE OF THE LUNGS IN HOOPING-COUGH. 
 
 and which observation shows to be the favorite seats of emphysema. 
 In those other cases of hooping-cough in which extensive collapse of 
 the lungs takes place, the emphysema is produced by just the opposite 
 means ; on which indeed I need not dwell now, since I explained them 
 fully in a former lecture. 1 I may, however, just observe, that the for- 
 cible expiratory efforts which are so characteristic of hooping-cough, as 
 they tend in one way to the production of emphysema, so in another 
 they exercise a powerful influence in occasioning collapse of the lung ; 
 and few cases of hooping-cough terminate fatally in which you will 
 not find after death a more or less considerable portion of lung in this 
 condition. It may be simply collapsed, resuming its natural appear- 
 ance readily when inflated ; or the bronchial tubes may have been the 
 seat of inflammation, and be more or less filled with puriform mucus, 
 when the characters of vesicular bronchitis will be superadded to those 
 of mere collapse or carnification, and air will permeate the organ very 
 imperfectly, or not at all. It cannot be necessary to describe again 
 those other changes which may take place in carnified lung, and which 
 end in the infiltration of pas into its* tissue, or in the formation of 
 vomicae, since I have already done so very minutely. 2 
 
 I do not dwell upon other appearances in the chest, such as pleurisy 
 and lobar pneumonia, which are much less often met with, and which 
 have none other than a perfectly casual connection with hooping-cough ; 
 but I must notice one morbid condition alleged to have been frequently 
 observed, and which is of the more importance, since it has served as the 
 foundation of a theory of the disease. The pneumogastric nerves have 
 been discovered by various observers redder than natural, and in some 
 cases swollen and softened — appearances which have been regarded as 
 indicating that they had been the seat of inflammation. Even those 
 observers, however, who have noticed this condition, appear to have 
 met with it but seldom, while others have sought for it in vain in a 
 
 1 Lecture xx, p. 271. 
 
 2 It would be unjust to leave this subject without calling the reader's attention to 
 the excellent account of collapse or carnification of the lung contained in Sir J. 
 Alderson's paper on the Pathology of Hooping-Cough, published in the year 1830, 
 in vol. xvi of the Medico-Chirurgical Transactions. In this paper he not only 
 describes very correctly the anatomical characters of this condition, which had 
 merely been indicated by previous observers, and speaks of it as a state different 
 from "pneumonia, which MM. Rufz and Gerhard did four years later, but he also 
 suggests an explanation of its occurrence, which the recent researches of MM. Bailly 
 and Legendre prove not to have been far from the truth. 
 
 It may be well to quote two passages from this paper: " In many other [cases] 
 I have invariably found the same appearances, uncomplicated with any evidence of 
 pleuritic inflammation. In the lower and posterior portions of the lungs, the struc- 
 ture was rendered very firm and dense ; the portions which were the subjects of 
 this change were exactly defined by the septa ; of a dull red color, devoid of air, 
 sinking instantly in water, and thin slices undergoing no change by ablution. The 
 individual lobules were more dense than in hepatized lungs ; and the cellular mem- 
 brane between them retaining its natural structure, conveyed to the touch the 
 
 same sensation that is felt on touching the pancreas I apprehend that 
 
 the appearances detailed differ from those found in peripneumony. In hooping- 
 cough, the lung is always dense and contracted, as if the air had been expelled, and 
 from the throwing out of adhesive matter, the sides of the air-cells had been agglu- 
 tinated together; while in hepatization the lung is less dense than in hooping- 
 cough, and is Tendered more voluminous than in its natural state " (pp. 90-91). 
 
TREATMENT OF THE FIRST STAGE OF HOOPING-COUGH. 391 
 
 large number of cases. Professor Albers, of Bonn, 1 states that, having 
 examined the bodies of 47 children who died of hooping-cough, he 
 found the nervi vagi perfectly healthy in 43. In 3 the vagus of the 
 right side, and in 1 that of the left side, was slightly reddened ; but 
 this redness corresponded to the side towards which the body had been 
 inclined, and in no respect differed from what is observed in the bodies 
 of plethoric persons, and of patients who have died of typhus fever. 
 Out of 24 examinations of the bodies of children who have died of 
 hooping-cough, it has only once happened to me to observe any altera- 
 tion in the appearance of the vagus, though my attention has been 
 directed to it on every occasion. In that instance both nerves seemed 
 to be of a decidedly redder color than natural, although they were not 
 otherwise altered. We are, I think, warranted in concluding that an 
 appearance so frequently absent, cannot be one of much moment, that 
 it is probably a post-mortem alteration, and that certainly it cannot be 
 adduced in support of any particular hypothesis as to the nature of the 
 disease. 
 
 I have endeavored to describe to you the symptoms of this affection, 
 to make you acquainted with the circumstances in which it occurs, with 
 the course that it usually follows, and with the chief dangers that 
 threaten a child while suffering from it. It now remains to examine 
 the treatment which may be best calculated to mitigate its severity, and 
 to ward off or overcome the dangers that attend it. 
 
 There are few diseases for the cure of which specifics have been more 
 eagerly sought after, or more earnestly recommended, than for that of 
 hooping-cough ; neither is there anything unreasonable in the expecta- 
 tion that a remedy may some day or other be discovered which shall 
 cut short its course with as much certainty as quinine arrests an inter- 
 mittent fever, or which shall render the constitution insusceptible to 
 its poison as generally as vaccination preserves from variola. At pres- 
 ent, however, no such remedy has been discovered ; and though the 
 severity of an attack of hooping-cough, or its duration, varies greatly 
 in different individuals, during different epidemics, or at different 
 seasons of the year, yet we are unable by any medicinal agents to pro- 
 duce effects such as in these cases flow from causes quite beyond our 
 control. 
 
 For the present, then, the treatment of hooping-cough must be con- 
 ducted in accordance with the ordinary principles of therapeutics, and 
 we shall study their application best by examining in succession the 
 course which, in each stage of the disease, it will be our duty to pursue. 
 The first stage of hooping-cough is distinguished, as you know, by 
 catarrhal symptoms, with some degree of febrile disturbance, and a 
 cough which gradually assumes more and more of a paroxysmal char- 
 acter, until at length it returns in well-marked fits, and is attended by 
 a distinct hoop. In the majority of cases the treatment of this first stage 
 of hooping-cough must be just that of an ordinary catarrh. The child 
 must remain in the house, and it is desirable that it should be confined 
 to its own apartments, both of which should be maintained at a tempera- 
 
 1 Quoted by Aberle, De Tussi Convulsiva, 8vo., p. 45. Yindobonae, 1843. 
 
392 TREATMENT OF THE SECOND STAGE OF HOOPING-COUGH. 
 
 ture of 60°, so that when it leaves the day for the night nursery, it may 
 not, as is too commonly the case, enter a colder atmosphere, and thus have 
 the irritability of the bronchi increased and the severity of the cough 
 aggravated. If these precautions are carefully observed, and the diet 
 is light and unstimulating, there is but little need of medicine beyond 
 what may be required to keep the bowels regularly open. If the cough 
 is at all troublesome, a mixture may be given, containing small doses 
 of the ipecacuanha and antimonial wines, with a few drops of laudanum 
 or of the compound tincture of camphor 1 — medicines that I should 
 advise you always to use in preference to the syrup of poppies, the 
 strength of which is very variable, and its action uncertain. If, as is 
 sometimes the case, the child should wheeze a good deal, this symptom 
 will be much relieved by the administration of an emetic of ipecacuanha 
 every evening, or more frequently if necessary. It is not always, 
 indeed, that either much care or much medicine is needed ; and if 
 hooping-cough comes on in a perfectly healthy child, in whom the 
 process of dentition is completed, and during the warm months of 
 summer, strict confinement to the house may not be necessary. Usu- 
 ally, however, care in this stage is very important, and will do much 
 towards mitigating the severity of the subsequent course of the disease, 
 while no precautionary measure is of so much moment as the preserva- 
 tion of the child from fluctuations of temperature, and from damp as 
 well as cold. 
 
 When the first stage of hooping-cough has passed into the second, in 
 which the disease assumes its characteristic features, the condition of 
 the patient must still determine whether any remedies are to be em- 
 ployed, and must likewise influence their selection. It sometimes 
 happens that the cough and hoop are very slight, and the paroxysms 
 but few in the course of the day ; and, in such circumstances, medicine 
 can well be dispensed with. If the paroxysmal character of the cough 
 is well marked, and the fits are of frequent occurrence, but the child in 
 other respects ails little, much benefit will accrue from the use of the 
 hydrocyanic acid. I usually begin with a dose of half a minim of the 
 acid of the London Pharmacopoeia every four hours for a child nine 
 months old ; and so in proportion for older children. The specific influ- 
 ence of the remedy is, I think, both more safely and also more efficiently 
 exerted by increasing the frequency of its administration, than by adding 
 to the dose, and I should therefore prefer to give half a dose every two 
 hours rather than to double the dose without increasing the frequency 
 of its repetition. 2 This remedy sometimes exerts an almost magical 
 influence on the cough, diminishing the frequency and severity of its 
 paroxysms almost immediately ; while in other cases it seems perfectly 
 inert ; and again, in others, without at all diminishing the severity of 
 
 1 See Formula No. 9, p. 263. 
 
 2 (No. 15.) (No. 16.) 
 
 R. Acid. Hydrocy. dil., ^iv. R. Acid. Hydrocy. dil., ti^iv. 
 
 Syrupi simplicis, gj. Mist. Amygdalae, gj. M. A tea- 
 Aquae distill, gvij. M. A teaspoon- spoonful to be taken every six 
 ful to be taken every six hours. hours. 
 For a child. 9 months old. 
 
TREATMENT OF THE SECOND STAGE OF HOOPING-COUGH. 393 
 
 the cough, it manifests its peculiar poisonous action on the system, so 
 as to render its discontinuance advisable. I have never but once, how- 
 ever, seen really alarming symptoms follow its use, though I have 
 employed it in many hundreds of cases. In that instance I gave one 
 minim of dilute hydrocyanic acid every four hours to a little boy two 
 years and a half old. He had hooped for four days before he came 
 under my care, and was then suffering from rather severe cough, and 
 considerable dyspnoea. He took the acid for four days without any 
 effect being produced either on his system generally or on the cough ; 
 but at the end of that time, after taking each dose, he uttered a cry, 
 became quite faint, and would have fallen if not supported. This re- 
 sult having followed three or four times, the child's mother discontinued 
 the medicine, and, of course 1 did not resume its employment. Similar 
 though less severe symptoms were produced by the same medicine in 
 the sister of this child, a little girl of five years of age; but in neither 
 instance was the severity of the cough in the least mitigated by it. 
 Though no other instances of the kind have come under my notice, I 
 always give a caution to the parents to diminish the dose of the medi- 
 cine, or even entirely to discontinue it, if the child appears faint or dizzy, 
 or bewildered, after its administration ; and I never persevere with the 
 use of the acid unless it gives a very decided earnest of good within 
 three or four days after its first exhibition. 
 
 In many instances, although the severity of the cough may be greatly 
 relieved by the hydrocyanic acid, it yet does not enable us entirely to 
 dispense, with other remedies. If there is much wheezing at the chest, 
 an emetic of ipecacuanha should be given once or twice a day, in order 
 to free the air-passages from the mucus which collects in them, often 
 in very considerable quantity, and thus tends by the obstruction it offers 
 to the free admission of air, to favor the occurrence of collapse of the 
 lung. The degree to which the child suffers from the accumulation of 
 phlegm in the bronchi must determine whether the emetic shall be given 
 once or oftener during the day. If it is given but once, the evening 
 should be the time selected for its administration ; and, after the air- 
 tubes have been thus relieved, the child will often rest well, instead 
 of passing as it otherwise would do a restless night, disturbed by 
 dyspnoea and frequent fits of coughing. In other instances the cough 
 is unattended by much secretion, the child scarcely wheezes at all, and 
 even after a severe paroxysm rarely vomits, and never rejects more than 
 a small quantity of phlegm ; but when night comes on, the cough grows 
 very distressing by its frequent return, even more than by the severity 
 of the paroxysms. When this is the case, a small dose of Dover's 
 powder, or of Dover's powder and the extract of hemlock, 1 often soothes 
 this irritability of the air-tubes, and diminishes the frequency of the 
 cough. The same effect, too, follows the use of belladonna, the dose of 
 
 1 (No. 17.) 
 R. Pulv. Ipecac, co., gr. ss. 
 Pulv. Extracti Conii, gr. j. 
 Pulv. Cinnamomi, gr. ij. 
 Saechari albi, gr. iv. M. 
 The powder to be taken at bedtime. For a child of two years old. 
 
391 TREATMENT OF THE SECOND STAGE OF HOOPING-COUGH. 
 
 which medicine, small at first, may afterwards be by degrees increased, 
 and that very largely, with less risk or inconvenience than attends the 
 employment in increasing doses of any sedative into the composition of 
 which opium enters. I always give the tincture as the handiest prepa- 
 ration ; and should begin with two minims every four hours for a child 
 of a year old. If there is a good deal of febrile disturbance, if the 
 cough is hard as well as violent, if it seems to occasion pain, and is 
 unattended by expectoration, while, in the intervals of the paroxysms, 
 a frequent, short, hacking cough distresses the child, and generally 
 diffused rhonchus is heard throughout the lungs, the hydrocyanic acid 
 may be advantageously combined with small doses of tartar emetic or 
 of the Vinum Ipecacuanha?. In other cases, if the existence of drowsi- 
 ness, with a flushed face, becoming livid during the fit of coughing, and 
 the suppression of the previously distinct hoop, betoken the presence of 
 cerebral congestion, the application of a few leeches to the head will not 
 only greatly relieve these symptoms but will also diminish both the fre- 
 quency and severity of the cough, and prepare the way for the more 
 effective employment of the hydrocyanic acid. 
 
 There are two proceedings which demand a special notice, as having 
 of late years been recommended almost as specifics in hooping-cough. 
 One of them consists in the inhalation of chloroform on the approach 
 of each paroxysm, as a means of cutting it short, or even of entirely 
 preventing its occurrence. There can be no doubt but that just as 
 chloroform sometimes controls convulsions or relieves spasm of the 
 glottis, so it is equally capable of diminishing, or even of arresting, the 
 violence of fits of hooping-cough. I have found it of great service in 
 some of those cases of the disease in which the return of each paroxysm 
 of coughing was the signal for the occurrence of general convulsions ; 
 but it scarcely need be added that its efficient employment in these 
 circumstances requires the constant presence in the house of some one 
 conversant with its administration. In those almost desperate cases, 
 too, there is the drawback from its use arising from the fact that inasmuch 
 as death may take place during any of the convulsive seizures, so its 
 occurrence at the time when the chloroform was being administered 
 would almost certainly leave the impression on the mind of the friends 
 that death was due to its employment. If, however, Avarning is given 
 beforehand of the possibility of this accident, the chloroform may be 
 resorted to as an agent of great power, though, as in other instances 
 where it is employed at short intervals, tolerance of it is soon established, 
 and it will cease in the course of twenty-four or forty-eight hours to 
 produce any effect whatever. In mild cases of the disease, the results 
 which one commonly attains are not remarkable ; for the sense of suffo- 
 cation which precedes and accompanies a fit of coughing, renders young 
 children intolerant of anything being held near their mouth ; while 
 the sense of nausea which the inhalation of chloroform produces, so dis- 
 gusts those who are older, that in spite of the relief which it may yield, 
 I have on several occasions seen older children, who at first had had 
 ready recourse to the chloroform, after a few trials discontinue it, pre- 
 ferring even the unmitigated cough to the nauseating effects of the 
 remedy. Still, with due precaution, its trial is free from any objection, 
 
CAUTERIZATION OF LARYNX — COUNTER-IRRITANTS. 395 
 
 and in the course of a chronic ailment there is often an advantage in 
 being provided with means which, though they may be of slight service 
 to the patient, at any rate convince the friends that we are not indifferent 
 to his sufferings, nor indisposed to try all means for their alleviation. 
 
 The other measure consists in the local application to the back of the 
 fauces, or directly to the larynx itself, of a solution of nitrate of silver, 
 of a strength varying from gr. xv to 3ij of the salt to an ounce of dis- 
 tilled water, by means of a probang, such as that employed by Dr. 
 Horace Green for the introduction of medicated solutions into the inte- 
 rior of the glottis. This proceeding was first advocated by Dr. Ebenezer 
 Watson, in a paper published in the year 1849, 1 and afterwards dwelt 
 on by him more fully in a book which appeared five years afterwards, 
 and in which he complains of his suggestions having been passed over 
 without notice. 2 Before the appearance of his book I had made a few trials 
 of his plan, and have subsequently resorted to it sufficiently often to 
 be able to form a fair opinion of its value. I have no doubt but that 
 in very many instances the sponge of the, probang is actually passed 
 within the glottis ; and also that by this manipulation, whether com- 
 pletely successful or not, the violence of the paroxysms of the cough is 
 sometimes lessened, and their frequency diminished. This result, how- 
 ever, was by no means constant ; the milder cases were those in which 
 the benefits of the proceeding were most apparent; while, as perhaps 
 might not unnaturally be expected, in those in which there was abiding 
 dyspnoea, or in which any bronchitic complication existed, little if any 
 good was obtained. 
 
 The great practical difficulty, however, and one which I am con- 
 vinced will prevent any frequent resort to the proceeding in the case 
 of children, arises from their extreme repugnance to it, and their dread 
 of its repetition. Sometimes by coaxing and promises I succeeded in 
 it daily for three or four days ; but no persuasion enabled me to carry 
 its employment further, while on several occasions I saw paroxysms 
 of cough brought on by the mere fear that the solution was about to 
 be applied. There are very few proceedings, indeed, which are so 
 surely and largely beneficial as to repay us for adopting them at the 
 cost of a passion of tears, or agony of terror, and this is certainly not 
 one of them. 
 
 Counter-irritation to the chest and spine is a popular remedy for 
 hooping-cough, in which many non-professional persons place great 
 confidence, while they employ it through all the stages of the disease. 
 I do not think that you will in general gain much by the employment 
 of counter-irritation until the disease has bewin to decline, though it is 
 then often of much service. There are, however, some circumstances 
 in which counter-irritation may be advantageously resorted to, even 
 before the affection has attained its greatest degree of severity. The 
 attacks of dyspnoea which sometimes occur during the increase of the 
 disease, are often much relieved by a mustard-poultice to the chest ; 
 and if, as occasionally happens, these attacks return, though with 
 
 1 Edinburgh Monthly Journal, Dec. 1849. 
 
 2 On the Topical Medication of the Larynx, &c, 8vo. London, 1854. See p. 123. 
 
396 DANGER OF OVERTREATING HOOPING-COUGH. 
 
 varying severity, almost every night for several nights together, the 
 application of a mustard-poultice to the chest, and the immersion of 
 the lower part of the body in a hot bath, on three or four successive 
 evenings, may be of service. In cases of this kind, too, the daily fric- 
 tion of the chest and spine with an embrocation of soap liniment and 
 the Tinctura Lyttse, so as to keep up a slight degree of redness of the 
 surface, is often beneficial ; or that popular remedy, Roche's embroca- 
 tion, may be used, if the parents of the child fancy, as they often do, 
 that it is possessed of some specific virtue. 
 
 As a general rule, blisters to the chest are not desirable remedies in 
 young children ; but if the cough should be frequent, hard, and pain- 
 ful, or if, in connection with the evidences of congestion of the brain, 
 the cough is suffocative and the hoop suppressed, much good often 
 results from their application. They must not, however, be allowed 
 to remain above four hours upon the skin ; neither is it desirable to 
 attempt to keep them discharging, on account of the very troublesome 
 sores which they sometimes produce. For the same reason, too, I do 
 not advise you to employ inunction of the tartar emetic ointment, 
 although this proceeding was once highly recommended, and very 
 generally adopted, as a remedy for hooping-cough. 
 
 Attention to maintain a warm and equable temperature around the 
 child, to prevent the stomach becoming disordered by unsuitable food, 
 and to avoid constipation, will in many instances suffice to conduct a 
 child in safety through the second stage of hooping-cough. If the 
 severity of the cough, or the condition of the child in other respects, 
 seems to call for more decided interference, your motto in the selection 
 and employment of remedies must be, "ne quid nimis :" and especially 
 must this be your rule in the management of those complications which 
 often render hooping-cough so dangerous a disease. 
 
 In no case is it of more importance to bear in mind this caution as to 
 the danger of overtreating a patient who suffers from hooping-cough, 
 than when, at the commencement of the second stage of the disease, a 
 sudden increase of fever, and the supervention of a state of permanent 
 dyspnoea, seem to announce to you that active inflammation has attacked 
 the lungs or air-tubes. It is quite possible that sugh may be the im- 
 port of the symptoms, but it is at least as likely that they result from 
 disturbance of the nervous system. In such a case, then, I would 
 advise you to allow nothing but the positive evidence of auscultation 
 to lead you to resort to free depletion and the use of large doses of 
 tartar emetic; — remedies to which you might feel disposed at once to 
 have recourse. If you feel in doubt, remain for some time with the 
 child, watch it carefully, auscultate it more than once during your visit, 
 and repeat your visit every two or three hours, 1 rather than resort at 
 
 1 I cannot refrain from directing the attention of junior practitioners to the 
 anecdote which Dr. Cheyne relates (at page xvii of the Introduction to his work 
 on Hydrocephalus), of the very different results that followed the practice of two 
 army surgeons, one of whom visited his patients, during the prevalence of an epi- 
 demic disease twice, the other four or live times daily. The moral which Dr. 
 Cheyne drew from the tale, though obvious enough, is not sufficiently borne in mind 
 by many who undertake the treatment of children's diseases. 
 
CASE ILLUSTRATIVE OF DANGER OF OVERTREATMENT. 397 
 
 once to measures which, powerful either for evil or for good, may, if 
 unwisely employed, destroy the life they were intended to save. 
 
 Example teaches louder than precept, and you may learn a useful 
 practical lesson from the following history : 
 
 A little boy, about two years old, had had slight catarrh for a fort- 
 night, and towards the end of this time it was thought he had hooped 
 once or twice, though very slightly. He ailed but little, and had had 
 none other than domestic remedies during this period ; but one night, 
 without any apparent cause, he became very feverish, his cough grew 
 worse, and his respiration very hurried. On this account he was depleted 
 very freely by leeches, and calomel and antimony were given in large 
 doses for two days, though without any considerable diminution of the 
 dyspnoea. When this treatment was first adopted, it was thought that 
 air entered one lung but scantily ; but on the evening of the second day 
 both lungs admitted air equally well, although a good deal of mucous 
 rale attended the respiration. On the morning of the third day, the 
 child's face was flushed, and he looked much oppressed ; his lips were 
 rather livid, his respiration was extremely hurried and irregular ; he 
 coughed little, but his cough had a suffocative character, and was not 
 attended by a distinct hoop. The hurried respiration was supposed to 
 indicate the continuance of graver mischief in the lungs than was appar- 
 ent on auscultation, and antimony was accordingly given in emetic 
 doses. It did not produce much sickness, and the respiration dimin- 
 ished but little in frequency during its employment. On the fourth 
 day the child still breathed very hurriedly, and his inspirations varied 
 from 40 to 60 in a minute, without there being any obvious cause for 
 these great changes in their frequency. On the fifth day the breathing 
 increased in rapidity, while the pulse began to lose power ; and not 
 only had the antimony ceased to exert any emetic action, but squills 
 and ipecacuanha failed to induce vomiting. Active measures were sus- 
 pended towards the evening of this day, and a grain of Dover's powder, 
 given every six hours, somewhat diminished the hurry of the breathing ; 
 but it was discontinued after the third dose, on account of the gradually 
 deepening drowsiness of the child. The child, however, still continued 
 heavy and oppressed, the cough became more frequent and more suffo- 
 cative, the breathing more rapid and more irregular. On the morning 
 of the seventh day, a fit of coughing terminated in convulsions ; and 
 from that time until the morning of the eighth day, when the child 
 died, they were extremely violent, frequent in their return, followed by 
 carpopedal contractions, which did not subside in the intervals between 
 them ; while after each convulsion the respiration became most distress- 
 ingly hurried and irregular. After a time the breathing grew constantly 
 labored, the face became of a deep livid color, the hands were clenched, 
 and the wrists bent upon the forearm ; the spine was drawn slightly 
 backwards, and sensation was quite abolished. At length a slight con- 
 vulsive movement passed across the face, and the limbs relaxed in death. 
 Permission was not obtained to make a post-mortem examination. 
 
 Other cases have come under my notice, in some of which I fell into 
 the error against which I have just tried to warn you : in some I saw 
 the patient too late to rectify the mistake which others had committed, 
 
398 TREATMENT OF THE NERVOUS SYMPTOMS. 
 
 while in some the right course of treatment adopted from the first was 
 followed by success. In a case such as I have related, the want of cor- 
 respondence between the general symptoms and the auscultatory signs 
 should have deterred from the copious depletion and the free use of 
 calomel and antimony in the first instance, while it still further contra- 
 indicated the employment of antimony in emetic doses subsequently. 
 Two or three leeches to the head, when the serious symptoms first came 
 on, would probably have relieved the congested brain ; the tepid bath 
 would have soothed the irritability and diminished the fever; and 
 hydrocyanic acid would, most likely, have been of service in quieting 
 the hurried breathing. If much febrile disturbance had still continued 
 small doses of ipecacuanha, antimony, and hyoscyamus, might have 
 been tried, the antimonial not being given in such doses as to exert any 
 very considerable depressing influence on the system. A stimulating lini- 
 ment to the chest and spine should have been used several times in the 
 course of the day, and any sudden access of hurried breathing should 
 have been met by the application of a mustard-poultice to the chest. 
 
 The difficulties of diagnosis are sometimes rendered smaller, and the 
 right course of treatment more obvious, by the occurrence of occasional 
 carpopedal contractions, or of momentary strabismus from the very 
 commencement of this nervous dyspnoea; or in other cases by the ab- 
 sence of any auscultatory signs of mischief in the chest, such as could 
 for a moment lead you to refer the hurried breathing to disease going 
 on in the lungs. 
 
 Even when acute bronchitis really exists, you must not forget the 
 peculiar impress which hooping-cough stamps upon it. You must bear 
 in mind the impediment to the due aeration of the blood which each fit 
 of coughing occasions, and the influence on the nervous system gener- 
 ally of the imperfect decarbonization of the circulating fluid ; how it 
 heightens the irritability of the spinal system, thus exciting the hurried 
 and irregular breathing, and rendering the child peculiarly liable to 
 convulsive seizures. If active interference, therefore, be necessary, you 
 would abstract blood very cautiously, while you would employ nitre, 
 ipecacuanha, and James's powder in small doses, as febrifuges and ex- 
 pectorants, rather than to attempt to bring the child rapidly under the 
 influence of antimony. At the same time, the peculiar tendency to" 
 obstruction of the air-tubes, and consequent collapse of the lungs, which 
 characterizes hooping-cough, would lead you to endeavor to keep the 
 bronchi free, by the administration once or twice a day of an emetic 
 of ipecacuanha. You would employ liniments, mustard-poultices, or 
 blisters to the chest, to combat any exacerbation of dyspnoea ; and if the 
 paroxysms of cough were severe, you would combine hydrocyanic acid 
 with your other remedies. If the powers appear to be on the decline, 
 and the child neither expectorated with the cough, nor rejected much 
 phlegm by vomiting although the bronchi were loaded with mucus, you 
 w r ould at once discontinue antiphlogistic measures, and have recourse 
 to the decoction of senega, with ammonia and squills, 1 while you en- 
 deavored by a nutritious diet to support your patient's strength. 
 
TREATMENT OF THE THIRI* STAGE OF HOOPING-COUGH. 399 
 
 The time allotted to this lecture will not enable me to do more than 
 just indicate the main points to which your attention should be directed ; 
 and I must now pass on to notice briefly your conduct in the third stage 
 of the disease. It is now that the cough diminishes in frequency and 
 severity, that the hoop grows less loud and less constant, and that any 
 signs of constitutional disturbance that had existed before by degrees 
 disappear. When the disorder runs this favorable course no medicine 
 is needed, and but few restrictions, beyond such as the avoidance of 
 damp and cold requires. Change of air generally expedites the cure; 
 and if the opportunity offers, and the season of the year is favorable, it 
 should never be neglected. There are many instances, however, in 
 which medical treatment in the decline of hooping-cough is of very 
 considerable service. It sometimes happens that the bronchi continue 
 loaded with secretion, which is either expectorated, or rejected by vom- 
 iting in very considerable quantities after each fit of coughing, while 
 the skin is cold, the tongue moist, and the pulse soft and rather deficient 
 in power. In this condition, alum, 1 long a popular remedy in hooping- 
 cough, is often of much service, diminishing the secretion, arresting the 
 sickness, and rendering the cough much less frequent. It may be given 
 in doses of three or four grains every four or six hours to a child of a 
 year and a half to two years old. This remedy, indeed, may sometimes 
 be used with advantage, even before the disorder has begun to decline, 
 if the condition be such as I have just referred to, namely, fever being 
 absent, and the bronchial secretion very abundant, even though the 
 cough is violent. In other cases, in which the cough continues violent 
 after the other symptoms have abated, and in which, though there is 
 no superabundance of secretion in the air-tubes, yet the attacks of cough 
 often end with the rejection of a considerable quantity of mucus from 
 the stomach, and loss of appetite and general dyspeptic symptoms^are 
 present, the hydrochloric acid is often of much service. It has been 
 recommended as a specific against hooping-cough, in doses of from two 
 to six drachms daily f but I have never employed it in other than 
 moderate doses, such as one would prescribe in other circumstances. 3 
 
 1 (No. 18.) 
 
 R. Alum Sulphat., gr. xxiv. 
 
 Acid. Sulph. dil., ^xij. 
 
 Syr. Rhceados, £iv. 
 
 Aqua? purse, §ijss. M. 
 
 A dessertspoonful every six hours. 
 
 2 I have made a few trials of the nitric acid in large doses, as recommended hy 
 Dr. Arnoldi, and by Dr. Gibb in his treatise on Hooping-Cough. Post 8vo., Lon- 
 don, 1854, p. 341; but cannot at all subscribe to Dr. Gibb's statement that "it 
 shortens the disease almost as effectually as quinine does intermittent fever." The 
 nitric acid has, within the past six years, fallen into comparative oblivion, and the 
 last new specific, vaunted as loudly as if its advocates had not extolled other remedies 
 before as equally infallible, is the bromide of ammonium. It has been employed 
 among the out-patients of the Children's Hospital on a scale large enough to demon- 
 strate its worthlessness. 
 
 3 (No. 19.) 
 R. Acid. Hydrochlor. dil., TT^xxxij. 
 Tinct. Opii, ti£iv. 
 Syr. Mori, ^iv. 
 Aquae purse, ,^ijss. M. 
 A dessertspoonful three times a day. 
 
400 TREATMENT OF THE THIRD .STAGE OF HOOPING-COUGH. 
 
 Another mode of treatment which has been vaunted as almost a 
 specific consists 1 in the administration of the sulphate of zinc and the 
 extract of belladonna, in doses gradually increased until the quantity 
 given is at last far larger than could have been employed at first with- 
 out the production of poisonous effects. I believe that, when on the 
 subsidence of the bronchitic symptoms which attend the first stage of 
 hooping-cough, the nervous element still persists, giving rise to fre- 
 quent, violent, spasmodic fits of coughing, a combination of zinc and 
 belladonna is often of much service. I believe that these remedies are 
 useful just as other tonics and antispasmodics are useful, but my own 
 experience would not lead me to think that two scruples of sulphate of 
 zinc, and six grains of belladonna, could be given to children of eight 
 years of age, with advantage, or even with safety. 
 
 If the cough continues frequent, and the hoop loud, while the only 
 signs of constitutional disturbance are those of mere weakness, iron will 
 generally put a stop to it sooner than any other remedy. 2 If, however, 
 there should be a degree of feverishness, or of gastro-intestinal disorder, 
 which for the present contraindicates the use of iron, Battley's liquor 
 cinchonse may be given with great advantage, in combination with small 
 doses of hydrocyanic acid f while every attention must of course be 
 paid, by mild alteratives and other appropriate means, to improve the 
 condition of the digestive organs. 
 
 It is probably unnecessary to enter into further details, to specify 
 minutely the diet that a convalescent requires, or to refer to the utility 
 of liniments to the chest, or the occasional benefit of anodynes at night. 
 Of all the means, indeed, which promote recovery from hooping-cough, 
 or from the feeble health that it often leaves behind, there is none to 
 compare with the salutary influence of change of air, and especially of 
 a change to the seacoast. 
 
 There still remain numerous remedies that have a more or less well- 
 merited reputation in cases of hooping-cough. I must content myself 
 with having pointed out to you the kind of weapons that, in different 
 circumstances, must be employed ; and must leave to you the selection 
 of the one whose form and size may, on different occasions, seem to you 
 most fitting. The armory is large enough to yield you an ample 
 choice. 
 
 1 Dr. Fuller, on Diseases of the Chest. 8vo. London, 1862, p. 336. 
 
 2 (No. 20.) 
 
 &. Mist. Ferri co., ^iv. 
 Tinot. Scillse, ^xvj. 
 Tinct. Conii, nj? x l. 
 Mist. Amygdalae, sjij giij. M. 
 A dessertspoonful Aree times a day. 
 
 3 (No. 21.) 
 
 R. Acid. Hydrocy. dil., n£viij. 
 Liq. Cinchonas, 3Jss. 
 S t yr. Aurant., 3Jss. 
 Aquse Flor. Aurant., giij. 
 Aquse destil./^vj. M. 
 ^ij two teaspoon fuls three times a day. 
 All the above are suited for children of two years old. 
 
PULMONARY PHTHISIS. 401 
 
 LECTUEE XXVIII. 
 
 Pulmonary Phthisis. — Differences exist between the tuberculous cachexia in the 
 child and in the adult — Statistical table illustrating its peculiarities in early- 
 life — Anatomical characteristics of pulmonary phthisis in the child — Frequency 
 of miliary tubercle and of gray granulations in the lung, independent of each 
 other, and of other forms of tubercle — Frequency of tubercular infiltration — 
 Karity of cavities — Frequent affection of bronchial glands — Description of each 
 of these peculiarities — Changes in tuberculous bronchial glands — Perforation of 
 bronchi, and elimination of tubercular matter. 
 
 Symptoms of phthisis. — Their differences from those of the disease in the adult — 
 Danger of overlooking its early stages, or of mistaking it for remittent fever, 
 &c. — Peculiarities of its subsequent course. 
 
 Bronchial phthisis. — Its characteristics — Kemarkable fluctuations in its course — Oc- 
 casional unexpected recovery — Case of its occurrence attended with expectoration 
 of tubercular matter — Its fatal termination usually preceded by merging of its 
 symptoms in those of general pulmonary phthisis — Occasional fatal haemoptysis, 
 but this accident not limited to cases of bronchial phthisis. 
 
 Phthisis in very early infancy. — Pulmonary symptoms often obscured by signs of 
 generally defective nutrition. 
 
 ~\Ye enter to-day on the examination of one of the most painfully 
 interesting diseases with which we have to do. It is a disease that we 
 not only often see in hospitals, or in the dwellings of the poor, but 
 which has brought grief into the habitations of many among us, and 
 has robbed us of those whom we most dearly loved ; while the very 
 mention of its name gives rise to a feeling of utter hopelessness as to 
 its issue. I need hardly say that I propose to-day to call your atten- 
 tion to Pulmonary Consumption or Phthisis, — a malady that attacks 
 persons of all ages, of both sexes, and of every rank, and which, under 
 every variety of condition, medicine seems to be equally unable to cure. 
 
 It may, however, occur to some of you that, important though this 
 affection is, yet in speaking of it I am transgressing the bounds that 
 I set myself, when I proposed to treat only of those maladies which are 
 either limited in their occurrence to the period of childhood, or on 
 which the early years of the patient impress some well-marked pecu- 
 liarity. It is true, indeed, that at whatever age phthisis comes on, it 
 presents the same grand features, it works the same kind of changes, 
 and tends to the same fatal result. But yet the disease in the young 
 subject displays differences from its character in the old sufficient to at- 
 tract the notice of the observant ; nor are these differences merely curi- 
 ous, but they influence our prognosis and modify our treatment — and 
 hence it is fitting that we devote some time to their examination. 
 
 " That great constitutional malady, of which pulmonary consumption 
 is only a fragment, plays its part," in childhood as well as in adult age, 
 " most conspicuously in the lungs." In the adult, however, the lungs 
 are so almost invariably the seat of tubercular deposit that out of 123 
 cases, M. Louis found but one exception to the rule that if tubercle 
 
 26 
 
402 
 
 ANATOMICAL PECULIARITIES 
 
 exists in any viscus, it will be discovered also in the lungs. In the 
 child, though the lungs are still the most frequent seat of tubercle, yet 
 M. Louis' law no longer holds good, for MM. Rilliet and Barthez 
 found 47 exceptions to it out of 312 instances in which tubercle was 
 discovered in some one or more organs of the body. 
 
 The first great difference, then, between the tubercular cachexia in 
 childhood and in adult age, consists in the same organs not being 
 equally liable to it at the two periods of life. 
 
 The following table will place this difference clearly before you. It 
 shows the proportion per cent, in which different viscera were the seat 
 of tubercle in children and in adults. The figures in the first column 
 are deduced from 312 cases which form the basis of MM. Rilliet and 
 Barthez's essay on the tuberculous cachexia ; those in the second, from 
 the 123 cases on which M. Louis' work on phthisis is founded ; and 
 the third contains the results arrived at by Lombard on an examina- 
 tion of 100 adults. 
 
 Of 100 instances in which tubercle was deposited in some of the viscera it was 
 
 present in — 
 
 
 Children from 1 
 to 15 years. 
 
 Adults from 20 years and 
 upwards. 
 
 According to 
 Rilliet and Barthez 
 
 According to 
 Louis. 
 
 According to 
 Lombard. 
 
 In the lungs, 
 
 " bronchial glands, .... 
 
 " mesenteric, " 
 
 " small intestines, 
 
 " spleen, 
 
 " pleura, 
 
 " peritoneum, 
 
 11 liver, 
 
 84 
 79 
 46 
 42 
 40 
 34 
 27 
 22 
 19 
 16 
 15 
 11 
 
 100 
 28 
 33 
 33 
 13 
 
 2 
 
 
 
 
 10 
 
 
 
 2 
 
 0.8 
 
 
 
 
 
 100 
 9 
 19 
 
 6 
 1 
 
 1 
 
 2 
 1 
 2 
 
 
 ' 
 
 " large intestines, 
 
 " membranes of the brain, . . 
 
 " kidneys, 
 
 " brain, 
 
 " stomach, 
 
 " heart and pericardium, . . 
 
 6 
 3 
 
 This table shows not only that the liability of certain organs to be- 
 come the seat of tubercle is different in childhood from what it is in 
 the adult, but also that tubercle is simultaneously deposited in a greater 
 number of organs in the young than in the old. This greater intensity 
 of the tuberculous cachexia in early life is a fact of much importance. 
 It explains how it happens that death sometimes takes place in the 
 child before tubercle has anywhere undergone those changes which 
 seem almost always to precede the fatal event in the adult. 1 
 
 These, however, are not the only peculiarities of the disease in early 
 life, but the anatomical characters of tubercle in the lungs (and of this I 
 am now more particularly speaking) differ in some respects in the child 
 from those which are observed in the grown person. 
 
 1 I have thrown together in the following note some details with reference to 
 phthisis in early life, which, though far too few to warrant the deduction of any 
 
OF PHTHISIS IN THE CHILD. 
 
 403 
 
 The first of these peculiarities consists in t*he frequency with which 
 gray granulations and crude miliary tubercles e*ist in the lungs indepen- 
 dent of each other, and of any other form of tubercular deposit. In the 
 adult, M. Louis 1 discovered miliary tubercles alone only in 2 out of 
 123 cases of phthisis ; and gray granulations alone only in 5 more. In 
 
 positive conclusions, may not be without value as furnishing materials for com- 
 parison with the results obtained by other observers. 
 
 Table of 497 Cases, showi/ig influence of Sex and Age in predisposing to 
 Pulmonary Phthisis. 
 
 Under 
 
 1 year. 
 
 . F. 
 
 Total Examinations, 29 17 
 
 Tubercle present in chesty 8 8 
 
 « not " " I 21 9 
 
 From 
 1-2. 
 
 From 
 2-3. 
 
 From 
 3-5. 
 
 From 
 5-10. 
 
 From 
 10-15. 
 
 M. F. 
 
 34 38 
 
 8 11 
 
 26 28 
 
 51. F. 
 
 47 33 
 17 11 
 30 22 
 
 51. F. 
 
 58 55 
 23 30 
 35 25 
 
 M. F. 
 
 83 75 
 40 38 
 43 37 
 
 M. F. 
 
 13 15 
 5 6 
 
 8 9 
 
 Total. 
 
 51. F. TOTAL 
 
 264 233 497 
 101 104 205 
 163 129 292 
 
 The degree of the tubercular deposit is not the same in all cases, but was stated 
 to have been slight in 60, moderate in 53, considerable in 92, which were thus dis- 
 tributed : 
 
 Slight, . . 
 Moderate, . 
 Considerable, 
 
 Under 
 1 year. 
 
 1 2 
 
 7 6 
 
 From | From 
 1-2. 2-3. 
 
 M. F. ! M . p. 
 
 2 0|41 
 
 1 5 ! 5 3 
 
 5 6 i 8 7 
 
 : From 
 I 3-5. 
 
 1 
 
 From 
 5-10. 
 
 From 
 10-15. 
 
 51. F. 
 
 7 13 
 
 6 7 
 
 10 10 
 
 M. F. 
 
 15 13 
 9 13 
 
 16 12 
 
 5L F. 
 
 4 1 
 
 1 
 
 1 4 
 
 Total. 
 
 51. F. TOTAL 
 
 32 28 60 
 
 22 31 53 
 
 47 45 92 
 
 lul 104 205 
 
 In 132 of the above cases, the forms assumed by the tubercular deposit were as 
 follows : 
 
 Gray granulations, . . . 
 
 Yellow tubercle, , 
 
 " " softened, . . . . 
 
 " in cretaceous state. 
 
 Tubercular infiltration, 
 
 Small vomicae, 
 
 Large cavities, , 
 
 Tubercle of bronchial glands, . , 
 
 63 
 
 40 
 7 
 2 
 
 12 
 5 
 4 
 
 44 
 
 Q42 
 
 40 
 74 
 11 
 
 21 
 
 11 
 
 4 
 
 C5 
 
 
 
 
 
 m 
 
 H.2 
 
 ? ffl ^ 
 
 ".2 
 
 a 
 
 o 
 
 
 *^ 
 
 ? c =2 
 
 5 £2 
 
 > 
 
 
 "3-3 
 
 IS 8 
 
 %* 
 
 &* 
 
 
 03 
 
 t* 
 
 >H 
 
 V 
 
 CQ 
 
 4 
 
 7 
 
 1 
 
 12 
 
 5 
 
 10 
 
 
 
 21 
 
 11 
 
 4 
 
 13 
 
 7 
 
 31 
 
 8 
 
 — 
 
 3 
 
 30 
 
 8 
 
 8 
 
 8 
 
 — 
 
 8 
 
 18 
 
 4 
 
 1 
 
 — 
 
 8 
 
 3 
 
 12 
 
 13 
 
 1 
 
 30 
 
 18 
 
 U 1 
 
 ss3 
 
 44 
 
 71 
 13 
 
 1 
 30 
 19 
 
 6 
 119 
 
 In 21 of the 119 cases in which the bronchial glands were the seat of tubercle the 
 pulmonary tissue was unaffected ; and this although thrice the deposit in the glands 
 was universal, and in one of the three cases had gone on to softening. 
 
 The tubercle of the glands was incipient in ..... 25 
 " " " general in ..... 54 
 
 " " " had reachpd the stage of softening in 21 
 
 " " " was in a firm, friable, cheesy state in 9 
 
 " " " was undergoing cretaceous change in 10 
 
 1 Kecherches sur la Phthisie, p. 3. 
 
404 FREQUENCY OF TUBERCULAR INFILTRATION. 
 
 the child, MM. Rilliet and Barthez 1 found miliary tubercles alone in 
 107, and gray granulations alone in 36 out of 265 cases; and 132 ex- 
 aminations made by myself, or in my presence, yield 34 instances of 
 the presence of miliary tubercles alone, and 23 of the presence of gray 
 granulations alone in the tissue of the lungs. 2 
 
 The great rapidity with which the deposit and development of 
 tubercle often take place in early life, is doubtless one chief cause of 
 this peculiarity. If we examine the lungs of an adult affected with 
 the tuberculous cachexia, we shall often observe their lower lobes con- 
 taining gray semitransparent granulations ; as we advance higher, we 
 shall probably find that the granulations have lost much of their trans- 
 parency, and that they present a yellowish spot in their centre, while 
 near to the apex of the lung the deposit exists in no other form than 
 that of bodies presenting the whitish-yellow color and friable texture 
 characteristic of crude tubercle. These appearances seem to betoken 
 that the deposit of tubercle has taken place slowly and at successive 
 periods, so that those tubercles which occupy the apex of the lung are 
 already approaching maturity at a time when the disease is just begin- 
 ning to invade the lower lobes. In the child, however, it not seldom 
 happens that all the lobes of both lungs present a nearly equal amount 
 of tuberculous deposit, and that this is seen to be nearly equally ad- 
 vanced in all. Thus we may find the gray granulations diffused in 
 about the same abundance through all parts of the lungs, and all 
 equally transparent ; or we may observe each granulation presenting a 
 yellow spot in its centre; or the change may be complete, and crude 
 yellow tubercle may be everywhere present. ■* 
 
 This same fact, of the acute course of tuberculization of the lungs in 
 children, receives a further illustration from the second anatomical 
 peculiarity of the disease; namely, the great frequency' with which 
 yellow infiltration of tubercle is observed in early life; MM. Rilliet 
 and Barthez having met with it in 88 out of 265 children, or in 33 per 
 cent. ; and I, in 30 out of 132, or in 22.7 per cent. It is a form of 
 degeneration of the lung which seldom exists alone, but is almost in- 
 variably associated with gray granulations or yellow tubercle, and 
 usually coexists with a state of very far advanced tuberculization of 
 the bronchial glands. It is often limited to one lobe, generally the 
 upper : or sometimes the middle lobe in those cases in which the right 
 lung is the seat of the disease. Those portions of the lung which are 
 affected by it become converted into a firm solid mass, having much 
 both of the color and consistence of cheese, presenting a smooth surface 
 when cut, and by its solidity compressing the bronchial tubes which 
 traverse it, so as considerably to reduce their calibre. If the patient's 
 life is prolonged, a process of softening generally takes place ; the tissue 
 breaks down, and a cavity is the result, the parietes of which are formed 
 by solid tubercle. At other times, especially if the disease runs its 
 
 1 Op cit,, vol. iii, pp. 221 and 227. 
 
 2 Of late years the pressure of other duties has interfered with my constant pres- 
 ence at post-mortem examinations. I have therefore not included the results of the 
 last seven years, not because I in any measure doubt their correctness, but because 
 I cannot personally vouch for their accuracy. 
 
COMPARATIVE RARITY OF CAVITIES IN THE LUNGS. 405 
 
 course with great rapidity, the lung thus infiltrated seems to undergo 
 a different kind of softening, which does not lead to the formation of a 
 central cavity, but pervades its tissue throughout, which then presents 
 a reddish-yellow, or rose-colored tint, and breaks down easily into a 
 kind of putrilage, as if the changes produced were the result of a mix- 
 ture of true pneumonic hepatization, and of tubercular degeneration. 
 Cases of this sort go far towards substantiating the correctness of M. 
 Rokitansky's theory with reference to the nature of this tubercular 
 infiltration, as compared with the ordinary form of tubercular deposit. 
 He conceives that the deposit of tubercle in the form of gray or yellow 
 granulations takes place in the interstitial cellular tissue of the lung ; 
 while iii the case of tubercular infiltration the matter poured out into 
 the interior of the pulmonary vesicles during an attack of pneumonia 
 becomes converted into tubercle under the influence of the tubercular 
 cachexia. 
 
 A third peculiarity of phthisis in the child, as contrasted with the 
 same disease in the adult, consists in the greater rarity of cavities in 
 .the lungs during early life. Of 123 cases which form the basis of M. 
 Louis' work on phthisis, cavities were present in by far the majority 
 of instances ; and though the numbers are not exactly stated, the 
 exceptions would seem to have been but very few. Out of 265 cases, 
 however, that came under the notice of MM. Rilliet and Barthez, only 
 76, or 28.6 per cent., presented cavities in the lungs; and they existed 
 in only 22.7 per cent, or in 30 of the 132 cases which came under my 
 own observation. These cavities sometimes resemble those which we 
 usually meet with in the adult ; and this is especially the case with 
 children above six years of age, in whom, indeed, the general charac- 
 ters of phthisis approximate closely to those of the same disease in the 
 grown person. In other instances, they are not so much caverns, as 
 very small excavations (vacuoles, as the French call them), produced 
 by the softening of small tubercular deposits. Such excavations com- 
 municate with the bronchi and with each other, and are sometimes 
 exceedingly numerous, but do not occasion such a destruction of the 
 pulmonary tissue as to produce anywhere a cavity of considerable 
 dimensions. Besides these two forms of cavity, there is a third, to 
 which I have already referred, namely, that produced by softening of 
 the yellow tubercular infiltration, which is more commonly met with 
 in very early life than subsequently. Cavities of this kind sometimes 
 form with great rapidity, and attain a considerable size. The whole 
 of one lobe of the lung may even become converted into a sac, which 
 is often almost quite empty, while its parietes are formed by little 
 besides the pleura and the fibrous capsule of the lung, with a very thin 
 lining of dense tubercular matter. It is far from unusual to meet with 
 cavities of this kind in the bodies of infants only a few months old, 
 who have never thriven, but have presented few signs of phthisis, with 
 the exception of progressive loss of flesh and strength, and somewhat 
 hurried respiration. 
 
 The last anatomical peculiarity of phthisis in infancy and childhood 
 to which I shall direct your attention, consists in the abundant deposit 
 of tubercle in the bronchial glands, and the changes to which that 
 
406 ANATOMICAL CHARACTERS OF BRONCHIAL PHTHISIS. 
 
 deposit gives rise. Even in the adult, tubercle is deposited in the 
 bronchial glands in about a fourth of all cases of phthisis ; but the 
 deposit there is subsidiary to its deposit in the lungs. In the child, 
 however, this is far from being always the case ; but the disease in 
 the glands is often as important as that in the lungs, sometimes much 
 more considerable. 
 
 The tubercular deposit does not appear to begin simultaneously in 
 all the glands, nor to advance in all with the same rapidity ; but those 
 about the bifurcation of the trachea, and close to the primary bronchi, 
 are usually the first affected; and the disease in them often attains a 
 more advanced stage than elsewhere. The state in which the glands 
 are most frequently met with is one of tubercular infiltration, the 
 whole of their substance being converted into a firm, resistant matter, 
 resembling a portion of lung which has been the seat of tubercular in- 
 filtration ; and this even although the number of affected glands may 
 be but small, and though the lungs be but little or not at all involved 
 in the disease. Sometimes, however, we may meet w 7 ith the affection 
 in an incipient state, and it is then usual to find the glands which it 
 has attacked somewhat enlarged and injected, and their tissue infiltra- 
 ted with fluid, and less firm than natural. The tubercular deposit 
 does not proceed invariably from the centre to the circumference, but 
 frequently two or three small deposits may be discerned at different 
 parts of the same gland ; or the tubercular matter may be accumulated 
 entirely at one end of the gland, w T hile its other extremity is merely 
 softened and injected. Even when the disease starts from several 
 points, it is not often that the deposit assumes the distinctly circum- 
 scribed form of miliary tubercle, and still less often that of gray granu- 
 lation ; but it generally presents the character of tubercular infiltration 
 which had taken place at the same time in two or three different situa- 
 tions. Sometimes it is impossible to distinguish any one spot as that 
 from which the disease commenced, but the whole tissue of the gland 
 has a whitish hue, which appears due to the general infiltration of 
 tuberculous matter. Whatever may have been the mode in which the 
 deposit of tubercle began, the tendency of the advance of the disease is 
 to convert the entire substance of the gland into firm tuberculous 
 matter, in which no trace of the original tissue can be detected. The 
 metamorphosis of the gland is attended with considerable increase of 
 its size; the enlargement, however, being much greater in the case of 
 those glands which are situated externally to the lungs, than of those 
 which are imbedded in the pulmonary substance. The enlargement of 
 the glands is not attended, as might have been anticipated beforehand, 
 with a thinning of their originally delicate cellular envelope, but it 
 increases in density and firmness, and at the same time acquires a very 
 considerable thickness. Most of the glands wdiich have become con- 
 verted into tubercle are inclosed within a cyst a line or more in thick- 
 ness, and extremely resistant; its inner surface being smooth, of a bright 
 rose tint, and sometimes presenting a considerable degree of vascularity . 
 
 In a large proportion of cases in which tubercle is found in the 
 bronchial glands, it has not passed beyond the crude stage ; but if life 
 is not cut short by the advance of phthisis in the lungs, a process of 
 
PERFORATION OF THE BRONCHIAL TUBES. 407 
 
 softening next commences; and the softening usually, though not 
 invariably, begins at the centre of the glands, and extends towards 
 their circumference. The softening is seldom found equally advanced 
 in all the glands ; but in some, a small central cavity containing liquid 
 tubercle is surrounded by a thick wall of solid matter ; while in others 
 the whole substance has been softened, and the gland is no longer any- 
 thing else than a cyst containing a quantity of puriform fluid. When 
 tubercle deposited in the lung has undergone the process of softening, 
 an effort is made by nature to get rid of the morbid matter, which is 
 expectorated ; and the cavity, thus emptied of its contents, now and 
 then cicatrizes, and the patient is cured. The cases of cure, indeed, 
 bear but a very small proportion to those in which death takes place, 
 for, in general, fresh deposits of tubercle successively undergo this 
 softening, until but a comparatively small portion of the lung remains 
 unaffected by the disease ; or the abundant secretion from the bronchial 
 tubes exhausts the patient, or death ensues from the degree to which 
 other organs are implicated in the tuberculous cachexia. When the 
 bronchial glands are the seat of the disease, a similar effort is made to 
 eliminate the morbid matter from the system ; and many circumstances 
 concur to render this a more hopeful task than it is when the pulmo- 
 nary substance itself is the seat of the disease. 
 
 The means by which this is effected deserve to be examined. When 
 tuberculization of the bronchial glands has attained an advanced stage, 
 we generally observe a process of thickening and infiltration to have 
 commenced in the cellular tissue around each gland, by no means un- 
 like that which takes place in the pia mater at the base of the brain in 
 cases of tubercular meningitis. This cellular tissue often assumes a 
 grayish semi-transparent aspect, and presents a number of minute 
 granules of tubercle diffused through it. By a process of combined 
 inflammation and tuberculization, the connection between the gland 
 and the adjacent bronchial tube becomes extremely intimate. The 
 cellular tissue in the intervals between the bronchial rings becomes 
 next infiltrated with tubercle, and is then the first part of the wall of 
 the bronchial tube which disappears during a process of absorption 
 that advances from without inwards. The cellular tissue sometimes 
 becomes quite removed before the cartilages of the bronchi are much 
 affected ; but in process of time they too become absorbed, and the 
 perforation of the tube is then complete ; the tuberculated gland, how- 
 ever, blocking up the aperture in its walls, and projecting into its 
 cavity. The next step consists in the thinning of the envelope of the 
 gland, and the next is the discharge of its contents into the tube : and 
 the cyst then in all probability collapses, and becomes applied to the 
 outside of the bronchus, so as to form a part of its parietes. But we 
 are still in want of some exact observations as to this last stage in the 
 cure of bronchial phthisis. 
 
 This process does not take place with equal frequency in all the 
 bronchial glands ; for those which are situated around the trachea, and 
 wholly external to the lung, meeting with no obstacle to their increase 
 in size, often attain a great magnitude without at all compromising 
 the integrity of the trachea. Those, however, which are in contact 
 
408 RECENT ANATOMICAL RESEARCHES ON PHTHISIS. 
 
 with the secondary and tertiary bronchi, and are imbedded in the pul- 
 monary substance (which prevents their attaining any considerable size) 
 not infrequently perforate the tube in the manner above described, — 
 and this not only after they have become softened, but even while the 
 tubercle they contain is still in the crude state. 
 
 Although the progress of the tubercular degeneration is most obvious 
 in those glands which are situated near to the larger air-tubes, yet it is 
 by no means limited to them, but is in many instances observed also 
 in the pulmonary glands that are imbedded in different parts of the 
 substance of the lungs. They do not, however, become inclosed within 
 a cyst as dense and resisting as that which surrounds the tuberculous 
 bronchial glands : while in a great number of instances the pulmonary 
 substance for a short distance around them presents a far more abun- 
 dant tubercular deposit than is apparent in any other part of the lungs. 
 If a tuberculous gland, thus imbedded in the tissue of the lung, should 
 become softened, the excavation thereby .produced may easily be mis- 
 taken for a cavity in the lung itself. A pulmonary cavity of such 
 small dimensions, however, is hardly ever solitary, unless it proceeds 
 from the softening of tubercular infiltration ; but the deposit of tubercle 
 which takes place in the neighborhood of a diseased pulmonary gland 
 is always in the form of distinct deposits — not of tubercular infiltration. 
 
 Tuberculization of the glands does not occasion perforation merely 
 of the bronchial tubes, but in some rare instances the oesophagus, tra- 
 chea, and pulmonary artery have been perforated by the same process 
 as is usually limited to the air-tubes. 
 
 In some cases in which tuberculization has never advanced far, it 
 comes to a standstill, and the tubercle itself undergoes the cretaceous 
 change. This, however, is a rare occurrence, for it has come under my 
 notice only in 10 out of 119 cases; though, on the other hand, it is 
 more frequent than in the lung, in which it has come under my notice 
 in the child only in 7 out of 132 instances. In 9 other instances, the 
 contents of the bronchial glands, though not actually cretaceous, were 
 very dry and friable, as if the more fluid constituents of the tubercle 
 had been removed, and the cretaceous change were about to commence. 
 This change has never come under my notice as having taken place in 
 any gland which had attained considerable size in consequence of the 
 deposit of tubercle in it, nor have I ever seen it when the tuberculiza- 
 tion of the glands was general, or when the lungs showed evidence of 
 general, or of advanced phthisical disease. 
 
 It is now more than five-and-twenty years since these peculiarities 
 first attracted my attention, and were insisted on by me in my lectures. 
 The researches of morbid anatomists, aided by the microscope, have 
 thrown abundant light on many questions then obscure; they have 
 shown that the so-called gray granulation is the one original form of 
 all tubercular deposit, and that the change from gray to yellow is but 
 the result of the natural metamorphosis of such deposit ; its caseation, 
 as it has been termed. They have further given its true interpretation 
 to the yellow infiltration, and have established as fact what some years 
 since was but plausible theory — that the appearance is due to the casea- 
 tion (I beg pardon for the word, which is not of my coining) of the 
 
SYMPTOMS OF PHTHISIS. 409 
 
 products of inflammation, not to any change in tubercle originally de- 
 posited ; that it is the evidence of a bygone pneumonia, though of a 
 change at the same time which attests the scrofulous character of the 
 patient in whom it has occurred. 
 
 Our deeper insight into the meaning of the facts does not alter the 
 facts themselves. The rapid change of gray into yellow tubercle illus- 
 trates still more forcibly the acute course which the disease sometimes 
 runs, than did the older views, according to which the two conditions, 
 though allied, were yet supposed to be distinct. The tendency to the 
 so-called tubercular infiltration illustrates the importance as it does the 
 frequency of bronchio-pneumonia in early life ; but explains at the same 
 time the fact that there is more hope of the eventual clearing up of the 
 signs of phthisis in early life when they have succeeded to acute symp- 
 toms, than when they have come on by slow degrees. 
 
 The symptoms of phthisis in early life resemble in many respects those 
 which characterize the disease in adult age, while the points of difference 
 become fewer and fewer in proportion as the child grows older, until 
 they cease altogether at the period of puberty. During childhood, how- 
 ever, even those cases which run a course most similar to that of ordi- 
 nary phthisis in the adult are in general distinguished by the absence 
 of haemoptysis at any stage of the affection, — the absence of expectora- 
 tion, or its very rare occurrence, — the comparative slightness of the 
 cough, and the rarity of those colliquative sweats which so much exhaust 
 the grown person. In many instances the child droops, loses its appe- 
 tite and flesh and strength, and complains of vague pain in the chest 
 and abdomen for many weeks before the occurrence of cough excites 
 any apprehension that the lungs are the seat of disease. When the 
 cough does come on, it is slight, short, and dry, and attracts atten- 
 tion by its frequency, rather than by the discomfort which it occasions 
 the child. Its usual amusements cease to occupy the child, who sits 
 about, listless and fretful in the daytime, while the skin often grows hot 
 and dry, and the lips become parched as night approaches; but there 
 is so little that is definite in these symptoms, that they are not infre- 
 quently supposed to indicate the existence of typhoid fever, or to be due 
 to the presence of worms in the intestines. 
 
 It is important to bear in mind that strumous dyspepsia, as it has 
 been called by many writers, is of more frequent occurrence in child- 
 hood than in adult age, and that its symptoms may be all that marks 
 the advance of phthisis in the lungs until within a month or two of the 
 patient's death. A definite commencement can almost always be assigned 
 to an attack of typhoid fever ; and the great heat of skin, the very 
 rapid pulse, the 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 mistaking for it those slighter and more vague ailments 
 that are experienced during the first stage of phthisis, in all except the 
 rare instances in which the disease runs a very acute course. The refer- 
 ring the symptoms of incipient 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 ravenous as it is deficient at another, — the tongue 
 
410 BRONCHIAL PHTHISIS. 
 
 either clean and moist, or else thickly coated, — the condition of the 
 bowels, which is generally one of constipation — and the marked relief 
 that almost always follows the action of purgatives, are indications of 
 the presence of worms sufficiently characteristic to guard the attentive 
 observer from error. 1 
 
 Fluctuations take place in the child's condition, and a casual attack 
 of bronchitis often seems to be the exciting cause of that aggravation 
 of the pulmonary symptoms which is observed before long. The res- 
 piration now becomes habitually quicker than natural, instead of merely 
 being easily accelerated, and is often accompanied with considerable 
 wheezing : the cough grows more frequent and lasts longer, but is still 
 in most instances unattended by expectoration, owing to the fact that 
 the child almost always swallows those matters which the adult would 
 spit up. The loss of flesh, and the decay of strength, advance even 
 more rapidly than the signs of pulmonary disease. Well-marked hectic, 
 however, is infrequent ; and if night-sweats occur, they are often limited 
 to the head and face. Towards the close of the disease the mouth often 
 becomes aphthous, especially in infants ; but though diarrhoea sometimes 
 occurs, it does not often seem to contribute so much to the exhaustion 
 of the child as to that of the adult, and that alternation of diarrhoea 
 and hectic sweats, which is so frequent in the grown person, is seldom 
 or never observed in the child. When death at length takes place, it 
 either occurs from exhaustion, or succeeds to some intercurrent attack 
 of bronchitis < or pneumonia; or follows the gradual supervention of 
 symptoms of tubercular meningitis ; a mode of termination of the dis- 
 ease more frequent in children under the age of three years, than in 
 those who are older. 
 
 In those cases in which tubercle has been deposited in great abundance 
 in the bronchial glands, constituting what is called bronchial phthisis, 
 the symptoms deviate still more from those which are usually observed 
 in the adult. Bronchial phthisis occurs in its best-marked form between 
 the ages of two and six years, although, as it is scarcely necessary to 
 observe, tuberculization of the glands is by no means limited to that 
 age. Its symptoms in many instances first become distinctly evident 
 after some severe bronchitic seizure, which either accompanied measles 
 or came on without any apparent exciting cause. In other cases, 
 although the commencement of the affection is not clearly traceable to 
 a single attack of severe bronchitis, yet the patients in whom it occurs 
 had in all probability been subject to frequent returns of catarrh or 
 bronchitis, which, though not alarming in their symptoms, yet left 
 behind them a cough that never entirely subsided. By degrees this 
 cough becomes severer : it returns in paroxysms not unlike those of 
 pertussis : it sometimes induces efforts to vomit, and can scarcely be 
 distinguished from the cough of the earlier stages of hooping-cough. 
 The respiration grows habitually oppressed and wheezing, the face 
 
 1 The observations of Dr. Ringer and others, which held forth the hope that the 
 thermometer would furnish the earliest and most trustworthy information of the 
 coming on of phthisis, before the disease manifests itself by local symptoms, do not 
 appear to have received adequate confirmation. They are dissented from by M. 
 Soger, a most competent and unprejudiced authority. Op. cit., p. 371. 
 
SYMPTOMS OF BRONCHIAL PHTHISIS. 411 
 
 becomes puffed and swollen, the veins of the neck distended just as in 
 patients with heart disease, and. the superficial vessels of the thorax 
 become enlarged, just as those of the abdomen do in cases of ascites, or 
 of mesenteric disease. 
 
 The great fluctuations which take place in the condition of the pa- 
 tient constitute one of the most striking characteristics of this form of 
 phthisis. Attacks of bronchitis sometimes come on, during which the 
 respiration is painfully accelerated and oppressed, and the paroxysmal 
 cough is merged for a time in a constant hacking, or in suppressed at- 
 tempts at coughing. These bronchitic symptoms, which often seem to 
 threaten life, and sometimes actually destroy it, clear up by degrees in 
 the majority of cases, but leave the child with a severer cough and a 
 more hurried respiration than before, Avhile 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 be- 
 comes 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 not also so large a measure of tuberculous affec- 
 tion 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 ad- 
 vanced : 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 regained, — and, were it 
 not that cough still continues, though less frequent and less severe, 
 that the breathing is more hurried than natural, and that ausculta- 
 tion contributes still further to undeceive us, — we might fancy that 
 all ground for anxiety was passing away, and that the child was on the 
 highroad 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 re- 
 covery 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 alternated with an expectoration of thick, puriform 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 dis- 
 charge from her nose. The abscesses had not been long healed when 
 her mother's alarm was excited by her expectorating blood mixed with 
 the phlegm which she brought up when coughing. Though not much 
 emaciated, the child looked unhealthy ; her pulse Avas very feeble, and 
 there were many small petechia? on her extremities. The lungs, how- 
 ever, were tolerably free from disease ; for nothing more was heard 
 during auscultation than a good deal of rhonchus mixed with some 
 
412 PHTHISIS IN VERY EARLY INFANCY. 
 
 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 time the child by degrees lost her cough, 
 and gained 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. 
 
 The fatal termination of bronchial phthisis usually takes place in 
 consequence of the lungs becoming seriously involved in the tubercular 
 disease, though life is sometimes suddenly cut off by haemoptysis, owing 
 to the perforation of one of the larger vessels of the thorax by a tuber- 
 culated bronchial gland. It must not, however, be supposed that this 
 is the only means by which fatal hemorrhage is produced, for it takes 
 place in other instances in precisely the same circumstances as in the 
 adult. Seven cases of fatal haemoptysis have come under my notice in 
 children ; but in four no examination was made after death. In the 
 fifth case, which was that of a boy between five and six years old, who 
 died at the end of nine months' illness, blood pouring in abundance 
 from his nose and mouth, the amount of disease, both of the lungs and 
 bronchial glands, was very considerable ; but no large vessel had been 
 perforated, and it was not possible satisfactorily to determine the source 
 of the hemorrhage. In the sixth case, that of a little boy five years 
 old, in whom symptoms of pneumonia had supervened upon previous 
 signs of phthisis, the source of the bleeding in the single and fatal 
 attack of haemoptysis, which took place at a time when he seemed 
 recovering, likewise eluded the most careful anatomical investigation. 
 In the seventh case, there was a cavity in the upper part of the right 
 lower lobe. This cavity was traversed by a vessel on which an aneurism 
 had formed, of the size of a hazelnut. The sudden rupture of this 
 .aneurism was the occasion of the patient's death. 
 
 A very considerable degree of tuberculization of the bronchial glands 
 Is by no means uncommon even in very early infancy : but it then 
 generally forms only a part of such extensive tubercular disease that 
 its special symptoms are lost in those of the general malady. In such 
 cases, too, it frequently occurs that the signs of thoracic disease are 
 almost entirely merged in those of generally defective nutrition. The 
 existence even of a large cavity in the lung may be announced in early 
 infancy by nothing more serious than some acceleration of the breathing 
 and an occasional short cough ; while the frequent vomiting, — the irreg- 
 ular, often relaxed, condition of the bowels, — the unhealthy evacua- 
 tions, — the red tongue and the aphthous state of the mouth, — may direct 
 the attention almost exclusively to the condition of the digestive organs. 
 
 Many points still remain for our investigation, but we must postpone 
 their consideration, and the study of the auscultatory phenomena of the 
 disease, to the next lecture. 
 
AUSCULTATORY SIGNS OF PHTHISIS IN CHILDHOOD 413 
 
 LECTURE XXIX. 
 
 Phthisis, continued — Peculiarities of its auscultatory signs in early life — Some of 
 less value than in the adult — Influence of tuberculous bronchial glands in ex- 
 aggerating the signs of disease of the lung — Difficulty in appreciating some 
 signs which are well marked in the adult — Sign peculiar to early life. 
 
 Different forms of phthisis. — Acute phthisis ; illustrative case — Tuberculous pneu- 
 monia — Bronchitis grafted on phthisis may lead to an overestimate of the 
 tuberculous disease. 
 
 Duration of phthisis ; its course sometimes very acute, at others extremely chronic. 
 — Cases in illustration — Modes of death in phthisis — Head symptoms some- 
 times precede death independent of cerebral disease. 
 
 Prophylaxis, and treatment of phthisis. 
 
 It would be little better than a waste of your time to enter into a 
 minute description of all the modifications of the respiratory sounds to 
 which the presence of tubercle in the lungs of children may give occa- 
 sion : our time will be better spent than in such detail, if we direct 
 our attention to those respects in which the auscultatory signs of phthisis 
 in childhood diifer from those which betoken its existence in the adult, 
 or in which the same auscultatory phenomena require a different inter- 
 pretation at the one period of life, from that which is justly applied to 
 them at the other. 
 
 The grand difference, indeed, is to be sought in the latter rather 
 than in the former of these respects. Tubercle, at whatever age it is 
 developed in the lungs, gives rise to much the same auscultatory phe- 
 nomena; but many of those modifications of the respiratory sound 
 which would warrant us in pronouncing positively that phthisis existed 
 in the adult, cannot be relied on with the same certainty in the child : 
 still less can they be regarded as proving the existence of so large an 
 amount of disease in the latter case as in the former. It may be stated, 
 then, that 
 
 1st. Many of the auscultatory signs of 'phthisis deserve less reliance, or 
 have a less grave import, in the child than in the adult. 
 
 One of the earliest signs of tubercular deposit in the lungs of the 
 grown person is furnished by that peculiar modification of the respira- 
 tory sound to which the name of coarse breathing has been applied ; 
 and this acquires still greater importance when associated, as it often 
 is, with dry rhonchus and creaking sounds. Much of the value of this 
 sign depends on its being limited to the infra-clavicular regions, or, at 
 least, on its being heard there w T ith much greater distinctness than 
 elsewhere. Since, however, the deposit of tubercle in the lungs of 
 children is more uniform, and more generally diffused than in the 
 adult, the additional value wdiich the localization of these signs fur- 
 nishes is lost; and it becomes impossible to determine wdiether the 
 
414 AUSCULTATORY SIGNS OF PHTHISIS IN CHILDHOOD. 
 
 bronchial irritation that they betoken is induced by the presence of 
 tubercle in the lungs, or by some other cause. 
 
 Prolongation of the expiratory sound beneath the clavicle, and inter- 
 rupted respiration, — the respiration saccadee of French authors, — which 
 are two of the earliest and most important indications of phthisis in 
 the grown person, are, on the whole, of less value in the child. Their 
 occurrence, indeed, should always excite suspicion as to the existence of 
 phthisis, but they are not infrequently very well marked in cases where 
 but slight disorder of the respiratory organs is present ; and where the 
 perfect recovery of the child, and its subsequent sound health, prove 
 that tubercular disease either was altogether absent, or at any rate was 
 extremely slight. 
 
 The exaggeration of these two signs is probably, in some measure, 
 due to a cause which adds greatly to the intensity of some other of 
 those auscultatory phenomena that usually betoken far-advanced 
 phthisis. MM. Eilliet and Barthez were, I believe, the first who 
 pointed out the fact that the bronchial glands, when enlarged by the 
 deposit of tubercle, and thus brought into contact with the walls of the 
 chest, which they do not touch in the healthy state, conduct to the ear 
 of the auscultator sounds that in other circumstances are imperceptible. 
 The air passing through the larger bronchi is now heard, on applying 
 the stethoscope to the w^alls of the chest, in the supra-scapular, and 
 less often in the infra-clavicular region, and can scarcely be distin- 
 guished from bronchial breathing produced by solidification of the 
 pulmonary tissue itself. The sounds which are caused by the presence 
 of mucus in the larger air-tubes are in the same way conducted to the 
 ear in other situations than those, — such as the root of the lung, where 
 alone they would be heard if the glands were not enlarged. The aus- 
 cultator may thus be betrayed into the error of supposing that hopeless 
 phthisis exists in cases where yet the amount of disease in the lung is 
 but small, and where life may be prolonged for many years. Morbid 
 sounds, too, produced in one lung, may thus be conducted to the walls 
 of the chest on the opposite side, and the extent of disease may, in con- 
 sequence, be overrated; or the sounds which, when perceived in the 
 front of the chest, may arise from real disease in that situation, being 
 transmitted to the back through the medium of the glands, may thus 
 give rise to the conclusion that far more serious mischief exists than is 
 really the case. The means of avoiding error from this cause consist 
 in the careful comparison of the results of auscultation with those of 
 percussion, and of those of auscultation on one day with those which it 
 yields a few days afterwards. If the sounds proceed from solidifica- 
 tion of the lung, or from cavities in its substance, the results of auscul- 
 tation will be as invariable as those of percussion ; but if they are 
 merely sounds transmitted from the larger air-tubes, they will be found 
 to vary much on different occasions ; while the dulness on percussion 
 in certain parts will continue unchanged, inasmuch as it proceeds from 
 the presence of the enlarged glands. This variability in the results 
 of auscultation is one of the most important indications of bronchial 
 phthisis. It depends not merely on the accidental variations in the 
 sounds produced in the larger air-tubes, but also on the changes which 
 
AUSCULTATORY SIGNS OF PHTHISIS IN CHILDHOOD. 415 
 
 the varying degree of compression of the bronchi, produced by the 
 increase or diminution in the size of the glands, may occasion, and on 
 the variations in the irritation of the air-tubes which this pressure 
 produces. The risk in cases of bronchial phthisis is not so much that 
 of forming an altogether erroneous diagnosis, as of expressing a prog- 
 nosis far more unfavorable than the nature of the case actually justi- 
 fies. In cases where a considerable measure of bronchitis is associated 
 with tuberculization of the glands, we are especially likely to fall into 
 this error, and can avoid it only by much caution, and by frequently 
 repeated auscultation. 
 
 There are differences of another kind, however, between the results 
 of auscultation in cases of phthisis in the young and old, and which 
 depend — 
 
 2c?. On the absence, or difficult appreciation, of some auscultatory phe- 
 nomena in the child, to which much value is attached in the case of 
 the adult. 
 
 To this head belong the differences resulting from the loss in the 
 child of almost all that information which, in older persons, is afforded 
 by the different modifications of the vocal resonance. The shrill voice 
 of the child, the small power of modulating it that is possessed in 
 early life, and the consequent difficulty of inducing the patient to utter 
 a few sentences, or even a few words, in the same key, even when fear 
 does not reduce the voice to a mere whisper, take away almost all 
 value from the modifications of the voice-sound in young subjects. 
 
 The extreme excitability of children tends, as it does also in the 
 female subject, to reduce very low the value of mere inequality of breath- 
 ing between the two lungs ; for it is by no means a rare occurrence for 
 the lung which on one day seemed to admit but little air, to yield the 
 sounds of well-marked puerile respiration on the next day, and for the 
 feeble respiration to have changed sides. Before, therefore, any con- 
 clusion can be drawn from the feebleness of the respiration in either 
 lung, its situation, degree, and extent must be confirmed by repeated 
 observation. 
 
 The finer variations in the sonoriety of the chest are not so easily 
 distinguished in childhood as in more advanced age. The main cause 
 of this appears to be furnished by the extreme resonance of the chest 
 in early childhood, which will admit of very considerable reduction 
 before percussion elicits a sound that the ear would recognize as at all 
 dull. Extremely gentle percussion is much more likely to bring out 
 the more delicate variations of sound, than those smart taps on the 
 chest, which, in the grown person, will often answer the purpose 
 sufficiently well. - 
 
 A last source of difference may be mentioned as arising — 
 
 3c?. From the occurrence of some physical signs peculiar to the form 
 which phthisis assumes in early life. 
 
 The only sign that comes with propriety into this category, is that 
 dulness between the scapulae which is not infrequently produced by 
 
416 CHARACTERISTICS OP PHTHISIS IN CHILDHOOD. 
 
 the presence of tuberculous glands, and which, when it coexists with 
 tolerable resonance over the upper part of the lungs, and moderately 
 good respiration in those situations, may be regarded as pathogno- 
 monic of bronchial phthisis. The absence of dulness in this situation, 
 however, does not of itself warrant the inference that the glands are 
 free from disease, but merely that they have not yet attained any very 
 considerable degree of enlargement. 
 
 It may perhaps be useful, before we proceed to the study of some 
 other peculiarities of phthisis in childhood, briefly to recapitulate the 
 general characteristics of the disease in early life. The chief of these 
 are — 
 
 1st. The frequent latency of the thoracic symptoms during its early 
 stages. 
 
 2d. The almost invariable absence of haemoptysis at the commence- 
 ment of the disease, and its comparatively rare occurrence during its 
 subsequent progress. 
 
 3d. The partial or complete absence of expectoration. 
 
 4th. The rarity of profuse general sweats; and the ill-marked char- 
 acter of the hectic symptoms. 
 
 5th. The frequency with which death takes place from intercurrent 
 bronchitis or pneumonia. 
 
 Bronchial phthisis is characterized by — 
 
 1st. The frequent development of its symptoms out of one or more 
 attacks of bronchitis. 
 
 2d. The peculiar paroxsymal cough which attends it, resembling 
 that of incipient pertussis. 
 
 3d. The great and frequent fluctuations in the patient's condition, 
 and the occasional apparently causeless aggravation both of the cough 
 and dyspnoea. 
 
 In very early infancy, phthisis is remarkable for the very frequent 
 latency of the chest symptoms, which, through its entire course, are 
 often entirely merged in the signs of impaired nutrition. 
 
 The most important peculiarities in the auscultatory phenomena of 
 consumption in the child are — 
 
 1st. 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. 
 
 2d. The apparent, and to some extent the real, exaggeration of the 
 signs both of early and far-advanced disease of the lungs, in some cases 
 of bronchial phthisis. 
 
 3d. The loss of that information which the phenomena of the voice 
 furnish in the case of the adult. 
 
 4th. The small value of inequality of breathing in the two lungs. 
 
 5th. The difficulty of detecting minute variations in the sonoriety of 
 the chest; and 
 
 6th. The existence of dulness in the interscapular region, together 
 with moderate resonance of the upper part of the chest, and tolerably 
 
COURSE OF PHTHISIS SOMETIMES VERY RAPID. 417 
 
 good respiration there, which are characteristic of the presence of en- 
 larged bronchial glands. 
 
 Hitherto we have been occupied with the study of the more common 
 forms of phthisis in childhood ; but deviations are occasionally met with 
 from the ordinary course of the disease, with which it behooves us to 
 make ourselves acquainted. Phthisis occasionally runs a course so 
 extremely rapid that many of its most characteristic symptoms have 
 not time to manifest themselves. In such cases we are exposed to con- 
 siderable risk of error, for the history of the patient's indisposition 
 goes back only to a few weeks or days ; the evidence of impaired nu- 
 trition is almost or altogether wanting, and the symptoms appear to be 
 those of an acute malady coming on suddenly, rather than those of a 
 slow and wasting disease. 
 
 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 24th 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 dentition. The 
 gums were lanced, and a mixture containing the vinum ipecacuanha? 
 was ordered, to which, finding the symptoms did not abate, small 
 doses of antimonial wine 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 pre- 
 vious 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. x4uscultation detected generally diffused small 
 crepitation 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 miliary tubercle, of tubercular infiltration, 
 and of masses of crude tubercle formed by the agglomeration of many 
 separate deposits. The pulmonary 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 on the second stage, and 
 there was very considerable injection of the bronchial tubes. The 
 various abdominal viscera contained tubercle, but it was not far ad- 
 vanced in the mesenteric glands. 
 
 This case represents a class in which there is much hazard of forming 
 
 27 
 
418 SIMPLE AND TUBERCULOUS PNEUMONIA. 
 
 an erroneous diagnosis. It shows the possibility of tubercular deposit 
 taking place to a very great extent without at all. interfering with the 
 general nutrition of the body, and without giving rise to any symptom 
 so serious as to attract the notice of a very careful and affectionate 
 mother. It illustrates also "the mode in which the fatal termination of 
 many cases of phthisis in children is brought about, and suggests the 
 inquiry whether there are any means of distinguishing between tuber- 
 culous pneumonia, and pneumonia which occurs uncomplicated with 
 phthisical disease of the lungs. 
 
 Pneumonia often complicates phthisis in early life, in circumstances 
 where no diagnostic difficulty occurs ; but it is of much importance to 
 detect the consumptive element in cases which to the superficial observer 
 present no other symptoms than those of acute inflammation of the lungs. 
 The existence of a considerable amo'unt of tubercular deposit in the lungs 
 may be suspected in those cases in which the degree of oppression of the 
 chest has, from the very commencement of the illness, been altogether 
 out of proportion to the severity of the catarrhal or bronchitic symptoms 
 with which the disease set in. A further evidence of its nature is afforded, 
 if the skin, though very dry, presents a less considerable or a less pun- 
 gent heat than attends simple pneumonia, while the pulse from the very 
 outset is less developed. Suspicion would be strengthened if the fre- 
 quency of respiration very greatly exceeded the amount of mischief dis- 
 closed 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 deterioration 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 crepitation of pneumonia ; while, though the smaller 
 sounds would be discovered 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 dis- 
 tinctly in the same situation. 
 
 The importance of distinguishing those cases in which inflammation 
 supervenes in a lung already the seat of tubercular deposit, from others 
 in which the organ had been previously healthy, is by no means con- 
 fined to cases of the severest kind, in which life is immediately threat- 
 ened. ' In every instance of pneumonia in early life, both your prognosis 
 and your treatment would be greatly modified if there were good ground 
 for believing that tubercular disease had for some time previously affected 
 the lungs. Hence follows the necessity for that very minute inquiry 
 as to the previous health of the patient, and of the other members of the 
 family, on which so much stress was laid at the commencement of this 
 course of lectures. If you learned that several children in the family 
 had already died of phthisis or of some other affection — such as tuber- 
 cular meningitis — which you knew to be most intimately associated 
 with the tuberculous diathesis, the possibility of the same complication 
 existing in the patient under your care would at once occur to you. 
 This complication would be rendered highly probable, if you were to 
 ascertain that the child had been particularly liable to catch cold, or had 
 
BRONCHITIS EXAGGERATES SYMPTOMS OF PHTHTSIS. 419 
 
 for some months been seldom free from cough for many days together, 
 or had suffered from cough every winter, for two or three years, and had 
 already experienced two or three attacks similar to that which you are 
 called on to treat, and which, though severe, had yet subsided by degrees, 
 without the employment of very active measures. The probability 
 would be raised almost to certainty if there existed that want of cor- 
 respondence between the general symptoms and physical signs, or be- 
 tween the results of auscultation and percussion, to which reference has 
 already been made ; or if the history of the present illness went back 
 to a period anterior to that which you would be disposed to assign to 
 it, if the affection had been simple pneumonia. 
 
 You would carefully abstain from all rigorous antiphlogistic measures 
 in the management of a case of tuberculous pneumonia. Bearing in 
 mind the influence of enlarged bronchial glands in rendering parts of 
 the chest dull on percussion, and in exaggerating in some respects the 
 morbid sounds, you would not overestimate the degree or extent of the 
 inflammatory mischief. At the same time you would not allow even a 
 considerable measure of improvement to lead you to speak too decidedly 
 of the ultimate recovery of your patient ; since you would not forget 
 that, if inflammation do not originate tuberculous disease, it may yet 
 communicate increased activity to its progress. 
 
 The overlooking the more serious malady, owing to its symptoms 
 being thrown into the shade by those of the other more curable affec- 
 tion, is not the only error to which you are exposed in cases of infan- 
 tile phthisis. The degree of irritation of the bronchi that exists in dif- 
 ferent instances, varies exceedingly ; sometimes it is so considerable 
 that when the child is placed under your care its respiration is wheez- 
 ing, difficult, and very hurried, its cough violent and exhausting; while 
 such is the general anxiety of the countenance, and so great is the de- 
 pression of the vital powers, that the struggle seems as if it could not 
 be long protracted. Percussion detects dulness at the upper part of the 
 chest ; the bronchi are so laden with phlegm that air scarcely penetrates 
 beyond the larger tubes, and mucous rale is heard throughout the 
 whole of the lungs, while at the upper part it is so large as to amount 
 almost to gurgling. You regard the case as one of far-advanced phthisis, 
 and suppose that softened tubercle is diffused through the whole of 
 both lungs, and that cavities exist at their apex. You form the most 
 gloomy prognosis, and entertain, very probably express, the conviction 
 that a few weeks at furthest will be the period of your patient's life. 
 By degrees, however, the most urgent symptoms subside, and some 
 signs of returning health appear ; the respiration grows slower and 
 more tranquil, the cough abates, perhaps almost ceases. The signs of 
 a cavity grow less and less distinct, in proportion as the secretion in 
 the bronchi diminishes ; and after some months, while the patient's 
 general condition deviates but little from a state of health, a little dul- 
 ness at the upper and back part of the chest, unequal breathing, pro- 
 longed expiration, or morbid sounds equally slight, are the only auscul- 
 tatory evidence that the most careful examination can discover of pul- 
 monary disease. 
 
 Xon-professional persons are apt to imagine the mistake in cases 
 
420 DURATION OF PHTHISIS. 
 
 of this kind to have been greater than it really was. The error is 
 one as to the degree of the malady rather than as to its kind. In 
 cases that present these symptoms, phthisis has in reality existed, but 
 the chief tubercular deposit has probably been seated in the bronchial 
 glands, and their enlargement gave rise to much of the dulnesson per- 
 cussion, and exaggerated the morbid sounds at the upper part of the 
 chest. From some accidental cause, such as cold or damp, or from the 
 mucous membrane of the bronchi sympathizing with disorder of the 
 digestive organs, or from inappropriate treatment, which aggravated 
 the evil it should have relieved, or even without any cause that we can 
 assign, it had come to pass that the air-tubes were in a state of great 
 irritation. The due regulation of temperature, appropriate general 
 treatment, and nature's own healing power, improved the health and 
 diminished the irritability of the bronchi ; while very probably the dis- 
 eased glands emptied themselves, at least in part, into the air-tubes, 
 and the tubercle was thus eliminated from the system. You should, 
 therefore, always express your opinion' very guardedly with reference 
 to the condition of a child suffering from phthisis, until you have con- 
 firmed the results of auscultation by its frequent repetition, and till you 
 have had the opportunity of determining how large a portion of the 
 physical signs is due to the morbid deposit, and how much to that irri- 
 tation of the , bronchi which you may fairly hope to mitigate, if not to 
 remove. 
 
 The average duration of phthisis in childhood is estimated by MM. 
 Rilliet and Barthez at from three to seven months, though, as they 
 justly observe, its extreme limits vary from two months in unusually 
 rapid cases, to two years and upwards in other instances, in which the 
 course of the disease is very protracted. It is my impression, indeed, 
 that the ordinary duration of phthisis in childhood is less brief even 
 among the poor than the observations of these gentlemen, made among 
 the children in the Hopital des Enfans, at Paris, have led them to 
 believe. I am certain too that in the wealthier classes of society, 
 phthisis, when not congenital, or when not coming on within the first 
 months of infancy, runs a much slower course, though it is not possible 
 to state in figures the conclusions drawn from private practice, in which 
 the number of observations has to make up for the imperfect and frag- 
 mentary character of each. The difference in duration, indeed, between 
 the two extremes of phthisis is very wide ; a few weeks limiting it in 
 some cases, while in others the disease has continued for two, three, 
 four, and nearly five years, before it terminated fatally. 
 
 That form of acute phthisis in which the patient dies as the result of 
 the constitutional malady rather than of local mischief going on in 
 some one organ, is much oftener met with as a sequela of some other 
 disease, such as measles, hooping-cough, or typhoid fever, than as an 
 idiopathic affection. It follows sometimes on the decline of one or 
 other of those disorders, and develops itself out of the convalescence 
 from it, the fever not entirely subsiding, the appetite not returning, the 
 strength not being regained, but the amendment which yesterday 
 seemed to promise, being belied by the deterioration of to-day ; and in 
 such circumstances, a month or five weeks will sometimes bring the 
 
CHRONIC PHTHISIS. 421 
 
 child to the grave, all its functions suffering so equally, that we feel at 
 a loss as to the one to which we should endeavor chiefly to minister. 
 
 But though less frequent, the cases are of greater moment, because 
 they are more likely to be misinterpreted, in which this acute tuber- 
 culosis develops itself out of a condition of previous health, though 
 that health is often er valetudinarianism than vigor. Causelessly, the 
 child loses flesh, and strength, and appetite, and cheerfulness ; it frets 
 about everything, but says it has no pain, that it ails nothing ; nor is 
 anything observable save that the pulse is habitually quicker, and the 
 skin often hotter than natural. The nights are restless, though the 
 child frequently wants to lie down in the daytime, and sometimes 
 delirium comes on towards bedtime; while when awake there is a 
 remarkable degree of nervousness, the manner is frightened, almost 
 hysterical. Often this condition gradually passes away as symptoms 
 of tubercular meningitis come on, and the case loses its peculiarities as 
 its hopeless nature becomes apparent ; though not infrequently, if we 
 examine the body after death, we shall be surprised at finding the 
 evidence of cerebral disease slighter than we had expected, and a little 
 fluid in the ventricles, a little opacity of the arachnoid and a few 
 granulations at the base of the brain, may be all the alterations dis- 
 coverable. In other instances the symptoms put on more and more 
 the character of fever; the delirium^ becomes more frequent, and at 
 last constant ; the prostration extreme, the tongue dry and tremulous, 
 the teeth covered with sordes, and the abdomen full, tender, tympan- 
 itic, so that the distinction between the case and one of typhoid fever is 
 almost impossible; and, indeed, the previous history of the patient, 
 and the longer duration of the ailment, constitute almost the only 
 means by which we can discriminate between them. This course of 
 phthisis, too, is not limited to any age, but may even be observed in 
 infants at the breast : and the extreme rarity of typhoid fever at so 
 early an age would in them still further raise the presumption that 
 the symptoms were due to the rapid development of tubercle. 
 
 So little notice has been taken of the chronic form of phthisis in 
 children, that it may be well to relate a few examples of it. 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 discovered that air entered the lung in the left infra-clav- 
 icular 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 appear tolerably well, though her cough never ceased 
 entirely ; but in the early part of the winter of 1 844 her health com- 
 pletely failed. Examination of the chest in the beginning of Decem- 
 ber elicited great deficiency 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 
 
422 CHRONIC PHTHISIS. 
 
 abundant moist sounds pervaded the lung posteriorly. In the left 
 Infraclavicular and mammary regions the respiration was very defi- 
 cient, and accompanied with distant moist sounds. Extreme coarse- 
 ness 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, re- 
 sonance 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 mucous 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 the respiration was 
 puerile in front, except quite at the upper part, where the breathing 
 was coarse, and attended with mucous rale ; and posteriorly the same 
 characters were still more marked. 
 
 It cannot be necessary to detail the results of the subsequent exam- 
 inations 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 ; sometimes she seemed 
 almost dying under an aggravation of all the symptoms, and then 
 again she rallied, and was able to walk about, and seemed tolerably 
 comfortable. Life was prolonged until June 1st, 1847 ; and she Lad 
 seemed almost as well as usual until a very few days before her death. 
 Unfortunately, permission to examine the body could not be obtained ; 
 but the stethoscopic signs enable us to trace back the phthisical disease 
 for more than five years, while the evidence of a large cavity in the 
 left lung was distinct twenty-one months before death took place. 
 
 Nor is this a solitary case, but if time allowed I could give many 
 other illustrations of the slow progress of phthisis, terminating some- 
 times in imperfect convalescence ; but oftener in gradual decline and 
 tardy death. Often, indeed, it is useless to speculate on the issue of a 
 case of chronic phthisis, or on its possible duration; for it is by no 
 means unlikely that the child may live, with but little deterioration in 
 its condition, until measles or hooping-cough imparts a fresh stimulus 
 to the consumptive disease, or excites some fatal attack of bronchitis or 
 pneumonia. I used to see occasionally a little boy, who was aged only 
 three years when he first came under my notice, and whom I had the 
 opportunity of watching till he was eleven years old. When first 
 brought to me he had been suffering from cough ever since an attack 
 of what his mother called inflammation of the lungs, when he was six- 
 teen months old ; his cervical glands had recently suppurated ; he had 
 unusually well-marked hectic fever, and profuse night-sweats; and a 
 month before I saw him had spit blood once. His right side yielded 
 throughout a dull sound on percussion ; breathing in that lung was 
 scanty, and attended by large moist sounds. The child went into 
 
CHRONIC PHTHISIS. 423 
 
 Devonshire to pass the winter, and, as I expected, to die thereof phthisis ; 
 but he returned in better health; he grew tall, and played about like 
 other children, though he seldom passed more than a few months with- 
 out attacks of a pleuritic character, the pain of which he used to refer 
 to his right side, and which usually subsided in the course of a few 
 days, without any treatment more severe than a mustard poultice, and 
 some diaphoretic medicine. His cough never left him entirely; but 
 both that and the quantity and character of his expectoration varied, 
 and sometimes he spat a little blood. In October, 1844, the ausculta- 
 tory signs were as follows : The left lung yielded, as it had constantly 
 done, the sounds of puerile breathing in front ; posteriorly, the breath- 
 ing in the lung was also good, except that there were some moist 
 sounds in the infrascapular region, and that the breathing had a coarse 
 and almost tubular character about the upper angle of the scapula. 
 In the right lung, in front, the respiration was puerile, with now and 
 then a little distant crepitus as low down as the lower edge of the 
 second rib, at which point the moist sounds became larger. Posteriorly 
 there were large moist sounds intermixed with puerile breathing in the 
 suprascapular region ; gurgling, cavernous breathing, and bronchial 
 voice about the scapula ; and lower down there was very little respira- 
 tion, and that of a broneb ial character, becoming quite inaudible in the 
 lateral region. In the axillary region the respiration was coarse, ac- 
 companied with large mucous rales. In March, 1849, I saw him for 
 the last time. He had then continued for more than eighteen months 
 free from any serious pleuritic attack, and from haemoptysis. His res- 
 piration was still hurried, but he had gained flesh, and sometimes had 
 walked five or six miles in a day without inconvenience. Auscultation 
 showed, too, that his disease had been stationary for the previous five 
 years — if, indeed, it had not actually improved. The moist sounds 
 about the left scapula were smaller, and heard over a smaller surface. 
 The indications of a cavity in the back part of the right lung continued 
 unchanged, but not increased ; while in other respects auscultation gave 
 exactly the same results as before. Other cases of a similar kind have 
 come under my observation, in which the history of phthisis went back 
 for several years, and in which the signs of caverns in the lungs were 
 unmistakable; the children continuing to lead a sort of valetudinarian 
 existence, improving in health, and gaining flesh and strength in the 
 summer, but losing ground again with the return of winter. 
 
 In the present condition of our knowledge, it is not possible to state 
 with certainty either the anatomical characters of phthisical cavities of 
 long standing, or the signs which, during the patient's lifetime, would 
 warrant the expectation that the disease will run a tardy course; but it 
 is well to bear in mind, that such cases are by no means very rare ; that 
 the powers of repair are far greater in the child than in the adult. We 
 must now, therefore, pass on to notice briefly the treatment of the dis- 
 ease, after glancing for a moment at the different modes in which it 
 brings about a fatal issue. 
 
 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 nutri- 
 tion generally is so impaired, that the patient dies, because the whole 
 
424 TREATMENT OF PHTHISIS. 
 
 machine is worn out. But though this is the case in many instances, 
 yet it often happens even when the powers have long seemed nearly 
 exhausted, and when the body is 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 termination 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 examina- 
 tion reveals the tubercular degeneration of the lungs, to which the in- 
 flammatory 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, 
 who, had life been prolonged/ would have sunk eventually under pul- 
 monary phthisis, dies of tubercular peritonitis. Many children, in whom 
 the signs of incipient phthisis have appeared, die of tubercular menin- 
 gitis, 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. Sometimes, too, the symp- 
 toms that precede death are those of fever of a typhoid character, rather 
 than of serious mischief in the chest ; though it will generally be found 
 in such cases that acute inflammation of the tubercular lung, how little 
 soever betrayed by local signs, has been the occasion of the patient's 
 symptoms, and the cause of his death. 
 
 Though the study of phthisis, in its effects and its symptoms, has 
 occupied us during almost the whole of two lectures, yet there need be 
 but little said with reference to its treatment. The main principles by 
 which we are to be guided in its treatment are the same at every age ; 
 nor do the differences in the patient's years bring with them many or 
 important modifications in the means by which these principles are to 
 be carried into action. 
 
 Among the prophylactic measures adapted to early life, none is of more 
 importance than the keeping the infant at the breast for the first twelve 
 or eighteen months of its existence, by which time it will have passed 
 through some at least of the dangers incidental to the period of teething. 
 The task of thus nursing the infant, however, ought not to be under- 
 taken by a mother who has shown any tendency to consumption, or in 
 whose family consumptive disease has been prevalent, but ought at once 
 to be intrusted to a healthy wet-nurse. This rule does not rest on 
 mere theoretical grounds ; but actual observation has shown that under 
 some morbid states of the system the milk undergoes great changes, and 
 loses much of its nutritive properties. In the case of the cow, these 
 changes have been ascertained by Dr. Klencke, of Leipsic, to be very 
 remarkable ; and analogical reasoning would warrant the belief that the 
 
TREATMENT OP PHTHISIS. 425 
 
 scrofulous taint in the human subject may give rise to alterations of a 
 similar kind. Dr. Klencke 1 confirmed the observation of Sir Robert 
 Carswell and others, that stall-fed cows are very liable to become tuber- 
 culous ; and found, moreover, that in these circumstances their milk 
 loses much or the whole of its sugar ; that the butter and casein diminish, 
 while albumen is found sometimes in as high a proportion as 15 per 
 cent., and elain in the proportion of 1.4 per cent., and that in some 
 cases lactic acid is likewise present. , Even if we set aside the assump- 
 tion of scrofulous disease being actually transmitted through the medium 
 of the milk, of which there is perhaps no clear evidence, it is yet appar- 
 ent that a very slight degree of such an alteration in its constituents 
 as has just been mentioned, must render it very unfit for the nutriment 
 of a delicate infant. 
 
 It is needless to dwell here on the general rules for feeding and cloth- 
 ing children as they grow older, or to insist on the necessity for the 
 bed-rooms being airy and well ventilated. When the damp and cold 
 weather of winter approaches, removal to a warm climate, in which 
 exercise in the open air may still be continued, is much to be preferred 
 to keeping the child for weeks together a prisoner to the house ; and 
 as a general rule more is gained bv change of climate in earlv life than 
 in adult age. In children who are old enough to be taught to wear it, 
 I have sometimes seen the respirator of much service, in enabling them 
 to continue to take exercise in the open air at a season when, in previous 
 years, exposure to the external air had always induced or greatly aggra- 
 vated the signs of bronchial irritation. Whenever catarrhal symptoms 
 appear, no care can be too great to bestow on the attempt speedily to 
 remove them. In doing so, however, and in the management of all 
 ailments that come on in children who have shown a disposition to con- 
 sumptive disease, much caution must be used, in order to avoid over- 
 treating them. On this account it is of extreme importance to encounter 
 them at their very commencement, when mild measures will suffice for 
 their cure ; and, for the same reason, the child should be defended with 
 the most punctilious care from the contagion of hooping-cough and of 
 the eruptive fevers — diseases in the course of which serious thoracic 
 complications are so apt to supervene. 
 
 In carrying out this plan of unwearied watchfulness, and of attention 
 to minute detail continued for months and years, you will have brighter 
 hopes with children for your patients, than if you were called on to 
 exercise similar precautions in the case of persons more advanced in 
 life. Without raising baseless expectations, too, you may communicate 
 something of hope to the parents, and thus lighten for them their anx- 
 ious task ; nor will the appearance even of decided physical signs of 
 tubercular deposit, nor the evidence that in some parts that tubercle 
 is softened, warrant an absolutely hopeless prognosis. Cases such as 
 have been related show how long life may be prolonged in circum- 
 stances the most inauspicious ; and, where speedy death has been ex- 
 pected, an unlimited reprieve seems almost a pardon. 
 
 1 Ueber die Ansteckung and Verbreitung der Scrofelkrankheit bei Menschen durch 
 don Genuss der Kuhmilch, 16mo., Leipzig, 1846. See especially chapter iii, pp. 
 
426 TREATMENT OF PHTHISIS. 
 
 It may suffice to have said thus much about the management of 
 phthisis in childhood ; for when the disease is actually developed, we 
 have the same indications as in the adult, and these must be met by 
 similar means. Iron, quinine, and the mineral acids are the most im- 
 portant of our tonic remedies ; and for these the extract of bark and 
 the extract of logwood may be substituted, if much tendency exists to 
 a relaxed state of the bowels. In cases where the glands of the neck 
 are affected, and where there seems to be reason for supposing that the 
 disease approximates to bronchial phthisis, the syrup of the iodide of 
 iron may be employed with advantage. Such cases, too, have seemed 
 to me to profit most by the cod-liver oil ; though I must confess that 
 my own experience of it does not altogether bear out the high encomi- 
 ums which have been bestowed upon it by some practitioners. Some- 
 times I have known it excite diarrhoea ; at other times it completely 
 spoils the appetite ; while, as a general rule, I think it is not borne 
 well in cases where dyspeptic symptoms are, as is so often the case, at 
 all a prominent feature in the disease. Sometimes, too, the child's re- 
 pugnance to the remedy is unconquerable ; though this does not often 
 occur. If given in a little orange wine, or orange juice, sweetened 
 with syrup of orange-peel if necessary, its taste is in general perfectly 
 disguised ; while sometimes, nauseous though the oil is, children be- 
 come really fond of its flavor. In some cases, where children either 
 cannot bear, or will not take, cod-liver oil, I have employed glycerin, 
 and in others the so-called pancreatic emulsion — a compound which, 
 in spite of the mistaken physiological hypothesis of its advocates, is a 
 serviceable nutriment. I do not know, however, that either it or glyc- 
 erin answers any higher purpose than that of food ; or that in this 
 respect either is superior to cream. The sickness and the paroxysmal 
 cough are best relieved by the hydrocyanic acid, with which the liquor 
 cinchona? of Mr. Battley may be combined, 1 in cases where we are 
 afraid to venture on any but the mildest tonics. Among local meas- 
 ures, the use of stimulating liniments to the chest is even more valua- 
 ble in early life than in the adult ; and sometimes the application of a 
 blister, about the size of a shilling, under one or other clavicle, and its 
 frequent repetition, is followed by a very great amendment in the 
 patient's condition, and by a marked improvement in the physical 
 signs furnished by the subjacent lung. 
 
 I have very rarely employed local depletion, except in the treatment 
 of the pneumonia which so often attacks the phthisical patient ; but it 
 
 1 See Formula No. 21, p. 400. 
 
 Another very useful formula in these cases, and one which has the further ad- 
 vantage of forming a very agreeable vehicle for the cod-liver oil, is the following: 
 
 (No. 22.) 
 R. Acid. Nitr. dil., t^xvj. 
 
 Acid. Hydrochlor. dil., Tn?xxiv. 
 Acid. Hydrocy. dil., ^viij. 
 Spiritus Chloroformi, Tr^xl. 
 Trae. Aurantii, giss. 
 Syrupi simplicis, gij. 
 Aquas destillatae, ad ;fiv. M. 
 A tablespoonful every six hours. For a child four years old. 
 
DISEASES OF THE HEART. 427 
 
 has then seemed sometimes to be of great service; and it will probably 
 bo safer to trust to a moderate abstraction of blood by leeches, followed 
 by small doses of antimonials, rather than to administer mercury, or to 
 give antimony in larger doses without previous depletion. The ha- 
 bitual cough of phthisis requires small doses of ipecacuanha wine, com- 
 bined or not with antimony, and laudanum or compound tincture of 
 camphor in small doses, — remedies which, on account of their strength 
 being definite, are always to be preferred, in the management of the 
 affections of childhood, to a preparation so variable as the syrup of 
 poppies. Opiates in various forms, and for various purposes, may be 
 needed to check diarrhoea, or to relieve suffering ; and you must not 
 allow any preconceived notion of the danger of employing opium in 
 infantile diseases to prevent your having recourse to so valuable a 
 medicine. 
 
 We must here leave this subject, so full of painful interest, and 
 proceed at our next lecture to the study of diseases of the heart in early 
 life. 
 
 LECTURE XXX. 
 
 Diseases oe the Heart. — "Rarer in childhood than in the adult, and why — But 
 rarity formerly exaggerated — Causes of disease of the heart in chilhood, rheu- 
 matism the most frequent — Heart sometimes affected when rheumatic symptoms 
 are very slight — Both endocarditis and pericarditis may come on independently 
 of rheumatism — As sequela? of scarlatina or other fevers — As consequences of 
 congenital defects — As complications of pleurisy — Or as purely idiopathic affec- 
 tions — Cases illustrative of pericarditis in different circumstances. 
 
 Endocarditis. — Symptoms not always well marked — Advance of valvular disease 
 sometimes very gradual — Doubt as to whether valvular disease is not sometimes 
 independent of previous inflammation. 
 
 Prognosis in valvular disease. — Less unfavorable in child than in adult — Power of 
 growing heart to adapt itself to effects of disease and to repair its evils — Such 
 favorable eases still exceptional — Importance of presence or absence of dilatation 
 in determining issue of case — Illustrative cases of dilatation without valvular 
 disease — Anamiic bruits much rarer in early life, but disordered action of heart 
 occurs at all ages — Summary of conclusions. 
 
 Among the many causes of suffering and death to which persons in 
 adult age or advancing years are exposed, diseases of the heart and 
 great vessels occupy a very prominent place. The frequency of these 
 affections is, indeed, but very imperfectly shown by our tables of mor- 
 tality, which represent them as occasioning less than one and a half per 
 cent, of the total deaths at all ages in the metropolis ; but we know 
 that in a large proportion of cases of rheumatism, asthma, bronchitis, 
 and dropsy, the real cause of the fatal event is to be found in the 
 cardiac mischief with which those maladies are so often associated. 
 
428 DISEASES OF THE HEART. 
 
 In childhood, however, many of the most influential causes of heart 
 disease are of comparatively rare occurrence ; rheumatism is popularly 
 regarded as an affection almost confined to youth and early manhood, 
 as granular degeneration of the kidney is to adult and declining age; 
 while all those forms of atheromatous deposit in the coats of arteries, 
 or in the substance of the valves of the heart, which are a fertile source 
 of suffering, and in their consequences a frequent cause of death, be- 
 long essentially to the processes of decay which accompany the decline 
 of life. Hence, probably it came to pass that being rarely looked for, it 
 was seldom found ; so that, thirty years ago, the subject of heart dis- 
 ease was entirely unnoticed in one of the two standard works on chil- 
 dren's diseases in our language, and was dismissed with a notice of six 
 lines in the other. It must almost provoke a smile now for me to 
 refer to the publication of a few cases of endocarditis in childhood by 
 myself in 1843 (soon after the appearance of MM. Rilliet and Barthez's 
 classical treatise, in which it had also been described, and cases of it 
 recorded), as having made a positive addition to medical knowledge. 
 I refer to it, however, for the illustration it affords of the slow steps 
 by which all progress is made, as well as of the evil done by allowing 
 inferential reasoning to interfere with actual observation. It was in- 
 ferred that heart disease must be very rare in childhood ; and therefore 
 it was not looked for. Rilliet and Barthez inquired for, and found it ; 
 and in a smaller field, and less skilled to search, I too did the same. 
 
 The advance of knowledge, brings with it now every year some fresh 
 illustration of the occurrence of heart disease in early life, in circum- 
 stances where it once would not have been expected. Rheumatism, if 
 less frequent than in the adult, is yet associated with affection of the 
 heart in a greater proportionate number of instances in the child. 1 The 
 state of the circulating fluid which attends and follows scarlatina seems 
 to predispose to inflammation of the lining or investing membrane of 
 the heart in childhood, in the same manner, though not to the same 
 extent, as does the state which accompanies Bright's disease in the 
 adult. In themselves, too, and iu their complications congenital mal- 
 formations constitute a large class of affections of the heart peculiar to 
 early life ; while the microscope has already taught us that fatty degen- 
 eration of the heart may occur in the infant of some months old, as 
 well as in the man of sixty years. Not many years since it would 
 have been necessary to adduce statistical evidence in support of the 
 assertion that disease of the heart was far from being of infrequent 
 occurrence in early life. This, however, is no longer requisite, for the 
 
 1 The carefully compiled statistics of St. Bartholomew's Hospital show for the 
 three years 1869-71 a total of 819 cases of acute rheumatism at all ages. Of these 
 cases 76 occurred between the ages of 5 and 15, 743 above that age. In 61.3 per 
 cent, of the former, and in only 33 1 per cent, of the latter, it was complicated with 
 heart affection. In the Hospital for Sick Children younger children are admitted, 
 and probably less severe cases of rheumatism than would be received into St. Bar- 
 tholomew's Hospital ; and the law as to the special liability to heart disease as a com- 
 plication of rheumatism in early life is found expressed there far more strongly. In 
 54 out of 100 cases of acute rheumatism in children between the age of 2 and 12 of 
 which I have a record, the heart was affected, and in 52 out of the 54 this affection 
 was permanent. 
 
CAUSES OF DISEASES OF THE HEART. 429 
 
 fact is universally admitted; and I may add that the 122 cases of dis- 
 ease of the heart, on which the following observations are founded, are 
 but a few of the total number that, during the past thirty years, have 
 come under my notice. 
 
 Of the above-mentioned 122 cases, 44 were instances of pericarditis, 
 either alone or associated with inflammation of the endocardium, 71 
 were cases of endocarditis, and 7 of dilatation or hypertrophy of the 
 heart, uncombined with valvular disease. I have purposely excluded 
 from consideration cases of mere malformation of the heart, since, in- 
 teresting though that subject is, it yet is one on which it would be for- 
 eign to my purpose to enter. 
 
 It would, I conceive, answer no useful end to occupy time with a 
 minute detail of those characters, either of pericarditis or of inflamma- 
 tion of the endocardium, which are common to all ages, while at the 
 same time it may be of some advantage to point out to you any special 
 difficulties which you "may encounter in detecting those affections in 
 early life, and any special circumstances which should make you anx- 
 iously watch for their occurrence. 
 
 In 5 cases of pericarditis, in 48 of endocarditis, and in 22 in which 
 both the pericardium and endocardium were involved, — making a total 
 of 75 out of 122 cases, or in 60.1 per cent., — rheumatism was either 
 certainly known, or alleged on good grounds, to have been the starting- 
 point of the mischief. Warned by what is known of the tendency of 
 rheumatism to involve the heart, you are not likely to overlook the 
 symptoms of cardiac affection, when fever, and pain, and swelling of the 
 joints announce the child's illness to be of a rheumatic character, and you 
 will be inexcusable if, in such circumstances, pericarditis or endocar- 
 ditis should escape your observation. But if you will always avoid 
 this error, you must bear in mind that, in the child, the heart is some- 
 times affected, even in cases where the extreme mildness of the general 
 rheumatic symptoms would, if your patient were an adult, leave no 
 room for the least apprehension on that score; and that the compara- 
 tively slight degree of fever, the small amount of pain in the limbs, and 
 the almost complete absence of swelling of the joints, afford no guar- 
 antee that the heart may not become the seat of serious disease. It 
 happens, too, less rarely in the case of children than of the adult, that 
 the general indications of rheumatism follow the heart affection, instead 
 of preceding it; so that fever, with hurried circulation and distinct 
 friction-sound, or endocardial murmur, may exist for two or three days, 
 or even longer, before the occurrence of pain, and the appearance of 
 swelling of the joints, show that the disease of the heart is only a part 
 of the great malady which has attacked the whole system. 
 
 Every threatening of rheumatism, therefore, is to be watched with 
 the most anxious solicitude in the young subject, since so serious a 
 complication as disease of the heart may accompany extremely slight 
 general symptoms. Nor must auscultation be neglected in cases of 
 what may seem to be simple fever, since rheumatic inflammation may 
 attack the heart before any other signs of rheumatism have manifested 
 themselves. 
 
 In 3 cases of pericarditis, in 10 of endocarditis, and in 2 where both 
 
430 CAUSES OF DISEASES OF THE HEART. 
 
 peri- and endocarditis were associated, or in 15 out of 122 instances, 
 the disease of the heart was traced to an attack of scarlet fever. The 
 cardiac symptoms did not manifest themselves in the acute stage of the 
 affection, but during the progress of desquamation. They were accom- 
 panied by fever and anasarca, which, however, did not exceed mere 
 puffiness of the face and extremities, until, in two of the instances of 
 pericarditis, both of which ran a chronic course, dropsy came on as the 
 consequence of the heart disease. 
 
 Acute endocarditis supervened in one instance on the decline of the 
 eruption of measles, and was associated with pneumonia, of which the 
 patient died. In two other cases of chronic valvular disease, the symp- 
 toms of heart affection developed themselves gradually after convales- 
 cence from measles in one instance, after recovery from typhoid fever 
 in the other ; and these, as well as the cases in which disease of the 
 heart supervened during the course of scarlatina, are doubtless to be 
 referred to the category of cardiac disease dependent on an altered state 
 of the circulating fluid, and suggest an additional ground for carefully 
 watching your patients during their convalescence from any form of 
 fever. 
 
 Congenital malformation of the heart seems to have an important, 
 though nOt perhaps an easily explicable, influence in predisposing to 
 inflammation of its valves, or of its investing membrane. Thus, in 
 one case of acute pericarditis, in one of chronic pericarditis with affec- 
 tion of the endocardium, and in two others of old-standing valvular 
 disease, there was some malformation of the heart which must have 
 existed from birth, though in two instances the symptoms did not 
 appear till long afterwards. In one of these two cases they came on 
 gradually, rather more than two months before the death of the child 
 at 8 years old ; in the other, they were first observed at 3 years old, 
 and death took place at the age of 15 years. It is well, then, in cases 
 of heart disease the origin of which is obscure, to bear in mind this 
 possible cause of the affection, and the rather since this consideration 
 may control our treatment, and keep us back from the employment of 
 overactive measures against an ailment which may owe its origin to 
 some cause utterly beyond the power of medicine to remove. 
 
 Five cases of pericarditis appeared to depend on the extension to the 
 pericardium of inflammation beginning in the pleura ; an occurrence 
 which, though not peculiar to early life, is, I believe, more frequent 
 then than at a later period, and also oftener overlooked, from the 
 child's restlessness and distress rendering all attempts at careful auscul- 
 tation of the front of its chest impracticable. To be aware of the possi- 
 bility of this occurrence will do much towards preventing you from 
 overlooking it. 
 
 Three cases of simple pericarditis, one of pericarditis coupled with 
 inflammation of the endocardium, and eight of endocarditis, were not 
 clearly traceable to any exciting cause. Knowing, however, how slight 
 an attack of rheumatism is often accompanied by heart affection, I 
 hesitate much more than I should once have done to pronounce them 
 idiopathic. In 3 out of the 7 cases, also, of dilated or hypertrophied 
 heart, unconnected with valvular disease, the symptoms supervened 
 
OBSCURITY OF SYMPTOMS OF PERICARDITIS. 431 
 
 gradually, and were not preceded by acute illness of any kind ; once 
 the symptoms of dilated heart came on during the course of very severe 
 chorea, and continued after its cessation, and once they followed a 
 violent blow on the chest. 
 
 I do not know of any special symptom of acute inflammation of the 
 pericardium in early life, but I am sure that it is often overlooked 
 when present ; and this, partly from the child's restlessness, partly 
 from its being masked in many instances by the signs of other disease 
 in the chest. To this latter cause it was probably due that I did not 
 detect pericarditis complicating pleurisy of the left side, in a boy six 
 years old, though on his death, two years afterwards, I found a patch 
 of old lymph on the left ventricle, near the apex of the heart, and a 
 good deal of old white lymph coating the right auricle, and white spots 
 at several points about the base of the heart, showing that the pericar- 
 dium had been the seat of extensive inflammation. The affection of 
 the pericardium was doubtless here, and is probably, in most of these 
 cases, secondary to that of the pleura, since the products of a far more 
 advanced inflammation are in general found in the latter cavity than 
 in the former. In some instances the two serous membranes would 
 seem to have become affected simultaneously, while in others the indi- 
 cations of pericarditis are perceptible before those of pleurisy appear. 
 In one case, which terminated fatally, the patient, a little girl aged 
 sixteen months, was almost moribund when she came under my notice : 
 convulsions came on in two or three hours, and she died after they had 
 continued for twelve hours. In this instance the attack had commenced 
 eight days previously, with violent sickness followed by severe febrile 
 disturbance and great dyspnoea, though by but little cough. In a 
 second case, that of a little girl aged three and a half years, slight 
 cough and febrile symptoms had existed for nearly a fortnight, when 
 they suddenly, and without any obvious cause, became greatly aggra- 
 vated ; the cough grew constant, short and hacking ; the respiration 
 rose to 72, the pulse to 156 in the minute. The child became extremely 
 restless, appeared to suffer much, made frequent efforts to vomit, and 
 often crammed her hand down her throat, as though to pull something 
 away which obstructed her breathing. In neither of these cases was 
 the existence of pericarditis suspected. In the last-mentioned case the 
 restlessness of the child precluded careful auscultation ; but dulness on 
 percussion, and bronchial breathing, were perceived through the whole 
 of the posterior part of the left side of the chest, and small crepitation 
 was heard on the right side. In a third case, a little boy, seven 
 months old, died in extreme distress at the end of four days, during 
 which his restlessness was extreme, and his cries were constant. Aus- 
 cultation was almost impossible, owing to his extreme disquiet, but 
 after death the lungs were found free from disease ; but recent lymph 
 was deposited on both layers of the pericardium, and its sac contained 
 sero-purulent fluid. It was interesting also to observe, on removing 
 the recent lymph from the heart's surface, that the visceral layer of the 
 pericardium was opaque and thickened, and of a dead white color, the 
 evidence of a former attack, which probably took place when the child 
 
432 DIAGNOSIS OF ACUTE PERICARDITIS. 
 
 was three months old, at which time he was alleged to have had 
 pneumonia. 
 
 There is little danger, in cases which set in with symptoms so severe 
 as those just described, of our falling into serious error, either of diag- 
 nosis or of treatment. Everything will point to most serious mischief 
 in the chest ; and even should the tender age of the child and its ex- 
 treme restlessness prevent careful auscultation, or should the signs of 
 heart disease be masked by those of mischief in the lung or pleura, 
 enough will yet be discovered to show the necessity for immediate and 
 active interference ; while, if we bear in mind the possibility of such a 
 complication, that will go far towards preventing us from overlooking 
 its occurrence. 
 
 I have seen other instances in which pericarditis secondary to pleurisy 
 supervened in the course of scarlatinal dropsy ; and if from these I 
 could deduce any additional sign to guard you against overlooking the 
 pericarditis it would be that furnished by very marked orthopnoea. 
 In one case — that of a little boy aged one year and eleven months — 
 this was especially remarkable ; for while in other respects his condi- 
 tion varied much and frequently, and the signs of thoracic mischief 
 differed greatly in their urgency, he constantly maintained the sitting 
 posture, and always most strenuously resisted any attempt to lay him 
 down. This peculiarity continued during an illness of many weeks, 
 and did not cease till his powers completely failed with the approach 
 of death. 
 
 Concerning rheumatic pericarditis I have no additional remark to 
 make ; but on account of its rarity it may be worth while to relate to 
 you a case in which acute inflammation of the pericardium occurred in 
 a little boy who was four months old at his death, and in whom free 
 communication existed between the two sides of the heart. He did 
 not come under my observation until the day on which he died ; but 
 the history which I heard of him was, that he was very livid at birth, 
 that respiration was established with difficulty, and that the dark hue 
 of his surface never went off completely. At times he seemed cheerful, 
 and used to breathe pretty well, but at other times he was attacked, 
 without apparent cause, by difficult respiration, during which he be- 
 came very cold and quite purple, made a grunting noise, and frothed 
 at the mouth. These attacks never came on while he was sucking : 
 they were preceded by crying, though usually he was very quiet. 
 
 On October 19, 1848, an attack came on similar to the previous 
 seizures, though more severe, lasting between one and two hours, and 
 not being preceded by crying. On the 20th a similar attack came on 
 and lasted from four to half-past seven p.m., and another returned on 
 the morning of the 24th, at noon of which day he was brought to me. 
 His surface was then generally very pale, but with a marked livid hue 
 of the lips and fingers, and around the mouth. His skin was cool, 
 almost cold, his respiration irregular and very frequent, and his pulse 
 extremely feeble. Auscultation detected no unnatural sound with the 
 heart's action. 
 
 As he was being carried home a fresh seizure came on, and proved 
 fatal in half an hour. 
 
IDIOPATHIC PERICARDITIS. 433 
 
 The lungs and pleura? generally were healthy. 
 
 The pleura where it is in contact with the pericardium, and that 
 membrane itself, were of a bright red color, with the vessels minutely 
 injected. The sac of the pericardium contained §j of a dirty yellow- 
 ish, sero-purulent fluid, in which little granules of lymph, like minute 
 grains of rice, were floating. It did not anywhere adhere to the heart, 
 but its parietal layer, which was intensely red, and beset with numer- 
 ous little ecchymoses, was lined through a great extent by a thin layer 
 of lymph. This layer was thicker on the right than on the left half 
 of the pericardium, and especially so about the right auricle. Lymph 
 was also deposited between the left auricle and the root of the pulmon- 
 ary artery. 
 
 The pericardium investing the heart was intensely red, and numer- 
 ous small flocculi of lymph covered its surface. Besides this there was 
 an old wdiite spot, half an inch long by a quarter of an inch broad, at 
 the apex of the left ventricle, having just the character of the white 
 spots of old pericarditis ; and there was another small spot on the pos- 
 terior surface of the right auricle. 
 
 The foramen ovale was w r ide open, so as to admit the finger with 
 ease ; the pulmonary artery was very small ; the ductus arteriosus wide 
 open, and the septum of the ventricle very imperfect ; the ductus ven- 
 osus was closed. 
 
 Reference has already been made to the occasional occurrence of 
 inflammation of~the investing or of the lining membrane of the heart 
 independent of any other disease, and unassociated with inflammation 
 of the lungs or pleura. In such cases the indications of disturbance 
 of the respiration are either altogether absent, or comparatively slight, 
 and if auscultation is neglected, or but carelessly performed, disease 
 may, in such circumstances, go on unchecked till it has disorganized 
 the heart, and doomed the patient to a life of remediless suffering. 
 
 A striking instance of this idiopathic inflammation of the pericardium 
 and lining membrane of the heart came under my notice many years 
 since, in the person of a healthy boy, eleven years old, who, on May 
 8, 1843, complained of feeling cold, and began to cough. The chilli- 
 ness was succeeded by fever, and he continued gradually getting w^orse 
 till the 13th, w T hen I visited him for the first time. He had had no 
 other medicine than a purgative powder. On May 13, I found him 
 lying in bed ; his face- dusky and rather anxious, his eyes heavy, and 
 his respiration slightly accelerated ; coughing frequently, but without 
 expectoration ; skin burning hot ; 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 pro- 
 longed rasping sound was heard in the place of the first sound, loudest 
 a little below the nipple, though very audible over the whole left side 
 of the chest, and also distinguishable, though less clearly, for a consid- 
 erable 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. 
 
 28 
 
434 IDIOPATHIC PERICARDITIS. 
 
 The child was cupped to six ounces between the left scapula and 
 the spine ; and a grain 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 promi- 
 nence of the cardiac region, and the heart's sounds were obscurer and 
 more distant than on the previous day. The bruit was now manifestly 
 a friction-sound louder at the base than at the apex of the heart, and 
 altogether obscuring the first sound ; while the second sound could be 
 heard over the aortic valves. Six more leeches were applied over the 
 heart, and the hemorrhage from their bites was so profuse as to occa- 
 sion some faintness. Mercurial inunction was now superadded to the 
 treatment previously employed, and the child's condition continued 
 through the loth to be much the same as it had been on the previous 
 day. On May 16th, there was some improvement in the general 
 symptoms, and the pulse was softer. The friction-sound was now no 
 longer audible, but a loud rasping sound was heard in the place of the 
 first sound. The second sound was now distinguishable at the apex of 
 the heart, as well as over the aortic valves, and its characters were 
 quite natural. On the 19th the child's mouth was slightly sore, and 
 the dose of the remedies was diminished. On the 22d the soreness of 
 the mouth was considerable, and all active treatment was discontinued 
 on that day. The child gradually regained his strength, but the bruit 
 accompanying the first sound continued, and was heard a month after- 
 wards, with no other change than being rather softer and more pro- 
 longed. Four years afterwards I saw him again. He had continued 
 well in the interval, and had never suffered 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. 
 
 In such cases as this the occurrence of the heart disease is not easy of 
 explanation. No sign of rheumatism appeared during the whole course 
 of the affection, nor was it associated with any other disorder, such as 
 scarlatina, which by the alterations that it induces in the composition 
 of the circulating fluid, could be supposed to favor the supervention of 
 inflammation of the heart or other viscera. 1 The organs of respiration 
 w r ere unaffected throughout, so that the case could not for a moment 
 be conceived to be one in which the heart disease w T as secondary, and 
 produced by the extension of the inflammation beyond the limits by 
 which it was originally circumscribed. But though the cardiac affec- 
 tion came on independently of those conditions, which we regard, and 
 w T ith justice, as usually 'essential to its production, it ran as acute a 
 
 1 As Bright's disease, for instance, in the adult favors the occurrence of peri- 
 carditis, according to the elaborate researches of Dr. Taylor, in vol. xxviii of the 
 Medico-Chirurgical Transactions. 
 
ACUTE ENDOCARDITIS. 435 
 
 course and produced injury as extensive, as if it had been excited by 
 any of its ordinary causes. 
 
 Idiopathic pericarditis, uncomplicated with pleurisy, and sufficiently 
 severe to give rise to symptoms appreciable during the lifetime of the 
 patient, is certainly a very rare occurrence. I cannot speak with ac- 
 curacy as to the frequency in early life of those white spots on the sur- 
 face of the pericardium, which were pointed out by M. Bizot and Sir J. 
 Paget 1 as being of such common occurrence in the adult, and which were 
 rightly regarded as of much moment so long as they were supposed to 
 be the invariable indications of a bygone inflammation. In some in- 
 stances they are no doubt due to that cause, and probably whenever 
 met with towards the base of the heart we shall not be wrong in re- 
 garding them as the results of inflammation. When found in their 
 more common seat in childhood, near the apex of the left ventricle, the 
 true explanation of their presence is furnished by the so-called attrition 
 theorv, which refers them to the friction of the heart against the resist- 
 ing chest- wall. 2 This theory, while it explains the presence of these 
 patches, deprives them at the same time of most of their pathological 
 importance. 
 
 The total number of .cases in which endocarditis, either acute or 
 chronic, was present, was 105. In 30 of tfiese its symptoms were 
 masked more or less completely, by complication with pericarditis ; 
 while in the remaining 75 instances the aifection of the endocardium 
 existed alone. Of the 75 cases of uncomplicated endocarditis, 30 were 
 attended with acute symptoms, while in the others the affection pre- 
 sented itself in a chronic form. In some of these cases the signs of 
 heart affection manifested themselves with considerable severity, and 
 consisted in uneasiness about the heart, palpitation, increase of its im- 
 pulse, with inequality of its pulsations on one occasion, irregularity of 
 its action on another ; dyspnoea and occasional orthopnoea. Symptoms 
 so marked as these compelled attention to the condition of the chest, 
 and auscultation at once detected the loud bruit of endocardial inflam- 
 mation. In others, however, just as in the adult, the stethoscope alone 
 gave information of the commencement of mischief, which otherwise 
 would have been unsuspected. 
 
 In the case in which endocarditis accompanied measles its symptoms 
 were masked by those of the pneumonia with which it was associated, 
 and in the instance where it succeeded to convalescence from that dis- 
 ease, no urgent symptoms appeared. In some of the cases of endocar- 
 ditis which came on without obvious exciting cause, though there was 
 much heat of skin, some acceleration of breathing, and some increase 
 of the heart's action, yet neither the general nor the local symptoms 
 
 1 Memoires de la Societe Med. d'Observation, tome i, p. 350; and Medieo-Chi- 
 rurgical Transactions, vol. xxiii. 
 
 2 Sir W. Jenner, in his Lectures on Eickets, already referred to, Med. Gazette, 
 April 7, 1860, p. 334, points out how it is that, owing to the deformity of the chest- 
 walls in rickets, the apex of the heart comes into close contact with the left rib just 
 where it projects or knuckles inwards, and thus occasions the white patches to be 
 seated near the left apex instead of about the centre of the anterior part of the right 
 ventricle, which is their common situation in the adult. 
 
436 TENDENCY OF VALVULAR DISEASE TO INCREASE. 
 
 were at all more urgent than are constantly observed in attacks of 
 simple fever, or of influenza in childhood. In other instances, where 
 the patient did not come under my notice till after the evil had reached 
 a chronic stage, there was so little history of any acute attack of illness 
 preceding it, as to render it impossible to fix the exact date at which it 
 began. It seems, then, that just as in rheumatic endocarditis, the 
 symptoms may vary in degree, and be in one case so severe as to force 
 themselves upon our notice, and in another so slight as almost to elude 
 our observation, so it is in cases where the endocarditis is or appears to 
 be idiopathic. In cases of acute rheumatism 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 
 studiously 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, until after auscultation. With 
 all your care, there will probably still be cases in which the com- 
 mencement of the heart affection will escape your notice ; in which you 
 will accidentallv make the discoverv of its existence when auscultating 
 
 J ml O 
 
 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. 
 
 The early detection of the disease is of the more importance, since 
 its gradual approach affords no assurance that it may not go on to ruin 
 the health, and at length to destroy the life of the sufferer. Xothing 
 could be more gradual than the advance of the early stages of the dis- 
 ease of the heart, in the case of a little girl ten 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 previous year she had been growing thinner, and had suf- 
 fered from palpitation of the heart, which had by degrees become more 
 and more distressing, and that for the past three months she had like- 
 wise been troubled with cough. The child when brought to me was 
 greatly emaciated ; her face Avas anxious and distressed ; her breath 
 short, so that it was with difficulty that she walked even a short dis- 
 tance ; 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 precordial 
 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 temporary relief to her sufferings, but neverthe- 
 less 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. 
 
TENDENCY OF VALVULAR DISEASE TO INCREASE. 437 
 
 For about a month before her death the cough altogether ceased, but 
 she was now 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 ex- 
 tremely difficult, and became increasingly slow, till she died on October 
 10. 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 at all atten- 
 uated ; the pulmonary veins were much dilated ; the left ventricle was 
 dilated, its walls were thickened ; the chordae 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 ex- 
 isted likewise slight thickening of the edges of the semilunar valves of 
 the aorta. 
 
 The symptoms in this case, from the earliest period to which the 
 patient's history goes back, were those of chronic valvular disease^ with 
 hypertrophy and dilatation of the heart ; but no clue is afforded us by 
 which we can guess when the inflammation of the endocardium, proba- 
 bly the first in this train of evils, attacked the heart. The constitutional 
 disturbance which attended it was so slight as to escape the mother's 
 notice, and to call for no special complaint from the child ; but it is 
 likely that more watchful care would have taken the alarm at some com- 
 paratively slight feverish seizure ; that auscultation would have dis- 
 covered the disease at its commencement ; and that treatment would 
 have diminished, though it might not have altogether prevented, the 
 subsequent disorganization of the heart. 
 
 I have referred to endocarditis as having been, though undiscovered, 
 still the probable cause of the disease of the heart in this instance. But 
 yet there is another explanation of the mischief, and one which some 
 other cases of chronic valvular disease that I have either watched during 
 life or examined after death would admit of, namely, that the mischief 
 has been produced by some other than an inflammatory process. We 
 know that this may be the case in the adult ; and equally so, I appre- 
 hend, in the child ; nor is the fact of less practical moment in the one 
 case than in the other. In each instance it influences our treatment, 
 and warns us not to be too active in the use of antiphlogistic measures, 
 nor too pertinacious in their continuance, and suggests the probability 
 that what Ave discover is only the sign of some long-past mischief. 1 
 
 It is true, indeed, that in very many instances the disease of the 
 valves goes on, as in the poor child whose case I have just related, from 
 bad to worse; inflammation in some instances recurring at intervals, 
 and adding something each time to the previous mischief; or the disor- 
 ganization of the heart advancing slowly but with uninterrupted course. 
 
 1 This supposition, which clears up what otherwise would be very obscure with 
 reference to the cause of some cases of chronic valvular disease, is, as probably scarcely 
 need be stated, propounded by Sir W. Stokes in his work on Diseases of the Heart, 
 8vo., Dublin, 1854. See page 146 and following pages. 
 
438 POWER OF THE GROWING HEART TO 
 
 But, nevertheless, one meets sometimes with exceptions to this rule, 
 and observes instances in which the signs of cardiac mischief remain 
 stationary, and the sufferings of the child grow less with its increasing 
 years. Nor is it, probably, that in these cases the disease simply does 
 not advance, but many things seem to show that there is, as Dr. Latham 
 suggests, " a certain protective power possibly inherent in the growing 
 heart, whereby it can accommodate its form and manner of increase to 
 material accidents, and so repress or counteract their evil tendencies." 
 
 Dr. Latham, 1 — whose name I cannot mention without the expression 
 of respect and gratitude clue to one to whose instructions I owe so 
 much, — relates, in illustration of this fact, the history of two young 
 ladies in whom the auscultatory signs of valvular imperfection existed 
 from early childhood, but who never suffered any important disturb- 
 ance of the general health that could be attributed to it. Instances 
 still more striking have come under my own observation, in which, not 
 only were the signs of heart disease present, without the evil results 
 that might be apprehended from it, but in which the suffering lessened 
 with advancing years ; though auscultation still gave assurance that its 
 cause persisted. A little girl, six years old, whose health had never 
 been robust, and who had suffered much from measles and scarlatina, 
 the latter of which left her liable to attacks of what was said to be in- 
 flammation of the chest, came under my notice at the end of April, 
 1846. She was then laboring under urgent dyspncea, with symptoms 
 of acute bronchitis, and, in the course of auscultation, a systolic mur- 
 mur w r as heard at the apex of the heart. The bronchitic symptoms by 
 degrees subsided, but dyspncea continued ; the child was wholly unable 
 to rest, except when propped nearly upright ; she was distressed by 
 palpitation; her cough was frequent, and, when w T orse than usual, she 
 expectorated with it small quantities of florid blood. Her face was 
 pale, but with a livid flush on either cheek; the carotids pulsated visi- 
 bly, and the jugular veins were distended, while her heart beat at the 
 rate of 150 in the minute. The heart's impulse was increased, and 
 dulness in the precordial region extended far beyond its proper limits. 
 It was next noted that the smallness of the pulse corresponded ill with 
 the laboring of the heart; and a distinct sense of fremissement, w T hen 
 the hand was laid upon the precordial region, completed the signs of 
 great contraction of the mitral orifice, with hypertrophy and dilatation 
 of the heart. From time to time the child suffered much since then 
 with a return of her old symptoms ; and, after the lapse of twenty 
 months, the bruit still continued: the hand placed upon the cardiac 
 region was still sensible of a distinct purring tremor, and the pulse w r as 
 exceedingly small and feeble. But the heart no longer labored as it 
 used to do ; its pulsations did not exceed 110 in the minute ; and though 
 the child was still unable to lie flat in bed, the distressing orthopncea 
 had ceased for many months. Her eyelids were no longer puffy, nor 
 her limbs anasarcous, as they were before ; her cough troubled her but 
 little, and hemoptysis was very rare. She had gained flesh, was cheer- 
 ful, and played, though not sb boisterously as other children might do, 
 
 ■ — * — — — ; • 
 
 1 On Diseases of the Heart, vol. i, pp. 241-3. 
 
CHECK THE PROGRESS OF DISEASE. 439 
 
 yet with such heartiness that I could scarcely believe her to be the little 
 suffering thing for whom, a year before, one would have chosen speedy 
 death as the happiest lot that could befall her. 
 
 Nor was this gradual recovery of the heart from serious injury less 
 striking in the case of the boy whose history I related to you as an in- 
 stance of idiopathic pericarditis and endocarditis. Not only did he 
 continue well four years after his recovery, but I saw him again ten 
 years after it, he being then twenty-one years old. The heart's impulse 
 was still considerable; the sound continued long and loud and rough, 
 but the young man had no other ailment than occasional palpitation, 
 and sometimes slight sense of discomfort at the chest: and this, although 
 he was leading a loose kind of life — strolling over the country as a 
 ballad-singer, often getting wet, and walking long distances of twenty 
 miles and upwards in ^ day, and this, as he said, without fatigue. 
 
 Other eases of a similar kind, though less remarkable than these 
 two, have come under my notice — cases which would warrant, I think, 
 a more hopeful prognosis in cases of valvular disease of the heart in 
 childhood than we should be justified in entertaining if our patient 
 were an adult. But consolatory as it is to know that time helps in 
 some instances to repair the damage done to the heart in childhood, 
 yet these fortunate cases are after all but exceptional ones. These ex- 
 ceptions, too, are not by any means proportionate to the number of in- 
 stances in which the original inflammatory attack has been slight, or 
 in which it has not recurred ; but of two cases whose early history has 
 been identical, the progress of the one will be by slow degrees of im- 
 provement towards comparative health, of the other by slow deteriora- 
 tion to a painful death. In the latter case, too, a post-mortem exam- 
 ination may often fail to discover any such large extent of valvular 
 disease as might be expected from the nature of the symptoms during 
 life. 
 
 On what, then, it may be asked, does the difference between the two 
 sets of cases depend ? I believe that the presence or absence of dilata- 
 tion of the heart, or the degree in which that condition exists, governs 
 the severity of the symptoms, and determines the issue of the case in a 
 very large number of instances. 
 
 In enumerating the cases on which the remarks in these lectures are 
 based, I referred to seven instances in which dilatation of the heart 
 existed unaccompanied by disease of the valves. In these cases the 
 absence of valvular disease was the more unexpected since a systolic 
 murmur was audible in all of them during life. 
 
 The first of these cases, and one of the most remarkable, came under 
 my notice in 1849. The patient was a little girl 7f years old, who had 
 been liable to palpitation of the heart since an attack of scarlatina two 
 years before. For some months previous to her coming under my 
 notice, her health had been indifferent ; but an attack of catarrh from 
 which she had suffered about a month, appeared to have called all her 
 symptoms into activity. I found her at the end of this time laboring 
 under generally ,diffnsed bronchitis, her face flushed, her respiration 
 hurried and irregular, varying from 60 to 80 in the minute ; her heart 
 
440 SHARE BORNE BY DILATATION OF THE HEART 
 
 beating at the rate of 130 ; and its pulsations attended with a loud 
 systolic bruit at the apex. Her condition deteriorated, the cough grew 
 harder and more distressing, and the respiration rose habitually to 
 between 80 and 90 ; while the child took a posture on her face, in 
 which she remained almost habitually, and never obtained any sleep 
 except in that attitude. I saw her for the first time on April 1. She 
 died on the morning of the 5th, quite quietly, having had an anodyne 
 of four minims of laudanum the previous night, w T hich procured her" 
 some rest, but no profound sleep. 
 
 There w r ere three patches of pulmonary apoplexy, each of about the 
 size of a walnut, in the right lung; and one in the left, somewhat 
 smaller ; the languette of the left upper lobe was in a state of collapse, the 
 air-tubes much congested, and containing a good deal of tenacious 
 mucus. The pericardium contained an ounce, of transparent serum. 
 The heart w r as almost as large as two fists, and of a rounded form ; its 
 increase of size being due apparently rather to enlargement of the right 
 than of the left half of the organ ; though the left cavities of the heart 
 also were unusually large. Both the left auricle and ventricle contained 
 a good deal of black coagulum. The enormously dilated right auricle 
 was filled with firm parti-colored coagulum ; and there was a good deal 
 of black coagulum in the right ventricle. The whole of the right ven- 
 tricle w T as enormously dilated; but the dilatation was most remarkable 
 at that part from which the pulmonary artery springs, and which 
 formed behind the pillars of the tricuspid valve almost a second ven- 
 tricle, so large was it. All the valves w T ere carefully examined, and 
 presented no trace of disease, and the foramen ovale was closed. 
 
 A boy, 10 years old, came into the Children's Hospital to die. No 
 history of his previous illness w r as obtained ; but he was very anasar- 
 cous, and had a large quantity of fluid in his abdomen, though his urine 
 w r as free from albumen. The pericardium was found universally adhe- 
 rent, and the endocardium throughout presented a remarkable degree 
 of opacity, though there w 7 as no thickening of any of the valves. The 
 heart was very much enlarged owing to dilatation of both its sides ; 
 though the left w T as the more aifectecl. The left ventricle alone w^as as 
 large as the whole heart of a child 9 J years old, whose body was in the 
 dead-house at the same time, though its walls w r ere scarcely thicker, 
 nor w T as the aortic orifice larger. 
 
 A little girl, when six years old, had an attack of rheumatism, not 
 very severe, since she w*as scarcely confined to bed at all by it. A 
 month afterwards she first complained of pain in her heart, which for 
 some weeks beat very much. Six months afterwards she began to swell 
 about her face ; the limbs afterwards became anasarcous, but the degree 
 of the anasarca had varied much. Nine months after the rheumatic 
 attack she was admitted into the hospital, being then 1\ years old. 
 There was some oedema of the legs and of the lower part of the back, as 
 well as of the abdominal integuments; no ascites, but considerable 
 enlargement of the liver. There w^as obvious bulging of the left side 
 of the chest. The heart's impulse was visible in the 4th, 5th, and 6th 
 interspaces. Apex beat in sixth interspace, 1} inch outside nipple *line, 
 
IN PRODUCTION OF SYMPTOMS. 441 
 
 and If inch in oblique line below nipple. Impulse somewhat heaving; 
 thrill and impulse in left costal angle. 
 
 Upper dulness limit 3d rib. 
 
 Right " " a finger's breadth to right of sternum. 
 
 Oblique diameter of heart 5| inches. 
 
 Transverse " " 5 " 
 
 Longitudinal " " 3f " 
 
 At apex a prolonged systolic murmur was heard, which diminished 
 rapidly in loudness as one passed upwards, though still audible over 
 whole heart's region. No second sound heard. 
 
 Rest and treatment relieved the child, who, having been admitted 
 on February 26, was able to return home on April 16. Her health, 
 however, soon failed again, when she lost the care and comforts of the 
 hospital. She was readmitted on May 6, complaining of constant 
 precordial pain, probably connected with the supervention of pericar- 
 ditis, for a friction-sound was now for a time audible. Once more she 
 improved, and left the hospital on August 13. Dr. Gee, at that time 
 the able and unwearied registrar of the hospital, now my much-valued 
 colleague, whose notes I have already quoted, found that the 
 
 Upper dulness limit had now extended to the socond rib, 
 
 Right " " u " " two inches to right of sternum, and half an 
 
 , inch to left of right nipple. 
 
 It had, however, already reached this limit on May 22. The heart's 
 impulse Avas less extensive than in February ; the friction-sound had 
 completely disappeared, but a systolic murmur was audible over the 
 whole precordial region ; and scarcely any second sound was to be 
 heard. 
 
 Since she left the hospital I have not seen this little one ; but there 
 can be no doubt but that if she has not already found a resting-place 
 and a grave within the walls of some other institution, she will come 
 again to seek such small mitigation of her sufferings as is all that 
 medicine has to offer her. I have related her case not because I 
 assume that it is an instance of dilatation of the heart, independent of 
 valvular disease, but because it is the dilatation which is the cause of 
 her suffering and the source of her danger ; and because I have now 
 seen many instances which seem to show that in early life the occur- 
 rence of this condition is the one great danger to guard against, since, 
 when it has occurred to any considerable extent, nature seems unable to 
 exert that power of repair and readjustment which, in other cases, she 
 sometimes puts forth so beneficially. 1 
 
 But how to guard against the danger? By rest — rest as complete 
 as can be given to an organ which is in perpetual activity, whose repose 
 
 1 I have not entered on the question of the mode of production of dilatation of 
 the heart in the young subject. I have no doubt but that muscular weakness has a 
 large share in its production, as the observance of extreme quiet after any attack of 
 endocardial inflammation or of exhausting disease has in its prevention. Dr. 
 Bristowe, in his able paper on Mitral Regurgitation, independently of Organic 
 Disease of the Heart, published in British and Foreign Medico-Chirurgieal Review 
 for July, 1861, discusses the subject most fully, and with thorough mastery of all 
 the questions involved in its elucidation. 
 
442 IMPORTANCE OF LONG -CONTINUED REST. 
 
 is but momentary and partial ; one half quiescent for a fraction of a 
 minute, while its other half is powerfully contracting — an alternating 
 ebb and flow which ceases only with life itself. Such rest as we can 
 give then is rather diminution of labor ; calling on the heart for as few 
 pulsations to the minute, and those as little vigorous as possible. I 
 suppose that in early life changes in the muscular substance of the 
 heart, whether for better or for worse, take place more readily than in 
 the grown person ; that therefore the heart's cavities after inflamma- 
 tion dilate, more readily, and mischief is thus done, which subsequent 
 hypertrophy atones for as best it can — how ill, and with how much 
 suffering, a few visits to the Children's Hospital will tell far better 
 than many words of mine. To avoid all this, our only means, and 
 those by no means ineffectual, consist in long-continued absolute rest 
 in the recumbent posture for many weeks ; and then for many months 
 more none but the gentlest movements ; for a year ,or more the being 
 carried up and down stairs; and for several years more no violent 
 exertion, no running, no dancing. I have known the strict observance 
 of these precautions followed by disappearance of the signs of valvular 
 insufficiency, by the lessening of the area of dulness, and by the com- 
 plete cessation of the morbid sound which had accompanied the heart's 
 action. The difficulty in carrying out these precautions rests not with 
 the children, but with their parents, who will seldom take the trouble 
 to understand the grounds for restrictions, or to listen to our unwelcome 
 tale of the agonies which their neglect will entail upon the little ones 
 in after years. Unfortunately, the doctor, who professes to be no more 
 than Nature's minister, holds but too often in the public esteem a far 
 inferior position to that of the bold empiric who pretends to be her 
 master. 
 
 One more caution may not be out of place with reference to cardiac 
 disease in early life, namely, that the presence of a bruit with the 
 heart's sounds in the child depends more invariably on organic disease 
 than in the adult; inasmuch as those endocardial, arterial, or venous 
 murmurs which are produced by an impoverished state of the blood 
 are very rarely indeed heard in children under seven years old, and 
 are by no means common until that age is attained at which the changes 
 that take place as puberty approaches have commenced, or are on the 
 eve of beginning. I think that I can speak with confidence as to the 
 rarity of such murmurs in childhood, though I cannot venture to as- 
 sign a reason for it ; since the very slight difference between the com- 
 position of the blood in early life and in after years can scarcely be 
 alleged as affording an adequate explanation of the fact. 
 
 At the same time, however, that we should be most keenly alive to 
 the importance of every sign of heart disease in early life, we should 
 bear in mind that the friends of our patients not infrequently take 
 causeless alarm at the occurrence of occasional palpitation and dyspnoea 
 on exertion, especially if accompanied with irregularity of the pulse. 
 Mere deranged action of the heart is by no means uncommon in chil- 
 dren of all ages, though rarer before seven years old than subsequently. 
 It is most frequently observed in fragile, excitable children, and is not 
 
GENERAL CONCLUSIONS. 443 
 
 readily amenable to direct treatment, though it subsides in the course 
 of time under a system of general management calculated to improve 
 the health, and of exercise judiciously regulated, and always kept 
 within such limits as not to occasion fatigue. 
 
 In conclusion, let me sum up in a few sentences the most important 
 facts concerning disease of the heart in childhood, which I have en- 
 deavored to bring before your notice : 
 
 1st. While disease of the heart is less common in childhood than in 
 the adult, there is no absolute immunity in early life from any of those 
 affections to which the organ in after years is liable. 
 
 2d. Of all the causes of heart affection, inflammation is the most 
 frequent ; and while all blood diseases predispose to its occurrence, none 
 exert so powerful an influence in exciting it as rheumatism. 
 
 3d. While inflammation is by far the most frequent cause of valvu- 
 lar disease, there is, nevertheless, reason to believe that it is not the 
 sole cause, but that the valves may become disorganized quite indepen- 
 dently of previous endocarditis ; and a knowledge of this fact ought to 
 govern our treatment in all cases where the history of the commence- 
 ment of the affection is at all obscure. 
 
 4th. The disposition of valvular disease to increase is not only liable 
 to more frequent exceptions in the child than in the adult, but there is 
 also in early life a special power of repair and of self-adjustment in the 
 heart which warrants our expressing a more cheerful prognosis than 
 w 7 ould be justifiable in cases of cardiac disease occurring in the grown 
 person. 
 
 5th. At the same time, however, the feebleness of the heart in early 
 life, the liability of the child to cachectic conditions and exhausting 
 diseases, the rapidity of the circulation, and the facility with which it 
 may be excited by very slight causes, all tend to favor the occurrence 
 of dilatation of the heart whenever a slight amount of valvular ob- 
 struction exists, or even altogether independent of it. Hence it be- 
 comes of even more importance in the child than in the adult to insist 
 on long-continued rest, and on the avoidance of all causes which could 
 tend to excite the circulation, not only after attacks of rheumatism, but 
 also after typhoid or scarlet fever, or of any of those more chronic dis- 
 eases, — such, for instance, as chorea, — which are not only associated 
 with disturbance of the circulation, but also with disorder of the circu- 
 lating fluid itself. 
 
444 PECULIARITIES OF THE DIGESTIVE ORGANS IN INFANCY. 
 
 LECTUEE XXXI 
 
 Diseases of the Organs of Digestion and Assimilation. — Peculiarities of the 
 digestive organs — They require a peculiar kind of food, the milk — Composition 
 of that fluid, its adaptation for the nutriment of the infant — Changes in the 
 digestive organs as the child grows older — These changes take place more slowly 
 in the human subject than in animals. 
 
 Evils of giving other food than the mother's milk until the infant is old enough 
 to bear it. — Shown by the increased mortality it produces — Different modes in 
 which such food acts injuriously — Appearances found in bodies of children who 
 have died from imperfect nutrition. 
 
 Great importance of infants being suckled, even for a short time. — Difficulty of 
 analysis of the milk — Suggestions for determining fitness of a person for duties 
 of a wet-nurse — Rules for management of children who are brought up without 
 the breast — Substitute for mother's milk — Caution with reference to occasional 
 unhealthy condition of cow's milk. 
 
 We prefaced our investigation of the diseases of the nervous and res- 
 piratory systems with an inquiry into the peculiarities of structure and 
 of function which characterize those organs in early life. A similar 
 inquiry will not be out of place now, as preliminary to the study of the 
 diseases of the organs of digestion and assimilation, and their dependencies, 
 
 Man, when he has attained to maturity, is able to support his life, 
 and to preserve his health, upon food of various kinds ; and the struc- 
 ture of his organs is such as to enable him to live upon an exclusively 
 animal diet, or upon food furnished entirely by the vegetable kingdom. 
 We know that in either case the ultimate elements from which the body 
 is nourished are the same ; but that while in the former instance they 
 are furnished as it were ready to hand, they have in the latter to be 
 eliminated by nature's chemistry, through a process which occupies 
 much time, and which requires considerable complexity in the apparatus 
 that effects it. 
 
 Those powers, however, of which the adult is possessed, belong in 
 but comparatively small measure to the infant. The growing animal, 
 indeed, needs proportionally more food than the adult; for not merely 
 is the daily waste to be repaired, and that constant reproduction of the 
 tissues to be provided for which is essential to the maintenance of vitality 
 in all parts of the body, but each day is to bring with it an increase in 
 size and stature. But though *in early life an ample supply of food is 
 so necessary, yet the organs by which it is to be assimilated, like those 
 which have other offices to perform, are at that time frail and delicate, 
 and must not be overworked. Their development is incomplete ; and 
 even those animals whose digestive apparatus becomes eventually most 
 complex, are fitted at first for subsisting only on the simplest food. 
 Thus, for instance, the peculiarities which characterize the digestive 
 process in ruminants do not begin till some time after birth : the fourth 
 stomach is the only one called into use; the others are little more than 
 
MILK THE PROPER FOOD OF THE INFANT. 445 
 
 indicated in the new-born animal. Preparations, however, for their 
 future mode of subsistence are early discernible in the herbivora, whose 
 dentition has already commenced at birth, and advances with rapidity 
 to attain its completeness. » In the infant, on the other hand, the jaws 
 which long remain edentulous, the non-developed caecum, and the sali- 
 vary glands, whose functions seem scarcely to commence for the first 
 few months of life, 1 sufficiently indicate that it is intended to subsist 
 longer than the young of most animals on food which shall require few 
 changes to be wrought in it. The food, soon converted in the stomach 
 passes rapidly out of it, and the infant speedily seeks for more, requir- 
 ing, as every one knows, to be fed far more frequently than the adult; 
 while digestion being perfected at once, and no necessity existing for 
 those supplementary processes which the caecum in after life effects, the 
 peristaltic action of the bowels is more rapid, excrementitious matters 
 are quickly expelled, and the healthy infant passes two or three evacua- 
 tions in the twenty-four hours. 2 
 
 But while the digestive organs are thus adapted to insure the rapid 
 performance of their functions, and to provide for the quick as well as 
 for the complete nutrition of the body, the question naturally suggests 
 itself, where shall that food be found which, while it yields the neces- 
 sary sustenance, is yet so easily assimilated as not to require powers of 
 which the delicate organs of the young are destitute? We should 
 search in vain through the animal and vegetable kingdom for any sub- 
 stance completely fulfilling these conditions; but nature has supplied 
 the want, and given to almost every mother the means of herself nour- 
 ishing her young. 
 
 Milky the proper aliment of the young, expressly prepared for it within 
 its mother's organism, contains, ready combined, all those elements 
 which are necessary, whether for its growth or for the maintenance of 
 its proper temperature, by serving as materials for respiration. The 
 mean of 89 analyses of human milk, by MM. Vernois and BecquereF 
 
 1 See the observations of Bidder and Schmidt, on the absence of secretion from the 
 saiivary glands of young animals, at p. 22 of their work, Die Verdauungs-Safte und 
 der Stoffweehsel, 8vo. Mitau und Leipzig, 1852. 
 
 2 I am indebted to my friend, Professor Bolleston, of Oxford, for demonstrating 
 to me the incorrectness of some of the statements adopted in the first three editions 
 of this work from Schultz's Essay, Ueber den Akt des Erbrechens, &c, in the Ana- 
 lekten iiber Kinderkrankheiten, vol. ii, Heft vi, p. 62, with reference to the pecu- 
 liarities in the form and position of the stomach during foetal and early infantile 
 life. Dr. Brinton, in a note at p. 318 of the Article " Stomach," in the Cyclopaedia 
 of Anatomy and Physiology, also notices some exaggeration in Schultz's statements. 
 1 cannot, however, mention in seeming disparagement the name of one whose scien- 
 tific career has long since been run, without adding, that in spite of failing health 
 which conducted him to an early grave, Schultz was a most laborious pioneer in those 
 investigations into the process of digestion which have yielded to others who have 
 followed him such an abundant harvest. 
 
 3 The statements with reference to the chemistry of the milk are taken from 
 Seherer's article " Milch," in Wagner's Handworterbuch der Physiologie, vol. ii, 
 p. 448; and from the elaborate work of MM. Vernois and A. Becquerei, Du Lait 
 chez la Femme, &c, 8vo., Paris, 1853. See their analysis, and the analyses of 
 former observers, in the table at p. 15 of their work. 
 
446 CHANGES IN THE DIGESTIVE ORGANS VERY GRADUAL. 
 
 yields the following result. It has a specific gravity of 1032.67, and 
 is composed of 
 
 Water, 889 08 
 
 Solid matters, • . . 110 92 
 
 These solid constituents are made up of 
 
 Sugar, 43.64 
 
 Casein and extractive matter, . . . .39.24 
 
 Butter, 26.66 
 
 Incombustible salts, 1.38 
 
 110.92 
 
 How small must be the effort needed to effect the assimilation of 
 this fluid! The chief of its solid constituents, the casein, differs little, 
 if at all, from the albumen of the blood, while in combination with it 
 is a considerable quantity of the phosphate of lime — a salt that enters 
 largely into the composition of the bones. Among its other compo- 
 nents we find butter and sugar, the former of which probably in part 
 contributes to the formation of the fat that is so abundantly deposited 
 in the healthy infant, while the remainder of it supplies materials for 
 the generation of heat, by being resolved, together with the saccharine 
 matter, into its ultimate elements of carbonic acid and water. This 
 food, too, is not merely suitable for the infant soon after birth, but it 
 continues to be the aliment most proper for it for many months; the 
 casein increasing in quantity as the infant grows older, and the de- 
 mand for materials to maintain its growth increases. 
 
 By degrees the stomach alters in form ; its muscularity increases ; 
 the powers of the digestive organs become greater, and the child grows 
 able to derive support from food in which the nutritive principles are 
 not presented in so simple a form as in the milk. At the ninth month 
 teeth begin to appear — the first clear evidence of those changes which 
 nature is working in the organism, and the indication that before very 
 long the child will be able entirely to dispense with that elaborately 
 prepared nourishment which it has hitherto derived from its mother. 
 In the human subject the process of dentition not only begins late, but 
 it goes on slowly ; the first molar tooth is seldom cut before the com- 
 mencement of the second year : dentition is not concluded till its end. 
 Nature's object in the laws by which she governs the brute creation, 
 appears to be, to fit the young animals as soon as possible to provide for 
 themselves, and to shorten the period during which they must depend for 
 sustenance on their mother ; and, therefore, they begin to cut their teeth 
 much sooner, and the process is completed within a much shorter time, 
 than in the infant. Young rabbits are always provided with two 
 teeth when born, and the others make their appearance within ten 
 days. In the different ruminants, the teeth have either begun to ap- 
 pear before birth, or they show themselves a few days afterwards; and 
 in either case dentition is completed within the first month, and in dogs 
 and cats during the first ten weeks of existence. 
 
 For the difference in this respect between the lower animals and 
 man, it seems to me that a moral reason, not altogether visionary, may 
 
EVILS OF OTHER FOOD THAN MOTHER'S MILK. 447 
 
 be assigned. The young animal has to learn nothing more than how 
 to apply those instincts with which Almighty power has endowed it 
 for its own support and the perpetuation of its species. But the infant 
 is to be trained to become a man : its moral as well as its physical 
 nature is to be cultivated : parental influence is to be the means of 
 doing this ; and Providence may have wisely determined that the 
 infant shall for months be dependent on its mother for support, in order 
 that her instinctive feelings may lay the firm foundation of the love 
 that causes her to cling to her little one with a fondness that surpasses 
 all other affection, and which gives her the patience, the gentleness, 
 the untiring energy, that make her the child's best guardian, friend, 
 and teacher, during its early years. 
 
 But whether it is right or wrong to seek in something higher than 
 the material, for the reasons of this physical law, it yet is a law, and 
 one which cannot be violated with, impunity. The infant whose 
 mother refuses to perform towards it a mother't part, or who, by acci- 
 dent, disease, or death, is deprived of the food that nature destined for 
 it, too often languishes and dies. Such children you may often see, 
 with no fat to give plumpness to their limbs, — no red particles in their 
 blood to impart a healthy hue to their skin, — their face wearing in 
 infancy the lineaments of age, — their voice a constant wail, — their 
 whole aspect an embodiment of woe. But give to such children the 
 food that nature destined for them, and if the remedy do not come all too 
 late to save them, the mournful cry will cease, the face will assume a 
 look of content, by degrees the features of infancy will disclose them- 
 selves, the limbs will grow round, the skin pure red and white ; and 
 when, at length, we hear the merry laugh of babyhood, it seems almost 
 as if the little sufferer of some weeks before must have been a change- 
 ling, and this the real child brought back from fairy-land. 
 
 • Much care, much patience, judicious management in all respects, 
 may, indeed counteract the otherwise inevitable evils that result from 
 the attempt to bring up infants by hand. The statement, however, 
 just made with reference to the hazard of such an experiment, and to 
 the evil consequences that almost of necessity attend it, is by no means 
 overcharged. M. Yillerme, one of the most distinguished statisticians 
 of France, has compared the results of the two systems as followed in 
 three of the principal foundling hospitals in that country. 1 At Lyons, 
 at the time when he wrote, each infant on its reception, was given into 
 the charge of a wet-nurse, and its stay in the hospice did not exceed a 
 very few days, after which it was sent to be nursed in the country. At 
 Rheims, the stay of the infant in the hospice was equally short ; but 
 neither while there, nor afterwards when at nurse in the country, was 
 it brought up at the breast. At Paris, the stay of the children in the 
 hospice was often very much longer ; but they were usually, though 
 
 1 De la Mortality des Enfans Trouves, in the Annales d'Hygiene, vol. xix, p. 47. 
 Further information on this and other allied subjects will be found in a review of 
 the works of Terme, Monfalcon, and others, on the Foundling Hospitals of France, 
 published by the author in the British and Foreign Medical Review for April, 1842. 
 
448 INFANTILE MORTALITY FROM ARTIFICIAL FEEDING. 
 
 Dot invariably, suckled by wet-nurses. The mortality under 1 year of 
 the children admitted into these institutions was 
 
 At L} 7 ons, .... 33.7 per cent. 
 " Paris, .... 50.3 » 
 
 " Kheims, V 63.9 " 
 
 These results need no comment, and render it almost unnecessary to 
 adduce any further evidence of the dangers that are inseparable from 
 the attempt to bring up infants on artificial food. One more illus- 
 tration of the fact, however, may be adduced from 1 the work of a be- 
 nevolent ecclesiastic, M. Gaillard, on the foundling hospitals of France. 
 He observes : 
 
 " At Parthenay, in the department of Deux-Sevres, of 1 53 found- 
 lings 54 died between the ages of one day and twelve months, or 35 
 per cent., which is a higher proportion than that presented at Poitiers. 
 
 At X , of 244 new-born infants, 197, or 80 per cent., had died by 
 
 the end of the first year. Struck by the enormous difference between 
 this rate of mortality and that afforded by the hospices at Poitiers and 
 Parthenay, I determined to investigate its cause. I ascertained that 
 in this hospice as much attention is paid to the children, and the 
 nurses are under as strict oversight, as at Poitiers and Parthenay. 
 
 But at X none of the children are suckled, but all are fed ; and 
 
 the reason assigned for so doing, is the fear of infecting the nurses 
 with syphilis. Be this as it may, I have been assured by many per- 
 sons connected with the institution, that the fearful mortality just 
 mentioned can be attributed to no other cause than the practice of not 
 suckling the children. The officers of the hospice have tried all 
 means to remedy this evil, but neither their own efforts, nor those of 
 some most excellent female assistants, have been of the slightest service; 
 and the only measure by which they could reduce the mortality, was 
 the having recourse to suckling the children by wet-nurses." 1 
 
 It can hardly be necessary to say, that these statements are not to be 
 taken as representing the ordinary mortality among infants brought up 
 by hand, since many causes will suggest themselves as concurring to 
 render the life of foundlings especially precarious. Neither, indeed, is 
 the whole of the mortality among other children who have been 
 deprived of the mother's milk, to be attributed to the food which is 
 substituted for it ; but in many cases, if the mother does not suckle her 
 infant, she delegates to another the performance of her other maternal 
 duties, and the baby is left to languish in the house of a stranger. 
 That this cause is very influential in producing a high rate of mortality 
 among infants, appears from the fact mentioned by M. Benoiston de 
 Chateauneuf, 2 that while among children suckled by their mothers 
 only 18.36 per cent, die within a year after their birth, 29 per cent, of 
 those put out to wet-nurse die during the same period. 
 
 It is not enough, however, for us to know that food other than the 
 mother's milk is injurious to the young infant; but it behooves us, both 
 
 1 Recherches sur les Enfans Trouves, &c., par l'Abbe A. H. Gaillard, 8vo., p. 166. 
 Paris, 1837. 
 
 2 Considerations sur les Enfans Trouves, 8vo., p. 57. Paris, 1824. 
 
INJURIOUS EFFECTS OF ARTIFICIAL FEEDING EXPLAINED. 449 
 
 as physiologists and as physicians, to push our inquiries further, — to 
 ascertain as far as possible the means by which this injurious effect is 
 produced, and to determine what organs of the body suffer most se- 
 verely, and the mode in which they are affected. Unfortunately, the 
 information which I am able to give you on these points is much less 
 definite than I could wish; for the evils that result from improper food 
 in infancy do not, like some diseases, arrest attention by their alarming 
 symptoms, or by their rapidly fatal result, and hence they have re- 
 ceived less than their due share of notice. 
 
 If improper food is given to an infant, the contractions of the 
 stomach are in general speedily excited, and the food is rejected. This 
 eructation of a portion of its food may indeed be noticed even in in- 
 fants at the breast, who have either sucked more than their stomach 
 can conveniently hold, or whose digestive powers are temporarily 
 weakened by some trivial ailment. But the hint which nature gives 
 is too often thrown away on those who have the charge of the infant. 
 Food of the same kind is given again perhaps in smaller quantity, or 
 with some slight difference in its mode of preparation; and part; or 
 the whole of it, is now retained for a time, though not long enough for 
 its complete assimilation ; but if not rejected by vomiting, it passes the 
 pylorus while digestion is but half completed. Unfortunately, the 
 farinaceous articles of food which are so often selected, on account of 
 their supposed lightness, as fit to form the almost exclusive diet of in- 
 fants, belong to the class of substances that are assimilated with diffi- 
 culty ; so that a large proportion of the contents of the stomach, in the 
 young child brought up by hand, enter the duodenum in a state wholly 
 unfit to be acted on by the bile. The intestines become irritated by 
 these undigested matters ; and, in the effort to get rid of them, diar- 
 rhoea is excited ; while, if not speedily expelled, they pass into a state 
 of fermentation or putrefaction, and thus produce those horribly offen- 
 sive evacuations which are frequently voided by children in these cir- 
 cumstances. 
 
 It would be natural to expect that a child should lose flesh and 
 strength, even if the food given to it were no otherwise objectionable 
 than as being difficultly digested. But not only are the sago, arrow T - 
 root, or gruel, with which the child is fed, in themselves less easy of 
 digestion than the milk, which is its proper aliment ; they, moreover, 
 when reduced to their ultimate elements, present essential differences 
 from it, and differences by which they are rendered so much the more 
 inapt to nourish the body during the period of its most active develop- 
 ment and growth. It would be out of place to enter here into minute 
 details with reference to the physiology of digestion, or the composition 
 of different articles of food, in order to illustrate this subject; neither, 
 indeed, is it necessary to do so. You are aware that physiological and 
 chemical research have proved that food has to answer two distinct 
 purposes in the organism ; the one to furnish materials for the growth 
 of the body ; the other to afford matter for the maintenance of its tem- 
 perature ; and that life cannot long be supported, except on a diet in 
 which the elements of nutrition and the elements of respiration bear a 
 certain proportion to each other. Now, in milk, the proper food of 
 
 29 
 
450 INFANTILE ATROPHY. 
 
 infants, the elements of the former are to those of the latter, according 
 to the approximative estimate of an English chemist/ in the propor- 
 tion of 1 to 2 ; while in arrowroot, sago, and tapioca, they are only as 
 1 to 26, and even in wheaten flour only as 1 to 7. If to this we add 
 the absence in these substances of the oleaginous matters which the 
 milk contributes to supply the body with fat (and which can be elimi- 
 nated from farinaceous substances only by a conversion of their ele- 
 ments, to which the feeble powers of digestion in early life are not 
 equal), and the smaller quantity, and, to a certain extent, the different 
 kind of the salts which they contain, it becomes at once apparent that 
 by such a diet the health, if not the life, of the infant must almost in- 
 evitably be sacrificed. The body wastes most rapidly ; for it is forced 
 from its own tissues to supply the nitrogenous elements essential to the 
 maintenance of life, and which its food contains in far too scanty a 
 proportion. Every organ in the body contributes to the general sup- 
 port, and life is thus prolonged, if no kind disease curtail it, until each 
 member has furnished all that it can spare, and then death takes place 
 from starvation ; its approach, indeed, having been slower, but the 
 suffering which preceded it not therefore less, than if all food had been 
 withheld. 
 
 I have dwelt at length upon this, which is the most frequent cause 
 of the atrophy of new-born children ; but similar effects are produced 
 when, from any other reason, an infant is imperfectly nourished, 
 whether, as sometimes occurs, the mother's milk is so deteriorated as to 
 be unsuitable for its support ; or, whether, as often happens, the child 
 having been weaned prematurely, its digestive organs are unequal to 
 the task of assimilating the food that has been substituted for the 
 mother's milk. In both cases the abdominal viscera become disordered, 
 nutrition is ill j:>erformed, and the child falls into a state of atrophy. 
 
 On examining after death the bodies of children who have died in 
 these circumstances, the complete absorption of all the fat, and the re- 
 moval of much even of the cellular tissue, is the point that first attracts 
 our notice. The thoracic viscera present no unnatural appearance, un- 
 less it be that large portions of the lungs are sometimes found in a 
 state of collapse. There is also seldom anything unnatural in the con- 
 dition of the liver, except the congested state of the organ, the vessels 
 of which, being often loaded with venous blood, form a marked con- 
 trast to the generally ansemic appearance of the other viscera. The 
 gall-bladder is usually full of bile, — probably because, as in the case 
 of persons who have died of inanition, the empty stomach has long 
 ceased to stimulate it to contraction by its movements. The stomach 
 and small intestines are in general nearly empty; the fundus of the 
 stomach is sometimes found more or less softened, — a condition the oc- 
 currence of which after death is probably favored by the tendency of 
 those kinds of food that are usually given in early life, to pass into a 
 state of fermentation, in the course of which an acid is produced that 
 is capable of dissolving the animal tissues. In some instances where 
 
 1 Dr. K. D. Thomson, On the Relation between the Constituents of the Food and 
 the Systems of Animals, in vol. xxix of the Medico-Chirurgical Transactions. 
 
DIETETICS OF EARLY LIFE. 451 
 
 children have been fed on an exclusively farinaceous diet, the mucous 
 membrane, even low down in the intestines, has been found covered 
 with a thin coating of starch, which presented the characteristic blue 
 color when tested with iodine. 1 The intestines are generally pale, 
 though with patches intermingled of a red or dark-gray color; besides 
 which, small circumscribed spots of bright vascularity are sometimes 
 interspersed through the small intestines, being especially evident at 
 their upper part. Peyer's glands usually appear much more prominent 
 than is natural ; sometimes they are of a brighter red than the surround- 
 ing intestine, and somewhat swollen, and sometimes they are of a dark- 
 gray tint, and present a singular punctated appearance. In the large 
 intestines there is also sometimes a remarkable development of the sol- 
 itary glands, the dark orifice of which renders them very evident ; and 
 in a few instances they become still more apparent from the mucous 
 membrane immediately around each presenting a dark-gray color. 
 The appearances, in short, are those of general inanition, coupled with 
 the signs of irritation or inflammation of the whole secreting apparatus 
 of the intestinal canal. 2 
 
 The full consideration of every question connected with the imper- 
 fect nutrition of infants would require little else than a complete treatise 
 on the dietetics of early life. In these Lectures I can aim at nothing 
 more than to bring before your notice a few points of the greatest im- 
 portance. 
 
 Although it is very desirable that for the first six months of their 
 
 1 According to some experiments by M. Guillot, of Paris, referred to by Dr. 
 Stewart, of New York, in a paper, republished from an American journal, in the 
 Dublin Medical Journal, March, 1845. 
 
 2 This account of the post-mortem appearances observed in infants who have been 
 imperfectly nourished, is not merely borne out by the very interesting paper of MM. 
 Friedleben and Flesch, in vol v of the Zeitschrift fiir rationelle Medicin, Heidel- 
 berg, 1846, but receives a remarkable illustration in the more recent work of M. 
 Bednar, Physician to the Foundling Hospital at Vienna. The observations of the 
 former gentlemen are founded on the examination of fifteen infants, all of whom 
 were under one year old, who were brought up, either exclusively or in great 
 measure, on artificial food, and who died, after long-continued illness, in a state of 
 atrophy, or else sank rapidly under profuse watery diarrhoea. In cases of the former 
 class, a condition regarded by the writers as the result of chronic inflammation of 
 Peyer's glands was the chief morbid appearance; while in those instances where 
 death took place rapidly swelling and congestion of the same bodies, — betokening, 
 as they believe, their recent inflammation, — were almost always present. They 
 found, too, that in all these cases the disease of the colon was comparatively slight, 
 and evidently secondary to the more serious changes in the small intestine. Dr. 
 Bednar's patients were all under three months, — many only a few days old, — 
 partly suckled by women each of whom had several nurslings, partly fed on arti- 
 ficial food. As might be anticipated, the mortality is high; and of such almost 
 uniform occurrence is swelling of the mesenteric and Peyerian glands, and even of 
 the solitary glands of the large intestines, that, when treating of diarrhoea, he speaks 
 of this state of the glands as being a condition of no sort of importance; and even 
 expresses the opinion that in the large intestines it is to be regarded as a physiologi- 
 cal rather than a pathological occurrence. No more striking comment could be 
 written on the mischiefs and the dangers of artificial feeding of infants. See pp. 
 37 and 38 of Bednar's Krankheiten der Neugebornen, &c., 1st ed., 8vo. Wien, 
 1850. The same facts, too, are still further illustrated by the more recent observa- 
 tions of Hervieux on the changes in Peyer's and the solitary glands in new-born 
 infants, published in the Gazette Medicale, fevr. 17, 1856 ; and several following 
 numbers. 
 
452 IMPORTANCE OF SUCKLING EVEN FOR A SHORT TIME. 
 
 existence children should derive their support entirely from their 
 mother, and that until they are a year or at least nine months old their 
 mother's milk should form the chief part of their food, yet many cir- 
 cumstances may occur to render the full adoption of this plan impracti- 
 cable. In some women the supply of milk, although at first abundant, 
 yet in the course of a few weeks undergoes so considerable a diminution 
 as to become altogether insufficient for the child's support ; while in 
 other cases, although its quantity continues undiminished, yet from 
 some defect in its quality it does not furnish the infant with proper 
 nutriment. Cases of the former kind are not unusual in young, toler- 
 ably healthy, but not robust women ; while instances of the latter are 
 met with chiefly among those who have given birth to several children, 
 whose health is bad, or whose powers are enfeebled by hard living or 
 hard work. The children in the former case thrive well enough for 
 the first six weeks or two months; but then obtaining the milk in too 
 small a quantity to meet the demands of their rapidly growing organ- 
 ism, they pine and fret, they lose both flesh and strength, and unless 
 the food given to supply their wants be judiciously selected, their 
 stomach and bowels become disordered, and nutrition, instead of being 
 aided, is more seriously impaired. If, however, a healthy wet-nurse is 
 employed to supply the mother's inability to nourish her child, its 
 health will soon return; and by the sacrifice of the infant of the poor 
 woman, the offspring of the wealthy will be preserved. But many 
 circumstances besides those moral considerations which should never 
 be forgotten before the determination is formed to employ a wet-nurse, 
 may put this expedient out of the question ; and it becomes, therefore, 
 our duty to inquire what course a mother should pursue, who has 
 learned by experience that she is unable to suckle her child for more 
 than a very short period. 
 
 Knowing the attempt to rear her child entirely at the breast to be 
 vain, the mother may in such a case naturally be tempted to bring it 
 up by hand from the very first. But, how short soever the period may 
 be during which the mother is able to suckle her child, it is very de- 
 sirable that she should nurse it during that period, and also, that her 
 milk should then constitute its only food. For the first four or five days 
 after the infant's birth the milk possesses peculiar qualities, and not 
 merely abounds in fatty and saccharine matters, but presents its casein 
 in a more easily assimilable form than subsequently. 1 It afterwards 
 loses these characteristics ; but still, during the first few weeks of life, 
 it contains casein in smaller quantities than enter into its composition 
 at a later period. The secretion, in short, is especially adapted to the 
 feeble powers of the digestive organs soon after birth ; and hence the 
 difficulty of providing any good substitute for it is greater in propor- 
 tion to the tender age of the infant, while art often imitates but ill that 
 gradual increase of the casein, by which the main element of the 
 
 1 See on this subject a very interesting paper by Dr. Moore, of Dublin, "On tbe 
 Coagulability of Human Milk," in Dublin Journal of Medical Sciences, May, 
 1849. 
 
CAUSES WHICH INFLUENCE THE MILK. 453 
 
 infant's sustenance is made to bear a constant proportion to the de- 
 mands of its daily growth. 1 
 
 The same course of conduct would be proper in the case of women 
 whose milk is of so poor a quality that their infants do not thrive 
 upon it, since, though its deficiency in casein may render it unfit for the 
 permanent support of the child, yet that circumstance will not prove 
 prejudicial to it during the first few weeks of its existence. 
 
 Unfortunately we are not possessed of any ready means by which we 
 can determine, in the majority of instances, that a woman's milk is ill 
 suited for the nourishment of her child ; and, in practice, the infant's 
 not thriving is often the first indication that we have of the propriety 
 of a change. Certain qualities, indeed, which healthy milk ought to 
 have, are readily ascertainable. Thus, for instance, it should have a 
 specific gravity of about 1.032, and an alkaline reaction; and, after 
 the first month, should be free from colostrum corpuscles ; while the 
 oil-globules, which should be present in great number, ought to be of 
 tolerably equal size, and each distinct from the other. In spite of pre- 
 senting all these characters, however, the milk may have undergone 
 very important changes, though of a kind which dexterous chemical 
 analysis will alone discover. An increase in the quantity of the fatty 
 matters in the milk seems, according to the observations of M. Becquerel, 
 to be an almost constant attendant upon all diseases, whether acute or 
 chronic, syphilis and far-advanced phthisis alone excepted ; while 
 acute diseases are attended by a notable increase, and chronic ailments 
 by a still more remarkable diminution of the casein. Such changes in 
 its composition cannot but modify very greatly its suitability as an 
 aliment for the child ; while the difficulty of ascertaining the existence 
 of any of these alterations may at least teach us that the apparently 
 healthy character of the milk is but "a very imperfect guarantee of its 
 real excellence. 
 
 Still, even though the difficulties of a complete analysis of the milk 
 will generally render the attempt to make it impracticable, and though 
 conclusions drawn from a partial examination will almost certainly be 
 erroneous, there are, fortunately, some general rules fairly deducible 
 from chemical analysis and clinical observation combined, which will 
 generally suffice to guide us aright in the choice of a person to under- 
 take the duties of wet-nurse to an infant whose mother, either from 
 necessity or choice, fails to perform the duty of suckling it herself. 
 The apparently good health of the woman and her child is of all evi- 
 dence the most conclusive in favor of her fitness; but M. Becquerel 
 
 1 Though I have allowed the above paragraph to stand unaltered in this edition, 
 yet it must be observed that the elaborate researches of MM. Vernois and Bec- 
 querpl do not altogether bear out its accuracy. They deny, on the strength of 
 twenty-six observations on the milk of different women within a fortnight after 
 delivery, that any such excess of sugar, and feeble proportion of casein, then char- 
 acterize it, as is stated above, on the authority of the late Professor Simon, of Ber- 
 lin. They admit the existence of a larger quantity of butter, which, however, con- 
 tinues only so long as the colostrum corpuscles are still present. It is, however, 
 much to be regretted that they did not institute a series of comparative observa- 
 tions, with reference to this point, on the milk of the cow, since the question in- 
 volved in the accuracy of one or the other of the opposing statements is of very 
 great practical importance. 
 
454 
 
 SUBSTITUTES FOR THE MOTHER S MILK, 
 
 found the nearest approach to a perfectly physiological state of the 
 milk in women from twenty to twenty-five years old, multipara, of 
 strong constitution, previously well-nourished, brunettes, with small 
 mammae but an abundant secretion of milk, from three to five months 
 after delivery, and in whom the menstrual discharge was suspended. 
 
 The question, however, which we often have to answer, and to 
 answer, too, sometimes very soon after the infant's birth, is not as to 
 the goodness of a wet-nurse, but as to the best substitute for the mother's 
 milk. Now it is obvious that the more nearly the substitute we select 
 approaches to the character of the mother's milk, the greater will be 
 the prospect of the attempt to rear the infant upon it proving successful. 
 Discarding, therefore, all those preparations of arrowroot, flour, or 
 biscuit-powder, in which the vulgar repose such confidence, we shall 
 not need any labored argument to convince us that in the milk of some 
 other animal we shall be likely to find the infant's most appropriate 
 food. You will perceive, however, by the subjoined table, that there 
 are many important differences between the milk of all the domestic 
 animals and of the human female ; both in the actual quantities of its 
 constituents, and in their relative proportion to each other. 
 
 Table showing the Composition of the Milk in Man and in various Animals. 1 
 
 
 Specific 
 Gravity. 
 
 1000 parts contain 
 
 The solid constituents are composed of 
 
 Fluid. 
 
 Solids. 
 
 Sugar. 
 
 Butter. 
 
 Casein and 
 
 Extractive 
 
 Matters. 
 
 Incom- 
 bustible 
 Salts. 
 
 In Man, . . 
 In the Cow, 
 
 In the Ass, 
 In the Goat, 
 In the Ewe, 
 
 1032 67 
 1033.38 
 1034.57 
 1033.53 
 1040.98 
 
 889.08 
 864.06 
 890 12 
 844.90 
 832.32 
 
 110.92 
 135 94 
 109.8£ 
 155.10 
 
 167.68 
 
 43.64 
 38.03 
 50.46 
 36 91 
 39.43 
 
 26 66 
 36.12 
 18.53 
 56.87 
 54.31 
 
 39.24 
 55.15 
 85.65 
 55.14 
 69.78 
 
 1.88 
 
 664 
 5.24 
 
 6.18 
 7.16 
 
 The above table shows you that it is only in the milk of the ass that 
 the solid constituents are arranged in the same order as in the human 
 subject; casein preponderating in the milk of the cow and ewe, and 
 butter in that of the goat. On this account, therefore, asses' milk is 
 regarded, and with propriety, as the best substitute for the child's 
 natural food. Unfortunately, however, expense is very frequently a 
 bar to its employment, and compels us to have recourse to cows' milk, 
 as being so much more readily procured. But though the cost may be 
 a valid objection to the permanent employment of asses' milk, it is yet 
 very desirable, when a young infant cannot have the breast, that it 
 should be supplied with asses' milk for the first four or five weeks, 
 until the first dangers of the experiment of bringing it up by hand 
 have been surmounted. The deficiency of asses' milk in oily matter 
 may, as has been suggested, 2 be very much rectified by the addition to 
 it of about a twentieth part of cream. The laxative property which it 
 
 1 Vernois and Becquerel, op. cit., p. 167. 
 
 2 By Dr. Moore, of Dublin, in his paper already referred to. 
 
SUBSTITUTES FOR THE MOTHER'S MILK. 455 
 
 possesses is not so easily counteracted ; and though Sir Henry Marsh's 
 recommendation of heating it to 212° sometimes removes this quality, 
 yet the experiment has not in my hands been by any means invariably 
 successful. In such cases, however, the addition of about a fourth part 
 of lime-water to the milk will generally suffice to control all tendency 
 to diarrhoea. 
 
 When cows' milk is given, it must be borne in mind that it contains 
 more casein than human milk, and less sugar ; and that it is therefore 
 necessary that it should be given in a diluted state, and slightly 
 sweetened. The degree of dilution must vary according to the infant's 
 age ; at first, the milk may be mixed with an equal quantity of water, 
 but as the child grows older the proportion of water may be reduced 
 to one-third. Attention must be paid to the temperature of the food 
 when given to the infant, which ought to be as nearly as possible the 
 same as that of the mother's milk, namely, from 90° to 95° Fahrenheit ; 
 and in all cases in which care is needed, a thermometer should be em- 
 ployed, in order to insure the food being always given at the same 
 temperature. Human milk is alkaline; and even if kept for a con- 
 siderable time it shows but little tendency to become sour. The milk 
 of animals in perfect health likewise invariably presents an alkaline 
 reaction, and that of cows when at grass forms no exception to this 
 rule. Comparatively slight causes, however, exert a marked influence 
 upon the milk of the cow in all respects ; even in the most favorable 
 circumstances, if the animal is shut up in a city and stall-fed, all the 
 solid constituents of its milk suffer a remarkable diminution ; while 
 the secretion further has a great tendency to become acid, or to undergo 
 even more serious deterioration. 1 There is evidently no occasion, then, 
 to assume any intentional adulteration of the milk, in order to account 
 for the symptoms of gastric and intestinal disorder so often produced 
 by it in the case of children brought up in large towns. Whenever, 
 therefore, the attempt is made to rear an infant by hand, in circum- 
 stances which render it impossible to obtain the milk of cows that are 
 at pasture, it is desirable that the milk should be daily tested, and that 
 any acidity should be neutralized by the addition of lime-water, or of 
 prepared chalk, in quantity just sufficient to impart to it a slightly 
 alkaline reaction. If the bowels are disposed to be constipated, carbo- 
 nate of magnesia may be substituted for the chalk. Unfortunately, 
 there seem, as I stated a day or two ago, to be good reasons for believ- 
 ing that the milk of stall-fed cows often undergoes a deterioration 
 much more serious than the merely becoming ascescent; and that 
 changes not infrequently take place in it such as must render it wholly 
 unfit for an infant's food, and calculated only to promote disease. The 
 possibility of their occurrence shows the necessity, when an infant who 
 is brought up by hand fails in health, for making a careful inquiry 
 
 1 See the analysis of Yernois and Becquerel, op. cit., p 131, and the results of Dr. 
 Mayer's observations on cows in Berlin and its neighborhood, in a valuable paper 
 on the Artificial Feeding of Infants, in the first volume of the Verhandlungen der 
 Gesellschaft fur Geburtshulfe in Berlin, 8vo., p. 56. Berlin, 1846; and also two 
 papers by Dr. Peddie in the London and Edinburgh Monthly Journal for 1848 ; 
 and the observations of Dr. Klencke, of Leipsic, already referred to at p. 424. 
 
456 INFANTILE ATROPHY. 
 
 into the source of the milk with which it is fed ; and for examining 
 the fluid, if possible, both chemically and under the microscope, before 
 proceeding to prescribe remedies for ailments which may be caused 
 entirely by the unwholesome nature of its food. 
 
 The quantity of food proper to be given to an infant at one time, and 
 the total amount which it may be supposed to require in the twenty- 
 four hours, though questions of most obvious importance, have hitherto 
 scarcely received any attempt at solution. The only observations bear- 
 ing on the subject, with which I am acquainted, were made some years 
 ago by M. Guillot 1 at the Foundling Hospital in Paris. He weighed 
 children both immediately before and immediately after suckling, and 
 found that the increase of weight varied from about two to five ounces 
 in children under a month old ; and concludes that a thousand grammes, 
 or about two pounds and a quarter avoirdupois, is the smallest quantity 
 of milk that would suffice for the daily nourishment of a healthy infant 
 during the first month of its existence. The number of children, how- 
 ever, on whom his observations were made, as well as the number of 
 observations on each child, were both far too few to yield more than a 
 very rough approximation to the truth with reference to this subject. 
 
 It may suffice for to-day, thus to have brought before you the main 
 principles by which you must be guided in the attempt to rear a young 
 infant by hand. Details as to the general dietetic management of in- 
 fancy or childhood would not only carry us beyond the period allotted 
 for this lecture, but would be a departure from our special object, — of 
 investigating the diseases of early life. 
 
 LECTURE XXXII. 
 
 Atrophy or Young- Children. — Not a special disease, but a condition that may 
 be induced by various causes. 
 
 Thrush, a peculiar affection of the mouth, generally associated with impaired nutri- 
 tion. — Its characters, different opinions as to its nature — General state of children 
 in whom it occurs. Microscopic researches as to its nature, the deposit produced 
 by a eryptogamie vegetation — Conditions that favor its development — Infer- 
 ences as to its treatment. 
 
 Dentition. — High rate of mortality while it is going on — Erroneous views with refer- 
 ence to the cause of this, and to the nature of the process — Physiology of denti- 
 tion — Order of appearance of the teeth — Pauses in their evolution — Frequently 
 attended with local suffering — Various morbid conditions of mucous membrane 
 of the mouth excited by it. 
 
 Management of children when teething. — Circumstances in which lancing the gums 
 is likely to be useful — Dietetic and. medical management — Treatment of affec- 
 tions of the mouth — Caution with reference to cure of cutaneous eruptions during 
 the time of teething. 
 
 At our last meeting we were occupied with various preliminary in- 
 quiries, of importance to the thorough understanding of the diseases of 
 
 i Journal fur Kinderkrankheiten, July, 1852, vol. xix, p. 118. 
 
THRUSH. 457 
 
 the digestive organs in early life, on the study of which we are now 
 about to enter. W r e examined the structural and functional peculiarities 
 of those organs in the young, and endeavored to ascertain wherein con- 
 sists the special fitness of the mother's milk for the nutriment of her 
 infant. We further tried to discover the mode in which other food acts 
 injuriously on the infant, and sought from the knowledge thus acquired 
 to deduce rules for our guidance, whenever it should become necessary 
 to provide a young child with a substitute for that sustenance which 
 nature intended that it should receive. 
 
 These considerations naturally brought under our notice the symp- 
 toms which betoken that the process of nutrition is imperfectly carried 
 on, and the appearances which, when death takes place from this cause, 
 are revealed on an examination of the body. It may seem to you, how- 
 ever, that the atrophy of young children calls for a more elaborate study 
 than ours of yesterday, and for a more minute account of its symptoms. 
 But to attempt this would be to enter upon almost endless details, which 
 would leave upon your memory no clear impression. Whether all food 
 is withheld from an infant, or whether it is supplied with food which 
 it cannot assimilate, or whether disease prevents it from digesting food 
 on which a healthy infant would thrive, the main result is the same, 
 and the child dies of inanition. Various accidents may abridge the 
 infant's life, or may make it sink in one case, in circumstances some- 
 what different from those which precede its death in another. Some- 
 times the vital powers grow so feeble that the inspiratory efforts no 
 longer suffice to fill the lungs with air ; sometimes the irritable stomach 
 rejects all food, while at other times diarrhoea comes on which no medi- 
 cine can check. But in these symptoms there is nothing characteristic 
 of one special cause — they may occur alike in the infant who, though 
 healthy when born, was early deprived of its mother's milk, or in the 
 child who is the subject of general tuberculous disease, or whose strength 
 has been exhausted and its digestive powers impaired by dysentery. The 
 symptoms, then, that accompany the atrophy of new-born children 
 must be expected to vary much in different cases ; while the considera- 
 tions brought before you in the last lecture will, I think, furnish you 
 with a clue to the complete understanding of them all. 
 
 Before we pass, however, to the special study of the diseases of the 
 digestive organs and their appendages, I wish to call your attention to 
 that peculiar condition of the mucous membrane of the mouth, popularly 
 known as the thrush, which is so frequently met with in connection with 
 the artificial feeding of young infants — so almost invariably associated 
 with the evidences of their impaired nutrition, that the present seems 
 to be the best place for noticing it. 
 
 If you examine the mouth of a young infant on whom the attempt 
 is being made to bring it up without the mother's milk, you will often 
 observe its mucous membrane to be beset with numerous small white 
 spots, that look like little bits of curd lying upon its surface, but which 
 on a more attentive examination are found to be so firmly adherent to 
 it as not to be removed without some difficulty, when the subjacent mem- 
 brane is left of a deep red color and often bleeding slightly. These 
 specks appear upon the inner surface of the lips, especially near the 
 
458 GENERAL SYMPTOMS OF THRUSH. 
 
 angles of the mouth or the inside of the cheeks ; and upon the tongue, 
 where they are more numerous at the tip and edges than towards the 
 centre. They are likewise seen upon the gums, though less frequently 
 and in smaller number. When they first appear they are in general of 
 a circular form, scarcely larger than a small pin's head ; but after having 
 existed for a day or two some of the spots become three or four times 
 as large, while at the same time they in general lose something of their 
 circular form. By degrees these small white crusts fall off of their own 
 accord, usually leaving the mucous membrane w T here they were seated 
 redder than before— a color which gradually subsides as the mouth 
 returns to its natural condition ; or the white specks are reproduced 
 and again detached several times before the membrane resumes its 
 healthy aspect. In some cases these specks coalesce, or the deposit, from 
 its first appearance, presents more of the character of a false membrane, 
 and the mouth is then seen to be extensively coated with it ; though 
 even then, if the deposit is carefully removed, the mucous membrane 
 beneath will be found neither bleeding nor abraded, but merely redder 
 than natural. In these circumstances the deposit generally loses some- 
 thing of the dead white color characteristic of the smaller spots, and 
 presents a slightly yellowish tint. On the Continent, where the severer 
 form of the affection is not infrequently seen, it was supposed, though 
 the opinion is now with propriety abandoned, to be an essentially differ- 
 ent ailment from the slighter forms of the disease, in which the points 
 of deposit are distinct, while further confusion was introduced into the 
 subject by the employment of the term aphthce 1 to designate both this 
 affection, and another of a perfectly different nature (which I shall speak 
 of hereafter), characterized by inflammation and ulceration of the mucous 
 follicles of the mouth. The term aphthce will be most properly em- 
 ployed as a synonym for this follicular stomatitis; while I prefer to 
 restrict the use of the word thrush 2 — of which the French muguet, the 
 old English term millet, are synonyms — to the ailment some of whose 
 characters I have just described, and for which there is at present no 
 correct designation in scientific terminology. 
 
 Children in whom either form of this deposit exists in any consider- 
 able degree usually appear out of health ; and it will generally be 
 found on inquiry that this indisposition had preceded for some days the 
 eruption in the mouth. For the most part such children are emacia- 
 ted, and present those symptoms that attend upon imperfect nutrition, 
 while the bowels are in general relaxed, and the evacuations of a green 
 color, and very sour. The acridity of the motions sometimes irritates 
 and inflames the margins of the anus, and a blush of erythematous 
 redness not infrequently extends over the nates and buttocks, while in 
 some instances a deposit of a similar kind to that in the mouth occupies 
 
 1 The use of the word HQai by Hippocrates, and its application by him to ulcera- 
 tions of the uterus, plainly shows that in his mind the idea of a breach of surface 
 was always associated with it ; though it is very probable that under a mistaken be- 
 lief of its nature he may also have used the same word to designate true thrush. 
 See Foesius, (Economia Hippocratis, sub voce. 
 
 2 A word the etymology of which is uncertain ; as is that of its Swedish synonym 
 Torsk, and the Danish and Norwegian Trodske. 
 
berg's discovery of cryptogamic vegetation in thrush. 459 
 
 the edges of the intestine. In spite, however, of the popular notion 
 with reference to this point, the appearance of the deposit at the margin 
 of the anus is of extremely rare occurrence, though redness and sore- 
 ness at the edge of the bowel are .very frequent. The deposit in the 
 mouth sometimes renders sucking very difficult, and may even impair 
 deglutition, while the child, thus obtaining but little food, lies in a 
 state of torpor and drowsiness, the result of its debility. 
 
 In its more serious form this affection was said to prove fatal to a 
 large number of the inmates of the different foundling hospitals on the 
 Continent. Observation has shown, however, that although the de- 
 posit exists in the mouth of very many children who die in those in- 
 stitutions, yet their death is due not to the local affection, but to the 
 constitutional disease, of which that is only one out of many evidences. 
 
 In spite of the exaggerated importance that w T as long attached to the 
 local affection of the mouth, which was erroneously imagined to be the 
 cause of all the symptoms of disordered health, of which it is in reality 
 merely the accompaniment, much uncertainty existed as to its real 
 nature, though it was generally imagined to be a variety of pseudo- 
 membranous inflammation, not unlike that of croup or diphtheria. 
 This hypothesis, however, which left many peculiarities of the disease 
 unexplained, has been conclusively set aside, and the real nature of 
 this, as of so many other ailments, has been made quite clear by micro- 
 scopic research. 
 
 In the year 1842 Professsor Berg, of Stockholm, physician to the 
 Foundling Hospital in that city, communicated to the Swedish Society 
 of Medicine his discovery of a cryptogamic vegetation in the deposit of 
 thrush ; and a German observer, M. Gruby, confirmed M. Berg's 
 researches in a paper addressed in the same year to the Royal Academy 
 of Sciences at Paris, though his views differed in some points from 
 those of M. Berg. From the time of this discovery two opposing 
 views of the nature of the affection have till recently been maintained. 
 According to the one opinion, the parasitic growth, like the muscardine 
 on the silk-worm, or the conferva? developed on other living animals, 
 itself constitutes the essential part of the disease ; while according to 
 the other, the white substance in the mouth is in reality an inflamma- 
 tory exudation, in which, though conferva? may be developed, yet 
 their presence is accidental, and subject to many exceptions. 
 
 The correctness of the former opinion, which was maintained by M. 
 Berg, and substantiated in great measure by his researches, has now 
 been so generally admitted that I need not further occupy your time 
 with details of the controversy, but will describe as briefly as possible 
 the nature of the affection as it has been ascertained by means of the 
 microscope ; and as it is described by one of the most recent observers, 
 M. Robin. 1 
 
 1 Not to incumber this lecture with the citation of authoritips, it may suffice to 
 refer to the valuable essay of Dr. Berg;, of Stockholm, analyzed in the Journal fur 
 Kinderkrankbeiten for September and October, 1847, and since translated into Ger- 
 man, under the title Ueber die Schwammchen der Kinder, 8vo., Bremen, 1848, as 
 a most able defence of the first-mentioned opinion ; and to the papers by Dr. Ivron- 
 enbt-rg, of Moscow, in that journal for February and September of the same year, 
 
460 NATURE AND TREATMENT OF THRUSH. 
 
 In connection with various disorders of the digestive apparatus in 
 children, and also in the course of some exhausting diseases in the 
 adult, the mucous membrane of the mouth, and sometimes also that 
 of the pharynx and oesophagus, becomes the seat of inflammation, 
 which, though by no means severe, is yet attended with a change of the 
 secretion from alkaline to acid, and with an abundant production of 
 epithelium. This state of the mucous membrane, though not abso- 
 lutely essential, is yet in the highest degree favorable to the develop- 
 ment on its surface of a fungus, the Oidium albicans, the sporules of 
 which in these circumstances increase with great rapidity, and elon- 
 gate into fibrils, by whose multiplication and accumulation, together 
 with the abundant epithelial scales, a thick white layer is formed upon 
 the dorsal surface of the tongue, the palate, the velum, the interior of 
 the cheeks, the lips, and even in some cases the pharynx and oesopha- 
 gus. It appears, too, that during the first weeks of infancy 1 the mu- 
 cous membrane of the mouth yields, even in a state of health, and 
 wholly independently of whether or no the child is brought up at the 
 breast, an acid reaction, a circumstance which accounts for the far 
 greater liability of infants than of adults to this affection, so that in the 
 former case a very slight disorder will lead to its development, while 
 in the latter it is the sign and the consequence of very serious disease. 
 
 This account of the affection explains many points previously inex- 
 plicable concerning it. It furnishes a reason for the prevalence of 
 thrush in foundling hospitals, and institutions of a similar kind, where 
 the same cups, spoons, &c, are used in common by the children, and 
 often without sufficient attention to cleanliness. That the disease may 
 be produced by the actual transplantation of the sporules from one 
 child to another was conclusively established by M. Berg, 2 who tried 
 the experiment in four instances, and found that on each occasion the 
 deposit of the sporules on the mucous membrane of the mouth of a 
 healthy infant was succeeded by the development of the conferva?, and 
 the occurrence of thrush. 
 
 The conditions, then, which generally coincide in the production of 
 thrush are — 1st, certain ailments of the digestive organs, dependent on 
 impaired nutrition ; 2d, consequent inflammation of the mucous mem- 
 brane of the mouth, associated with an increase in the acidity of its 
 secretion, and an unusually abundant formation of epithelium ; and 3d, 
 the development on the surface of a cryptogamic vegetation, which is 
 not the cause, but rather the result of the child's illness. It follows, 
 then, that in the treatment of this affection the removal of the constitu- 
 tional disturbance is of at least as much importance as the ministering 
 
 for observations and arguments tending to support the opposite view. The elabo- 
 rate essay of M. Seux, in his Reeherches sur les Maladies des EnfVmts, 8vo., Paris, 
 1855, also claims mention here, for in it every question connected with this affection 
 is treated of with an almost painful minuteness. With reference to the production 
 of confervse on the mucous surfaces of the human body in disease, the fullest account 
 has been given by Hannover, in Miiller's Archiv. for 1842, p. 281 ; and by M. 
 Robin in his Histoire naturelle des Vegetaux parasites qui croissent sur 1 'Homme 
 et sur les Animaux vivants, 8vo., Paris, 1853. 
 
 1 Seux, op; cit., pp. 18-21. 2 Seux, op. cit.,pp 76-80. 
 
NATURE AND TREATMENT OF THRUSH. 461 
 
 to the local malady. Two facts, indeed/ will serve, without further 
 comment, to place this matter in a very strong light ; one is, that in 
 21 out of 26 examinations of the bodies of children who had died of 
 thrush the small intestines presented morbid appearances, which, 
 though of various kinds, were all analogous to those referred to in the 
 last lecture as dependent on imperfect nutrition and artificial feeding. 
 The other is, that while in the Foundling Hospital at Marseilles the 
 mortality of children affected with thrush is only 5 in 100, in that at Paris 
 it has been stated by different observers as 9 in 10, 109 in 140, 22 in 24, 
 and 25 in 48. Of the two institutions, that at Paris is the more salu- 
 brious ; but there the appearance of the affection of the mouth is the 
 signal for the immediate withdrawal of the child from the breast ; while 
 at Marseilles the opposite plan is pursued, and a child, even though 
 previously fed artificially, is at once given to a wet-nurse on the first 
 siom of thrush being discovered. The extreme rarity, too, with which 
 in private practice the thrush in a young infant assumes the characters 
 of a serious affection furnishes further proof, if it were wanting, that 
 the local ailment is of little moment apart from the complications 
 which impart to it its gravity. It will, therefore, be inexpedient to 
 dwell here on anything more than the local treatment of the case, since 
 its general management must vary as widely as the causes to which 
 the affection of the mouth is due. One point of considerable moment, 
 and to which less care than it deserves is usually paid, is the removing 
 from the mouth, after each time that the infant has fed, all remains of 
 the milk or other food that it has taken. For this purpose,, whenever 
 the least sign of thrush appears, the mouth should be carefully wiped 
 out with a piece of soft rag, dipped in a little warm water, every time 
 after food had been given. Supposing the attack to be but slight, this 
 precaution will of itself suffice in many instances to remove all traces 
 of the affection in two or three days. If, however, there be much red- 
 ness of the mucous membrane of the mouth, or if the aphthous spots 
 be numerous, some medicated topical application is useful. Various 
 detergents have been recommended, among which the mel boracis, and 
 a mixture of the Armenian bole with honey, are very frequently em- 
 ployed. An objection, however, has been raised, and I think on good 
 grounds, to any application into the composition of which honey or 
 other saccharine matters enter, on the ground that the tendency of 
 those substances to pass into a state of fermentation will make them 
 favor, rather than prevent, the formation of confervse in the interior of 
 the mouth. It is my custom to dissolve half a drachm of borax with 
 one drachm of glycerin in an ounce of water, and to direct that after 
 the mouth had been carefully cleansed with warm water this lotion 
 should be applied to it on a piece of lint or soft linen. In the milder 
 forms of the affection the borax lotion usually answers every purpose. 
 Should it, however, appear insufficient, a solution of two grains of 
 the nitrate of silver in an ounce of distilled water may be employed 
 in the same way twice a day, while at other times the solution of borax 
 may be used in the manner just directed. 
 
 1 Op. cit., pp. 147 and 218-220. 
 
462 MORTALITY DURING DENTITION. 
 
 The close connection that subsists between this local affection and 
 the condition of generally impaired nutrition, which engaged our atten- 
 tion yesterday, induced me to bring the subject now under your notice. 
 I do not know, however, that any better plan can be adopted, in study- 
 ing the diseases of the organs of digestion and assimilation, than closely 
 to follow an anatomical arrangement, and to consider, first, the diseases 
 of the mouth, then those of the stomach, then those of the intestines, 
 and lastly those of the other abdominal viscera. 
 
 It may, perchance, seem to you that, according to this plan, it is not 
 proposed to assign any place of importance to the disorders of dentition, 
 though in our tables of mortality w r e find teething registered as having 
 occasioned the death of nearly 5 (4.8) per cent, of all children who died 
 in this metropolis under one year old, and of 7.3 per cent, of those who 
 died between the age of twelve months and three years. Many other 
 circumstances, too, tend to increase the impression which this fact 
 naturally makes ; for not only do nurses attribute to teething the most 
 varied forms of constitutional disturbance, and mothers express serious 
 apprehensions as the period of dentition approaches, but medical men 
 hold forth to anxious parents the expectation that their child will have 
 better health when it has cut all its teeth. The time of teething, too, 
 is in reality one of more than ordinary peril to the child ; though why 
 it should be so is not always rightly understood. It is a time of most 
 active development of the organism — a time of transition from one mode 
 of being to another, in respect of all those important functions by whose 
 due performance the body is nourished and built up. Statistics, 1 em- 
 bracing the largest numbers, prove the dangers of this period, and 
 warrant us in regarding the completion of the process of teething as a 
 fair subject for congratulation. 
 
 The error which has been committed with reference to this matter, 
 not merely by the vulgar, but by members of our own profession also, 
 consists, not in overrating the hazards of the time when changes so 
 important are being accomplished, but in regarding only one of the 
 manifestations — though that, indeed, is the most striking one — of the 
 many important ends which nature is then laboring to bring about. 
 A child in perfect health usually cuts its teeth at a certain time and in 
 a certain order, just as a girl at a certain age presents the various signs 
 of approaching puberty, and at length begins to menstruate. In her 
 case we do not fix our attention solely on the menstrual flux ; nor, if 
 it fail to appear, do we have recourse to the empirical employment of 
 emmenagogue medicines. We examine into the cause of its absence ; 
 try to ascertain whether it depends on the state of .the health in general, 
 or of the uterine system in particular, and regulate accordingly our 
 attempts at cure. The epoch of dentition is to be looked at just in the 
 same way as that in which we regard the epoch of puberty. Constitu- 
 tional disturbance is more common, and serious disease more frequent, 
 at those times than at others ; buf their causes lie deeper than the tooth 
 
 1 See, for. instance, the table of mortality at different months, at p 36 of MM. 
 Quetelet et Smits, Recherches sur la Reproduction et la Mortalite, &c. 8vo., 
 Bruxelles, 1842. 
 
GENERAL CHANGES IN THE SYSTEM DURING TEETHING. 463 
 
 which irritates the gum that it has not yet pierced in the one case, or 
 than the womb which has not yielded the due discharge of blood in the 
 other. Yon might produce hemorrhage from the uterine vessels in the 
 latter instance, or might cut through the gum which inclosed the teeth 
 in the former, with no other effect than that of aggravating the condi- 
 tion of your patient. 
 
 In speaking of the diseases of the nervous and respiratory systems, 
 your attention has on several occasions been drawn to the greater fre- 
 quency of some of those affections just at the time when the process of 
 teething is going on ; and you will have to remark a similar fact with 
 reference to some of the disorders of the abdominal viscera. These 
 maladies, however, are not peculiar to the time of teething, nor, when 
 they occur at that period, do they present symptoms different from those 
 which characterize them in other circumstances, while it often happens 
 that the changes which mark the transition from infancy to childhood 
 are accomplished so quietly as to be attended with no notable disturb- 
 ance of the general health. 
 
 The great changes which Nature is constantly bringing about around 
 us and within us are the result of laws operating silently but unceas- 
 ingly ; and hence it is that in her works we see little of the failure 
 which often disappoints human endeavors, or of the dangers which 
 often attend on their accomplishment. Thus, when Nature's object is 
 to render the child no longer dependent on the mother for its food, she 
 begins to prepare for this long beforehand. The first indication of.it 
 is furnished by the greatly increased activity of the salivary glands ; 
 organs whose function, as I told you in the last lecture, seems for some 
 little time after birth to be wholly in abeyance. If you look into the 
 mouth of a young infant you will be struck by the very small amount 
 of saliva that moistens its surface — a fact that explains in great measure 
 the tendency to dryness which the tongue then presents under the in- 
 fluence of very trivial ailments. About the fourth or fifth month, 
 however, this condition undergoes a marked alteration ; the mouth is 
 now found constantly full of saliva, and the child is continually drivel- 
 ling ; but no other indication appears of the approach of the teeth to 
 the surface, except that the ridge of the gums sometimes becomes 
 broader than it was before. No further change may take place ibr 
 many weeks ; and it is generally near the end of the seventh month, 
 oftener later than earlier, before the first teeth make their appearance. 
 The middle incisors of the lower jaw are generally the first to pierce 
 the gum; next in order appear the middle incisors of the upper jaw; 
 then usually the lateral incisors of the lower, and last of all the lateral 
 of the upper. This, however, is not quite invariable, for sometimes all 
 the upper incisors are cut before the lower lateral incisors make their ap- 
 pearance. The first four molars next succeed, and often without any very 
 definite order as to whether those of the upper or of the lower jaw are 
 first visible, though in the majority of cases the lower molars are the 
 first to appear. The four canine teeth follow; and lastly, the four pos- 
 terior molars — making, in all, the number of twenty deciduous teeth. 
 
 We must not, however, picture to ourselves this process as going on 
 uninterruptedly until completed — a mistake into which parents often 
 
464 GENERAL MANAGEMENT OF TEETHING CHILDREN. 
 
 fal^ whose anxiety respecting their children is consequently excited by 
 observing that, after several teeth have appeared in rapid succession, 
 dentition appears to come to a standstill. Nature has so ordered it 
 that the process of dentition, beginning at the seventh or eighth month, 
 shall not be completed until the twenty-fourth or thirtieth ; and has 
 doubtless done so in some measure with the view of diminishing the 
 risk of constitutional disturbance which might be incurred if the evo- 
 lution of the teeth went on without a pause. A little observation will 
 show you that, while the irruption of the lower central incisors is gen- 
 erally completed in a week, an interval of six weeks or two months 
 often takes place before the upper incisors make their appearance, which 
 then are in general quickly followed by the lateral incisors. A pause 
 of three or four months now frequently occurs before we see the first 
 molar teeth, another of equal length previous to the appearance of the 
 canine teeth, and then another still longer before the last molars are 
 cut. 
 
 Though a perfectly natural process, dentition is yet almost always 
 attended with some degree of suffering. Many of us, no doubt, can 
 remember feeling much pain when we cut our wisdom teeth, and chil- 
 dren probably experience the same kind of annoyance. This, however, 
 is not always the case ; for sometimes we discover that an infant has 
 cut a tooth, who had yet shown no sign of discomfort, nor any indica- 
 tion that dentition was commencing, with the exception of an increased 
 flow of saliva. More frequently, indeed, the mouth becomes hot, and 
 the gums look tumid, tense, and shining, while the exact position of 
 each tooth is marked for some time before its appearance, by the promi- 
 nence of the gum ; or the eruption of the teeth is preceded or accom- 
 panied by a somewhat different condition of the mouth, in which there 
 are much heat, and intense redness of the mucous membrane, an ex- 
 tremely copious flow of thin saliva, and a disposition to the formation 
 of small aphthous ulcerations on the tongue, at the outer surface of the 
 alveolae, or at the duplicature of the lip, though the gums themselves 
 may not be particularly swollen or painful. Either of these states is 
 usually attended with some degree of febrile disturbance, and appar- 
 ently with considerable suffering to the infant, who is constantly fretful 
 and peevish, or cries out occasionally as if in pain. A third morbid 
 condition of the mouth is sometimes seen, which is usually ushered in 
 or attended by very considerable fever and disorder of the chylopoietic 
 viscera. The gums then become extremely hot and swollen, and un- 
 usually tender, especially over some tooth or other in particular, and 
 in that situation we find the gum swollen up into a kind of little tumor. 
 Small unhealthy ulcerations, with a sloughy appearance, often form 
 upon the summit of the gum, and especially around any tooth which 
 has partly pierced through it. To this affection, which is often very 
 painful, and often difficult of cure, the name of Odontitis Infantum has 
 been applied by some continental writers. 
 
 In considering the rules by which you must direct the management 
 of children when teething, it can scarcely be necessary to caution you 
 against regarding all diseases that may come on during dentition as of 
 necessity connected with that process, or with the general changes then 
 
GENERAL MANAGEMENT OF TEETHING CHILDREN. 465 
 
 going on in the organism : still less need I warn you against looking 
 upon all ailments at that time as s) r mptomatic of the local uneasiness 
 which the child suffers in its mouth. Some persons, indeed, act as if 
 they held both these notions to their fullest extent ; and, following up 
 in practice this coarsely mechanical theory, they lance the gums of 
 every child who has not yet cut all its teeth, almost or altogether irre- 
 spective of the nature of the affection from which it suffers. Such a 
 proceeding is nothing better than a piece of barbarous empiricism, 
 which causes the infant much pain, and is useless or mischievous in a 
 dozen instances for one in which it affords relief. Still less is the gum- 
 lancet to be employed, merely with the view of expediting the process 
 that nature is engaged in. The gradual protrusion of the teeth occa- 
 sions the slow absorption of the superjacent gum, and for this process 
 the division of the gum by a scalpel forms at best but a clumsy sub- 
 stitute. 
 
 The circumstances in which the use of the gum-lancet is really indi- 
 cated are comparatively few. You may employ it when a tooth is so 
 nearly through that you can feel sure it will burst the gum in a day 
 or two at latest ; for then, by making an incision through the very 
 thin gum, you may certainly spare the infant much suffering. Or you 
 may lance the gums if they are red, and swollen, arid tense, and in- 
 jected ; but then you scarify them in order that they may bleed, and 
 that their congested vessels may be thus relieved : you do not divide 
 them to let out the imprisoned tooth. In such circumstances it may 
 be necessary to repeat your scarification several times with the same 
 object ; and it is therefore well to explain beforehand to the mother the 
 reasons of your proceeding, lest she should expect to see the tooth at 
 once make its appearance. There are, besides, cases in which the gene- 
 ral constitutional disturbance that often attends dentition continues for 
 several days, or even weeks, while yet the condition of the swollen gum 
 remains unaltered, and the tooth does not seem to approach nearer to 
 the surface. In such a case you may try the experiment of lancing 
 the gums, or you may try it in the case of a child in whom you have 
 already observed that catarrh, or fever, or diarrhoea has been excited 
 by the approach of each tooth to the surface, and has ceased immedi- 
 ately that the tooth has pierced the gum. Lastly, in the cases of sud- 
 den and apparently causeless convulsions, which are occasionally met 
 with in children, you will be justified in lancing the gums if you find 
 that the process of dentition is going on with activity ; but you would 
 do no good if you lanced the gums during one of those periods of re- 
 pose which you will remember interrupt from time to time the evolu- 
 tion of the teeth. You must therefore inquire not merely what teeth 
 the child has cut, but also when the last made their appearance ; and 
 must seek for some evidence either that the process is still going on, or 
 that its activity is once more recommencing, before you w T ould have 
 ground for supposing the source of irritation of the nervous system to 
 be such as your gum-lancet would relieve. 
 
 If the process of teething is going on perfectly naturally no inter- 
 ference, medical or other, is either necessary or proper. The special 
 liability of children to illness at this time must indeed be borne in 
 
 30 
 
466 TREATMENT OF THE AFFECTIONS OF THE MOUTH. 
 
 mind, and care must be taken not to make any alteration in the 
 infant's food while it is actually cutting its teeth, but rather to choose 
 the opportunity of some one of those pauses to which reference has 
 been made, as occurring between the dates of appearance of the succes- 
 sive teeth, for any such change. Should the child at any time appear 
 very feverish some simple febrifuge medicine may be given ; as, for 
 instance, a mixture of the bicarbonate of potash not quite neutralized 
 with citric acid, to each dose of which two or three minims of the 
 tincture of hyoscyamus may be added if the child is very restless and 
 fretful. 1 The diet must be carefully regulated ; and as the heat of the 
 mouth may induce the child to suck too often, in order to obtain the 
 grateful relief of moisture, and by so doing to overload its stomach, 
 water or barley-water should be freely given to it ; and the mother 
 should be cautious not to put it too frequently to the breast. If the 
 child has been weaned still greater care will be required, for it will 
 often be found that it is no longer able to digest its ordinary food, 
 which either is at once rejected by the stomach, or else passes through 
 the intestines undigested. Very thin arrowroot, made with water, 
 with the addition of one-third of milk, will suit in many cases; or you 
 may occasionally substitute for this equal parts of milk and water, 
 thickened by dissolving isinglass in it till its consistence equals that of 
 thick barley-water ; or may employ the white decoction of Sydenham 
 with the addition of one part of milk. If the bowels are disordered, 
 half a grain of Dover's powder night and morning will often restrain 
 their overaction ; while the child may take during the day a mucilagi- 
 nous mixture, 2 containing small doses of the vinum ipecacuanhse and 
 of some alkali, as the bicarbonate of potash or the liquor potassge. 
 The dysuria from which infants sometimes suffer when teething is re- 
 lieved by a similar plan of treatment, with the addition of small doses 
 of castor-oil if the bowels do not act regularly ; while the tepid bath is 
 often extremely serviceable in diminishing that great heat of skin 
 which exists in many of these cases. 
 
 That state of the mouth in which small aphthous ulcers appear upon 
 the tongue and about the alveola? is usually connected with disorder of 
 the digestive organs, to the relief of which our treatment must be 
 chiefly directed. It is seldom necessary to do more locally than to pay 
 great attention to cleanse the mouth every time after the child has 
 sucked or taken food, and afterwards to apply to it a solution of borax, 
 in the manner I pointed out to you at the commencement of this 
 lecture. Now and then the submaxillary glands become swollen and 
 tender while the infant is cutting some of its teeth ; but this condition 
 generally subsides of its own accord. Sometimes, however, the irrita- 
 
 1 See Formula No. 3, p. 53. 
 
 2 (No. 23.) 
 R. Mistura? Acacise, gvj. 
 Liquoris Potassae, n^xxx. 
 Yin. Ipecacuanha?, ii^xxiv. 
 . Syrupi Altheae, giv. 
 Aquas purae, gxiij. M. 
 A dessertspoonful every six hours. For a child from 12 to 18 months old. 
 
CUTANEOUS AFFECTIONS IN TEETHING CHILDREN. 467 
 
 tion extends to some of the absorbent glands beneath the jaw or near 
 its angle; and in scrofulous subjects they occasionally inflame and sup- 
 purate. In such children, too, strumous ophthalmia and otorrhoea are 
 not infrequently excited by dentition. 
 
 That severe form of inflammation of the gums to which the name of 
 Odontitis has been given sometimes occasions great suffering, and may 
 even endanger the child's life, though no instance has come under my 
 own notice in which it proved actually fatal. The gum-lancet will 
 here do no good whatever, its employment would be intensely painful, 
 and that unhealthy ulceration which attends the inflammation of the 
 gums would attack the edges of the cut, and thus aggravate, instead of 
 relieving, the child's sufferings. Local depletion by leeches, however, 
 is extremely useful in such cases. Some writers have suggested that 
 the leeches should be applied to the gum itself; but I have always 
 contented myself with the much easier plan of applying them to the 
 angle of the jaw, and have seldom been disappointed in obtaining very 
 marked relief of all the symptoms. The diet must be most carefully reg- 
 ulated, the state of the bowels attended to, and a mildly antiphlogistic 
 plan of treatment adopted, while the borax lotion may be used locally 
 with advantage. There is, however, one remedy which acts in the various 
 forms of stomatitis almost like a charm, and which proves exceedingly 
 useful even when inflammation of the mouth is associated with the 
 process of teething. This remedy, for the introduction of which into 
 practice in cases of stomatitis the profession is indebted to Dr. Hunt, 1 
 is the chlorate of potash, which may be given dissolved in water and 
 sweetened, in the close of four grains every four hours to a child a year 
 old, with almost a certainty of effecting a cure in the course of four or 
 five days. 
 
 Two or three exceptions, however, to the ordinary course of even 
 severe odontitis have come under my notice, in which the affection of 
 the gums became chronic, and so continued during the whole period of 
 dentition. The gum in these cases was spongy and livid, like that of 
 a person suffering from scurvy, and so swollen that the teeth were al- 
 most hidden by it, while an unhealthy ulceration of its edges sur- 
 rounded each tooth. In one instance this condition lasted during the 
 whole period of cutting the incisor teeth; but the gum got well during 
 the pause which ensued before the molar teeth made their appearance ; 
 while in another scarcely any improvement was apparent until, at the 
 age of two years and four months, the first dentition was completed. 
 The children in both of these cases were weakly, and in one of them 
 an eruption of purpura, which appeared at the age of fifteen months, 
 served to assimilate the characters of the ailment even more closely to 
 scurvy, while the only treatment which was beneficial consisted in the 
 employment of acids, quinine, and wine in small quantities. I refer 
 to these cases on account of their singularity; and their occurrence 
 was, indeed, the more remarkable, since they were met with in the 
 children of persons in the upper ranks of society, and resident in 
 healthy situations in the country. 
 
 1 Medico-Chirurgical Transactions, vol. xxvi, p. 142. 
 
468 INFLAMMATION OF THE MOUTH. 
 
 In conclusion, I may just refer to those eczematous and impetiginous 
 eruptions of the face and scalp which often occur in teething children. 
 The old prejudice which regards diseases of the skin appearing at this 
 time as having in them something salutary, and that consequently it is 
 not desirable to attempt their cure, is not destitute of a certain founda- 
 tion in fact. Instances of the sudden disappearance of eruptions on 
 the scalp during the period of dentition being followed by serious im- 
 pairment of the general health, by convulsions, or by other signs of 
 mischief in the brain, are far from uncommon. Their removal, there- 
 fore, must never be attempted, except by the gentlest means, while 
 every threatening of the supervention of cerebral congestion, or of 
 more serious disease of the brain, must be most closely watched for and 
 most vigorously combated. Sometimes too it will be found that, when- 
 ever the cutaneous affection has made a certain advance towards cure, 
 the signs of other disease invariably appear. In such a case it is wiser 
 to content yourselves with keeping the local ailment in check, rather 
 than, by persevering in the attempt to cure it, to endanger in far more 
 serious respects the welfare of the child. 
 
 LECTURE XXXIII. 
 
 Inflammation of the Mouth, or Stomatitis. — Its three varieties. 
 
 Follicular stomatitis. — Often a secondary affection— Most frequent before dentition 
 is completed — Its symptoms — Character of the aphthae, or ulcerations of the 
 mouth — Not a serious disorder — Its treatment. 
 
 Ulcerative stomatitis. — Principally affects the gums — Its course usually chronic — ■ 
 Has very little tendency to degenerate into gangrene — Its treatment — The 
 chlorate of potash almost a specific for it. 
 
 Gangrenous stomatitis. — Extremely rare, but very fatal — Essential differences be- 
 tween it and the other forms of stomatitis — Dependent on alterations of the 
 blood, such as occur in fevers — Its mode of commencement, symptoms, and 
 course — State of the gangrenous parts on dissection. 
 
 Treatment — Importance of efficient cauterization — What caustics are to be used, 
 and how they are to be applied. 
 
 The disease does not depend on the administration of mercury. 
 
 Cynanche Tonsillaris. — Unusual in young children — Its symptoms not peculiar. 
 
 Hypertrophy of the Tonsils. — Its frequency and importance in childhood— Its 
 symptoms — Extreme dyspnoea sometimes produced D3' it — Modifications it pro- 
 duces in form of mouth and nose — Deformity of chest resulting from it, how 
 produced — Treatment — Erequent necessity for excision of tonsils. 
 
 Eetro-pharyngeal Abscess. — An affection of great rarity, not confined to child- 
 hood — Sometimes idiopathic, sometimes succeeds to fevers — Its symptoms — 
 Illustrative cases— Occasional difficulty in its diagnosis — Treatment. 
 
 Cynanche Parotidea. — Most common near period of puberty— Epidemic and 
 contagious — Its symptoms — Metastasis of inflammation rare — Treatment. 
 
 Amoxg the local accidents which complicate dentition we noticed a 
 condition of the mucous membrane of the mouth, which, though not 
 
FOLLICULAR STOMATITIS. 469 
 
 attended by serious danger, is often the source of much suffering to the 
 patient. 
 
 Inflammation of the mouth, however, is an occurrence by no means 
 confined to the period of teething, but it comes on in children of all 
 ages, assumes very different forms, and leads to very different results 
 in one case from those which characterize it in another. The mucous 
 follicles of the mouth are the chief seat of the disease in one case, the 
 substance of the gum in another, that of the cheek in a third. In the 
 first the affection issues in the formation of several small ulcers, which 
 heal eventually of their own accord ; in the second an unhealthy pro- 
 cess of ulceration destroys the gums and denudes the teeth, but it is 
 tardy in its advance, and tends to a spontaneous cure ; while in the 
 last mortification involves all the tissues of the cheek, and spreads with 
 a rapidity which remedies generally fail to check, and which is arrested 
 at last only by the patient's death. 
 
 Each of these varieties of stomatitis requires from us more than a 
 passing notice. 
 
 The first — the follicular stomatitis of some writers, the aphthous stom- 
 atitis of others — is met with either as a concomitant or sequela of 
 measles, or as an idiopathic affection. In the former case it depends 
 on the extension to the mouth of a state of inflammation similar to that 
 which gives rise to the eruption on the skin ; in the latter it is often 
 associated with obvious gastric or intestinal disorder. Under either of 
 these conditions it is rare after five years of age ; and though it often 
 depends on causes quite independent of dentition, yet from the period 
 when teething has commenced, to the end of the third year, is the time 
 of its most common occurrence ; while in early infancy aphthce are un- 
 usual, though genuine thrush, such as I have described in the last 
 lecture, is a frequent ailment. When it constitutes an idiopathic affec- 
 tion, more or less fever and restlessness, loss of appetite, an unhealthy 
 state of the evacuations, and frequently a relaxed condition of the 
 bowels, precede the local ailment for several days. Attention is gener- 
 ally called to the state of the mouth by the child being observed to 
 suck, or to take food, with manifest pain and difficulty ; while at the 
 same time the secretion of saliva is greatly increased, and the sub- 
 maxillary glands are swollen and tender. The mouth is hot, its 
 mucous membrane generally of a livid red, while a coat of thin mucus 
 covers the centre of the tongue. On the surface of the tongue, espe- 
 cially near its tip ; on the inside of the lips, particularly on the lower 
 lip and about its fold ; on the inside of the cheek, near the angles of 
 the mouth ; and less often in other situations also, may be seen several 
 small isolated transparent vesicles, or the ulcers which, after bursting, 
 they leave behind. The ulcers are small, of a rounded or oval form, 
 not very deep, but having sharply cut edges ; and their surface is 
 covered by a yellowish-white, firmly adherent slough. When attention 
 is first directed to the mouth several of these small ulcerations usually 
 exist, for the vesicular stage of the affection appears to be generally 
 very short, while the ulcers are indolent, and sometimes continue for 
 many days without showing any disposition to heal or to increase in 
 size. The eruption of a single crop of vesicles, and the change of those 
 
470 FOLLICULAR STOMATITIS. 
 
 vesicles into minute ulcerations, that heal in the course of time, do not 
 complete the history of this affection ; for while the mucous membrane 
 in the situation of some of these ulcers at length resumes its natural 
 condition, other vesicles appear, which again degenerate into little 
 ulcers, and thus keep up the ailment, sometimes for weeks together. 
 In some cases, not above five or six of these little ulcers exist at once, 
 or they may even be less numerous, while it is very seldom that more 
 than fifteen or twenty of them are observable at one time. By the 
 successive appearance of fresh ulcerations, and the coalescence of seve- 
 ral, au ulcerated strip of considerable extent sometimes forms, especially 
 at the tip of the tongue, or on the lower lip. When the ulcers are 
 healing, no change in their aspect is observable, and they continue to 
 the last covered by the same yellow slough, but by degrees they dimin- 
 ish in size : and seldom or never is any cicatrix observable in the 
 situation which they occupied. In some cases the affection is compli- 
 cated with a herpetic eruption about the edges of the lips, the vesicles 
 of which degenerate into ulcerations similar to those observed in the 
 interior of the mouth, and by their soreness add very much to the 
 sufferings of the patient. 
 
 Even though no remedies should be employed, this affection shows 
 no tendency to rapid increase ; it is but very seldom that any crypto- 
 gamic formation, such as characterizes thrush, takes place on the sur- 
 face of the ulcerations, or that any tendency appears to the formation 
 of false membrane in the mouth ; while even when most severe it is 
 unattended by any disposition to gangrene. It is sometimes a source 
 of much annoyance to the child, but need never excite any serious 
 solicitude, except when it occurs as a sequela of measles. In that case, 
 however, as was observed in a former lecture, 1 it occasionally becomes 
 associated with diphtheritic deposits on the fauces, and with ulcerative 
 inflammation of the larynx, though our anxiety is then excited less by 
 the affection itself than by its concomitants. 
 
 In the treatment of this affection our attention must be chiefly 
 directed to correcting the gastric and intestinal disorder by which it is 
 accompanied; and when this object has been attained the local ailment 
 in many cases speedily subsides. The borax lotion mentioned in the 
 last lecture is one of the best local applications that can be used ; but if 
 the ulcerations show no tendency to heal, it may be desirable to touch 
 them once a day with a solution of five grains of nitrate of silver in an 
 ounce of distilled water. 
 
 Between the mild affection we have just been studying, and the 
 second form of stomatitis, to the examination of which we are now about 
 to pass, there are comparatively few points of resemblance. This 
 variety of the disease attacks the gums, and sometimes destroys them 
 extensively, unlike the former ailment, which even though it should 
 continue long, seldom occasions any actual loss of substance. The 
 process, however, by which the destruction of the gums is accomplished 
 is one of ulceration, not of mortification — a fact which it is of impor- 
 tance to bear in mind, lest we should fall into the error of some ob- 
 
 1 Lecture .XXV, p. 368. 
 
ULCERATIVE STOMATITIS. 471 
 
 servers, who have confounded together, under the name of Cancrum 
 Oris, both this affection and that more formidable malady, true gan- 
 grene of the mouth. There can be no doubt, indeed, but that in a few 
 rare instances gangrene has supervened on the long-standing ulceration ; 
 though I believe with M. Trousseau that this never occurs except when 
 the atfection has already extended to the adjacent surface of the cheek. 
 The affinities of this disease are unquestionably with diphtheria rather 
 than with gangrene, though I am not sure that this affinity amounts to 
 actual identity. 1 It is characterized by ulceration as much as by the 
 deposit of false membrane on the ulcerated surface ; it is invariably 
 unaccompanied by any of those signs of constitutional disorder which 
 are so conspicuous in pharyngeal diphtheria, and to the best of my 
 knowledge no increase of its prevalence has been observed to be associ- 
 ated with the more frequent occurrence of diphtheria. But whether 
 the two diseases are the same or only similar, it will probably be con- 
 venient to express the resemblance by the term Diphtheritic or Diph- 
 theroid Stomatitis ; though I am not prepared at present to discard its 
 old appellations of Noma 2 and of Ulcerative Stomatitis, by which it 
 used formerly to be designated. In any case, however, it will be con- 
 venient to restrict the term Cancrum Oris to Gangrenous Stomatitis, or 
 gangrene of the mouth. 
 
 It is by no means a constant occurrence for any special derangement 
 of the general health to precede the attack of ulcerative stomatitis, though 
 the children who are affected by it are seldom robust, and in many in- 
 stances are such as have suffered from deficient food, or from a damp 
 and unhealthv lodging, or from both. In children who are not verv 
 carefully tended, the ulceration has sometimes made considerable prog- 
 ress before its existence is suspected, and the profuse flow of the saliva, 
 or the offensive smell of the breath, is the symptom which at length 
 excites attention. Coupled with this, too, there is often considerable 
 swelling of the upper lip, and the submaxillary glands are frequently 
 swollen aud painful. On opening the mouth, the gums are seen to be 
 red, and swollen and spongy, and their edge is covered with a dirty 
 white or grayish pultaceous deposit, on removing which their surface is 
 exposed, raw and bleeding. At first, only the front of the gum is thus 
 affected ; but as the disease advances, it creeps round between the teeth 
 to their posterior surface, and then, destroying the gum both in front 
 and behind them, leaves them denuded, and very loose in their sockets; 
 but it is not often that they actually fall out. The gums of the incisor 
 teeth are usually first affected : those of the lower jaw T more frequently 
 and more extensively than those of the upper ; but if the disease is 
 severe, the gums at the side of the mouth become likewise involved, 
 though it is seldom that the two sides suffer equally. Sometimes 
 aphthous ulcers, like those of follicular stomatitis, are seen on the inside 
 of the mouth in connection with this state of the gums; but oftener it 
 exists alone. On those parts of the lips and cheeks, however, which 
 
 1 See, with reference to this question, Trousseau, Clinique Medicale, 2d ed., vol. i, 
 p. 383. 
 
 2 From vojuAi, used by Hippocrates with reference to putrid and eroding ulcers. 
 See Foesius, (Economia Hippocratis, sub voce. 
 
472 SYMPTOMS OF ULCERATIVE STOMATITIS. 
 
 are opposite to, and consequently in contact with, the ulcerated gums, 
 irregular ulcerations form, which are covered with a pultaceous pseudo- 
 membranous deposit, similar to that which exists on the gums them- 
 selves. Sometimes, too, deposits of false membrane take place on other 
 parts of the inside of the mouth, the surface beneath being red, spongy, 
 and bleeding, though not distinctly' ulcerated. If the disease is severe 
 and long-continued, the tongue assumes a sodden appearance, and is 
 indented by the teeth ; and the cheek, on one or other side, is somewhat 
 swollen, while the saliva, though rather less abundantly secreted than 
 at the commencement of the affection, continues horribly fetid, and 
 often streaked with blood, the gums themselves bleeding on the slightest 
 touch. But even if left alone, the affection usually subsides in the 
 course of time, though it may continue almost stationary for days or 
 weeks together, and this notwithstanding that the general health is 
 tolerably good. The termination of this unhealthy ulceration by gan- 
 grene is so rare, that though a very large number of cases of ulcerative 
 stomatitis have come under my notice, I have seen only one instance 
 in which it was succeeded by true gangrene of the mouth. When re- 
 covery has commenced, the disease ceases to spread ; the drivelling of 
 fetid saliva diminishes ; the white pultaceous deposit on the gums, or 
 on the ulcerations of the cheek or lips, becomes less abundant; the 
 ulcers themselves grow smaller ; and, finally, the gums become firm, 
 and their edges of a bright red, though still for a long time showing 
 a disposition to become once more the seat of the ulcerative process, and 
 continuing for a still longer time to cover the teeth but very imper- 
 fectly. 
 
 Various internal remedies and local applications have been at differ- 
 ent times recommended for the eure of this affection. Tonics have been 
 much employed, and the supposed analogy between this state of the 
 gums and that which exists in scurvy, has led practitioners to give the 
 preference to remedies reputed to be possessed of antiscorbutic proper- 
 ties. Lotions of alum, or the burnt alum in substance, or the chloride 
 of lime in powder, have all been used locally with more or less benefit. 
 It was my custom also to prescribe these remedies in cases of ulcerative 
 stomatitis ; but since I became acquainted with the virtues of the chlo- 
 rate of potash, I have learned to rely upon it almost exclusively. It ap- 
 pears, indeed, almost to deserve the name of a specific in this affection ; 
 for a marked improvement seldom fails to be observed in the patient's 
 condition after it has been administered for two or three days ; and in a 
 week or ten days the cure is generally complete. Three grains every 
 four hours, dissolved in water, and sweetened, is a sufficient dose for a 
 child three years old ; and five grains every four hours appear to answer 
 as w^ell as a larger dose for a child of eight or nine. If the bowels are 
 constipated, a purgative should be previously administered ; but there 
 seems to be no form, nor any stage of the affection, in which the chlo- 
 rate of potash is not useful. The diet should be light but nutritious, 
 and quinine or other tonics are sometimes serviceable if the child's health 
 should continue feeble after the local malady has been cured. 
 
 Ulcerative stomatitis is an affection of such frequent occurrence, that 
 many instance of it come under my notice every year, especially during 
 
GANGRENOUS STOMATITIS. 473 
 
 the damp autumnal months ; while it is attended with so little danger 
 that the only ease which I have known to prove fatal was one in which 
 gangrene of the mouth supervened upon it. Gangrenous stomatitis, on 
 the other hand, is a disease so rare, that I have only ten times had the 
 opportunity of witnessing it; but so fatal, that in eight out of those ten 
 cases the patients died. The larger experience of other observers shows 
 an almost equally unfavorable result, since twenty out of twenty-one 
 cases that came under the notice of MM. Billiet and Barthez had a fatal 
 termination ; and a recent French writer, 1 who has collected from dif- 
 ferent sources 239 cases, which did not all occur in children, states that 
 176 of the number, or 75 per cent., terminated fatally. The formidable 
 nature of the disease requires that we study it more closely than con- 
 sidering the rarity of its occurrence would otherwise be necessary; and 
 it is the more important to do so, in order that we may avoid the not 
 very uncommon error which confounds this dangerous affection with 
 that comparatively trifling ailment — ulcerative stomatitis. 
 
 The constitutional disturbance which often precedes the other two 
 affections of the mouth that' we have just been studying, was seen to be 
 generally of a trivial nature, and never so severe as to excite serious 
 anxiety. Gangrene of the mouth, on the other hand, seldom comes on, 
 except in children whose health has been already much impaired by 
 previous disease, and especially by such diseases as are connected with 
 important changes in the circulating fluid. In strict propriety, indeed, 
 I doubt whether we ou^ht not to remove both this and those other 
 allied affections, in which the skin or the genital organs become the 
 seat of gangrene, from among the class of local ailments, and refer them 
 to the category of blood diseases. Of twenty-nine cases of gangrene of 
 the mouth, which MM. Rilliet and Barthez either observed themselves, 
 or of which they found mention in the writings of other physicians, 
 only one appeared to be an instance of the disease in an idiopathic form ; 
 while in twelve cases it followed an attack of measles. Of the ten cases 
 which I have observed, and five of which I examined after death, two 
 succeeded to typhoid fever, four to measles ; one, which eventually re- 
 covered after the application of strong acid to the slough, and with the 
 help of all the comforts of the hospital, appeared to have been induced 
 by want and an unhealthy dwelling ; one came on in a child whose 
 health had been completely broken down by ague, one supervened in a 
 tuberculous child, who had been affected for many weeks with ulcera- 
 tive stomatitis in a severe form ; and in the tenth instance the active 
 employment of mercury for the cure of acute encephalitis produced pro- 
 fuse salivation, which was followed by gangrene. Though not confined 
 to any one period of childhood, gangrene of the mouth is more frequent 
 between the ages of two and five than either earlier or later. Of the 10 
 cases that came under my own observation, 2 were in children between 
 two and three years old, 2 in children aged three, 4 in children 
 between four and five, 1 at six and a quarter, and 1 at eight years of 
 age. Of the 29 cases mentioned by MM. Rilliet and Barthez, 19 
 occurred between two and five ; 10 between six and twelve ; and M. 
 
 1 Tourdes, Du Noma, &c, 4to. These de Strasbourg, 1848. 
 
474 GANGRENOUS STOMATITIS. 
 
 Tourdes' 1 comparison of 102 cases between one and a half and twelve 
 years, likewise yields the greatest number during the third and fourth 
 years. 
 
 Although all the tissues of the cheek become involved in the course 
 of this affection, yet difference of opinion has existed with reference to 
 the part in which it commences ; some observers conceiving that it 
 usually begins in the substance of the cheek, while others regard the 
 mucous membrane as being the part which is invariably the first 
 attacked. So far as my own observation enables me to judge, I am dis- 
 posed to regard this latter view, which is that of MM. Billiet and 
 Barthez, and of M. Baron, and which is moreover supported by the 
 minute researches of Professor Albers, 2 of Bonn, as generally correct. 
 At the same time, however, I must admit that I have had but few 
 opportunities of personally investigating this subject, while a very com- 
 petent observer, Dr. Loschner, 3 physician to the Children's Hospital 
 at Prague, while he admits the occasional commencement of the affec- 
 tion in either way, believes the former to be the more common. Ac- 
 cording to his observations, the appearance of a swelling, having a hard 
 central spot or nucleus, surrounded by tense, elastic, but less firm 
 tissue, gradually passing off into the texture of the adjacent parts, is 
 the first step in the process ; ulceration of the mucous membrane being 
 secondary to this peculiar infiltration of the cellular tissue of the cheek. 
 It is, indeed, very probable that the gangrene sometimes begins in the 
 one way and sometimes in the other ; while any dispute concerning it 
 loses almost all its practical moment, if we regard this and other forms 
 of gangrene as resulting from merely accidental differences in the mode 
 in which the graver deterioration of the circulating fluid manifests 
 itself. 
 
 The early stages of the affection are attended by scarcely any suffer- 
 ing, owing to which, as well as to the circumstance that the children 
 in whom it supervenes are almost always laboring under some other 
 disease, or in the course of convalescence from it, it is probably due 
 that the malady is often not discovered until after it has made consid- 
 erable progress. There may for a day or two have been an unusual 
 fetor of the breath, and a profuse secretion of offensive saliva ; but the 
 appearance of swelling of the cheek is frequently the first symptom 
 that leads to a careful examination of the state of the mouth. The 
 characters of the swelling of the cheek are almost pathognomonic of 
 gangrene of the mouth. It is not a mere puffiness of the integument, 
 unaccompanied by any change of its color, such as is sometimes ob- 
 served in ulcerative stomatitis ; but the cheek is tense, and red, and 
 shining — it looks as if its surface had been besmeared with oil, and in 
 the centre of the swollen part there is generally a spot of a brighter 
 red than that around. The cheek feels hard, and is often so unyield- 
 ing that the mouth cannot be opened wide enough to get a good view 
 
 i Op. cit., p. 31. 
 
 2 Archiv. f. physiol. Heilkunde, ix, 7-8, 1850 ; and Schmidt's Jahrb., 1851, No. 2, 
 p. 195. 
 
 3 Der Brand im Kindesalter, in the Vierteljahrsschrift fur die prakt. Heilkunde, 
 vol xv, p. 58. 
 
ITS SYMPTOMS. 475 
 
 of its interior. The disease is almost always limited to one side, and 
 generally to one cheek. Sometimes, however, it extends to the lower 
 lip ; and occasionally it begins in that situation. The upper lip is now 
 and then reached, by the progress of the disease, but is never its pri- 
 mary seat. Whatever be the situation of the external swelling, there 
 will generally be found within the mouth, at a point corresponding to 
 the bright red central spot, a deep excavated ulcer, with irregular jagged 
 edges, and a surface covered by a dark-brown shreddy slough. The 
 gums opposite to the ulcer are of a dark color, covered with the putri- 
 lage from its surface, and in part destroyed, leaving the teeth loose, 
 and the alveola? denuded. Sometimes, especially if the disease is fur- 
 ther advanced, no single spot of ulceration is recognizable, but the 
 wmole inside of the cheek is occupied by a dirty putrilage, in the midst 
 of which large shreds of dead mucous membrane hang down. As the 
 disease extends within the cheek, a similar process of destruction goes 
 on upon the gum ; the loosened teeth drop out one by one, and the 
 alveolar process of the jaw loses its vitality for a more or less consid- 
 erable extent, while sometimes a portion of the ramus of the jaw itself 
 becomes necrosed. The saliva continues to be secreted profusely, but 
 shows, by the changes which takes place in its characters, the progress 
 of the disease. At first, though remarkable for its fetor, it is other- 
 wise unaltered ; but afterwards it loses its transparency, and receives 
 from the putrefying tissues over which it passes, a dirty greenish or 
 brownish color, and at the same time acquires a still more repulsive 
 odor. 
 
 While the gangrene is thus going on inside the mouth, changes no 
 less remarkable are taking place on the exterior of the face. The red- 
 ness and swelling of the cheek extend, and the deep red central spot 
 grows larger. A black point appears in its midst : at first it is but a 
 speck, but it increases rapidly, still retaining a circular form ; it attains 
 the bigness of a sixpence, a shilling, a half-crown, or even a larger size. 
 A ring of intense redness now 7 encircles it, the gangrene ceases to extend, 
 and the slough begins to separate. Death often takes place before the 
 detachment of the eschar is complete, and it is fortunate when it does 
 so, for sloughing usually commences in the parts left behind. The in- 
 terior of the mouth is now exposed ; its mucous membrane and the 
 substance of the cheek hang down in shreds from amidst a blackening 
 mass, and form one of the most loathsome spectacles that can be con- 
 ceived; while the horrible stench which the mortified parts spread 
 around, makes the task of watching the poor child as repulsive as it is 
 distressing. 
 
 Happily it is not often that acute suffering of the child occurs to 
 heighten the distress of the sad scene. Usually the patient has but little 
 pain from the very first, but is generally more drowsy than natural, 
 though sometimes the nights are restless ; and in those cases in which 
 gangrene of the mouth supervened in the course of typhoid fever, the 
 delirium which existed before continued unmodified. The pulse grows 
 feebler as the disease advances ; but cheerfulness is often undisturbed, 
 and the child will sit up in bed playing as happily with its toys as though 
 it ailed nothing, long after the appearance of the black eschar on the 
 
476 POST-MORTEM APPEARANCES IN GANGRENOUS STOMATITIS. 
 
 cheek has shown the case to be all but hopeless ; or even after the slough 
 has become detached, and the cavity of the mouth exposed. The desire 
 for food, too, often continues unabated till within a few hours of the 
 child's death, which generally takes place quietly, though sometimes it 
 is preceded by convulsions. 
 
 Since gangrene of the mouth occurs in the course of a great variety 
 of diseases, the only morbid appearances characteristic of it are those 
 which result from the local mischief. On three occasions I dissected 
 the gangrenous parts very carefully, and the alterations which presented 
 themselves to my notice were precisely the same as have been described 
 by MM. Rilliet and Barthez. The absorbent glands, both superficial 
 and deepseated, on the affected side, are enlarged, and the cellular tissue 
 of the cheek is infiltrated with serum, which is more abundant the 
 nearer one approaches to the slough. In the substance of the eschar 
 the distinction of parts is no longer easy, but w T ith care the vessels and 
 nerves may still be traced ; and the reason why fatal hemorrhage so 
 seldom cuts short the life of patients suffering from this affection is at 
 once explained by the clot which plugs up the vessels for some distance 
 on either side of the gangrenous mass. On one occasion I found the 
 root of the tongue, the tonsils, pharynx, both surfaces of the epiglottis, 
 and about an inch of the oesophagus, completely coated with a moderately 
 firm, yellow false membrane about a line in thickness, easily detached 
 and leaving the subjacent mucous membrane only a little redder than 
 natural. A few patches of a similar deposit existed in the larynx, but 
 not continuous with that in the pharynx. In this case, great difficulty 
 of deglutition had existed for three days before the death of the child. 
 The association of diphtheria with gangrene of the mouth is, indeed, an 
 accidental complication, and not one of frequent occurrence, but pneu- 
 monia is met with in so large a number of instances, that it must be 
 looked on as more than an accidental occurrence, and probably as a 
 result of the general deterioration of the circulating fluid to which the 
 gangrene itself is clue, rather than as owing to any cause acting especially 
 on the lungs. It existed in 19 out of 21 cases, which formed the basis 
 of MM. Rilliet and Barthez's 1 observations, and in 4 out of the 5 in- 
 stances in which I was able to examine the bodies after death. In the 
 5th case, that of a girl, three years old, who died on the 10th day of can- 
 crum oris, and on the 23d from the appearance of the rash of measles, 
 though there was no pneumonia, yet the evidences of the relation of the 
 affection to the class of blood diseases were most remarkable. The 
 gangrene had been limited to the right side of the face ; but in addition 
 to a thrombus in the upper part of the right internal jugular vein, a 
 large black unchanged clot occupied its lower part ; and thrombus oc- 
 cupied the left internal jugular at its entrance into the subclavian vein. 
 Both lungs were crepitant, but both were studded with a large number 
 of small resistant nodules, for the most part of the size of a small pea, 
 some of which were solidary, others aggregated, and were especially 
 numerous in the dependent part of the lower lobe, and in its free anterior 
 margin. On section, these nodules were found to be formed of puri- 
 
 1 Maladies des Enfans, vol. ii, p. '379. 
 
TREATMENT OF GANGRENOUS STOMATITIS. 477 
 
 form fluid, contained in the parenchyma of the lung, the tissue of which 
 around them was neither inflamed nor condensed. . 
 
 The arrest of the sloughing is the one point to which in the treatment 
 of this affection the attention of all practitioners has been directed. The 
 small amount of success which has attended their efforts is partly at- 
 tributable to the circumstance that the affection has frequently been 
 overlooked until it has already made considerable progress ; in part also 
 to the fact that, when recognized, the local remedies employed in order 
 to check the gangrene have either been too mild, or have been applied 
 with too timorous a hand. Unfortunately, too, there is considerable 
 difficulty in applying any caustic effectually to the interior of the mouth ; 
 for the tense and swollen condition of the cheek prevents our obtaining 
 easy access to the gangrenous parts. The use of chloroform, however, 
 happily removes that other great difficulty which the severe pain atten- 
 dant on the cauterization formerly opposed to its effectual performance. 
 Ineffectual cauterization, indeed, is useless, or worse than useless ; and 
 though every endeavor should be made to prevent the needless destruc- 
 tion of healthy parts, yet of the two evils, that of doing too much is un- 
 questionably less than that of doing too little. Of this, indeed, we need 
 have the less fear, since the power of repair after the gangrene has once 
 been arrested is most remarkable ; and I saw some years since, in a case 
 which was under the care of my colleague, Mr. Holmes, a perforation 
 of the cheek near the angle of the lower lip contract from the size of a 
 florin to a mere pinhole aperture, which at length closed, leaving a com- 
 paratively small amount of puckering of the adjacent parts, and certainly 
 none of that frightful deformity which one would have fancied to be 
 inevitable. It is of importance, moreover, not only that the cauteriza- 
 tion should be done effectually, but also that it should be practiced early. 
 M. Baron, indeed, speaks of incising the slough in the cheek, and then 
 applying the actual cautery to the part; but I am not aware of any in- 
 stance in which this suggestion has been acted on with a good result. 
 When once the mortification has extended through the substance of the 
 cheek, the chances of arresting its progress must be very few. As the 
 sloughing advances from within outwards, it is to the interior of the 
 mouth that our remedies must be applied ; and since the advance of 
 the disease is too rapid to allow of our trying mild means at first, and 
 afterwards resorting, if necessary, to such as are more powerful, we 
 must employ an agent sufficiently energetic at once to arrest its prog- 
 ress. Various caustics have been recommended for this purpose, but 
 none appear to be so well fitted to accomplish it as the strong hydro- 
 chloric or nitric acid. I am accustomed to employ the latter, applying 
 it by means of a bit of sponge, or of soft lint or tow, fastened to a quill ; 
 while I endeavor, by means of a spoon or of a spatula, to guard the 
 tongue, and other healthy parts, as far as possible from the action of 
 the acid. In one of the cases that I saw recover, the arrest of the 
 disease appeared to be entirely owing to this agent; and though the 
 alveolar processes of the left side of the lower jaw, from the first molar 
 tooth backwards, died, and exfoliated, apparently from having been 
 destroyed by the acid, yet it must be owned that life was cheaply 
 saved even at that cost. Some increase of the swelling of the cheek 
 
478 MERCURY SELDOM CAUSES GANGRENE OF THE MOUTH. 
 
 almost invariably follows the application of this agent — a circumstance 
 which may at first occasion unfounded apprehension lest the disease be 
 worse. Twelve hours, however, must not be allowed to elapse without 
 the mouth being carefully examined, in order to ascertain whether the 
 disease has really been checked, or whether there is any appearance of 
 mortification in the parts beyond the yellow eschar left by the first ap- 
 plication of the acid. The cauterization may now be repeated, if it 
 appears necessary, and even though the disease had seemed completely 
 checked ; yet reliance must not be placed on the improvement continuing, 
 but the mouth must be examined every twelve hours, for fear the morti- 
 fication should spread unobserved. During the whole progress of the 
 case the mouth must be syringed frequently with warm water, or with 
 camomile tea mixed with a small quantity of the solution of chloride of 
 lime, in order to free it from the putrid matters that collect within it, 
 and to diminish as much as possible their offensive odor. Should the 
 case go on well, the frequent repetition of the strong acid will be un- 
 necessary ; but the surface may still require its application in a diluted 
 form, or it may suffice to syringe the mouth frequently with a chloride 
 of lime or carbolic acid lotion, or to apply the chloride in powder once 
 or twice a day, according to the suggestion of MM. Rilliet and Barthez. 
 In all of the cases of this affection that have come of late years under 
 my notice, I have likewise employed the chlorate of potash internally, 
 but it has not appeared to exert much influence over it ; and valuable 
 though the remedy is in ulcerative stomatitis, yet I should scarcely feel 
 disposed to rely upon it, to the exclusion of local treatment, in true 
 gangrene of the mouth. Two cases, however, of cancrum oris succeed- 
 ing to fever in children of twelve and thirteen years of age, were treated 
 with most complete success by Dr. Burrows, in St. Bartholomew's Hos- 
 pital, without the employment of any other local measures than a chlo- 
 ride of soda gargle, but with good diet, wine and chlorate of potash, 
 in doses of ten grains every four hours. 
 
 During the whole course of treatment you have another indication 
 to fulfil, namely, to support your patient's strength by nutritious diet, 
 and by the employment of wine and other stimulants, and by the admin- 
 istration of quinine, or of the extract or tincture of bark, or of what- 
 ever form of tonic may seem best suited to the peculiarities of the case. 
 
 In conclusion, let me remind you that during the whole progress of 
 the case your prognosis must be regulated by the state of the local 
 disease, rather than by the urgency of the general symptoms. So long 
 as the sloughing is unchecked the affection is tending rapidly to a fatal 
 issue, and this even though the pulse is not very feeble, though the 
 appetite is good, and the child still retains its cheerfulness. 
 
 It might seem to you to be an omission on my part, if I left the 
 subject of inflammation and gangrene of the mouth, without some notice 
 of the supposed influence of mercury in its production. There can be no 
 doubt but that this preparation, even when given in small doses, has in 
 a few instances produced severe ptyalism, inflammation of the mouth, 
 loss of the teeth, and necrosis, more or less extensive, of the lower jaw. 
 In some cases, too, the inflammation has terminated in gangrene of the 
 cheek, which has presented many of the characters that we have just 
 
HYPERTROPHY OF THE TONSILS. 479 
 
 been noticing; and in such circumstances inquests have sometimes been 
 held, and blame has been attached to the medical attendant for alleged 
 want of caution in the administration of so powerful an agent as mer- 
 curv. Now, although mercury should never be given without neces- 
 sity, nor its administration continued without watching its effects most 
 carefully, yet I cannot but regard the supervention of gangrene of the 
 mouth during its use as merely an accidental coincidence, or else as the 
 result of some peculiar idiosyncrasy of the patient, such as has been 
 observed in the adult as well as in the child. Nearly 60,000 children, 
 of all ages, have come under my care, during my connection with the 
 Children's Infirmary and the Children's Hospital, and I have admin- 
 istered mercury to any of them who seemed to require it, but hardly 
 ever saw salivation follow' its employment before the completion of the 
 first dentition ; and never but once observed that medicine, at any age, 
 to produce an affection of the mouth sufficiently serious to cause me a 
 moment's anxiety. In that one instance, however, the death of the 
 child, a boy aged four years and a half, was, I think, due to the em- 
 ployment of mercury. 
 
 An inconvenience — I do not know that it deserves a more serious 
 designation — inseparable from the arrangement of subjects which I 
 have adopted, is that we pass at once from diseases that are very haz- 
 ardous, to others which are of a comparatively trifling character, or are 
 the sources of discomfort rather than of severe suffering. Of this some 
 of the ailments which remain for our consideration to-day are no inapt 
 illustrations. 
 
 Inflammation of the soft palate, tonsils, and fauces, constituting 
 Ci/nanehe Tonsillaris, is not strictly limited to any age, nor attended 
 with any special symptoms when it occurs in the child. It is, however, 
 comparatively rare under twelve years of age, and is almost always less 
 severe than at or after puberty, while I scarcely remember to have met 
 with it under five years of age — a circumstance which attaches special 
 importance to sore throat in young children, since it will usually be 
 found to betoken the approach of scarlet fever or of diphtheria rather 
 than the existence of simple inflammation of the tonsils. 
 
 But, though acute inflammation of the tonsils is unusual in early 
 childhood, a sort of chronic inflammation of those glands, which leads 
 to their very considerable enlargement, is far from uncommon; and 
 this hypertrophy of the tonsils, which, in the adult, is little more than 
 an inconvenience, is, in the child, not infrequently the cause of more 
 serious evils. It is seldom traceable to any acute attack of angina, but 
 usually comes on in children who are out of health, feeble, and strumous ; 
 or takes place slowly during the latter stages of the first dentition, the 
 irritation of which appears in some cases to be its only exciting cause. 
 
 Unless accidentally discovered, the enlargement of the tonsils has usu- 
 ally become very considerable before it attracts much notice, and hence 
 it is comparatively seldom observed in children under three years old, 
 though M. Robert, a French surgeon, 1 who has written a very excellent 
 paper on the subject, speaks of having noticed it as early as the siith month. 
 
 1 In the Bulletin General de Therapeutique, May and July, 1843. 
 
480 HYPERTROPHY OF THE TONSILS. 
 
 One of the first symptoms that attract attention is the habitually 
 loud snoring of the child during sleep, owing to the enlarged tonsils 
 pressing up the velum, and thus obstructing the passage of air through 
 the posterior nares, while at the same time the voice becomes thick ; 
 and both of these symptoms are remarkably aggravated during, and 
 for some time after, even slight attacks of catarrh. An amount of 
 enlargement of the tonsils sufficient to cause these symptoms is by no 
 means uncommon, and if it does not exceed this extent the inconveni- 
 ence to which it gives rise will in general disappear altogether with 
 the development of the mouth and vocal organs at the period of puberty. 
 Often, however, it is more considerable, and then the tonsils produce a 
 degree of deafness, partly by actual pressure on the Eustachian tubes, 
 partly by the state of habitual congestion which they maintain in the 
 parts in their neighborhood ; the respiration, moreover, becomes rather 
 labored, and the child has a constant hacking cough, occasionally aggra- 
 vated and paroxysmal — two symptoms which I have known to raise 
 in more than one instance an unfounded apprehension of phthisis ; and 
 to lead in other cases, where some phthisical disease actually existed, 
 to the expression of a more gloomy prognosis than was warranted by 
 the amount of mischief in the lungs. Now and then the difficulty of 
 respiration from mere enlargement of the tonsils has been so consider- 
 able as to threaten life. My friend and former colleague, Mr. Shaw, 
 once had a little boy under his care, who, in addition to constant 
 dyspnoea, suffered from occasional fits of suffocation arising from this 
 cause ; and one of these fits w T as so severe that in order to preserve the 
 child's life it was necessary to perform laryngotomy. Recently, too, I 
 saw a little boy two years old, whose life was in urgent danger from 
 enlargement of the tonsils, which, however, were happily removed, and 
 the otherwise inevitable opening of his windpipe was thus avoided. 
 
 The long existence of considerable enlargement of the tonsils, and 
 the consequent almost complete obstruction to the passage of air through 
 the nostrils, give rise to a peculiar alteration in the form of the parts 
 thus thrown out of use. The nostrils become extremely small, narrow, 
 and compressed ; and the peculiar character w T hich the physiognomy 
 thus acquires is further increased by the accompanying modification in 
 the development of the upper jaw. The superior dental arch remains 
 very narrow, so as not to allow adequate room for the teeth, which 
 consequently overlap each other very much, while at the same time the 
 palate becomes unusually high and arched. Nor is this the only mode 
 in which due development is interfered with ; but it was noticed many 
 years ago by Dupuytren that enlargement of the tonsils and the pigeon- 
 breast very usually go together. The fact was confirmed by others, 
 but I believe that Mr. Shaw 1 was the first person to offer an explana- 
 tion of it. He pointed out how the obstacle to the free entrance of air 
 into the lungs prevents their being filled at each inspiratory effort ; so 
 that a vacuum would be formed between them and the walls of the 
 
 1 Medicaf Gazette, Oct. 23, 1841. See also his remarks in the article Thorax, in 
 the Cyclopaedia of Anatomy and Physiology, p. 1039; and also those of M. Kobert, , 
 in his paper already referred to. 
 
EXCISION OF ENLARGED TONSILS. 481 
 
 chest, were it not that the pressure of the external air on the yielding 
 parietes of the thorax forces them inwards to occupy the vacant space ; 
 and doing so most readily where their resistance is least, namely, at the 
 commencement of the costal cartilages, produces the well-known lateral 
 flattening of the thorax, and prominence of the sternum. The little 
 boy whose case I have just mentioned as necessitating the operation of 
 laryngotomy, gave in his own person a striking illustration of the cor- 
 rectness of the explanation which I have just given you. " On his 
 admission into the hospital," says Mr. Shaw, " and for several w r eeks 
 afterwards, it was observed that he had the pigeon-breast form of 
 chest ; but after his tonsils were excised, and his breathing had been 
 perfectly free for some time, the sternum subsided to its proper level, 
 and the thorax recovered its natural shape." 
 
 Enlargement of the tonsils, then, though at first sight it may appear 
 a trivial ailment, is yet one which you must by no means neglect. A 
 weakly child, whose tonsils are but slightly enlarged, will often get rid 
 of his ailment as he gains health and strength, or at puberty will com- 
 pletely outgrow it. Any slight attack of cold, however, is apt to be 
 followed by the increase or the return of the enlargement ; and though 
 this may often be kept in check by the application of powdered alum 
 once or twice a day to the tonsils, or by touching them every day or 
 two with the solid nitrate of silver, yet on the whole the tendency is 
 towards the increase rather than the lessening of the evil. In no case, 
 indeed, in which the hypertrophy of the tonsils is considerable, or of 
 long standing, have I found these measures, or the painting the exterior 
 of the throat just above the angle of the jaw with tincture of iodine, 
 of much service, and excision of the tonsils is then the only remedy. 
 Since, too, chloroform can be administered for this operation, as well as 
 for any other, provided the mouth is kept open by a suitable gag, such 
 as Mr. T. Smith has invented for operations on the cleft palate, there 
 is no longer any necessity for waiting until the child is old enough to 
 exercise some self-control. There is one circumstance which would al- 
 ways induce me, independent of other grounds, to advise the immedi- 
 ate excision of enlarged tonsils ; namely, the existence of a constant or 
 frequent cough, or the presence of any other symptom warranting a 
 suspicion of phthisical disease in the chest. The enlarged tonsils not 
 only mechanically interfere with the ready entrance of air into the 
 lungs, but they keep up a constant irritation of the air-passages, and 
 thus maintain a condition most unfavorable to the arrest of tubercular 
 disease in the chest ; while on more than one occasion I have seen most 
 threatening symptoms disappear with great rapidity after their removal. 
 If, after the tonsils have been removed, the chest is long in regaining 
 its natural form, the use of dumb-bells, and the careful practice of 
 gymnastic exercises, are often of much service. Dupuytren's recom- 
 mendation, too, to stand the child with its back against a wall, and 
 then placing the hand upon the most prominent part of the sternum, 
 to press firmly upon it during each expiratory effort, remitting the 
 pressure, during inspiration, in order that the child may fill its chest 
 as completely as possible, I have found to be, in spite of its seeming 
 
 31 
 
482 RETRO-PHARYNGEAL ABSCESS. 
 
 roughness, extremely valuable as an additional means of removing the 
 deformity of the pigeon-breast. 
 
 In the year 1840, Dr. Fleming, of Dublin, 1 called attention to the 
 occasional occurrence of abscess behind the pharynx, which pressing 
 forward against the trachea, gives rise to urgent dyspnoea and sometimes 
 even produces suffocation. Isolated cases of this accident had, indeed, 
 fallen under the notice of previous observers, but by none, with the 
 exception of Abercrombie, 2 had they been made the subject of special 
 remark; while to Dr. Fleming unquestionably belongs the merit of 
 having laid down distinct rules for its diagnosis, and clear directions 
 for its treatment. Since Dr. Fleming's paper was published, many 
 other instances of the affection have been recorded, especially by M. 
 Mondiere 3 and Duparcque, 4 the latter of whom also pointed out certain 
 distinctive differences between cases where the matter accumulates be- 
 hind the pharynx, and others in which it collects lower down, behind 
 the oesophagus ; and by Dr. Allin, 5 an American physician, who in a 
 very able paper has collected the statistics of fifty-eight cases of the 
 affection. Neither form of it is exclusively confined to early life ; yet 
 it happens in children with sufficient frequency to entitle it to some 
 notice in a course of Lectures on the Diseases of Childhood. 6 
 
 There are a few cases on record of the formation of retro-pharyngeal 
 abscess as the result of direct injury ; 'or of its occurrence in connec- 
 
 1 Dublin Journal of Medical Science, vol. xvii, p 41. 
 
 2 Edinburgh Medical and Surgical Journal, vol. xv, 1819, p. 260. t 
 s L'Expenence, Jan. 20, 27, and Fevrier 3, 1842. 
 
 4 Annales d'Obstetrique, Dec. 1842, p. 242. 
 
 5 New York Journal of Medicine, vol. vii, Nov. 1851, p. 307. 
 
 6 M. Mondiere states' that 11 out of 18 patients whose history he collected had 
 not reached adult age, and that 7 were between 11 weeks and 4^ years old ; and M. 
 Duparcque mentions that in 10 out of the 30 cases to which he refers, the ago of the 
 patients was less than 4^ years. Unfortunately, however, M. Mondiere's references 
 are very incomplete, and M. Duparcque gives none at all. In this respect, Dr. 
 Allin's paper leaves nothing to he desired. In all the instances in which the age is 
 not expressly stated in his tables, it is yet apparent from the context that the patient 
 had reached adult age, or at least had passed the period of puberty. If to the 58 
 cases that he mentions 11 others be added from different sources, we obtain the fol- 
 lowing results : 
 
 Under six months old, ......... 5 
 
 Between six months and one year, or stated to be infants, . . 8 
 
 " one year and two, ........ 3 
 
 " two " three, 2 
 
 " three " five, 7 
 
 " five " ten, 1 
 
 " ten " fifteen, 2 : 
 
 Above " fifteen, 41 
 
 69 
 
 Of the eleven additional cases it maybe stated that four in the adult are recorded 
 by M. Mondiere in his paper in L'Experience ; two in the child are recorded by 
 Dr. Abercrombie in the Edinburgh Journal ; one in an infant is related by Dr. 
 Nolt in the Deutsche Klinik, and republished in Schmidt's Jahrbiieher, vol. lxxvi, 
 1852, p. 236 ; the remaining four are those which came under my own observation. 
 To all these must be added the laborious compilation of M. G-autier, Des Absces 
 Eetropharyngiens, 8vo., Geneve et Bale, based on 97 observations, of which 95 are 
 collected from different sources, 2 are original. I do not know, however, that the 
 work suggests any important modification either of opinions or of practice. 
 
CASES OF RETRO-PHARYNGEAL ABSCESS. 483 
 
 tion with disease of the cervical vertebrae, an instance of which has 
 come Under my own observation. Leaving, however, these exceptional 
 cases out of consideration, the affection may be said to present itself 
 either as a sequela of fever, or as an idiopathic disease ; the latter much 
 more frequently than the former. In either case the characteristic 
 indications of its existence are difficulty in swallowing and in breath- 
 ing ; often accompanied with a peculiar sound in respiration, though 
 not with the stridor of croupy breathing, nor with the loud clangor of 
 croupy cough. These symptoms are aggravated in the recumbent 
 posture, any attempt to assume which is followed by immediate 
 threatening of suffocation ; though, in spite of this, the affection often 
 continues with unabated severity, but yet without destroying life, for 
 several days together, and presents in this respect a very important 
 difference from the course of croup. Moreover, a remarkable stiffness 
 of the neck, and retraction with immobility of the head, are present in 
 many instances ; while, though the glands are not enlarged, there is 
 often a distinct swelling of the lateral parts of the neck, which is fre- 
 quently more apparent on one than on the other side. If in these cir- 
 cumstances the finger is carried over the root of the tongue, and down 
 towards the pharynx, a firm, somewhat elastic swelling will be detected, 
 closing more or less completely the canal of the pharynx, and project- 
 ing forward over the opening of the glottis, so as to interfere with the 
 access of air to the lungs. Sometimes on opening the mouth and de- 
 pressing the tongue, the swelling can be distinctly seen almost or quite 
 in the mesial line, pressing forward the velum palati, and obviously 
 encroaching greatly on the entrance of the windpipe ; but sometimes 
 the tumor is situated too low down to be brought into view, while in 
 other cases the mouth cannot be opened sufficiently to allow of the back 
 of the throat being seen ; and the tumor can then be detected only by 
 the finger. 
 
 Four cases of the affection have come under my own observation, of 
 which two were idiopathic, while in the other two the abscess was 
 secondary to disease of the cervical vertebra?. The first patient was 
 an idiot girl, 5J years old, who was attacked by mild scarlatina on 
 January 24th. During the course of the fever no remarkable symp- 
 tom presented itself, but on its decline the child complained much of 
 her mouth, frequently put her hand to it, and refused all except liquid 
 food on account of its hurting her : but on looking into her throat, 
 neither redness nor swelling was perceptible. 
 
 About February 7, swelling appeared near each angle of the lower 
 jaw, but rather lower down than in the situation of the parotid gland. 
 The swelling on the left side subsided on the application of a few 
 leeches, but that on the right side increased, and at the same time the 
 difficulty in deglutition became more distressing. By February 13, 
 the dysphagia had become very much increased; the child could 
 swallow only by gulps, and at each effort she was greatly distressed 
 for breath ; though at other times she lay in a half-conscious state, 
 with labored respiration, and frothing slightly at the mouth. On the 
 16th the child was still worse : her respiration was very difficult, 
 though not attended by the violent struggle for breath which is so 
 
484 CASES OF RETRO-PHARYNGEAL ABSCESS. 
 
 often observed in cases of croup; a dirty -yellowish puriform matter, 
 rendered frothy by air, now collected as a sort of foam at her mouth, 
 and deglutition almost choked her; but still there was no swelling of 
 the tonsils, and the swelling of the side of the neck was so tense that I 
 did not think it possible for matter to be anywhere near the surface. 
 On the following day she died, apparently as much from exhaustion 
 as from asphyxia ; it having for some days been impossible to give her 
 more than a very small quantity of nourishment. 
 
 Immediately on dividing the cervical fascia on the right side, a 
 quantity of thick, yellow, healthy pus poured out. This matter had 
 burrowed close to the oesophagus to within little more than an inch of 
 the clavicle; and also in an oblique direction behind the oesophagus 
 towards the left side, completely detaching it from its connections on 
 the right side, though not on the left. It passed up behind the oesoph- 
 agus and pharynx quite to the base of the skull, a few shreds of 
 cellular tissue bathed in pus being all that remained of their posterior 
 attachments. The tonsils were not enlarged, and the glottis was neither 
 red nor swollen, but quite natural. 
 
 In the other case the affection was idiopathic, and the child a boy 
 only eight months old. He became dull, drooped, and appeared to 
 have a stoppage in his nose which rendered respiration difficult. After 
 these vague symptoms had lasted for a month, the child began to 
 swallow with difficulty, and deglutition sometimes was quite impossible, 
 while his respiration, habitually difficult, became especially so when he 
 w^as asleep. For five weeks he was treated for some supposed head 
 affection with aperients, cold lotions to the head, &c. ; and for another 
 week, his symptoms having increased in severity, his case was regarded 
 by another practitioner as one of bronchitis. 
 
 At the end of six weeks from his first indisposition the boy came 
 under my notice. He was lying asleep in his mother's arms, his head 
 rather thrown back, his face very pale and somewhat puffy, his mouth 
 wide open, and his tongue turned up to the roof of his mouth. His 
 breathing was labored, and attended with an extremely loud constant 
 cluck, not at all resembling the stridor of croup. This sound was 
 louder and his breathing was more difficult when asleep than while 
 awake, though both were very marked even then, and the entrance of 
 air into the lungs was imperfect, especially on the left side. 
 
 The child sucked moderately well, leaving off to breathe very fre- 
 quently, but managing to swallow, and not returning the milk either 
 through the nose or mouth. 
 
 On passing my finger down the throat, I felt a hard body at the 
 root of the tongue, which seemed to occupy the space completely, and 
 on depressing the tongue I saw the uvula and velum forced forward 
 by a body completely occupying the isthmus of the fauces. The sur- 
 face of this tumor was generally red, but one or two yellow spots 
 appeared on it, as if due to the presence of matter showing through a 
 thin investment ; and a sharp-pointed bistoury, the blade of which 
 was defended by plaster, being plunged into it, nearly an ounce of 
 yellow pus escaped, and the tumor immediately collapsed. 
 
 Air now entered the chest freely ; the child sucked readily, and soon 
 
DIAGNOSIS OF RETRO -PHARYNGEAL ABSCESS. 485 
 
 fell asleep, breathing quietly. The same evening, his respiration be- 
 coming once more less tranquil, his mother put her finger down his 
 throat, and pressed, as she has been directed, against the side of the 
 abscess, when a little pus escaped, with immediate relief to the child. 
 On the day after the puncture the swelling was the size of a hazelnut, 
 situated almost completely to the left of the mesial line. It felt hard 
 to the touch, but a little pus could be squeezed out of it on pressure ; 
 and this continued to be the case for about three days, the swelling 
 itself not entirely disappearing for nearly three weeks, though it pro- 
 duced no further symptom, and the child afterwards continued perfectly 
 well. In one of the two cases which were secondary to disease of the 
 cervical vertebrae, the abscess was not suspected during life, and was 
 discovered only on a post-mortem examination in front of the spinal 
 column, and reaching from the exposed odontoid process down to the 
 apex of the lung. In the other case, the boy, aged 3J years, with dis- 
 ease and deformity of the cervical spine, was admitted into the hospital 
 on account of dyspnoea so urgent as to raise the question of the neces- 
 sity for immediate tracheotomy. Happily the prominence at the back 
 of the pharynx was detected ; and from 3 to 4 ounces of pus were let 
 out by an opening made at the back of the throat. The dyspnoea 
 ceased at once ; and the disease of the bones passed into a quiescent 
 state during the child's stay of a month in the hospital. 
 
 Though in the first case the affection was not recognized during life, 
 yet in it no less than in the second the characteristic symptoms of 
 retro-pharyngeal abscess were clearly manifest. Such, too, I believe to 
 be the case in the great majority of instances, though there are circum- 
 stances which now and then somewhat obscure the diagnosis. In the 
 first place, there does not seem to be any uniformity in the character 
 of the earlier symptoms — fever and cerebral disturbance attending it in 
 some cases, dyspnoea being the prominent symptom in others : so that 
 suspicion as to the real nature of the disease is often lulled to sleep, and 
 the true import of the dysphagia or of the difficult breathing is not ap- 
 prehended even when it becomes manifest. Moreover, the duration of 
 the earlier symptoms is very various ; and while the disease sometimes 
 runs a chronic course, in other cases it attains an extreme degree of 
 severity in two or three days, and even destroys life within that period 
 by the intensity of the cerebral disturbance which sometimes accompa- 
 nies it. Nor is this all : but dysphagia, though generally insisted on 
 as a pathognomonic symptom of the affection, is sometimes not very re- 
 markable ; while now and then, as in one of the cases related by Dr. 
 Abercrombie, and in that detailed by Dr. Peacock, it was altogether 
 absent. In the latter case, too, owing to the peculiar form of the ab- 
 scess, no tumor was discovered on inspection of the throat, nor was any 
 perceived even on introduction of the finger. This, however, is an ex- 
 tremely unusual occurrence. 
 
 M. Duparcque enumerates the following symptoms as peculiar to 
 cases where the abscess has formed behind the oesophagus : 1st. Severe 
 pain, produced even by moderate pressure on the larynx and upper 
 part of the trachea. 2d. The circumstance that such pressure produces 
 entire suspension of respiration. 3d. Displacement of the larynx for- 
 
486 CYNANCHE PAROTIDEA. 
 
 wards and to the right. I cannot, however, from my own experience 
 say anything as to the special significance of these symptoms, though 
 they are certainly such as one would anticipate meeting with, where the 
 seat of the abscess is lower than the pharynx. 
 
 From the uncertainty of its early signs it is not possible to lay down 
 any definite rules for the treatment of the first stage of this affection. 
 In some instances, indeed, as in the case of a child one month old, 1 re- 
 lated by Dr. Fleming, it is probably not recognized at all, but comes 
 to an end by the matter making for itself a way before the more for- 
 midable symptoms of dyspnoea and difficult deglutition have manifested 
 themselves, and escaping through the nares. 
 
 In the subsequent stages of the affection, when its nature has become 
 clearly obvious, the indication is a very simple one ; and there is seldom 
 much difficulty in carrying it out. The abscess is to be punctured, and 
 with the escape of the matter all the formidable symptoms at once dis- 
 appear. For this purpose a sharp-pointed bistoury, the blade of which 
 is protected by sticking-plaster wrapped round it, answers generally 
 perfectly well ; but for cases where the seat of the tumor is very low 
 down, or where there is difficulty in opening the mouth, a trocar and 
 a canula, such as Dr. Fleming employed for the purpose, may be pref- 
 erable. The only additional caution which I have to offer for the sub- 
 sequent management of the patient is, that for a day or two pressure be 
 occasionally made with the finger on the tumor, in order to keep the 
 sac of the abscess completely empty, since otherwise the matter may 
 collect again, and give rise to a renewal of the former symptoms. 
 
 Inflammation of the parotid gland — the Cynanche parotidea of 
 scientific writers, called mumps by the vulgar — is an affection met 
 with among children and young persons, concerning which a few 
 words only need be said ; and I know of no more suitable place than 
 the present for introducing it, though strictly speaking its affinities 
 would seem to be rather with the exanthemata, and especially with 
 measles. It attacks young persons after seven years of age, much 
 oftener, and with much greater severity, than infants or very young 
 children. Though it sometimes occurs as a sporadic affection, it is 
 more commonly met with as an epidemic : and being likewise propa- 
 gated by contagion, it not infrequently attacks most of the inmates of 
 a boarding-school, or of any other public institution in which large 
 numbers of the youth of either sex are collected together. Its period 
 of incubation seems to vary extremely, from eight to twenty-one days 
 being the alleged limits and twelve days the most usual time, in which 
 it approximates to the law that governs the incubation period of mea- 
 sles. 2 The seat of the disease is in one or both parotid glands, and in 
 the adjoining cellular tissue ; but if the attack is at all severe, the sub- 
 maxillary and other salivary glands generally become involved during 
 its progress. It generally set in with the ordinary symptoms of slight 
 fever or catarrh, which are followed in about twenty-four hours by 
 
 1 Loc. cit., p. 58. 
 
 2 Eilliet and Barthez, op. cit., 2ded., vol. ii, p. 613; and Wagner, Jahrb. f. Kin- 
 derhulk, 1869, p. 335. 
 
TREATMENT OF CYNANCHE PAROTIDEA. 487 
 
 stiffness of the neck and pain about the lower jaw, any movement of 
 which, either for the purpose of speaking or of mastication, is obviously 
 attended with considerable suffering. At the same time, too, a swell- 
 ing makes its appearance about the angle of the lower jaw, sometimes 
 on one side only, at other times on both ; and this swelling increasing 
 rapidly in size, occasions great disfigurement of the face. The swelling 
 is usually very tense, but the color of the skin is in general unaltered, 
 except in some cases in which the glands on both sides, being swollen, 
 and pressing much upon the veins, the return of blood from the head 
 is impeded, and the face assumes a flushed appearance. If the swell- 
 ing is very considerable, deglutition for a short time is rendered so 
 difficult as to be almost impossible, and the tongue becomes dry from 
 the child breathing with its mouth open ; but the secretion of saliva is 
 neither morbidly increased nor diminished. If the disease is severe, 
 the child suffers much, is very feverish, and may even be lightheaded ; 
 but in the course of forty-eight hours from the appearance of the swell- 
 ing it reaches its height, and the fever begins to subside and the swell- 
 ing to diminish. The time of the final disappearance of the swelling 
 is very variable, being five or six days in some cases, ten days or a 
 fortnight in others ; Avhile in some instances the glands on one side are 
 affected first, and when the attack is subsiding there, those of the oppo- 
 site side become affected in a similar way, and the duration of the ail- 
 ment is thus protracted. The occurrence of suppuration in the neigh- 
 borhood of the gland is a rare termination of the inflammation ; but is, I 
 believe, oftener met with in infants and young children than in those 
 who are approaching the period of puberty. On the other hand, me- 
 tastasis of the disease from the parotid to the mamma, the testicle, or 
 the brain, of all of which instances are recorded by different writers, 
 appears to be rare in proportion to the tender age of the patient. The 
 most formidable of those metastases, indeed — that to the brain — would 
 seem to be an accident very seldom met with ; and neither of it, nor of 
 the translation of the disease to the mamma or the testicle, can I say 
 anything from personal experience. 
 
 The treatment of this affection is in general very simple, and requires 
 the judicious selection of precautionary measures rather than active 
 interference. Mild antiphlogistic medicines, with the application of 
 warmth locally, are all that is usually needed ; and local depletion is 
 neither necessary nor useful. The period during which much distress 
 and much difficulty of deglutition exist is generally very short ; so that 
 even in severe cases it will be our wisest course to await the spontane- 
 ous subsidence of the swelling. If suppuration should take place in 
 the cellular tissue about the gland, a warm poultice must be substi- 
 tuted for the fomentations previously employed. Even when the 
 gland remains enlarged, as it sometimes does for some time after the 
 subsidence of the febrile symptoms, it is yet in general the best plan to 
 let it alone, since the swelling is sure eventually to disappear of its 
 own accord. 
 
 With reference to the management of the metastases of the disease, I 
 have no observations to make, further than that inflammation of the- 
 
488 VOMITING IN EARLY INFANCY. 
 
 brain, however induced, is not an affection with which w T e can safely 
 temporize ; while a mild and palliative treatment will generally answer 
 every purpose, when either the mamma or the testicle has become the 
 seat of the affection. 
 
 LECTURE XXXIV. 
 
 Diseases of the Stomach. — Vomiting often symptomatic of disease elsewhere — 
 Occasionally occurs suddenly in a previously healthy infant without signs of 
 general illness — Its treatment — Is often one out of many symptoms of indiges- 
 tion — Infantile dyspepsia — Sometimes connected with general debility of the 
 system; at others, dependent on special disorder of the stomach — Its symptoms 
 and treatment. 
 
 Softening of the Stomach — Discovered after death in various degrees — Differ- 
 ent theories as to its nature — Great frequency in early infancy — Explanation of 
 this fact. 
 
 H^ematemesis and Mel^na. — Very rare — Sometimes connected with injury to 
 the child during labor — Their occurrence often difficult of explanation — Illus- 
 trative cases — Spurious hamiatemesis. 
 
 The diseases to which the stomach is liable in early life are neither 
 numerous nor important, although its functions are more or less dis- 
 ordered in the course of most of the affections of childhood. Vomiting, 
 indeed, is more frequent in the infant than in the adult, and the greater 
 irritability of the stomach continues even after the first few months of 
 existence are past, and does not completely cease during the early years 
 of childhood. Hence it happens, as we have already seen, that vomiting 
 is sometimes one of the first symptoms of inflammation of the lungs or 
 pleura ; while it frequently ushers in the eruptive fevers, and marks the 
 early stages of cerebral disease. Causes more purely local produce a 
 similar effect, and vomiting often attends upon infantile diarrhoea, and 
 is associated with signs of intestinal disorder, especially when such dis- 
 order has been excited by improper food. But besides these cases, in 
 which the disorder of the stomach is either the result of disease seated 
 elsewhere, or in which the disturbance of its function is sufficiently ex- 
 plained by the nature of the ingesta, instances are sometimes observed 
 in which the stomach becomes so irritable as almost always to reject its 
 contents, or in which, though the food taken is not brought up again, 
 the organ is unable to effect its digestion. 
 
 It sometimes happens that young infants are suddenly seized with 
 vomiting, which, though violent, and frequently repeated, is attended 
 by few or no indications of general intestinal disorder. The child in 
 such cases seems still anxious for the breast ; but so great is the irrita- 
 bility of the stomach, that the milk is either thrown up unchanged im- 
 mediately after it has been swallowed, or it is retained only for a very few 
 
INFANTILE DYSPEPSIA. 489 
 
 minutes, and is then rejected in a curdled state; while each application 
 of the child to the breast is followed by the same result. It will 
 generally be found, when this accident takes place in the previously 
 healthy child of a healthy mother, that it has been occasioned by some 
 act of indiscretion on the part of its mother or nurse. She perhaps has 
 been absent from her nursling longer than usual, and, returning tired 
 from a long walk, or from some fatiguing occupation, has at once offered 
 it the breast, and allowed it to suck abundantly ; or the infant has been 
 roused from sleep before its customary hour, or it has been overexcited 
 or overwearied at play, or, in hot weather has been carried about in 
 the sun without proper protection from its rays. 
 
 The infant in whom, from any of these causes, vomiting has come on, 
 must at once be taken from the breast, and, for a couple of hours, neither 
 food nor medicine should be given to it. It may then be offered a tea- 
 spoonful of cold water ; and should the stomach retain this, one or two 
 more spoonfuls may be given in the course of the next half-hour. If 
 this is not rejected, a little isinglass may be dissolved in the water, which 
 must still be given by a teaspoonful at a time, frequently repeated; or 
 cold barley-water may be given in the same manner. In eight or ten 
 hours, if no return of vomiting takes place, the experiment may be 
 tried of giving the child its mother's milk, or cow's milk diluted with 
 water, in small quantities, and from a teaspoon. If the food thus given 
 does not occasion sickness, the infant may in from twelve to twenty- 
 four hours be restored to the breast ; with the precaution, however, of 
 allowing it to suck only very small quantities at a time, lest the stom- 
 ach being overloaded, the vomiting should again be produced. 
 
 In many instances where the sickness has arisen from some accidental 
 cause, such as those above referred to, the adoption of these precautions 
 will suffice to restore the child's health. If, however, other indications 
 of gastric or intestinal disorder have preceded the sickness, or are as- 
 sociated with it, medicine cannot be wholly dispensed with. Accord- 
 ing to the age of the child, a quarter, half, or a whole grain of calomel 
 may be laid upon the tongue, while sucking is forbidden, and the plan 
 already recommended is in other respects strictly carried out. If the 
 vomiting has already continued for several hours before the adoption of 
 any treatment, a small mustard poultice may likewise be applied to the 
 epigastrium. In about a couple of hours after the calomel has been 
 given, the child may have a teaspoonful of a mixture containing small 
 doses of the bicarbonate of potash and chloric ether, or of ether and of 
 hydrocyanic acid ; and this may be continued every three or four hours 
 so long as any unusual irritability of ihe stomach remains. 
 
 Sickness, however, is not always a solitary symptom, unattended by 
 other indications of gastric disorder, but is sometimes associated with 
 the signs of general impairment of the digestive powers. In its graver 
 forms, Indigestion is associated with greatly impaired nutrition, and 
 with all those serious results which are characteristic of the atrophy of 
 young children. But it sometimes happens that, though the child does 
 not lose much flesh, yet digestion is ill performed, and various dyspep- 
 tic symptoms appear, which would be troublesome rather than alarm- 
 ing, if it were not that they are often connected with the strumous di- 
 
490 INFANTILE DYSPEPSIA. 
 
 i 
 
 athesis, and are the first indications of a state of constitution in which, 
 after the lapse of a few months, pulmonary phthisis is very apt to 
 supervene. 
 
 In some of these cases there is complete anorexia, the infant caring 
 neither for the breast nor for any other food that may be offered it. It 
 loses the look of health, and grows pale and languid, although it may 
 not have any especial disorder either of the stomach or of the bowels. 
 It sucks but seldom, and is soon satisfied ; and even of the small quan- 
 tity taken, a portion is often regurgitated almost immediately. This 
 state of things is sometimes brought on by a mother's overanxious 
 care, who, fearful of her infant taking cold, keeps it in a room too hot 
 or too imperfectly ventilated. It follows, also, in delicate infants on 
 attacks of catarrh or diarrhoea, but is then for the most part a passing 
 evil which time will cure. In the majority of cases, however, the loss 
 of appetite is associated with evidence of the stomach's inability to 
 digest even the small quantity of food taken, and there exists more or 
 less marked gastric or intestinal disorder. Anorexia, too, is far from 
 being a constant attendant upon infantile dyspepsia ; but in still more 
 numerous instances, although the power of assimilating the food is in 
 a great measure lost, yet there is an unnatural craving for it, and the 
 infant never seems so comfortable as when sucking. But though it 
 sucks much, the milk evidently does not sit well upon the stomach ; 
 for soon after sucking the child begins to cry, and appears to be in 
 much pain until it has vomited. The rejection of the milk is followed 
 by immediate relief; but at the same time by the desire for more food, 
 and the child can often be pacified only by allowing it to suck again. 
 In other cases, vomiting is of much less frequent occurrence, and there 
 is neither craving desire for food, nor much pain after sucking, but the 
 infant is distressed by frequent acid or offensive eructations ; its breath 
 has a sour or nauseous smell, and its evacuations have a most fetid 
 odor. The condition of the bowels that exists in connection with these 
 different forms of dyspepsia is variable. In cases of simple anorexia, 
 the debility of the stomach is participated in by the intestines ; their 
 peristaltic action is feeble, and constipation is of frequent occurrence, 
 though the evacuations do not always present any marked deviation 
 from their character in health. Constipation, how r ever, though a fre- 
 quent, is not an invariable attendant on indigestion, but the bowels in 
 some cases act with due regularity. If the infant is brought up en- 
 tirely at the breast, the evacuations are usually liquid, of a very pale 
 yellow color, often extremely offensive, and contain shreds of curdled 
 milk, which, having escaped through the pylorus, pass unchanged along 
 the whole tract of the intestines. In many instances, however, the in- 
 fant having been observed not to thrive at the breast, arrowroot or 
 other farinaceous food is given to it, which the digestive powers are 
 quite unable to assimilate, and which gives to the motions the appear- 
 ance of putty or pipeclay, besmeared more or less abundantly with in- 
 testinal mucus. The evacuations are often parti-colored, and some- 
 times one or two unhealthy motions are followed by others wdiich ap- 
 pear perfectly natural ; while attacks of diarrhoea often come on, and 
 the matters discharged are then watery, of a dark, dirty-green color, 
 and exceedingly offensive odor. 
 
TREATMENT OF DYSPEPSIA FROM DEBILITY. 491 
 
 Dyspeptic infants, like dyspeptic adults, often continue to keep up 
 their flesh much better than could be expected, and in many cases 
 eventually grow up to be strong and healthy children. Still, the con- 
 dition is one that not merely entails considerable suffering upon the 
 child, but, by its continuance, seriously impairs the health, renders the 
 child but little able to bear up against any intercurrent disease, and 
 develops the seeds of latent phthisis. 
 
 Within the space that can be allotted to each subject in these lectures, 
 it is not possible to do more than just glance at some of the main points 
 to be borne in mind in the treatment of infantile dyspepsia. Those 
 cases, the chief symptom of which consists in the loss of appetite, 
 usually require and are much benefited by a generally tonic plan of 
 treatment. All causes unfavorable to health must be examined into, 
 and, as far as possible, removed. It must be seen that the nursery is 
 well ventilated, and that its temperature is not too high ; while it will 
 often be found that no remedy is half so efficacious as change of air. 
 Next, it must not be forgotten that the regurgitation of the food is due 
 in great measure to the weakness and consequent irritability of the 
 stomach ; and care must therefore be taken not to overload it. If these 
 two points are attended to, benefit may then be looked for from the ad- 
 ministration of tonics. These tonics may either be such as the infusion 
 of orange-peel with a few drops of sulphuric acid and of some tinc- 
 ture f or, should any disposition to diarrhoea have appeared, the extract 
 with the compound tincture of bark will be preferable f or, if the stom- 
 ach is very irritable, the liquor cinchonas in combination with small 
 doses of hydrocyanic acid 3 may be given with advantage, when any 
 other medicine would be rejected. As the general health improves, 
 the constipated condition of the bowels so usual in these cases will by 
 degrees disappear. Even if the symptom should call for medical in- 
 terference, it is not by drastic purgatives that its cure must be at- 
 tempted. A soap suppository will sometimes excite the bowels to daily 
 action ; or friction of the abdomen twice a day with warm oil, or with 
 a liniment composed of one part of Linimentum Saponis, one of olive 
 oil, and two of tincture of aloes, will sometimes have the same effect. 
 Should it become necessary to give aperients internally, the decoction 
 of aloes sweetened with licorice, and mixed with caraway or aniseed 
 water, generally answers the purpose very well; 4 while the employment 
 
 1 (No. 24.) 
 R. Acid. Sulph. dil., rr^xvj. 
 Tinct. Aurantii, ^j. 
 Syrupi, gj. 
 Inf. Aurantii, J|j. 
 Aq. Cinnamomi, gij. M. 
 A teaspoonful three times a day for a child a year old. 
 
 2 See Formula No. 4, p. 57. 
 
 3 See Formula No. 21, p. 400. 
 
 4 (No. 25.) 
 R. Decoct. Aloes Co , gvj. 
 Extr. Glycyrrhizse, £)j. 
 Aquse Anisi, gij. M. 
 One or two teaspoonfuls when required for a child a year old. 
 
492 TREATMENT OF DYSPEPSIA FROM GASTRIC DISORDER. 
 
 of mercurials must be restricted to cases in which there is very evident 
 deficiency in the biliary secretion. 
 
 A different plan must be adopted in those forms of indigestion which 
 depend on some cause other than mere debility of the system. The 
 rule, indeed, which limits the quantity of food to be taken at one time 
 is no less applicable here, for the rejection of the curdled milk may be 
 the result of nothing more than of an effort which nature makes to re- 
 duce the work that the stomach has to do within the powers of that 
 organ. But when, notwithstanding that due attention is paid to this 
 important point, uneasiness is always produced by taking food, and is 
 not relieved till after the lapse of twenty minutes or half an hour, 
 when vomiting takes place or when the infant suffers much from flatu- 
 lence and from frequent acid or nauseous eructations, it is clear that the 
 symptoms are due to something more than the mere feebleness of the 
 system. 
 
 It is not, however, in these cases, the mere fact of the infant vomit- 
 ing its food, or of the milk so vomited being rejected in a coagulated 
 state, which indicates the stomach to be disordered, but it is the cir- 
 cumstance of firmly coagulated milk being rejected w T ith much pain, 
 and after the lapse of a considerable interval from the time of taking 
 food, which warrants this conclusion. 1 The coagulation of its casein 
 is the first change which the milk of any animal undergoes when in- 
 troduced into the stomach, though the coagulum formed by human 
 milk is soft, flocculent, and not so thoroughly separated from the other 
 elements of the fluid as the firm hard curd of cow's milk is from the 
 whey in which it floats. In a state of health, the abundantly secreted 
 gastric juice speedily redissolves the chief part of the casein, while the 
 subsequent addition to it of the alkaline bile converts it into an albu- 
 minate of soda ; and being thus assimilated as nearly as possible to the 
 characters of one of the chief elements of the blood, it is easily ab- 
 sorbed by the lacteals, and passes into the mass of the circulating fluid. 
 
 Milk tends, however, to undergo changes spontaneously, which pro- 
 duce its coagulation, and the occurrence of these changes is greatly 
 favored by a moderately high temperature, such as that which exists 
 in the stomach. But the alterations in the fluid which attend upon 
 this spontaneous coagulation are very different from those which are 
 brought about in it by the vital processes of digestion. A free acid 
 becomes developed abundantly within it, and the acid thus generated 
 shows none of the solvent power of gastric juice, but by its presence 
 impedes rather than favors digestion. Every nurse is aw r are that a 
 very slight acidity of the milk with which the infant is fed will suffice 
 to occasion vomiting, stomach-ache and diarrhoea; and the result, as 
 far as the child is concerned, must be much the same whether the ace- 
 tous fermentation had begun in the milk before it was swallowed, or 
 whether it commences afterwards, in consequence of the disordered 
 
 1 The physiology and chemistry of the digestion of milk will be found fully 
 treated in the article Milch, in Wagner's Handworterbuch der Physiologie; and in 
 Elsasser's Essay, Ueber die Magenerweichung der Sauglinge, 8vo. ; 
 They are the authorities for the statements in the text. 
 
DIET OF DYSPEPTIC INFANTS. 493 
 
 condition of the stomach, and the absence of a healthy secretion of 
 gastric juice. 
 
 The nature of the food is the first point that requires attention in 
 the management of these cases of infantile dyspepsia. If the child had 
 been fed on cow's milk, the symptoms may have been produced by the 
 gastric juice being unable to redissolve the hard curd formed by the 
 coagulation of its casein. In this case the infant may sometimes be 
 restored to health without the employment of any medicine, by dilut- 
 ing the milk, by substituting asses' milk for it, or even by giving 
 whey for a day or two, until the stomach recovers its powers of digest- 
 ing casein. The addition of a small quantity of some alkali — as the 
 carbonate of potash, or prepared chalk, or lime-water — to the milk, is 
 another precaution which should not be omitted, since, while it does 
 not at all interfere with digestion, it tends to prevent the matters taken 
 into the stomach so readilv undero;oino; the acetous fermentation. The 
 indiscriminate employment of alkalies as medicines is, however, not to 
 be recommended ; — they are of service combined with minute doses of 
 laudanum, when the irritability of the stomach is extreme, as in those 
 cases which were referred to at the commencement of this lecture ; — 
 they are also useful in cases of a more chronic kind, where the sour 
 smell of the evacuations, and the frequent occurrence of acid eructa- 
 tions, indicate the presence of an excess of acid in the primes vice. I 
 do not give them by themselves, but in combination with some tonic, 
 as the infusion of calumba, to which the extract of dandelion and the 
 tincture of rhubarb may be added, if, as sometimes happens, 1 the func- 
 tions of the liver appear to be but ill performed. 
 
 Vomiting of the milk in a coagulated state is no proof of the pres- 
 ence of an excess of acid in the stomach. It may indicate a condition 
 in which the secretion of the gastric juice is either disordered or insuffi- 
 cient, and in which the acetous fermentation is set up in the contents 
 of the stomach, because the organ is inadequate to the proper discharge 
 of those vital functions which would prevent its occurrence. Such 
 cases — and they are many, and among them may be classed all those 
 in which the breath is offensive and the infant is distressed by nauseous 
 eructations — are benefited by the mineral acids in combination with 
 some bitter infusion ; as, the infusion of cascarilla with hydrochloric 
 acid, 2 and recently I have employed Morson's pepsin wine, in ten or 
 fifteen minim doses three or four times a day, with considerable advan- 
 
 1 (No. 26.) 
 
 R. Soda? Sesquicarb , gv. xxiv. 
 
 Extr. Taraxaci, ^ij. 
 
 Tinct. Rhei, £}. 
 
 Inf. Calumbae, gxj. 
 
 Aqua? Carui, £iv. M. 
 Two teaspoonfuls twice a day. 
 
 2 (No. 27.) 
 
 R. Acid. Hydrochlor. dil., ^xvj. 
 
 Syr. Aurantii. £j. 
 
 Tinct. Aurantii, gj. 
 
 Inf. Cascarilla?, £x. M. 
 A teaspoonful three times a day. 
 
494 SOFTENING OF THE STOMACH AND INTESTINES. 
 
 tage. I have often observed the action of the bowels become regular, 
 and the appearance of the evacuations healthy, during the administra- 
 tion of these remedies. The use of mercurials, indeed, so generally 
 resorted to in order to correct some real or fancied disorder of the liver, 
 has become too indiscriminate a practice. The diarrhoea with very 
 pale light yellow evacuations, that comes on in some of these cases, is 
 often arrested by a spare diet and by the administration of very small 
 doses of sulphate of magnesia and tincture of rhubarb ; such as five 
 grains of the former and ten minims of the latter three times a day to 
 a child a year old. 1 In cases where diarrhoea has been long continued, 
 or where the evacuations are very white, and resemble putty, mercu- 
 rials are generally needed ; as they are also, in those cases where the 
 horribly offensive odor of the evacuations proves that the contents of 
 the intestines have been undergoing a process akin to putrefaction. 
 The mercury and chalk powder, in small doses night and morning, is 
 the mildest preparation that can be given. Sometimes, however, it 
 causes nausea or vomiting, and very small doses of calomel must then 
 be substituted for it ; while, if the mercurial should excite the bowels 
 to overaction, this tendency may generally be checked by combining 
 it with Dover's powder. 
 
 The same rules must guide us in the management of children in 
 whom, though they are still at the breast, the symptoms of dyspepsia 
 make their appearance. Disorder of the digestive function is, how- 
 ever, much less common before weaning than afterwards. It may 
 depend on the mother's milk being from some cause or other ill 
 adapted to the support of the child ; and hence the condition of the 
 parent's health must in all these cases engage our attention. 
 
 With these general rules I must dismiss the subject of indigestion, 
 content to have pointed out the principles that should guide you. It 
 must be left to your own experience in future years to supply the 
 details. I have touched on the subject, too, only with reference to the 
 infant, for as the child grows older and its food becomes the same as 
 that of the adult, the symptoms of disorder of its digestive organs be- 
 come the same too, and require a similar treatment. 
 
 In most works on the diseases of childhood we used to meet with an 
 enumeration of rather obscure symptoms which were stated to indicate 
 the existence of gastritis or gastro-enteritis, and to be followed by more 
 or less considerable softening of the stomach or intestines, or of both. 
 A similar condition of the stomach was observed by John Hunter in 
 the adult, and was conceived by him to be the result of the action of 
 the gastric juice upon the tissues after death. The carefully conducted 
 experiments of Dr. Carswell have completely confirmed the opinion of 
 Mr. Hunter with reference to the agent by which this softening is 
 effected ; while they have further shown that it is independent of the 
 
 1 (No. 28.) 
 ]&. Magnesia? Sulphatis, gj. 
 Tinct Rhei, gij. 
 Syr. Zingiberis, gj. 
 Aquae Carui, r^ix. M. 
 A teaspoonful three times a day. For children a year old. 
 
SOFTENING OF THE STOMACH AND INTESTINES. 495 
 
 person's previous health. Some writers, among whom may be men- 
 tioned those eminent authorities M. Cruveilhier and Professor Roki- 
 tansky, have however dissented in a measure from these views, and 
 have endeavored to distinguish between two kinds of softening, one of 
 which they regard as a post-mortem occurrence ; the other, which is 
 that chiefly observed in infancy, they consider to be the result of dis- 
 ease. This distinction, however, is now 7 generally, and I believe cor- 
 rectly, regarded as untenable, and softening of the stomach in both its 
 forms may be considered as equally due to change in the tissues after 
 death. 1 
 
 This conclusion, however, has not been definitively arrived at suffi- 
 ciently long to warrant me in passing over the condition without some 
 notice, or without reference to the grounds which have led to the 
 opinion which I have just expressed so unhesitatingly. 
 
 The state is met with varying in degree from a slight diminution in 
 the consistence of the mucous membrane, to a state of complete difflu- 
 ence of all the tissues of the organ, in which it breaks down under the 
 finger on the slightest touch, or even gives way of its own accord, and 
 allows of the escape of its contents into the abdomen. When the 
 change is not far advanced, the exterior of the stomach presents a per- 
 fectly natural appearance, but on laying it open, a colorless or slightly 
 brownish, tenacious mucus, like the mucilage of quince-seeds, is found 
 closely adhering to its interior, over a more or less considerable space 
 at the great end of the organ, and extending along the edges of its 
 rugse. This mucus is easily washed away, and the muscular coat of 
 the stomach in those parts to which it had adhered is then left almost 
 or altogether bare, and denuded of its mucous membrane. When the 
 change has gone further, the stomach at its great end presents a semi- 
 transparent appearance, though not uniformly so, but in streaks run- 
 ning in the direction of the rugae; the destruction of the tissues having 
 in those situations reached deeper than elsewhere, and involved a por- 
 tion of the muscular as well as the mucous coat of the organ. If 
 roughly handled, the stomach in many cases gives way, an irregular 
 rent taking place at its great end, where the coats of the organ are 
 found to be soft and pulpy, and to break down easily under the finger. 
 In the next degree, the coats of the stomach are found to have been 
 already dissolved in some parts, so that the contents of the organ have 
 escaped into the abdominal cavity. The whole of the great end of the 
 stomach, and a considerable extent of the posterior wall, are now re- 
 duced to a gelatinous condition, in which no distinction of tissues is 
 apparent ; and the parts thus altered are either transparent and color- 
 less, or else of a pale rose-red hue. The interior of the organ some- 
 times presents a similar tinge, even beyond the limits to which the 
 softening of its tissue has extended. This, however, is by no means 
 constantly observed, while in no case is there any injection of the ves- 
 sels of the stomach, or any evidence of its having been the seat of real 
 inflammatory action. The opaque and brownish appearance of the 
 
 1 No better summary of the reasons for this opinion is given anywhere than by 
 Yogel, in his Lehrbuch der Kinderkrankheiten, 4th ed., Erlangen, 1869, p. 121. 
 
496 SOFTENING OF THE STOMACH AND INTESTINES. 
 
 tissues — characteristic of pulpy softening — is but seldom met with in 
 infancy. 
 
 Softening of the intestines, though much less frequent than softening 
 of the stomach, is observed in similar circumstances, and presents much 
 the same characters. The exterior of the intestines is generally anae- 
 mic, and the softened parts show no traces of increased vascularity, but 
 are either colorless or of a pale rose hue. The mucous membrane in 
 their interior is neither ulcerated nor abraded, but is found in some 
 parts to be much softened, or even altogether absent in small patches. 
 The muscular coat too is sometimes destroyed, though no abrupt edge 
 marks the limits of its destruction, but there is a gradual attenuation 
 of the tissue down to the spot where the peritoneum is laid completely 
 bare. Several of these softened patches are generally met with in the 
 same subject, and at some of them the bowel is often found to have 
 given way, or it breaks down in the attempt to lay open its cavity. 
 
 The allegation, that softening of the stomach in the adult occurs 
 with greater frequency in persons who have died from some diseases, 1 
 than in those who have died from others, has led to the hypothesis that 
 in the former case a diseased and superabundant secretion of gastric 
 juice during the life of the individual had caused the softening of his 
 stomach after death. The same hypothesis has been applied to account 
 for its peculiar frequency in infancy, since at no period of life is gastric 
 disorder so common as then. Some writers have advanced still further, 
 and have endeavored to connect the existence of a softened state of the 
 stomach after death with certain well-marked symptoms of disorder of 
 its functions : for my own part, however, I have not been able to discover 
 any peculiarity in the character of such symptoms, nor even any con- 
 stancy in their occurrence. 
 
 The much greater frequency of softening of the stomach and intes- 
 tines in infancy and early childhood than in adult age, and the greater 
 amount and wider extent of the alterations, have received considerable 
 elucidation from the researches of Dr. Elsasser.' 2 He found that a 
 much more rapid action upon animal tissues than that exerted by the 
 gastric juice, was put forth by any substance capable of undergoing the 
 acetous fermentation, combined with pepsin. Such substances are fur- 
 nished by the milk as well as by the various farinaceous and saccharine 
 matters on which infants almost exclusively subsist. The tendency of 
 these substances to undergo the acetous fermentation -is checked by the 
 presence of healthy gastric juice, while, as we know by experience, it 
 takes place very readily in infants who are dyspeptic, and to a very 
 
 1 The very elaborate work of MM. Herrich and Popp, Der plotzliche Tod aus 
 inneren Ursachen, 8vo., Kegensburg, 1848, contains, at p. 330, a table of 140 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 stomaeh would be discovered 
 after death. In by far the greater number of the cases the stomach was empty, 
 showing that the occurrence very often did not depend on digestion going on at the 
 time of death ; while the period of childhood, the rapid course of the fatal disease, 
 and death from cerebral affections, were the only circumstances which appeared to 
 have any clearly appreciable influence in favoring its production. 
 
H.EMATEMESIS AND MEL^ENA. 497 
 
 remarkable degree in many cases of infantile diarrhoea. Facts bear out 
 to a very great extent the opinion of M. Elsasser. Out of 104 cases 
 of softening of the stomach that came under the notice of two very 
 eminent German physicians, MM. Herrich and Popp, 72 were met 
 with in the period of infancy or early childhood. My own notes on 
 this point, though too few to be of any weight, yet point to a similar 
 conclusion ; for of 14 cases of softening of the stomach or intestines, or 
 of both, observed out of a total of 61 cases in which the condition of 
 those viscera was carefully recorded, 11 were met with in children 
 under two years of age ; while out of a total of 389 examinations of 
 infants under the age of three months in the Foundling Hospital at 
 Vienna, M. Bednar 1 met with 100 instances of softening of the stomach 
 or intestines; in 61 of which death had taken place from diarrhoea. 
 I need scarcely add that this theory of M. Elsasser's is only supplemen- 
 tary to Mr. Hunter's, and is perfectly reconcilable with the correctness 
 of his observations, and of those of Dr. Carswell. 
 
 Among those rare diseases, too seldom met with for any person to 
 have what can be called real experience about them, may be mentioned 
 the vomiting and purging of blood occasionally observed in infants and 
 young children. In the greater number of cases the occurrence has 
 taken place within a few days 2 after birth, sometimes within a few 
 hours, and in some instances has followed a tedious or difficult labor, 
 in which the head of the child has been much compressed, or its abdo- 
 men has been pressed on, or otherwise injured during attempts at its 
 extraction ; while in other cases the difficult establishment of respira- 
 tion has seemed to be the predisposing cause of the hemorrhage. Very 
 often, however, no reason can be assigned for it ; and the vomiting of 
 blood, sometimes associated with its discharge per anum, has been un- 
 attended with other indications of disorder of the abdominal viscera. 
 In most cases the hsematemesis has not recurred above two or three 
 times in any quantity; and the children, though at first very much 
 exhausted by the loss of blood, have, in about half the cases, eventually 
 recovered. In a few instances, however, recovery has been partial, and 
 the children have sunk into a cachectic condition, in which they died. 
 When death has taken place from the immediate effects of the hemor- 
 rhage, the liver and the abdominal veins have sometimes been found 
 gorged with blood, and blood has been found within the intestines, or 
 extravasated within their coats, constituting what has been termed 
 abdominal apoplexy — appearances which have been supposed to indi- 
 cate that some impediment to the establishment of the new course of 
 the circulation which the blood should follow after birth, had given 
 rise to the accident. 
 
 I have nothing to say about the treatment of an accident which in 
 general occurs too causelessly to furnish indications for its prevention, 
 
 1 Die Krankheiten der Neugebornen, &c, 8vo , p 76. Wien, 1850. 
 
 2 Within 6 days in 17, and within 36 hours in 9 out of 20 cases collected by M. 
 Rilliet, in his Essai sur les Hemorrhagies Intestinales chez les Nouveaux-nes, pub- 
 lished in Gaz. Med de Paris, No. 53, 1848 ; and reproduced in vol. ii of the second 
 edition of his and M. Barthez's Traite des Maladies des Enfans, pp. 295-310. 
 
 32 
 
498 H^IMATEMESIS AND MELJ3NA. 
 
 and too suddenly to allow of the employment of measures for its arrest; 
 but I will give you the result of my scanty experience concerning it, 
 which amounts to three cases. In one of these cases the hemorrhage 
 occurred without apparent cause soon after birth, and ceased spontane- 
 ously; while in the other two it took place at a later period, and ap- 
 proached in its characters more nearly to similar occurrences in adult 
 age. 
 
 The subject of the first observation was a male child, who. was born 
 of a healthy mother, after a short and easy labor, at 11 a.m. on Sep- 
 tember 23, 1845. The infant was well grown, and apparently strong 
 and healthy, and continued so till 2 J a.m. on the 24th, when, without 
 any previous sickness, or other indication of illness, he vomited nearly 
 half a teacupful of blood. This vomiting was not attended by any 
 pain, nor was any large quantity of blood rejected afterwards, but the 
 child continued at intervals of not more than an hour to throw up small 
 quantities of dark greenish matter, resembling meconium, and mixed 
 with mucus ; and on the morning of the 25th he vomited a small por- 
 tion of coagulated blood, as big as the top of the little finger. Between 
 the time of the child's birth and the morning of the 25th, the bowels 
 acted seven times; the motions were rather scanty, and consisted en- 
 tirely of meconium. The child sucked well, did not appear in distress; 
 its surface was warm, and its abdomen neither full nor tender. The 
 matters vomited did not decompose, although they were kept for some 
 days ; and when examined under the microscope, they were seen to be 
 made up of a great number of granular globules, with which were in- 
 termixed some scales of tessellated epithelium. 
 
 The 27th of September was the last day on which the. dark solid 
 matter like meconium was vomited; but the child continued to be sick 
 occasionally until October 7, although the attacks of sickness did not 
 seem to be excited by sucking, but occurred in general when the stomach 
 was empty, and ended with the rejection of a small quantity of mucus, 
 occasionally of a greenish color. The bowels were rather constipated, 
 and the evacuations for the first week after the child's birth continued 
 very dark-colored ; they afterwards assumed a more natural color ; but 
 the bowels remained very constipated during the whole of the child's 
 life. The child never throve; it lost flesh, occasionally vomited the 
 milk, had a frequent and troublesome cough; its strength decayed, and 
 it died exhausted on April 28, 1846, at the age of seven months. On 
 examining the body, nothing was found to explain the child's illness ; 
 there was no tubercle in any organ ; the viscera were anaemic ; no trace 
 of inflammatory action was visible anywhere. A few lobules in both 
 lungs were in a collapsed condition ; the small intestines presented 
 several recent intussusceptions; and the stomach was remarkably small, 
 and undeveloped in form as well as in size ; but no other morbid ap- 
 pearances existed in any part of the body. 
 
 In the second case, the child, likewise a boy, had perfectly good 
 health till he was two months old, when he began to appear stuffed at 
 his chest, and had frequent though not severe cough. At the age of 
 ten weeks, he brought up a small quantity of dark blood while cough- 
 ing, and afterwards had frequent attacks of retching and vomiting, in- 
 
ILLUSTRATIVE CASES. 499 
 
 dependent of cough. During these attacks he brought up a dark-red 
 fluid, like blood, sometimes in as large a quantity as two-thirds of a 
 teacupful. On February 17, 1844, after these symptoms had continued 
 for four days, I saw the child, whose face was slightly flushed, and the 
 expression of his countenance dull. His abdomen was full and rather 
 tender, especially in the right hypochondriac region; his urine was very 
 high-colored, and his evacuations were quite white. From February 
 17 to April 13, the child remained under my care, and during this time 
 the above-mentioned symptoms continued, although with a gradual 
 amelioration in the child's condition. Within a week after I first saw 
 him, he had a severe conslusive seizure, and attacks of a similar kind 
 occurred a great many times afterwards, independent of any obvious 
 cause. The bowels were always constipated; the evacuations usually 
 very white, though occasionally almost black, sometimes accompanied 
 with a slight discharge of blood ; and blood was now and then voided 
 unmixed with fecal matter. The stomach became very irritable, and 
 the child suffered from frequent vomiting ; the matters rejected being 
 untinged with blood for days together, and then, without any apparent 
 reason, blood was abundantly mingled with them. Sometimes the 
 infant cried much, and appeared in very great pain ; and these attacks 
 often terminated in the rejection of a considerable quantity of nearly 
 pure blood. 
 
 The face soon lost its flush, and became pale ; but the puffiness con- 
 tinued, and was evidently due to a slight degree of anasarca. From 
 the tender age of the child, I was unable to obtain any of his urine, in 
 order to ascertain whether or not it contained albumen. The treatment 
 followed w r as directed to diminish the abdominal tenderness, by the 
 application of a couple of leeches over the right hypochondrium, and to 
 overcome the constipated state of the bowels, and induce the healthy 
 action of the liver, by the employment of small doses of mercurials, 
 and of the sulphate of magnesia, to which it became sometimes neces- 
 sary to add the administration of an active purgative. In May, 1844, 
 the child was sent to Margate, where the convulsive attacks and other 
 symptoms altogether ceased. On his return to London, after a stay of 
 six months at the seaside, his health failed — partly, as it seemed, in 
 consequence of his mother's poverty preventing her from supplying him 
 with proper food. In November, 1846, when much out of health, and 
 suffering from diarrhoea, he came again under my care, but died sud- 
 denly of hemorrhage into the arachnoid. 1 There w T as no appearance in 
 the abdominal viscera after death which threw any light on the cause 
 of the hsematemesis and melama, from which the child had suffered for 
 so many«months during his early infancy. 
 
 The subject of the third observation was a little boy, the child of a 
 healthy father but strumous mother, who had thriven well at the breast 
 till he was four months old, when he cut some of his incisor teeth ; and 
 his health had seemed less good since that period. There was, how- 
 ever, no marked ailment until he was weaned at nine and a half months ; 
 but after that he drooped, became much less cheerful, and his evacua- 
 
 1 The particulars of his last illness are given in Lecture V, p. 66. 
 
500 SPURIOUS H^MATEMESIS. 
 
 tions were seen to be white and unhealthy. He was in this condition 
 when ten months and a week old ; his abdomen, though large, was 
 generally soft ; but pressure in the left hypochondrium seemed to give 
 pain; and careful examination detected a tumor there of the size of a 
 small apple. On the evening of the same day on which he was first 
 seen, the bowels having acted spontaneously in the morning, the child 
 suddenly, and without any effort or straining, voided between three and 
 four ounces of pure blood, partly fluid, partly coagulated. The discharge 
 of blood occasioned faintness, and left the child very pallid, but appar- 
 ently not suffering. He slept tolerably well during the night, but the en- 
 suing morning at 7 a.m. voided nearly the same quantity of blood as on 
 the previous evening, unmixed with faeces, but apparently somewhat 
 diluted with intestinal mucus. Some warm water thrown up the bowel 
 returned, stained with blood, but unmixed with fecal matter, as did a 
 second enema administered six hours afterwards. In the course of the 
 same day he had two scanty evacuations, both composed almost entirely 
 of bloody mucus, and with such slight admixture of adhesive, white, 
 fecal matter, almost like putty in appearance, that I did not feel my 
 anxiety lest the case should turn out to be one of intussusception of the 
 intestines entirely removed until nearly twenty-four hours afterwards, 
 when, after a dose of castor oil, two tolerably healthy evacuations were 
 passed. The tenderness of the abdomen had now completely subsided, 
 the swelling in the left hypochondrium (possibly the enlarged and con- 
 gested spleen) had entirely disappeared ; and the child, in spite of the 
 quantity of blood it had lost, appeared much better than before the 
 hemorrhage occurred. 
 
 This amendment, however, was not of long duration; no hemorrhage, 
 indeed, returned, but the child had an attack of very severe diarrhoea, 
 attended with great emaciation and much abdominal pain, which lasted 
 for nearly six weeks. After the diarrhoea ceased, the child still con- 
 tinued weak and thin, and suffering, and died convulsed in the middle 
 of June, after vague head symptoms of two days' duration. 
 
 In this last case no post-mortem examination could be made, so that 
 we are uncertain what connection, if any, subsisted between the hemor- 
 rhages at the outset of the child's illness, and the obstinate diarrhoea 
 which came on soon after, and had so large a share in occasioning its 
 death. One thing, at any rate, these cases illustrate, and one worth 
 bearing in mind, viz., that formidable as the occurrence is, and large as 
 the quantity of blood which is lost may be, still the immediate danger 
 to life is far less than, but for this evidence to the contrary, we should 
 most naturally apprehend. 1 
 
 It will not be necessary to do more than allude to cases of what has 
 been called spurious hcematemesis, in which an infant vomits blood 
 drawn from some crack or ulceration of its mother's nipple, or which 
 has been furnished by some little vessel cut in dividing the framurn 
 linguae, or in performing some other operation on its mouth. You 
 
 1 The affection is, however., much more serious in infancy than in adult age ; for 
 of .twenty-three cases .referred to .by M. Rilliet (loc. cit., p. 307), eleven had a fatal 
 termination. 
 
INFANTILE JAUNDICE. 501 
 
 would at once suspect the source of the blood vomited after the opera- 
 tion on the infant's mouth, and an examination of the mother's nipple 
 in a case of hsematemesis will guard you against the other possible 
 source of error. 
 
 LECTURE XXXV. 
 
 Icterus of New-born Children. — Generally a trivial affection — Not usually 
 dependent on intestinal disorder, but on imperfect performance of functions of 
 skin and respiratory organs — Sometimes results from absence or closure of 
 hepatic or cystic ducts — Is then associated with great tendenc}' to hemorrhage, 
 and proves speedily fatal. It occasionally occurs in children in the same cir- 
 cumstances as in the adult. 
 
 Constipation sometimes results from mechanical obstruction of intestines. — Which 
 may be congenital — As from imperforate anus or impervious rectum — Varieties 
 of these malformations — Their general symptoms — Special signs of each — -Their 
 comparative danger and appropriate treatment. 
 
 Obstruction of intestines from causes not congenital — Strangulated hernia very rare 
 in infancy— Intussusception of intestines — Its symptoms — Usually more char- 
 acteristic than in the adult — Its generally fatal result — But occasional spontane- 
 ous cure — Suggestions for its treatment. 
 
 It is curious to watch the changes which take place in the color of 
 the infant during the first few days after its birth, and to notice how 
 the vivid red fades by degrees into the pale rose-tint of the skin of a 
 healthy baby. But there is often a transition state between the two 
 when the skin, neither red nor pale, has a dull yellow tinge, which 
 comes on about the third day after birth, and, deepening for a day or 
 two, subsides but very gradually : the child, however, all the time seem- 
 ing quite well, the bowels acting properly, and the urine not being 
 high-colored. Though to this condition the name of jaundice has been 
 applied, it yet is no real jaundice; but is merely the result of the 
 changes which the blood, in the overcongested skin, is undergoing: 
 "the redness fading as bruises fade, through shades of yellow, into the 
 genuine flesh color." 
 
 This icteroid tinge of the skin is unassociated with the altered hue of 
 the conjunctiva, which is seldom absent when the functions of the liver 
 are disordered ; and it has, therefore, been proposed 1 to distinguish the 
 physiologieal change in the color of the skin, which takes place after 
 birth, by the name of local icterus, and to apply the term of general 
 icterus to cases in which the yellow hue of the surface is an indication 
 of hepatic disorder. 
 
 Even the general icterus, however, is not often of serious moment, 
 though the assumption that it is a perfectly natural state in which the 
 
 1 Seux, op. cit., p. 280. 
 
502 INFANTILE JAUNDICE 
 
 skin, and- other secreting organs, are called on for a few days to assist 
 in disposing of the bile, until the demand for it to minister to the di- 
 gestive functions becomes equal to its abundant supply, is shown to be 
 erroneous, by the circumstance that jaundice does not affect perfectly 
 healthy children, who have been born at the full time, have been nour- 
 ished exclusively at the mother's breast, and been sheltered from cold 
 without being overburdened with clothing or confined in a vitiated 
 atmosphere. In the Dublin Lying-in Hospital, where the children 
 are defended by the most watchful care from the evils either of cold or 
 of a vitiated atmosphere, the occurrence of infantile jaundice is rare ; 
 while in the Foundling Hospital at Paris, jaundice is so common that 
 comparatively few infants escape it. Almost all the children at the 
 Foundling Hospital have been exposed to the action of cold while 
 being brought to the institution, and suffer from the combined influ- 
 ence of cold and bad air while inmates of it — causes w T hich interfere very 
 seriously with the due performance of the functions of the skin and of 
 the respiratory organs. 
 
 The children in whom jaundice is most frequent and most intense, 
 are the immature and the feeble ; while in none is it so often met with, 
 or in such an intense degree, as in 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 their chest or abdomen. Interruption 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 cir- 
 culates in part through channels which ought to have been closed from 
 the time of birth. These facts seem to substantiate the opinions enter- 
 tained by many writers of high authority, that the jaundice of young 
 children is not due to any cause primarily seated in the liver, but 
 rather to the defective respiration, and the impaired performance of 
 the functions of the skin, of which the hepatic disorder and constant 
 jaundice are but the effects. 
 
 As the respiratory function, and that of the skin, increase in activity 
 — which they will do if the cause of their imperfect performance is but 
 slight or temporary — the jaundice disappears of its own accord. Great 
 attention must be paid during its continuance to avoid exposure of the 
 child to cold, while no other food than the mother's milk should be 
 given. If the bowels are at all constipated, a grain of Hyd. c. Creta 
 may be given, followed by a small dose of castor oil, and the aperient 
 will often seem to hasten the disappearance of the jaundice ; but in a 
 large number of cases even this amount of medical interference is not 
 needed. 
 
 Besides these cases, however, in which the jaundice is at most but a 
 very trivial ailment, instances are sometimes met with where it is a 
 symptom of very serious import. Thus, for instance, it has been ob- 
 served to attend upon the peritionitis of new-born infants, and on that 
 enteritis which, like the affection of the peritoneum, is one of the en- 
 demic diseases of foundling hospitals. It sometimes depends on inflam- 
 mation of the liver, occasionally on phlebitis of the umbilical veins — 
 
FROM MALFORMATION OF RILIARY DUCTS. 503 
 
 diseases, all of them, to which in private practice we are strangers. 
 Lastly, it is occasionally due to congenital absence of the hepatic or 
 cystic biliary ducts, or to the obstruction of those ducts by inspissated 
 bile. 
 
 When dependent on the former of these causes, death takes place 
 sooner or later ; and though now and then life is prolonged for several 
 weeks or months, during which time, as might be expected, the evac- 
 uations are destitute of bile, yet in the majority of instances the fatal 
 issue takes place within a fortnight after birth ; and this in consequence 
 of hemorrhage from the umbilicus immediately after the separation of 
 the funis. It is characteristic of the bleeding which occurs in these 
 circumstances that it is not furnished exclusively — sometimes, indeed, 
 not at all — 'from the umbilical vessels, but is rather a constant oozing 
 of blood from the granulating surface of the navel. The blood, too, is 
 almost completely destitute of the power of coagulation, so that it is 
 neither restrained by styptics nor controlled by tying the umbilical 
 vessels. The only means indeed, on which we can rely for checking 
 the bleeding is the ligature en masse, as it has been termed ; or, in 
 other words, the transfixing the integuments at the root of the navel 
 with a couple of hare-lip pins, and twisting around them several coils 
 of strong silken ligature. In the only case of this form of hemorrhage 
 which has come under my observation, the bleeding w T as suppressed by 
 these means, though the child died apparently exhausted in the course 
 of the ensuing twenty-four hours, or about thirty-six hours after the 
 separation of the navel and the commencement of the bleeding. Of 
 course, when bleeding is dependent on a congenital malformation of 
 the hepatic ducts, all interference is useless as far as the preservation 
 of the child's life is concerned ; but, at the same time, the death of an 
 infant from hemorrhage will leave a more painful impression on the 
 parents' minds than its sinking somewhat later from the remote though 
 inevitable consequences of the condition. Xow and then, too, in spite 
 of the coexistence of hemorrhage and jaundice, the former has been 
 checked, and the latter had disappeared ; the child completely recover- 
 ing ; and, in other instances which terminated fatally, though the um- 
 bilical vessels have been found open, and no clots within their canals, 
 and the foetal passages for the blood still pervious, yet the bile-ducts 
 have sometimes been found quite pervious and arranged in a perfectly 
 natural manner. 
 
 In some rare instances, as has been mentioned, life is prolonged ; and 
 w r hen that is the case, a condition of general atrophy comes on, attended 
 with enlargement of the abdomen in both hypochondriac regions ; and 
 some intercurrent attack of diarrhoea generally exhausts the feeble 
 powers when only a few months have passed. Some years ago, through 
 the courtesy of Mr. Jones of Tenby, I saw a remarkable case of this 
 kind, where life was prolonged for six and a half months, in spite of 
 absence of the gall-bladder ; but in almost all instances death takes 
 place within the first two months. In the case which I have just 
 referred to, no hemorrhage took place at any time ; but on the third 
 day after birth, the surface began to be yellow, and, at the end of three 
 weeks, the yellow tinge was very deep. At the same time a swelling 
 
504 CASES OF INFANTILE JAUNDICE. 
 
 of the size of an egg was first noticed in the right hypochondriac region ; 
 while the evacuations from the second day after birth were white like 
 cream, and the urine was habitually high-colored. 
 
 The child was thirteen weeks old when I first saw her ; she was 
 small, ill-thriven, sallow, icteroid, but not intensely jaundiced. Her 
 abdomen measured twelve inches and three-quarters at the umbilicus, 
 and fourteen and one-third two inches lower down. This enlargement 
 was due to a tumor which dipped dowm on the right side, nearly into 
 the pelvis, sloping off on the left side, so as to project much less there, 
 though its hard edge was still distinctly traceable. 
 
 In three months more the child died, much emaciated, while its 
 abdomen was distended by a pint and a half of fluid in the peritoneal 
 cavity. The spleen was much larger than natural, forming a prominent 
 tumor in the left iliac and lumbar regions. Its color was darker, and 
 its tissue firmer than natural. On examination of the liver, which was 
 much enlarged, and weighed eleven ounces and a half, it was ascertained 
 that the gall-bladder was absent, and in its place were tw r o small sacs 
 without any outlet, one of them of the size of a pea, the other twice as 
 large, containing a tenacious matter of a greenish color, and not unlike 
 inspissated bile ; while the hepatic ducts were impervious and greatly 
 dilated. 
 
 The interest of such cases is chiefly that which they offer to the 
 morbid anatomist ; but one sad and somewhat strange peculiarity with 
 reference to them is, that they are apt to be met with in several succes- 
 sive children of the same parents. I knew one lady who lost in suc- 
 cession three out of five children, soon after their birth, with most 
 intense jaundice, which in one instance was ascertained to be associated 
 with malformation of the biliary ducts; in the second, no examination 
 was made after death ; and in the third, malformation was said, though 
 scarcely on adequate authority, not to have existed. Another, one 
 of whose children I saw die of infantile jaundice from impervious 
 biliary ducts, had already lost three infants from the same cause; and 
 her sister's only infant had also died in similar circumstances. The 
 hereditary tendency to this condition receives a fresh illustration from 
 the circumstance, that, in twenty-six out of seventy-nine cases of um- 
 bilical hemorrhage in the new-born infant, collected by Dr. Stephen 
 Smith, 1 of New York, other children of the same parent had died from 
 the same untoward accident; while the more elaborate statistics of 
 Dr. Grandidier, of Cassel, 2 give a total of forty-one infants of eighteen 
 mothers in whom umbilical hemorrhage occurred. 
 
 1 In New York Journal of Medicine, July, 1855, vol. xv, p. 73. Pour times it 
 occurred in two children of the same parents, twice in three, and thrice in four. 
 Further information on the subject of umbilical hemorrhage with jaundice will be 
 found in a paper hy Dr. A. B. Campbell, in the Northern Journal, August, 1844; 
 in the valuable paper of Mr. Kay, in Med. Gazette for March, 1849 ; in that of Dr. 
 Manley, in the same journal for May, 1850; in the dissertation of M. E. Dubois, of 
 which an abstract is given in the Arch. Gen de Medecine for October, 1849; in an 
 essa} 7 by Dr. Bowditch in the American Journal of Medical Science, January, 1850; 
 and in a lecture by M. Roger, of Paris, republished in the Journal fur Kinderkrank- 
 heiten, July, 1853. 
 
 2 Journal fur Kinderkrankheiten, May, 1859, vol. xxxii, p. 380. 
 
TREATMENT OF JAUNDICE IN CHILDREN. 505 
 
 Jaundice may also occur in older children in the same circumstances 
 as in adults, and associated with similar symptoms ; the evacuations 
 being white, the urine high-colored, and more or less pain and tender- 
 ness being experienced in the hypochondriac region. Such cases are 
 most frequently met with during the summer or autumn, especially at 
 times when diarrhoea is prevalent, the skin sometimes assuming a gen- 
 erally yellow tinge as the purging subsides ; while in other instances 
 the jaundice occurs as an idiopathic affection, though apparently due 
 to the same causes as have produced diarrhoea in other children. 
 
 In the instances that have come under my notice, the skin has no't 
 assumed a very deep yellow tinge, and the constitutional symptoms 
 have seldom been severe. Now and then, however, considerable 
 febrile disturbance precedes the appearance of the jaundice for two or 
 three days ; the skin is dry, though not very hot ; vomiting occurs ; 
 and the child complains much of headache and dizziness, and rests ill 
 at night, or awakes in a state of alarm. The resemblance between 
 these symptoms, and some of those which occur in cases of real cere- 
 bral disease, is almost sure to excite much apprehension in the mind 
 of the parents, and may even render it a difficult task for you to form 
 a correct diagnosis. The following circumstances will, however, usu- 
 ally suffice to preserve you from error : the attack has not, in most 
 instances, been preceded by those indications of generally failing 
 health which so often exist during many days before the symptoms of 
 tubercular meningitis manifest themselves, and it is not attended either 
 by the anxious expression of countenance, the heat of head, or the 
 intolerance of light, by which cerebral disease is accompanied. Though 
 the sleep may be disturbed, it is usually less so than in tubercular 
 meningitis ; the pulse is less frequent ; and though the child vomits 
 occasionally, it does not suffer from constant nausea. When to these 
 symptoms tenderness on pressure in the hypochondriac region is super- 
 added, with the appearance in a day or two of high-colored urine and 
 of white evacuations, and lastly, of the yellow tinge of the skin, no 
 further possibility of error remains. 
 
 The treatment of jaundice in the child calls for but very simple 
 remedies. The employment of small doses of the sulphate of magnesia, 
 in combination with the tincture of rhubarb, every four or every six 
 hours, with three grains of the Hyd. c. Creta for a child of five years 
 old, at bed-time, will generally suffice to restore the patient to health 
 in the course of four or five days. Should the appetite continue bad, 
 and the child fretful and languid, after the subsidence of the jaundice 
 and the return of the evacuations to a more healthy character, the 
 compound infusion of roses, either alone or in combination with small 
 doses of sulphate of magnesia, will be found of much service. In 
 some cases, however, removal to the country, or to the seaside, appears 
 to be absolutely necessary to the child's complete recovery. 
 
 Far more frequent than cases of actual jaundice, are instances of 
 what is popularly termed sluggish liver in children, in which the 
 bowels are usually constipated, and the evacuations almost always pale 
 and deficient in bile. Without being positively ill, children thus 
 affected are usually sallow and look out of health j their appetite is 
 
506 TREATMENT OF JAUNDICE IN CHILDREN. 
 
 variable, and their tongue never quite clean, but slightly coated with 
 yellowish fur. In such cases it not infrequently happens that mer- 
 curials become almost a domestic remedy, and that calomel is the 
 aperient constantly resorted to as often as the costive bowels require 
 the employment of medicine. Other cases, too, of a somewhat differ- 
 ent kind are not unusual, in which calomel is again considered the 
 panacea. They are the cases of children, for the most part somewhat 
 older than those who constitute the former class, whose general health 
 is good and their bowels are usually regular, but who, every few weeks 
 or months, are attacked by a severe headache accompanied by bilious 
 vomiting which lasts for several hours, and then subsides, leaving the 
 patients in a state of extreme exhaustion, from which they do not re- 
 cover for many days. 
 
 Cases of this latter class are far less serious than the others. They 
 are for the most, part instances of congestion of the liver, brought on 
 either by some error in diet, or, as is far more commonly the case, by 
 a system of habitual overfeeding. It is by no means necessary for 
 the production of these symptoms that the food should be improper, 
 or that its quantity should be very excessive, but it quite suffices that 
 it should be a little in excess of the actual necessities of the system, 
 and of the power of the digestive organs to assimilate. In these cases 
 there can be no sort of objection to the administration of a dose of 
 calomel to arrest the sickness, and by its purgative action to assist in 
 relieving the liver ; but it is the careful regulation and due restriction 
 of the diet which will alone prevent the frequent recurrence of the 
 attack. 
 
 Cases of the other kind are by no means so simple. They are met 
 with in delicate children : often in those in whose family there exists 
 some taint of scrofulous or tubercular disease ; and in them not infre- 
 quently the symptoms of habitual intestinal disorder, and deficiency 
 of the biliary secretion, become at last merged in the signs of general 
 tuberculosis or of tabes mesenterica. I do not know what is the actual 
 state of the liver in these cases, but I am sure that the empirical 
 recourse to mercurials, which do but remove for a short time some of 
 the symptoms of a deepseated constitutional disorder, is not a judici- 
 ous proceeding. In a large proportion of instances, indeed, with 
 increased health and strength, there comes almost spontaneously an 
 improved state of digestion and a more efficient performance of the 
 functions of the liver. And to this amendment of the general health 
 our first endeavors must in these circumstances be directed, — air, situa- 
 tions, climate ; all those points to which in cases of threatening tuber- 
 cular disease our attention is always turned, are here, too, of far more 
 importance than mere medicine, though that of course cannot be dis- 
 pensed with. I often find the nitro-muriatic acid 1 specially service- 
 able, both as a tonic, and also as a remedy which acts upon the liver 
 and increases the secretion of bile; while, if an aperient is needed, the 
 powdered aloes, or powdered extract of rhubarb, will either enable us 
 to dispense with mercurials altogether, or at least will allow us to give 
 
 1 See Formula No. 22, p. 426. 
 
CONSTIPATION FROM MALFORMATION OF INTESTINES. 507 
 
 them in smaller doses than otherwise we should be compelled to em- 
 ploy. Sometimes, however, this treatment seems of no avail, and we 
 are compelled to put the patient on a regular course of mercurials. 
 This has seemed to be best done by the employment of small doses of 
 the perchloride of mercury ; not alone, but in combination with the 
 infusion of bark, or the Liquor Cinchonas, and Liquor Taraxaci ; ] and 
 from the steady continuance of this treatment I have seen recovery 
 take place, even where little appeared to promise a favorable issue. 
 The danger of tuberculosis is the one great risk which in these cases 
 must be borne in mind ; low diet, violent purgatives, must be avoided, 
 and the constitutional symptoms rather than the mere amount of dis- 
 order of the functions of the liver must govern our prognosis and regu- 
 late our conduct. 
 
 I have nothing to add to what has already been said on the subject 
 of constipation — which is to be regarded as a symptom of various 
 diseases rather than as a special idiopathic affection. To this rule, 
 however, an exception must be made in those cases in which the due 
 action of the bowels is prevented by some mechanical impediment. 
 Such an impediment is, in some rare instances, presented by congenital 
 malformation of the intestines, whose calibre has been found greatly 
 diminished, or their canal completely obstructed, or even their conti- 
 nuity altogether interrupted. These occurrences, although of great 
 interest and importance, from their relation to the laws that regulate 
 foetal development, yet for the most part afford no scope for the interfer- 
 ence of medical or surgical skill. But while we pass over, as foreign 
 to our purpose, the general study of these malformations, we must take 
 some notice of one variety of them, in which the obstacle to the escape 
 of the faeces is situated low down in the large intestine, since their 
 diagnosis is often easy, and their cure not always beyond the resources 
 of our art. 
 
 The cause of the obstruction in these cases is not always of the same 
 kind, nor is the patient in every instance exposed to the same amount 
 of danger. But three different classes of the malformation may be 
 recognized, in each of which our prognosis must somewhat differ, 
 although in almost all it must be doubtful, and in many extremely 
 unfavorable. 
 
 To the first class may be referred all those cases in which the rectum 
 is perfect, but the canal is closed either by a false membrane obstruct- 
 ing its orifice, or situated higher up in the intestine, or by the cohesion 
 of the opposite sides of the gut. 
 
 The second class includes cases in which, although the natural aper- 
 
 1 (No. 29.) 
 " R. Liq. Hydr. Perehlor., gj. 
 Liq. Taraxaci, gij. 
 Liq. Cinchona?, ^j. 
 Tinct. Aurantii, ^j. 
 Syrupi, ^iij. 
 Aqua? destil., Bjiij. M. 
 A tablespoonful twice a day for a child three years old. 
 
508 MALFORMATION OF LARGE INTESTINE. 
 
 ture is absent, yet the intestine terminates by opening into the urethra, 
 bladder, or vagina. 
 
 To the third class belong those instances in which the intestinal 
 canal is not merely occluded, but also malformed, or altogether absent 
 for a more or less considerable extent. 
 
 The affection in any form is so rare as to render a correct estimate 
 of the comparative frequency of its varieties by no means easy. Dr. 
 Collins observed only one instance of it out of 1 6,654 children born in the 
 Dublin Lying-in Hospital during his mastership ; 1 and Dr. Zohrer, of 
 Vienna; 2 mentions that he met with it only twice out of 50,000 new- 
 born children. A comparison of seventy-five cases derived from differ- 
 ent sources yields seventeen belonging to the first class, twenty-nine to 
 the second, and twenty-nine to the third ; but it is probable that many 
 instances of simple closure of the anus have passed unrecorded, while 
 all the instances of more serious malformation have been described. 
 
 Whatever be the seat of the obstruction, its existence is betrayed by 
 much the same train of symptoms in all cases. Attention is first excited 
 by the infant not having voided any meconium, although from twelve 
 to twenty-four hours may have elapsed since its birth. A dose of 
 castor-oil or of some other aperient, given with the view of exciting 
 the bowels to action, fails of producing this effect, while it is either 
 returned by vomiting, or, if not actually rejected, it causes nausea and 
 retching. Before long, the child shows indications of uneasiness, and 
 has attacks of pain, in which it cries, and seems to suffer much. In 
 some cases it remains quiet in the interval between these attacks, and 
 seems drowsy, but in other cases it appears to be in a state of constant 
 discomfort, which it betrays by a whimpering cry. The attempt to 
 suck is almost always followed by retching, frequently by actual vomit- 
 ing ; and attacks both of retching and vomiting often come on when 
 the stomach is quite empty. In some cases nothing more is thrown 
 up than a little mucus, which is sometimes of a greenish color; while 
 in other instances vomiting of meconium takes place : but this occur- 
 rence is by no means constant. The abdomen becomes distended and 
 tympanitic, and grows larger and more tense the longer that life con- 
 tinues, while at the same time the child's discomfort is much aggra- 
 vated by any pressure upon it. The restlessness increases, and the 
 attacks of pain grow more severe, the child often making violent 
 straining efforts during their continuance ; but as the powers of life 
 decline, these efforts become more feeble, though the retching and 
 vomiting often continue to the last: The period at which death takes 
 place varies much, for though, in the majority of instances, the child 
 dies within a week from its birth, yet cases are on record in which it 
 has survived for several weeks ; and an instance has been mentioned 
 to me by Mr. Arnott, in which he saw a child live for seven weeks 
 and three days, although the colon terminated in a blind pouch, and 
 the rectum was entirely absent. Death usually occurs under a gradual 
 
 1 System of Midwifery, p. 509 
 
 2 OesteiT. med. Wochenschr. and Canstatt's Jahresber. fur 1842, Bd. i, S. 456. 
 
MALFORMATION OF LARGE INTESTINE. 509 
 
 aggravation of the previous symptoms ; but now and then it is ushered 
 in by the sudden supervention of a state of collapse, owing to the over- 
 distended intestine having given way. This is, however, a rare occur- 
 rence, for I find mention of it having happened only in three out of 
 the seventy-five cases to which I have referred. 
 
 Coupled with the general signs of intestinal obstruction, there are in 
 each case some special indications of the peculiar form of malformation 
 to which the obstruction is due. If the anus is merely closed by a 
 membrane or by the cohesion of its edges, the collection of the meco- 
 nium above may give rise to the formation of a distinct tumor between 
 the buttocks ; while sometimes the dark color of the meconium shows 
 through the thin integument by which its escape is prevented. In 
 other cases the anus itself is well formed, but the introduction of the 
 finger or of a bougie into the rectum detects the existence of some 
 obstruction within the gut. Again, in other instances, there is no 
 trace of an anus, or a small depression is all that marks the situation 
 which it should occupy ; the rectum either ending in a blind pouch, 
 or communicating with the vagina, urethra, or bladder. 
 
 Although the diagnosis in all cases is sufficiently easy, yet the carry- 
 ing out the very obvious indication of relieving the patient, by pro- 
 viding for the escape of the contents of the intestines, is often very 
 difficult; and even, when accomplished, its result is in many instances 
 extremely uncertain. If the obstruction is situated at the orifice of the 
 anus, a crucial incision through the membrane which closes it or the 
 introduction of a trocar, will afford immediate relief. Our prognosis 
 also may, in these circumstances, be very favorable ; for of fifteen cases 
 of this kind, all but one had a favorable issue. After the opening has 
 beeu established, however, some attention must be paid to prevent its 
 becoming closed, or much contracted. For this purpose it has been 
 recommended that a tent should be kept in the anus for some days, 
 though to this it has been objected that a constant straining effort is 
 thereby produced, and the frequent introduction of the finger or of a 
 bougie into the passage is therefore recommended, as preferable to 
 leaving any body constantly within it. 1 
 
 If the obstacle is occasioned by a membrane seated higher up in the 
 rectum, we may still hope to succeed, though our prognosis must be 
 more guarded, since two out of four cases of this description had a 
 fatal result. In one of the fatal cases it appeared that rupture of the 
 intestine had already taken place before any operation was performed ; 
 in the other, the death of the child was accounted for by the discovery 
 
 1 I may just mention having seen great pain and difficulty in defecation pro- 
 duced in an infant aged seven months by congenital smallness of the anal opening. 
 For the first three months of life the child had not suffered from this condition, but 
 afterwards, when the motions began to be slightly more consistent, constipation 
 became very troublesome, defecation difficult, painful, and attended by great tenes- 
 mus, while the evacuations were not infrequently streaked with blood. The open- 
 ing admitted the finger with difficulty, and its edges tightly constringed it, while 
 the rectum above was much dilated, and permanently distended with faeces. The 
 daily employment of a bougie relieved the inconvenience, which I refer to here 
 only on account of its rarity. 
 
510 OPERATIONS FOR CURE OF IMPERFORATE RECTUM. 
 
 of a second septum higher up in the rectum than that which had been 
 divided. 
 
 The existence of an anus, and a small extent of gut above it, although 
 a decidedly favorable feature in a case, does not warrant quite so hope- 
 ful a prognosis as we might in the first instance feel disposed to adopt. 
 The probabilities, indeed, are that the distance is not great between the 
 end of the rectum and the cul-de-sac in which the anus terminates ; yet 
 a considerable space may intervene between the two, or, as in a case 
 which Mr. Arnott was so good as to communicate to me, the rectum 
 may be found altogether absent, the colon terminating in a blind ex- 
 tremity, and floating loose in the abdominal cavity. In the majority 
 of instances, the two blind pouches are connected together by the inter- 
 vention of an eighth or a quarter of an inch of dense cellular tissue, 
 which sometimes presents an almost ligamentous character ; and in some 
 cases the end of the large intestine is situated anterior to the extremity 
 of the cul-de-sac that leads from the anus. Owing to this latter circum- 
 stance, the operation for the relief of this condition has sometimes failed ; 
 the instrument, although introduced deep enough, yet passing behind 
 the distended bowel. Out of nine cases of this kind, eight had a fatal 
 termination; the bowel on four occasions not having been reached at all ; 
 while once the opening made in it was too small to allow of the free 
 escape of the meconium. It may be added, that in three of the fatal 
 cases there existed such contraction of the calibre of different parts of 
 the large intestine as would of itself have opposed a serious obstacle to 
 the child's recovery. 
 
 In twelve cases the anus was absent, and in some of these instances 
 no trace of it existed, while the rectum terminated in a cul-de-sac at 
 from one to two inches from the surface. In five of these cases the 
 attempt to open the intestine was successful, and the child eventually 
 did well ; while in two other cases, although temporary relief followed 
 the operation, yet symptoms of inflammation of the bowels came on, 
 which terminated fatally in the course of a few days. In three instances 
 it was not found possible to reach the bowel ; and in two others, although 
 an opening was made, yet its size was insufficient to afford a free vent 
 to the accumulated meconium ; and the fatal issue, though deferred, was 
 not prevented. Failure to reach the intestine seems to have depended 
 either on the trocar not having been introduced sufficiently deep, or on 
 its having been directed too far backwards. The danger of hemorrhage, 
 or of wounding the bladder, of which some operators seem to have been 
 apprehensive, is not much to be feared ; for I find but one instance on 
 record in which the bladder was accidentally Avounded, and not one of 
 fatal or even of serious hemorrhage. Better success also appears to 
 have been obtained in those cases in which a sufficiently deep and free 
 incision was made with a bistoury in the direction of the rectum, than 
 in those in which a trocar was at once introduced. The suggestion of 
 M. Amussat, that in these cases the blind sac of the intestine should be 
 drawn down, and its cut edges attached by sutures to the margin of the 
 external skin, in order to prevent the infiltration of fecal matter be- 
 tween the end of the rectum and the wound in the integuments, and to 
 
OPERATIONS FOR CURE OF IMPERFORATE RECTUM. 511 
 
 diminish the clanger of the aperture closing, is worth bearing in mind. 
 It was adopted with apparent advantage by Mr. Waters in a case of 
 this kind recorded by him in the Dublin Journal for May, 1842, on 
 which he operated with success ; and I was a witness to its advantages 
 in a little boy on whom Mr. Shaw operated successfully some years 
 since at the Middlesex Hospital. 
 
 Several years ago I was present at the post-mortem examination of 
 a child, aged fourteen months, whose history illustrated very forcibly 
 the importance of the precaution to which I have just referred. The 
 rectum was imperforate at birth, though an anus existed. Relief was 
 readily afforded by puncture with a trocar, but no attempt was made to 
 bring down the intestine to the edges of the opening. The child soon 
 passed from under observation, and when seen again, it was asserted 
 that no evacuation had taken place for a month, and that for a long 
 time constipation had been growing more and more obstinate. The 
 child died speedily : its abdomen being enormously distended both with 
 faeces and flatus. The circular fibres of the large intestine had under- 
 gone the most extraordinary hypertrophy ; doubtless to enable them to 
 overcome the resistance offered to the expulsion of their contents ; a task 
 to which at last they had proved unequal. This resistance was seen to 
 be due to the contraction of the original opening just above the anus, 
 while the intestine was quite permeable beyond ; a misadventure which 
 might have been obviated by care in the performance of the operation, 
 and by watchfulness afterwards. 
 
 Beside these cases in which the malformation was confined to the 
 rectum, I find mention of three others in which the rectum Vas en- 
 tirely absent, and the intestine terminated in a cul-de-sac as high up 
 as the colon. In two other cases in which the attempt to discover the 
 rectum failed, the life of the child was preserved by the establishment 
 of an artificial anus. M. Amussat has of late recommended that, in 
 all cases in which fluctuation cannot be detected through the skin, an 
 artificial anus should at once be formed in the left lumbar region, as 
 being a safer proceeding than the attempt to open the bowel from the 
 perineum. When we consider, however, the loathsome nature of the 
 infirmity to which a person is condemned in whom an artificial anus 
 exists, we shall probably be disposed still to regard the operation for 
 its formation as a last resource, to be employed only in the event of 
 our failing to discover the rectum by an operation instituted on the 
 perineum. 
 
 In some cases, although the anus is absent, yet the intestine is not 
 imperforate, but opens either into the vagina in the female, or into the 
 bladder or urethra in the male subject. In either case the malforma- 
 tion is due to a similar cause — namely, an arrest of development, 
 whereby the separation between the bowel and the sinus uro-geni talis 
 has never been completed. The malformation in the female subject is 
 not attended with immediate danger to life, and fortunately it admits 
 of cure in the great majority of instances. I find, indeed, that in seven 
 out of ten cases of this description, an operation was attempted, and 
 that in every instance it proved successful. In some cases the mere 
 establishment of the natural opening of the anus, with the introduction 
 
512 OPERATIONS FOR CURE OF IMPERFORATE RECTUM. 
 
 of a tube into the rectum, was sufficient to effect a cure; but a more 
 complex operation was in general necessary, the principle of which con- 
 sisted in dividing all the parts from the vagina into the rectum ; though 
 the details of the proceeding, and the means whereby a reunion of the 
 two canals was prevented, varied in different cases. 
 
 The result is very much more unfavorable when a communication 
 subsists between the intestine and the bladder or urethra in the male ; 
 for eight out of eleven cases of the former kind, and the same number 
 out of nine of the latter kind, ended in the death of the infant. The 
 connection with the bladder is generally established by means of a 
 very slender canal which enters that viscus at or near its neck ; but in 
 one instance in which the rectum w r as wanting, fche colon terminated 
 by opening with a wide aperture into the upper part of the bladder. 
 A slender duct is likewise the usual channel of communication between 
 the rectum and the urethra, and this duct generally enters the mem- 
 branous portion of the urethra, just in front of the prostate. Cruveil- 
 hier, however, met with an instance in which the rectum opened under 
 the glans penis ; and a somewhat similar case, in which there was a 
 small aperture through which meconium passed in front of the scrotum, 
 came under the notice of Mr. South, and is mentioned by him in his 
 edition of Chelius's Surgery. 
 
 The existence of a communication between the rectum and the ure- 
 thra or bladder is generally indicated by the urine voided being 
 tinged with meconium; but it seldom happens that the contents of the 
 intestines are discharged by the urethra with freedom sufficient to pre- 
 serve thk child from the suffering and danger that attend upon an im- 
 perforate state of the rectum. Even when life has been prolonged for 
 some time, yet the infant's death is in general merely deferred, for 
 the symptoms of obstruction appear, and at length prove fatal, after 
 the faeces have acquired a firmer consistence than they possessed during 
 the first few months of existence. These cases, too, do not appear to 
 be favorable for an operation, since the rectum usually terminates high 
 up, and in five out of ten cases in which it is stated that the attempt 
 was made to puncture the intestine, this attempt was unsuccessful. In 
 Mr. South's case the rectum was punctured by a trocar introduced an 
 inch deep, and though much difficulty was experienced in keeping the 
 passage free, yet the child survived and grew up to manhood. Of the 
 other two successful cases, one of which is recorded by Mr. Miller, 1 and 
 the other . by Sir W. Fergusson, 2 both were cured only with much 
 trouble and difficulty. For a full account of the difficulties these gen- 
 tlemen had to contend with, and the means by which they overcame 
 them, I must refer you to the history of the cases in the Edinburgh 
 Medical Journal. A third successful case has since been recorded by 
 the late Professor Wutzer, of Bonn, 3 in which there was no trace of 
 anus, and the incision was carried an inch and three-quarters before 
 the intestine was reached. I saw the child in this case when nine 
 
 1 Edinburgh Medical and Surgical Journal, No. 98, p. 61. 
 
 2 Ibid., vol. xxxvi, p. 363. 
 
 3 Kheinische Monatschrift fur praktische Aerzte, June, 1851. 
 
INTUSSUSCEPTION OF THE INTESTINES. 513 
 
 months old; he was a healthy infant, and passed his evacuations gener- 
 ally per rectum, though a small quantity of fieces was still frequently 
 intermixed with his urine. 1 
 
 An insuperable obstacle to the action of the bowels may occur in 
 children, just as it sometimes does in older persons, either from the 
 stranr/u/ation of an external hernia, or from the invagination of a portion 
 of intestine. Although hernia is by no means an uncommon affection 
 in early life, yet it is, I believe, a very rare occurrence for the intestine 
 to become strangulated. Such an accident, however, may take place, 
 even in very young infants, of which a case related by Sir W. Fergiis- 
 son, where he operated for strangulated inguinal hernia on an infant 
 only seventeen days old, may be mentioned as a striking illustration. 
 Bearing in mind its possibility, therefore, you would examine any in- 
 fant or child, in whom abdominal pain, vomiting, and obstinate con- 
 stipation came on, just as carefully as you would an adult in similar 
 circumstances, lest it should be found out, when too late, that the symp- 
 toms had been due to some unsuspected external hernia. 
 
 The strangulation of an external rupture is probably a rarer acci- 
 dent in early infancy than the occurrence of intussusception of one or 
 more portions of the intestines. This condition, indeed, is frequently 
 met with in the bodies of children who have died of various diseases, 
 and wholly independent of any symptoms of disorder of the bowels 
 during the patient's lifetime. Sometimes a single intussusception ex- 
 ists, but oftener there are several ; ten, twelve, and even more, have 
 occasionally been observed in the same subject. They are almost in- 
 variably confined to the small intestine, are most numerous in the 
 ileum, and though seldom involving more than three or four inches, 
 have been found to include more than double that extent of bowel. 
 Their great frequency, the absence of any symptom of them during 
 life, and of any indication of inflammation about the intestines after 
 death, all confirm the general opinion that they take place during the 
 act of dying. 
 
 But while this form of intussusception, limited to the small intestine, 
 and producing no symptoms during life, is extremely common in early 
 childhood, few accidents are rarer than the invagination of the large 
 intestine, so that MM. Billiet and Barthez state that they have not 
 met with it even once in 500 post-mortem examinations of children 
 between the ages of two and fifteen years. In early childhood, the 
 various causes which in the adult may produce insuperable obstruction 
 of the bowels seem not to exist ; and our diagnosis is made easier, I 
 think that I may even say our prognosis less absolutely hopeless, from 
 a knowledge of the fact that the symptoms of intestinal obstruction in 
 the infant point almost invariably to invagination of the large intestine. 
 
 Children in whom intussusception takes place are generally infants 
 
 1 I cannot do better than refer, for a detail of all the important surgical questions 
 involved in cases of imperforate anus, to Mr. Curling's able treatise on Diseases of 
 the Eectum, 2d ed., London, 1863, pp. 192-232; as also to Holmes, Surgical Treat- 
 ment of Diseases of Infancy and Childhood, 2d ed. London, 1869, pp. 152-180; 
 Guersant, Notices sur la Chirurgie des Enfans, 8vo., Pari--, 1867, pp. 196-201; and 
 Giraldes Maladies Chirurgieales~des Enfans, 8vo., Paris, 1868, pp. 118-139. 
 
 33 
 
514 SYMPTOMS OF INTUSSUSCEPTION. 
 
 under a year, often under six months old. 1 Their previous history 
 does not in general display any liability either to constipation or to 
 diarrhoea; nor, in the greater number of instances, has the manifesta- 
 tion of the symptoms followed the administration of any aperient medi- 
 cine. Sudden and violent vomiting, followed by loud cries and other 
 indications of uneasiness, which, ceasing for a time, return at uncertain 
 intervals, and are accompanied by violent straining, and efforts to empty 
 the bowels, are the earliest symptoms of the accident. At first some 
 faeces are voided during these efforts, but afterwards the matters dis- 
 
 1 Nine cases of intussusception have come under my own notice, of which 4 re- 
 covered, 5 died. 
 
 The 4 recoveries were 
 
 The 5 deaths were 
 
 1 Male, aged 6 months. 
 1 Female, " 6 " 
 1 Male, " 14 " 
 1 Female, *' 10 years. 
 
 1 Male, aged 4 months, who died in 36 hours. 
 
 1 Female, " 6 " " " 48 " 
 
 1 Female, " 8 years u " 18 davs. 
 
 1 Female, » 12 " " " 9 " 
 
 1 Male, " 3 " " " 3 months. 
 
 The two male children recovered under a soothing treatment, with a careful 
 avoidance of aperients ; the elder of the female children recovered under the use of 
 inflation of the intestine by the rectum ; while in the younger the invagination 
 yielded. to the copious injection of warm water after inflation had been tried with- 
 out success. The two youngest of the fatal cases were moribund when they came 
 under my notice. In the child twelve years old the intussusception affected three 
 inches of the small intestine about a foot above the ileo-caecal valve ; and in 
 the one aged 8 years, 7 inches of the small intestine were invaginated through 
 the valve. The case of the boy was very singular, for the whole of the, large intes- 
 tine was invaginated, so that during the expulsive efforts which the child made, the. 
 inverted caecum with the opening of the appendix Vermiformis was protruded beyond 
 the anus, while the finger could be passed by the rectum through theileo-ea?cal valve, 
 and the large intestine was for all practical purposes abolished. Death took place 
 at last from peritonitis. The case was under my observation for only three days 
 before the patient's death. 
 
 The most complete statistics of this condition are furnished by Rilliet, in his 
 valuable essay published originally in the Gazette des Hopitaux, 1852, but reprinted 
 at p. 806 of the 2d ed., of the 1st vol., of his work on Diseases of Children ; by M. 
 Duchaussoy, in vol. xxiv, of the Memoires de l'Academie de Medecine, 1860; and 
 lastly in the verj^able paper of Dr. Smith, of New York, published in the American 
 Journal, January, 1862. and reproduced in his work on Children's Diseases, of which 
 the 2d edition, published in 1872, is now before me. Deducting those cases which 
 are common to his table and M. Rilliet's, and also 3 in which no age is given, and 
 adding my 9 cases, we have a total of 71 cases in children under 15, of which 40 
 occurred during the first year of life, 31 in the succeeding 14 years. 
 
 2 were between 1 and 2 years old. 
 «• 2 5 " " 
 
 " 5 15 " " 
 
 3 were 
 
 under 
 
 3 
 
 mon 
 
 ths 
 
 old. 
 
 2 
 
 11 " 
 
 « 
 
 4 
 
 (< 
 
 
 1 1 
 
 11 
 
 3 » 
 
 a 
 
 5 
 
 u 
 
 
 « 
 
 18, 
 
 9 " 
 
 it 
 
 6 
 
 a 
 
 
 (< 
 
 — 
 
 4 » 
 
 a 
 
 7 
 
 a 
 
 
 n 
 
 31 
 
 2 " 
 
 u 
 
 8 
 
 a 
 
 
 a 
 
 
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 9 
 
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 " 
 
 10 
 
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 u 
 
 11 
 
 a 
 
 
 a 
 
 
 1 « 
 
 a 
 
 12 
 
 a 
 
 
 u 
 
 
 40 
 
SYMPTOMS OF INTUSSUSCEPTION. 515 
 
 charged from the bowels are either mucus tinged with blood, 1 or else 
 pure blood, and that sometimes in considerable quantities. If an enema 
 is given, the fluid thrown up immediately returns, it appearing not 
 properly to enter the intestine ; while on a few occasions the existence 
 of an obstruction has been discovered on introducing the finger into the 
 rectum. The vomiting is almost immediately renewed whenever either 
 food or medicine is given, but fecal matters are seldom if ever dis- 
 charged by the mouth. The child has intervals of quiet, from which 
 it is roused by the returns of pain ; it is often thirsty, and though the 
 sickness continues unabated, yet it seems eager for the breast, and sucks 
 frequently. The condition of the addomen is variable; and though a 
 distinct tumor may be detected in some cases, at a spot which is found 
 afterwards to correspond to the situation of the intussusception, yet it 
 happens, in at least as large a number of instances, that the most care- 
 ful examination fails to detect anything unnatural in its state, and that 
 it continues uniformly soft up to the time of the patient's death. The 
 continuance of the intussusception leads to the exhaustion of the in- 
 fant's strength ; its pulse grows more and more feeble, its face becomes 
 anxious and sunken, and it falls in the intervals between its attacks of 
 pain into a quiet, half-comatose condition. In the majority of cases 
 convulsions come on a few hours before death, which always takes 
 place within a week, oftener in from forty-eight to seventy-two hours. 
 Now and then, however, instead of going on from bad to worse, the 
 symptoms abate, the pain ceases, the vomiting subsides, the bowels act 
 spontaneously, and were the indications of invagination less character- 
 istic, we might, on seeing the speedy and complete recovery of the 
 patient, almost doubt whether our first diagnosis had not been errone- 
 ous. Such a case was that of a little boy fourteen months old, well- 
 nourished and previously healthy, who was suddenly attacked, at 5 
 A.M., on June 12, 1855, by pain and sickness. He at that time passed 
 one fecal motion, but the pain continued, and at 8.30 A.M., he voided 
 a second, which consisted of pure blood. At 10 A.M. I saw him ; he 
 looked very ill, his face w T as extremely anxious, he shivered sometimes, 
 the pain returned at intervals, and he was still frequently sick. The 
 abdomen was neither full nor tender except in the csecal region, where 
 there was a firm oblong tumor, about the size of a hen's egg, very ten- 
 der to the touch. A linseed poultice was applied over the abdomen, 
 hydrocyanic acid was given to allay the sickness, and the child was 
 allowed only a very small quantity of drink at a time to allay the 
 thirst, which was very urgent. In eight hours the child was better, 
 the bowels had acted twice spontaneously, and but very little blood 
 was contained in the evacuations. On the next morning all traces of 
 the tumor had disappeared, and the abdomen was equably soft and tol- 
 erant of pressure ; and no symptom recurred from this time to excite 
 any apprehension. 
 
 Another somewhat similar case came under my notice in a child 
 
 1 The credit of drawing attention to the value of the intestinal hemorrhage in 
 these cases as a sisrn of intussusception, belongs to Mr Gorham, who^e essay on this 
 affection, in No. 7 of the Guy's Hospital Reports, may be consulted with profit. 
 
516 TREATMENT OF INTUSSUSCEPTION. 
 
 aged six months, in whom symptoms equally characteristic, with the 
 exception of the abdominal tumor, which* was not present, likewise 
 ceased spantaneously. Such a result is nevertheless not to be generally 
 looked for, and M. Billiet states the results of fifteen cases occurring 
 in children between four months and four and a half years of age to 
 yield ten deaths to five recoveries. 
 
 The treatment of intussusception in the child must be conducted on 
 the same principle as would govern our conduct if the patient were an 
 adult, though, as the symptoms enable us to arrive at a tolerably cer- 
 tain knowledge of the nature of the case earlier in the infant than in 
 the grown person, we should be absolutely without excuse if we were 
 to persevere in the use of active purgatives in order to overcome the 
 constipation. It was during the suspension of the active remedies 
 which had been previously employed, that the second of the two cases 
 which I have referred to took a favorable turn ; and the studious 
 avoidance of any other than soothing measures was succeeded by the 
 spontaneous disappearance of the symptoms and removal of the abdom- 
 inal tumor in the other. I should regard the supervention of the 
 symptoms of intussusception as calling for the immediate discontinu- 
 ance of all aperient medicines administered by the mouth; and for the 
 steady adoption of a soothing plan of treatment. Warm poultices to 
 the abdomen, hydrocyanic acid, for the sake not merely of its power in 
 allaying sickness, but also of its generally sedative properties, and 
 the administration of opium in small doses to control the pain and 
 allay the spasm, would be the remedies to which I should trust, while 
 I should insist on all food being given in extremely small quantities. 
 If at the end of twelve or at most of twenty-four hours, the symptoms 
 had not disappeared, I should without further delay resort to the in- 
 flation of the intestine with air, as a means of mechanically unfolding 
 the invagination likely to be more effectual than the employment of 
 large enemata, which yet in some instances, one of which came under 
 my own observation, has proved successful. In three of the cases 
 which have come under my own observation, inflation was resorted 
 to ; in one (that to which Sir T. Watson has referred in his Lectures) 1 
 it was followed by the disentanglement of the involution, and the 
 child's recovery ; in a second, after its failure, the abundant injection 
 of warm water was successful ; while, in a third, where the small in- 
 testine w T as concerned, the experiment, as might be expected, was un- 
 successful, and the child died. In infancy, however, by far the larger 
 proportion of cases of intussusception affect the large intestine only ; 
 and it is especially in infants under the age of one year that the experi- 
 ment of inflation has proved successful. But even in older children, 
 as the case just mentioned shows, life has sometimes been saved by its 
 employment ; and it is by an oversight, which I notice only on account 
 of its rarity, that Mr. Holmes, in his valuable work on " Surgical 
 Diseases of Children/' 2 refers to it as an " idea/' and speaks of its 
 results as " imaginary."" 
 
 With reference to the question of surgical interference, I know of no 
 
 1 5th ed , vol. ii, p. 553. 2 2d ed., 1869, p. 569. 
 
DIARRHCEA. 517 
 
 observations on the child that tend specially to elucidate it. One 
 point, however, deserves consideration ; namely, that as in infancy the 
 seat of the obstruction is almost invariably in the large intestine, the 
 uncertainty as to the possibility of liberating it which, in the adult, 
 often causes hesitation, does not beset us here. I am not acquainted 
 with any data from which to determine the comparative risks of gas- 
 trotomy at different periods of life ; but it is not without moment to 
 know that the detachment of the invaginated portion of bowel, and 
 subsequent recovery of the patient, which now and then happen in the 
 adult and in the child, appear never to occur in the infant, who sinks 
 before such processes have time to take place. 
 
 LECTUEE XXXYI. 
 
 Diarrhoea. — Its two forms, the simple and the inflammatory — Causes of the affoc- 
 ♦ tion — Influence of age — Of process of dentition — Of temperature, and season of 
 the year. 
 
 Symptoms of simple diarrhoea — Not usually a dangerous affection — Occasional 
 hazard from great exhaustion that it produces — Cessation of purging sometimes 
 independent of real amendment — Danger of secondary diarrhoea. 
 
 Inflammatory diarrhoea. — Occasional want of correspondence between the symptoms 
 and morbid appearances — Latter observed chiefly in large intestine — Very simi- 
 lar to those discovered in dysentery of the adult. 
 
 Symptoms of inflammatory diarrhoea. — Occasional disturbance of nervous system at 
 the outset — Progress of the disease — Its tendency to a chronic course. Life 
 sometimes cut short by intercurrent bronchitis — By head symptoms — By relapse 
 after temporary amendment. 
 
 Iisua systematic course of lectures like the present, subjects of very 
 various interest and importance come successively before us. We 
 were engaged yesterday in the study of some affections which for- 
 tunately are of very rare occurrence ; but to-day we pass to the ex- 
 amination of one of the most common, and at the same time one of 
 the most serious disorders of infancy and childhood. The importance 
 of diarrhoea in early life indeed, is not to be estimated merely by the 
 number of deaths which our tables of mortality represent it to have 
 occasioned ; for the figures that they display would Avarrant our dis- 
 missing it with a comparatively short notice. 1 But we shall come to a 
 very different conclusion, if we consider the frequency of the affection, 
 and the slight causes which often suffice to induce it ; the dangers to 
 
 1 According to the Fifth Report of the Registrar-General, the deaths in London 
 from diarrhoea, dysentery, and cholera, as compared with the total deaths from all 
 ascertained causes, were, in children under one year old, in the proportion of 3 9 per 
 cent. ; between one and three 2.3 per cent. ; from three to five, 6 per cent. ; from five 
 to ten, 1.1 per cent.; and from ten to fifteen, 1 per cent. 
 
518 
 
 CAUSES PREDISPOSING TO DIARRHCEA, 
 
 health which result from its long continuance ; and the greatly increased 
 hazard to which its supervention in the course of some other disease 
 exposes the patient. 
 
 Under the common name of diarrhoea, many of the older writers on 
 the diseases of children have included all cases, without distinction, 
 in which there is an unnatural increase in the alvine discharges. On 
 the other hand, some among the moderns, rejecting the word diarrhoea 
 from their medical nomenclature, have treated only of certain inflam- 
 matory affections of the intestines of which they believe the flux to be 
 symptomatic. Neither of these arrangements, however, is free from 
 objection, for while the former draws no. adequate distinction between 
 cases in wmich the disorder of the functions of the bowels is the result 
 of some accidental and temporary cause, and others in which it is the 
 consequence of organic disease, the latter involves an attempt to dis- 
 tinguish, on purely anatomical grounds, between affections which present 
 the same symptoms and require the same treatment. 
 
 In the present state of our knowledge, it will perhaps be the safer 
 way to attempt no further subdivision than into the two grand classes 
 of simple diarrhoea, or catarrhal diarrhoea as it has been termed by some 
 writers, and inflammatory diarrhoea, qy dysentery. Even in this arrange- 
 ment it must be confessed that there is something arbitrary, for the two 
 affections are closely allied to each other. In the child, as in the adult, 
 they often prevail at the same time — they are to a considerable degree 
 dependent on the same causes, and are in a measure amenable to the 
 same remedies ; while the milder complaint not infrequently passes into 
 the more severe. Before we proceed, therefore, to the study of the special 
 characters of either affection, it may be well to examine into some of 
 those conditions which are alike favorable to the production of both. 
 
 The following table, deduced from 2129 cases of diarrhoea or dysen- 
 tery that came under my notice at the Children's Infirmary, shows that 
 the age of the child has much to do with the occurrence of the affection : 
 
 Cases of diarrhoea in children at the 
 following ages. 
 
 Were to all cases of diar- 
 rhoea in children under 
 
 Were to all diseases at 
 the same age in the 
 
 15 in the proportion of 
 
 proportion of 
 
 Under 6 months 
 
 9.7 per cent. 
 
 16.1 per cent. 
 
 Between 6 " and 12 months 
 
 15.7 
 
 200 
 
 u 12 u ci 18 " 
 
 20.9 
 
 2H.8 " 
 
 " 18 " " 2 years 
 
 13.9 " 
 
 25.4 " 
 
 " 2 }'ears » 3 " 
 
 12.1 " 
 
 15.0 " 
 
 « 3 « "5 " 
 
 11.2 " 
 
 9.3 « 
 
 u 5 u << io « 
 
 11.5 " 
 
 7 9 " 
 
 « io " i« 15 ii 
 
 4.7 " 
 
 7.7 " 
 
 You will observe that the period of the greatest prevalence of diarrhoea 
 coincides exactly with that time during which the process of dentition is 
 going on most actively, and that exactly half of all cases of diarrhoea 
 occurred in children between the ages of six months and two years. 
 So close, indeed, is the connection between teething and diarrhoea, that 
 
SYMPTOMS OF SIMPLE DIARRHCEA. 519 
 
 a French physician, M. Bouchut, 1 found that only twenty-six out of 138 
 children entirely escaped its attack during the period of their first denti- 
 tion, while forty-six suffered from it severely. The older writers on 
 medicine, whose notice this fact did not escape, attributed the disturbance 
 of the bowels to a sort of sympathy between the intestinal canal and the 
 gums, swollen and irritated by the approach of the teeth to their surface. 
 The frequent observation of cases in which an attack of diarrhoea attends 
 the eruption of each fresh tooth, and ceases when it has cut through the 
 gum, shows that such an hypothesis is not altogether without founda- 
 tion. But besides the influence of nervous irritation in quickening for 
 a time the peristaltic action of the bowels, and thus inducing diarrhoea, 
 it must be borne in mind that there exists during the period of teething 
 a more abiding cause, which strongly predisposes to its occurrence. All 
 parts of the digestive canal, and of its dependencies, are now undergoing 
 an active evolution to fit them for the proper assimilation of the varied 
 food on which the young being will soon have to subsist. Just as the 
 salivary glands now begin to secrete and pour out saliva in abundance, 
 so the whole glandular system of the intestines assumes a rapidity of 
 growth, and an activity of function, which under the influence of com- 
 paratively slight exciting causes, may pass the just limits of health. In 
 too many instances, causes fully adequate to excite diarrhoea are abun- 
 dantly supplied in the excessive quantity or unsuitable quality of the 
 food with which the infant is furnished ; for it is forgotten that its con- 
 dition is one of transition, in which something more than ordinary care 
 is needed ; while, in accordance with that mistaken humoral pathology 
 so popular among the vulgar, the profuse secretion from the irritated 
 glands is regarded as the result of a kind of safety-valve arrangement 
 whereby nature seeks to moderate the constitutional excitement attendant 
 upon teething. 
 
 But, besides these conditions seated within the organism which pre- 
 dispose to diarrhoea, and those occasions furnished from without by 
 the food with which the child is supplied, atmospheric influences con- 
 stitute a third, and a very important class of causes, which at one time 
 render diarrhoea very frequent, and at another greatly check its prev- 
 alence. 
 
 On a comparison of the result of eight years' observation at the 
 Children's Infirmary, I find that 
 
 In the 3 rnos. Nov., Dec, Jan., diarrhoea formed 7.9 per cent, of all cases of disease. 
 " Feb., March, April, " 9.5 " " 
 
 " May, June, July, " 15.3 " " 
 
 " Aug., Sept., Oct., " 23.0 " » 
 
 The above-mentioned causes dispose alike to diarrhoea and dysen- 
 tery ; but among the dwellings of the poor in this metropolis, as in 
 every large city, conditions abound which often stamp on the disease 
 the characters of the more serious malady. Before investigating them, 
 however, we may first study the symptoms of the milder affection, which, 
 
 1 Manuel Pratique des Maladies des Nouveaux-Nes, 2d ed., 8vo., p. 530. Paris, 
 1852. 
 
520 SYMPTOMS OF SIMPLE DIARRH(EA. 
 
 though much the more frequent, yet, if uncomplicated, is seldom or 
 never fatal. 
 
 When the attack comes on in perfectly healthy children, it often sets 
 in quite suddenly, with vomiting of the contents of the stomach, and 
 afterwards of mucus, which sometimes has a yellow or greenish color. 
 The sickness does not in general continue, though exceptions are met 
 with in some of the more severe cases, in which the stomach remains 
 very irritable during the whole period that the affection lasts. In 
 either case the vomiting is almost immediately succeeded by increased 
 action of the bowels, the matters discharged being at first the healthy 
 faeces ; but they soon assume a bright yellow color, like that of the yolk 
 of egg, and are often intermixed with slime, or in other cases they pre- 
 sent a frothy appearance. The bright yellow color of the evacuations, 
 often, though by no means always, changes to green under exposure 
 to the air ; w T hile, if the diarrhoea should continue, the faeces present in 
 many instances a green color when voided, similar to that which is 
 frequently produced by the administration of mercury. In other cases 
 the green and yellow colors appear intermixed in the evacuations, 
 while the presence in them of numerous white specks, the casein of the 
 undigested milk, shows that the function of the stomach is interfered 
 with by the same cause as produces the overaction of the bowels. 
 The source of the green color of the evacuations has not yet been quite 
 satisfactorily determined. In some cases it probably depends on the 
 action of the acids of the alimentary canal upon the coloring matter of 
 the bile ; but the late Dr. Gokling Bird's investigations have proved it 
 not to be always due to this cause, and have rendered it probable that, 
 in many instances, it results from the presence of altered blood in the 
 evacuations. As the child returns to health, the faeces become less 
 watery, and then resume their yellow color ; or stools of a natural 
 character alternate with others of a green color and unhealthy aspect, 
 or in which a very large quantity of mucus is present. The action of 
 the bowels, too, becomes less frequent, and the child often regains its 
 usual health in four or five days, though sometimes a disposition tp 
 diarrhoea is left behind, and the disorder is liable to be re-excited by 
 very slight causes. 
 
 In the majority of cases this overaction of the bowels is not attended 
 by much fever or constitutional disturbance, though, if it should come 
 on during teething, the general feverishness of the child is often some- 
 what aggravated. The appetite is usually much impaired, while the 
 thirst is often considerably increased, and the child seems very desir- 
 ous of cold water. The tongue is moist, in general thinly covered 
 w T ith mucus, through which the papillae appear of a brighter red than 
 natural ; but the tongue is neither very red, nor much coated. The 
 abdomen is soft, seldom either full or painful ; and the pain which 
 attends the diarrhoea is very variable ; sometimes it is completely absent, 
 the stools being expelled without either effort or suffering ; while in 
 other cases pain comes on severely at intervals, and then ceases so soon 
 as the bowels have acted. Although there is seldom much tenesmus, 
 yet a slight degree of it attends upon simple diarrhoea in the child 
 much more frequently than in the adult. There is, as might be antici- 
 
SIMPLE DIARRHOEA. 521 
 
 pated, a loss of the natural look of health — the face grows pale, the 
 eyes appear sunken, and the child becomes fretful and languid — while, 
 if the attack Sets in severely, a day or two sometimes suffices to re- 
 duce the child to a state of extreme weakness and exhaustion ; and 
 in young infants, all the symptoms of spurious hydrocephalus some- 
 times make their appearance. 
 
 The diarrhoea that occurs in connection with the irritation occa- 
 sioned by teething is in general more gradual in its onset, and slower 
 in its progress, than that which depends on some more transient cause. 
 It is likewise often associated with catarrhal symptoms ; and both the 
 catarrh and diarrhoea frequently continue until the tooth having pierced 
 the gum the irritation of the mucous membrane subsides ; but to be 
 renewed when a fresh tooth approaches the surface. 
 
 Although the dangers attendant on simple diarrhoea, especially when 
 it occurs in healthy children, are not considerable, yet the affection is 
 one which it is never wise to make light of. On more than one occa- 
 sion I have seen an infant reduced by it to a state of such extreme 
 exhaustion as seriously to endanger life. Diarrhoea, indeed, is the 
 exciting cause of the greater number of cases of that spurious hydro- 
 cephalus, 1 in which cerebral disturbance from debility simulates real 
 inflammatory disease of the brain. In such circumstances, too, the 
 diarrhoea has not infrequently ceased for some time before the other 
 more alarming symptoms made their appearance. The cessation of 
 diarrhoea may be due, not so much to the quieting of irritation, as to 
 the exhaustion of the nervous energy which is essential to the perform- 
 ance of their secretory function by the glands of the intestines, or to 
 the due maintenance of the peristaltic movements of the bowels. In 
 infants prematurely weaned or improperly fed after being taken from 
 the breast, we often see this fact exemplified in the cessation, some 
 twelve or twenty-four hours before death, of the diarrhoea from which 
 they have been suffering for weeks together. Nor must we ever make 
 too sure that because purging has ceased, therefore danger is over ; or 
 venture to relax our watchful care, until the continuance of amend- 
 ment for twenty-four hyurs or more, shows that there is indeed no 
 longer anything to fear. 
 
 This, however, is not the only danger to which previously healthy 
 children are exposed by an attack of simple diarrhoea ; for if not quickly 
 checked, it sometimes assumes the more serious characters of dysentery, 
 and occasions severe and long-continued suffering. When diarrhoea 
 supervenes in children who are recovering from some disease, such as 
 measles, in which a tendency to relaxation of the bowels often marks 
 the period of convalescence, or who have been suffering from a pro- 
 tracted ailment, such as hooping-cough, it sometimes occasions the 
 patient's death, although it may leave behind in the intestinal canal 
 no traces of serious mischief. Still more frequently is this the case 
 with infants who have been brought up by hand, or who have thriven 
 badly at the breast. A troublesome purging, continuing for weeks 
 together, exhausts the strength of such infants, and at length occasions 
 
 » See Lecture XI, p. 131. 
 
522 
 
 their death ; but yet the intestinal canal in many instances presents no 
 trace of more serious mischief than an unusual degree of distinctness of 
 the follicles of the small intestines, and of the solitary glands of the 
 colon and rectum. 
 
 In proposing at the commencement of this lecture, to distinguish 
 between simple and inflammatory diarrhoea, I yet was forced to ac- 
 knowledge that the distinction was one rather of degree than of kind ; 
 or perhaps it would be more correct to say, that our observation has 
 not hitherto been minute enough to enable us to draw the line of de- 
 marcation strictly between the two affections. Even MM. Rilliet and 
 Barthez, 1 whose opportunities have been so extensive, and whose indus- 
 try was so untiring, confess their inability to refer the symptoms that 
 attend upon the different varieties of diarrhoea to any distinct and 
 invariable anatomical lesions. They remark that not merely are 
 exceedingly different appearances discovered after death in cases where 
 the same symptoms have been' observed during life, but that likewise 
 there is often no proportion between the intensity of the two; and that 
 sometimes no morbid appearances are found, even where well-marked 
 symptoms had existed. Usually, indeed, in cases where the morbid 
 appearances are slight, the symptoms during life have not been severe. 
 Occasionally, however, the reverse has occurred ; and the diarrhoea has 
 been intense, the pain considerable, and the abdomen tense and tym- 
 panitic. MM. Rilliet and Barthez state, that out of 127 children who 
 had died of different diseases, 84 had presented the symptoms of 
 inflammatory diarrhoea, or entero-colitis, and the characteristic appear- 
 ances of that affection were manifest on an examination of their intes- 
 tines after death ; in 24, though no symptoms had existed during life, 
 similar changes w T ere discovered; while in 19,. the signs of disease were 
 present during life, but its morbid appearances were absent. It is 
 true that these observations refer to children above two years of age, 
 and to cases in which diarrhoea had occurred as a secondary affection ; 
 but my own observations would lead me to believe that a similar state- 
 ment might be made with reference to younger children, and to cases 
 of idiopathic diarrhoea. 
 
 These circumstances prevent our deducing from the results of ana- 
 tomical investigation those practical conclusions which we should other- 
 wise be inclined to draw from them ; but they do not warrant us in 
 altogether omitting to inquire what changes we shall be most likely to 
 meet with in cases of fatal diarrhoea. 
 
 These changes will be found chiefly, though not exclusively, in the 
 large intestine; and though usually much less serious than those which 
 are observed in cases of fatal dysentery in the adult, they yet present 
 very similar characters. In those cases in which the structural altera- 
 tions have been least considerable, the attention is arrested less by any 
 great increase of vascularity in the intestine, than by the remarkable 
 distinctness of the orifices of the solitary glands, which appear like 
 almost innumerable dark spots upon the surface of the mucous mem- 
 brane. In many cases, and especially in those in w T hich the diarrhoea 
 
 1 Op. cit., vol. i, pp. 509-12; and 2d ed., vol. i, p. 747. 
 
MORBID APPEARANCES IN INFANTILE DYSENTERY. 523 
 
 was profuse at the time of the patient's death, not merely are the open- 
 ings of these follicles distinct, but the glands themselves are enlarged, 
 and project like small millet-seeds, or small pins 7 heads, beyond the 
 level of the surrounding tissue. This enlargement of the solitary 
 glands is usually associated with increased vascularity of the mucous 
 membrane; which does not, however, assume the characters of a gen- 
 eral erythematous redness, but is confined to that part of the membrane 
 which covers each gland, or which surrounds its base. If the disease 
 advances further, ulceration succeeds to this inflammation of the glands. 
 A small circular or slightly oval spot appears upon their summit, and 
 increases in size and depth, until it has destroyed the glandular struc- 
 ture and the mucous membrane, and has produced a deep cup-like 
 depression or ulceration, the base of which is formed by the muscular 
 coat of the intestine. On one occasion I observed, in the midst of 
 enlarged and ulcerated glands, some others equally large, but on which 
 the excavated ulcer had not yet formed ; their summits presenting a 
 small round or oval spot, of a yellowish color — most probably a minute 
 slough not yet detached from the surface. Besides that loss of substance 
 which results from the ulceration or sloughing of the glands themselves, 
 a process of thinning and destruction likewise affects other parts of the 
 mucous membrane, especially in those situations which correspond to 
 the edges of the intestinal rugae. In some parts the membrane appears 
 to be merely attenuated, while in others it seems to have entirely dis- 
 appeared, though the limits of its destruction are not marked by the 
 same well-defined edges as circumscribe the ulcers of the glands, nor 
 is the loss of substance so deep. On the inner surface of an intestine 
 thus affected may be seen a number of narrow, white lines, inclosing 
 between them islets of mucous membrane, and often having such an 
 arrangement as to give to those portions of membrane the form of 
 irregular parallelograms. This superficial destruction of the mucous 
 coat of the intestine is often much more complete in the rectum and in 
 the sigmoid flexure of the colon, than elsewhere ; and when this is the 
 case, the surface of the bow r el presents a uniformly rough appearance. 
 It is also in the lower part of the large intestine that the ulcerative 
 process is most frequent and most extensive; and if care is not taken 
 to examine the last few inches of the rectum, we may come to the mis- 
 taken conclusion that ulceration is altogether absent, in cases where 
 more careful investigation would have easily convinced us of its exist- 
 ence. On one occasion, I found the disease in the lower part of the 
 large intestine to be so far advanced that the interior of the sigmoid 
 flexure of the colon and of the rectum presented an irregular tubercu- 
 lated surface, of an ash-gray color, which appeared eaten into holes by 
 a number of small circular pits or ulcers, w r ith sharply cut edges. 
 Besides these changes in the interior of the large intestine, a thickening 
 of its submucous coat is almost always observable, whenever the diar- 
 rhoea has continued for any considerable length of time. It is in the 
 rectum and sigmoid flexure of the colon that this thickening is most 
 perceptible ; and in this situation a gelatinous-looking matter is some- 
 times deposited in such abundance beneath the mucous membrane, as 
 to prevent the intestine from becoming collapsed when it is divided. 
 
524 SYMPTOMS OF INFLAMMATORY DIARRHEA; 
 
 But it is not merely in the morbid appearances presented by the 
 large intestines, but also in the subsidiary changes observed in other 
 parts of the intestinal canal, that the close relation is manifested be- 
 tween the diarrhoea of the infant and dysentery in the adult. The 
 changes in the small intestine are almost always confined to the lower 
 part of the ileum, and become more striking the nearer we approach to 
 the ileo-csecal valve. They consist in a more or less intense redness of 
 the mucous membrane, which sometimes appears thickened, and presents 
 something of a velvety appearance, studded over with numerous dark 
 spots, — the orifices of the solitary glands. In other instances, the sur- 
 face of the reddened mucous membrane appears slightly roughened, as 
 if sprinkled over with fine sand ; while near to the caecum this rough- 
 ening 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 affec- 
 tion of the mucous membrane of the ileum, Peyer's glands are not in- 
 frequently 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 observed one or two spots of ulceration on that cluster of 
 Pever's glands which is situated close to the ileo-csecal 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. Lastly, I 
 may observe that the mesenteric glands, even in the vicinity of the dis- 
 eased large intestine, deviate but little from a state of health, being at 
 most a little larger, and of a somewhat redder color, than usual, — a 
 condition which contrasts remarkably with their serious affection in 
 cases of typhoicLffever in childhood, where yet the intestinal lesion is 
 often much less considerable. 
 
 The symptoms of inflammatory diarrhoea sometimes become developed 
 very gradually out of what had seemed at first to be nothing more 
 than a simple looseness of the bowels ; but, in the majority of cases, 
 they present, almost from the outset, a graver character than those of 
 simple diarrhoea, and are associated with more serious constitutional 
 disturbance. When the attack comes on suddenly, it often commences 
 with vomiting; and though in many instances the sickness does not 
 recur frequently, yet sometimes the irritability of the stomach continues 
 for twenty-four or forty-eight hours to be so extreme, that every drop 
 of fluid taken is immediately rejected, and that frequent efforts at vom- 
 iting are made even when the stomach is empty. Violent relaxation of 
 the bowels occurs almost simultaneously with the vomiting ; and the 
 child sometimes has as many as twenty or thirty evacuations, or even 
 more, in the course of twenty-four hours. The motions are at first 
 fecal ; but they soon lose their natural character, and become inter- 
 mixed with slime, often streaked with blood. At first they are abun- 
 dant, and are often expelled with violence ; but before long they be- 
 come scanty, though sometimes they still gush out without much effort 
 on the part of the child. The character of the evacuations again 
 
SYMPTOMS OF INFLAMMATORY DIARRHCEA. 525 
 
 changes; in the severest cases they not only lose their fecal appearance, 
 but become like dirty-green water, with which neither blood nor intes- 
 tinal mucus is intermingled. Usually, however, when the first violence 
 of the purging has a little abated, although some serous stools may still 
 be voided, yet the evacuations consist chiefly of intestinal mucus inter- 
 mixed with a little fseces, and more or less streaked with blood. The 
 scanty mucous stools are generally expelled with much straining and 
 difficulty; a few drops of blood sometimes follow them; and once or 
 twice at an early period of the attack, I have known an infant void as 
 much as a tablespoon ful of pure blood. 
 
 The constitutional symptoms which accompany an attack of this de- 
 scription are usually very severe; the skin becomes dry and very hot, 
 though unequally ; the pulse is quickened, often very much so ; the 
 head is heavy; the child fretful and irritable if disturbed, though other- 
 wise it lies drowsily in its nurse's lap, with its eyes half open, aud 
 scarcely closing the lids even when they are touched with the finger. 
 Xow and then, too, the disturbance of the nervous system at the com- 
 mencement of one of these attacks of diarrhoea is so considerable, that 
 a state of excitement alternates with one of stupor, that convulsions 
 seem impending, and that there are distinct carpopedal contractions, 
 or startings of the tendons of the wrist or forearm. Now and then, 
 too, T have known convulsions actually occur, and be succeeded by a 
 comatose condition, from which the child never recovered to more than 
 a sort of semi-consciousness; exhaustion speedily following the first 
 violent disturbance of the nervous system. The abdomen is usually 
 full, and rather tympanitic, but seldom very tender; nor does the child 
 seem to suffer much pain, though sometimes a degree of tormina appears 
 to precede each action of the bowels. The tongue at first is moist, 
 coated slightly with mucous fur ; its papillse are often of a bright red, 
 as are also its tip and edges ; while, if the disease continues, the redness 
 becomes more general, and the tongue grows dry, though it is not often 
 much coated. The thirst is generally intense, the child craving for 
 cold water, and crying out for more the moment that the cup is taken 
 from its lips; and the thirst is quite as urgent even in those cases where 
 the stomach is so irritable that it immediately rejects whatever is 
 swallowed. There is scarcely any affection in which the loss of health 
 and of flesh is so rapid as in the severer forms of diarrhoea ; and a 
 period of twenty-four hours will in some cases suffice to reduce a pre- 
 viously healthy infant to a condition in which its eyes are sunken, its 
 features sharp, its limbs shrunken, and its strength so impaired that, 
 though I have never seen an instance of it myself, I can yet well under- 
 stand that death may sometimes take place in the course of a few hours 
 from the commencement of the attack. This rapidly fatal termination 
 is far from unusual in some of the Southern States of America, where 
 diarrhoea, under the various names of Cholera Infantum, the Summer 
 Complaint, or Gastrofollicular Enteritis, annually destroys many thou- 
 sands of children. 1 
 
 1 The essential identity of this disease with the infantile diarrhoea of our own and 
 other temperate climes is conclusively established by Dr. Parker, of New York, in 
 a paper published in the American Monthly Journal for May, 1857. 
 
526 SYMPTOMS OF CHRONIC DYSENTERY. 
 
 A rapidly fatal termination, however, is not that which is in general 
 observed in this country; but, how urgent soever the symptoms may 
 have been, there is in most instances a spontaneous subsidence of them 
 in the course of forty-eight hours at furthest ; or a measure of abate- 
 ment of their severity follows the use of remedies. The sickness en- 
 tirely ceases ; the bowels act much less frequently, probably not above 
 ten or twelve times in the twenty -four hours ; but they act irregularly, 
 five or six evacuations being passed within an hour or two, and then 
 no action of the bowels occurring for four or five hours together. The 
 appearance of the motions likewise varies, and apparently without 
 cause, being mucous, green, watery, intermingled with blood, all in the 
 course of a single day, and with no accompanying modification in the 
 infant's symptoms. The tenesmus in general continues; and in weakly 
 children, or in those who have previously suffered from diarrhoea, pro- 
 lapsus ani not infrequently occurs ; though this accident happens less 
 commonly in infants than in children of two or three years old. 
 
 There is much uncertainty in the further course of the affection, and 
 in the way in which it tends in one instance towards recovery, and in 
 another to a fatal issue. Many fluctuations generally interrupt the 
 progress of those cases which terminate favorably ; while, when it event- 
 ually proves fatal, the affection often assumes a chronic character, and 
 does not end in death until after the lapse of several weeks. 
 
 In such chronic cases the patient's condition, though progressively 
 tending from bad to worse, presents but little difference from day to 
 day. The loss of flesh goes on until the child is reduced to a degree 
 of emaciation as great as is ever witnessed even in the most advanced 
 stage of mesenteric disease or pulmonary consumption, though its ex- 
 treme attenuation is sometimes concealed by the anasarcous swelling 
 of its face and hands. The appetite fails completely, or becomes very 
 capricious ; and the child refuses to-day the food which yesterday it 
 took with eagerness. In course of time, the desire for drink is lost 
 too ; for though there may be no return of vomiting, yet nausea is 
 excited by everything which the child takes. The tongue grows red 
 and dry, coated with brown or yellow fur towards its root, or aphtha? 
 appear upon its tip and edges, or the whole inside of the mouth becomes 
 coated with thrush. The diarrhoea continues much as it was before, 
 except that the action of the bowels is now almost immediately excited 
 by either food or drink. The evacuations are usually of a green color, 
 often particolored, and though generally watery, yet they vary both in 
 their consistence and in their other characters, without apparent cause. 
 Slime, blood, and pus are sometimes present in the stools, at other times 
 absent; and it does not often happen that purulent matter is present 
 in large quantity in the evacuations, or for many clays together, though 
 I have observed this in some cases that recovered, as well as in others 
 which had a fatal termination. The body is no longer able to maintain 
 its proper temperature, but the extremities are almost invariably cold ; 
 small indolent abscesses occasionally form about the buttocks ; and on 
 one occasion I saw an eruption of large vesicles, like those of pemphigus, 
 make their appearance on the hands, arms, and neck of an infant eight 
 months old, about ten days before her death. In the condition of weak- 
 
VARIOUS CAUSES OF DEATH IN ITS COURSE. 527 
 
 ness to which the child is now reduced, a slight aggravation of the 
 diarrhoea, or a return of vomiting, suffices to put out its feeble life ; or, 
 even should no such accident occur, death takes place from pure ex- 
 haustion. 
 
 But various causes may abridge this protracted course of the affec- 
 tion ; and hence it results that death not infrequently takes place before 
 the mischief in the intestines has become so serious as it is usually found 
 to be in cases of fatal dysentery in the adult. Bronchitis is one of the 
 most frequent of these intercurrent maladies, while the symptoms that 
 attend it are often so slight, that danger to the patient from this source 
 is very frequently overlooked. It happens, indeed, in many cases, that 
 almost from the outset of an attack of diarrhoea, the mucous membrane 
 of the respiratory organs sympathizes with the irritation of the intes- 
 tinal canal, and from the very commencement of its illness the child 
 has slight cough, the continuance or even the aggravation of which 
 attracts but little notice. Unless, therefore, auscultation is carefully 
 practiced, and often repeated, there is little in such cases to call atten- 
 tion to the state of the respiratory organs until the accumulated secre- 
 tions in the bronchi have already seriously interfered with the entrance 
 of air into the pulmonary vesicles, and have occasioned the collapse of 
 a considerable extent of the substance of the lungs. 
 
 Life is sometimes cut short by other causes in the course of infantile 
 diarrhoea. The disturbance of the nervous system that attends the 
 attack issues now and then in convulsions, and these convulsions end 
 in a state of stupor which terminates in death — an occurrence fortu- 
 nately rare, but of which instances may be observed during those hot 
 seasons of the year when bowel complaints are usually epidemic. Less 
 rare than a fatal termination of this kind is the infant's death under 
 symptoms of a gradually deepening coma, which may have supervened 
 on the suppression of the diarrhoea, or on its great mitigation. Many 
 of the symptoms by which this condition is accompanied are such as to 
 indicate the exhaustion of the infant's powers ; but it happens in many 
 instances that there is an occasional flush of the face, or a temporary 
 heat of skin, or some other passing sign of an attempt at reaction, just 
 sufficient to mislead the practitioner, and to betray him into a vacillat- 
 ing line of practice that proves fatal to his patient. 
 
 Lastly, there are cases, and those by no means few, in which the 
 onset of a severe attack of diarrhoea has been promptly met and judici- 
 ously treated, in which the symptoms have yielded, and the child has 
 appeared convalescent. Some slight error in diet, however, a variation 
 in the temperature, or the too early withdrawal of medicine, is followed 
 by a return of the vomiting and purging; or the relapse may take place 
 without our being able to assign for it any adequate cause. The active 
 symptoms which attended the original seizure are absent now; the 
 evacuations, though very watery, generally contain neither blood nor 
 slime ; but medicine is often wholly unable to check them. The vital 
 powers fail speedily, and death often takes place in three or four days 
 from this exacerbation of the symptoms ; while an examination of the 
 body after death shows no evidence of recent mischief in the intestines, 
 
528 INFANTILE DIAKRHCEA AND DYSENTERY OF ADULT. 
 
 but only the traces left by the first attack, and these manifestly in course 
 of disappearance. 
 
 AYe must postpone until the next lecture the very important subject 
 of the treatment appropriate to all the varieties of diarrhcea and its 
 different corn plications. 
 
 LECTUEE XXXVII. 
 
 Diakkhcea, continued. — Close resemblance between inflammatory diarrhoea and 
 the dysentery of the adult — Local conditions favoring its occurrence, as damp, 
 want of drainage, &c. 
 
 Treatment of simple diarrhcea. — Of diarrhcea in connection with teething — Use of 
 astringents. 
 
 Treatment of inflammatory diarrhcea. — In its acute stage — Treatment of certain 
 symptoms — As the irritability of the stomach, the cerebral symptoms — Indica- 
 tions for the use of stimulants — Of astringents — Management of the chronic 
 stage — Use of enemata — Diet in this stage. 
 
 Management of intertrigo excited, by diarrhcea. — And of prolapsus ani. 
 
 Those of you who were present at yesterday's lecture could hardly 
 fail to be struck by the close resemblance which exists between the 
 severer forms of infantile diarrhoea and the true dysentery of the adult. 
 In both cases similar morbid appearances are discovered, occupying 
 the same parts of the intestinal canal; in both the symptoms during 
 life are almost identical, their resemblance being disturbed mainly by 
 the greater excitability of the nervous system in early life ; whence it 
 arises that convulsions and other signs of serious cerebral disorder are 
 often observed in the infant affected with diarrhoea, while they are but 
 seldom noticed in the adult suffering even from severe dysentery. But 
 this difference is one of degree rather than of kind, since the morbid 
 poison, whatever be its nature, to which dysentery is due in the adult, 
 produces in favorable circumstances disorders of the nervous system 
 analogous to those which we may have frequent opportunities of 
 observing in the infant. If dysentery, for instance, break out epi- 
 demically in a large prison, the inmates of which have had the excita- 
 bility of their nervous system increased by the debilitating influence 
 of long confinement, tremors, cramps, spasms, convulsions, or stupor, 
 may attend upon the affection, and death may take place under symp- 
 toms that betoken disturbance of the brain or spinal cord. You will 
 find ample proof of this in Dr. Latham's account of the Disease at the 
 Penitentiary in the year 1823; and in Dr. Baly's Gulstonian Lectures 
 on Dysentery, which are based on observations at the same establish- 
 ment. Among the striking examples of this complication related by 
 those writers, some are recorded in which, though death took place, 
 

 MALARIA A CAUSE OF DYSENTERY. 529 
 
 neither the brain nor the spinal cord presented any sign of disease. 
 Just of the same kind, and equally independent of any appreciable 
 change of structure, are the nervous symptoms that often come on in 
 the course of infantile diarrhoea. I shall have presently to refer to the 
 important practical bearings of this fact, when we come to consider the 
 treatment of diarrhoea and its complications. 
 
 Before we pass to that subject, however, we must inquire whether 
 there are any special conditions that tend to engender the severer forms 
 of bowel complaint in childhood, over and above those general causes 
 of diarrhoea to which your attention was directed in the last lecture. 
 I believe that such special conditions do exist — that they abound in 
 the locality where most of my observations have been made — and that 
 they are precisely the same as prevailed far more extensively in this 
 metropolis at the time that the bloody flux annually carried off large 
 numbers of its inhabitants. 
 
 In almost every country and climate, and in circumstances in many 
 respects very different, dysentery has been known to occur, but in each 
 instance it has been possible to connect the prevalence of the disease 
 with some source or other of malaria. Although while I was a phy- 
 sician to the Finsbury Dispensary, a large amount of disease among 
 children came under my notice, yet my acquaintance with those severer 
 forms of infantile diarrhoea w T hich approach to the characters of dysen- 
 tery, and which give rise to similar lesions, has been derived almost 
 exclusively from observations made in Lambeth and the adjoining 
 parishes. 1 The children in both districts are alike subjected to the 
 evils of improper and insufficient food, and of close and ill-ventilated 
 dwellings ; but in the latter there are superadded certain very impor- 
 tant influences of a local character. A considerable portion of the dis- 
 trict on the Surrey side of the Thames lies below high-water mark ; 
 and the kitchens and cellars of some of the houses near the river 
 become flooded at unusually high tides. The sewage throughout is 
 very defective : in many parts it is effected entirely by open drains, 
 while in some places there are mere cesspools, which have no commu- 
 nication with any drain whatever. Cases of infantile dysentery do not 
 occur with the same frequency in all parts of this district, but they are 
 most numerous and most severe wherever these noxious influences are 
 most abundant. Proof, too, of the intimate connection that subsists 
 between these conditions and the occurrence of infantile dysentery is 
 afforded by cases such as the following : 
 
 With the return of every spring, a poor woman brought to me her 
 younger children suffering from diarrhoea, which they seemed to out- 
 grow when about three years old. This diarrhoea was always obsti- 
 nate, very apt to assume a dysenteric character, and was almost sure to 
 return if medicines were discontinued before the return of the cold 
 season. On one occasion, her infant, aged about fifteen months, who 
 
 1 To this statement I may now add, that since the opening of the Hospital for 
 Sick Children, the patients of which come from much the same district as that 
 inhabited by my former patients at the Finsbury Dispensary, the severer forms of 
 infantile dysentery have again come less frequently under my notice. 
 
 34 
 
530 TREATMENT OF SIMPLE DIARRHCEA. 
 
 had had diarrhoea severely in the previous autumn, suffered a return 
 of it with the returning warmth of spring. The infant's symptoms 
 were very alarming, and the child had frequent convulsions ; on which 
 account I visited her at home. I then found that the infant spent the 
 whole of the day in a back room on the ground floor which looked out 
 upon a little yard, at the bottom of which there was a large cesspool, 
 whence there came a most offensive smell during the whole of the 
 warm weather. I urged the mother to remove her infant from this 
 room, and to occupy instead a front room on the first floor in the same 
 house, which looked upon the street. When this had been done, the 
 convulsions ceased almost at once, and the diarrhoea was not long 
 before it disappeared. I attended this woman's children for other 
 affections on several occasions during the ensuing eighteen months, but 
 after their removal to the more wholesome room I heard nothing of 
 their suffering from diarrhoea. I may just add, that in similar circum- 
 stances I have met with a few instances of the sudden and apparently 
 causeless occurrence of convulsions, in two or three children of the 
 same family. Some years since, a little girl, five years old, was seized 
 with convulsions, which recurred frequently for between two and three 
 days, leaving her in a state of stupor. By degrees the symptoms of 
 very severe typhoid fever developed themselves out of this disturbance 
 of the nervous system ; the disease during the whole of its course pre- 
 sented an adynamic character, and required the free employment of 
 wine and stimulants. While she was convalescent, the health of her 
 elder sister, who was eight years old, began to fail, and before long she 
 experienced convulsive attacks of an anomalous character not unlike 
 fits of hysteria, which returned at intervals of two or three days for 
 several weeks together, three or four fits sometimes recurring in the 
 course of a single day. These seizures were accompanied by much de- 
 bility, and they disappeared by degrees under the use of preparations 
 of iron, and a generally tonic plan of treatment. 
 
 In studying the treatment of diarrhoea and dysentery in early life, 
 we will pass successively in review the different forms of the disease ; 
 beginning with the simplest and least dangerous, and passing to the 
 more formidable varieties of the affection, and to those complications 
 which add so greatly to its hazard. 
 
 In a large proportion of cases of simple infantile diarrhoea, the ail- 
 ment tends to subside in a day or two, and finally to cease of its own 
 accord. While, therefore, in consideration of the tender years of the 
 patient, no such case can be regarded as altogether trivial, yet in many 
 instances, but little medical interference is needed. Great care, how- 
 ever, is required in this, as well as in the more serious forms of diar- 
 rhoea, to prevent the affection being aggravated by any error of diet, or 
 even by the infant being allowed to partake too freely of food other- 
 wise suitable for it. If, therefore, the sickness with which the attack 
 sets in has not altogether subsided, the child should be taken com- 
 pletely from the breast for a few hours, and should have nothing 
 more than a few spoonfuls of water or barley-water, till the irritability 
 of the stomach has abated. If the disposition to vomit has completely 
 ceased, it will yet be right to put the infant less frequently to the 
 
TREATMENT OF DIARRHOEA IN CONNECTION WITH TEETHING. 531 
 
 breast ; while it is supplied, if thirsty, with water, or barley-water, in 
 small quantities at a time. In children already weaned, a similar plan 
 must be carried out ; solid food being for a time withdrawn, and thin 
 arrowroot, or barley-water and milk, in equal parts, being substituted 
 for it, or whey, if, as happens not very rarely, the child should be 
 unable to digest the curd, which then irritates the bowels and passes 
 through them unchanged. If the attack is clearly traceable to some 
 improper article of food, a dose of castor-oil will sometimes get rid of 
 the irritant cause and of the diarrhoea together. Unless this is the 
 case, however, it is better not to give the aperient, since its action in 
 these circumstances is somewhat uncertain ; and instead of relieving, it 
 may aggravate the diarrhoea. Provided there is neither much pain nor 
 much tenesmus, and the evacuations, though watery, are fecal, and 
 contain little mucus and no blood, very small doses of the sulphate of 
 magnesia and tincture of rhubarb have seemed to me more useful than 
 any other remedy ; l and I seldom fail to observe from their use a 
 speedy diminution in the frequency of the action of the bowels, and 
 a return of the natural character of the evacuations. In these cases 
 also I have tried the sulphuric acid, which has of late been so much 
 vaunted as almost a specific in catarrhal diarrhoea. I have given it in 
 doses of four minims every four hours, to infants a year old, sweetened, 
 and mixed with caraway-water. Though successful in some instances, 
 it has in my hands failed to control the diarrhoea more frequently 
 than the sulphate of magnesia and rhubarb mixture ; and the only 
 cases where it seemed to possess a decided superiority over that remedy 
 were those which were attended with frequent vomiting and great 
 irritability of the stomach. 
 
 In the diarrhoea that comes on in connection with teething, it has seemed 
 to be better to pursue a somewhat different plan. It is usually attended 
 by a greater amount of constitutional disturbance than is observed in 
 the diarrhoea of younger infants, and by some degree of febrile excite- 
 ment. There is, likewise, in many instances, a considerable disposition 
 to catarrhal affection of the respiratory mucous membrane, which needs 
 to be carefully watched, lest by its increase it should become a source of 
 serious danger to the child. The diarrhoea in the majority of these cases 
 comes on gradually, and its subsidence takes place gradually too. Now 
 and then the gum may appear at one spot so tense and swollen as to 
 induce us to scarify it; and if the tooth is very near the surface, this 
 proceeding may sometimes greatly diminish the diarrhoea, by relieving 
 the irritation which excited it. Any such marked benefit, however, is 
 quite an exceptional occurrence ; and unless the state of the gums is such 
 as of itself to indicate the propriety of scarifying them, it would be a 
 cruel and useless piece of empiricism to subject the child to the distress 
 of the operation. Instead of the saline and rhubarb mixture which I 
 have just mentioned, I usually employ in these cases small doses of ipe- 
 cacuanha in combination with an alkali ; and think that I have found 
 great benefit from this plan. Three or four drops of liquor potassse, 
 and the same quantity of vinum ipecacuanha?, mixed with mucilage, 2 
 
 1 See Formula No. 28, p. 494. 2 gee Formula No. 23, p. 466. 
 
532 TREATMENT OF INFLAMMATORY DIARRHCEA. 
 
 and given in a little milk about every four hours, is a suitable dose for 
 an infant a twelvemonth old. At the same time the child should be 
 placed in a tepid bath every night ; and a powder of one grain of Dover's 
 powder, and one of mercury with chalk, given to it afterwards, will 
 often be found to procure for the little patient, previously restless and 
 fretful, some hours of quiet repose. If the child should appear much 
 exhausted, a slight stimulant, such as four or five drops of the spirit of 
 nitrous ether, may be advantageously combined with each dose of the 
 mixture ; and in all cases of simple diarrhcea it behooves us to watch 
 most carefully against the powers becoming too much depressed, either 
 by the profuseness of the purging or by its continuance. 
 
 Supposing in any case that a considerable degree of looseness of the 
 bowels should continue after a lapse of two or three days astringents 
 must be resorted to ; and I know of none better than the extract of log- 
 wood, in combination with tincture of catechu. 1 The logwood, more- 
 over, is something besides a mere astringent; it is a very valuable 
 tonic in all cases where gastro-intestinal disorder has existed; and it is 
 one which children take readily. It is, however, not very popular in 
 the nursery, because it imparts to the evacuations a deep pink color, 
 which leaves an indelible stain upon the napkins — a fact which it is as 
 well to mention when you prescribe the medicine. The mercury and 
 chalk and Dover's powder may be still continued at bedtime if the 
 evacuations, though less frequent, are still slimy and unhealthy. If 
 either the evacuations or the infant's breath have a sour smell, three 
 grains of the sesquicarbonate of soda may be added to each dose of the 
 mixture; or if the child is not wholly fed at the breast, a drachm of 
 prepared chalk may be stirred up with each pint of milk given to it ; 
 and after the powder has been allowed to settle, enough will still remain 
 suspended in the fluid to counteract any slight acidity in the alimentary 
 canal. If, after the bowels have become quite regular, some tonic should 
 still be required, the extract of bark, with small doses of the tincture, 2 
 will be one of the best that can be given. You will observe that all the 
 remedies mentioned occupy but a very small compass, — a point the im- 
 portance of which is never to be forgotten in prescribing for children. 
 
 But there are cases which wear a much more serious aspect than those 
 the treatment of which we have hitherto considered. Even in true in- 
 flammatory diarrhoea, however, depletion is but seldom needed ; for 
 either the abdominal tenderness is inconsiderable, or if the attack set in 
 with great severity, it will be generally found to have occasioned so 
 much depression as to contraindicate the abstraction of blood. Still, 
 in cases of recent date, if the abdominal tenderness is considerable, and 
 if it is associated with much heat of skin and febrile disturbance, a few 
 leeches may be applied in either iliac region. The child should be care- 
 
 1 (No. 30.) 
 R. Extr. Haematoxyli, gj. 
 Tinct. Catechu, ^ij. 
 Syrupi, 3J. 
 
 Aquae Carui, >px. M. 
 A teaspoonful three times a day. For a child a year old. 
 2 See Formula, No. 4, p. 57. 
 
TREATMENT OF INFLAMMATORY DIARRHOZA. 533 
 
 fully watched for some hours afterwards, in order to prevent any ex- 
 cessive loss of blood ; since considerable hemorrhage not infrequently 
 follows the application of leeches to the abdomen, and it is not always 
 very easily arrested. On this account, I think you may find it the better 
 plan to apply the leeches to the margin of the anus, in which situation 
 they will relieve the bowels at least as much, while the bleeding from 
 them will be completely under your control. In the majority of in- 
 stances the pain and tenderness of the abdomen- are much eased by the 
 application of a large hot bran poultice; the frequent renewal of which 
 often affords great comfort to the child. 
 
 If the irritability of the stomach is not so great as to prevent its 
 administration, no medicine is of such general application, or of such 
 essential service, in these cases, as a mixture containing a small quan- 
 tity of castor oil diffused in mucilage, with the addition of a few T drops 
 of tincture of opium, which I was led to use in the inflammatory diar- 
 rhoea of children from observing the great benefit Avhich followed its 
 employment by my friend the late Dr. Baly, in the treatment of dys- 
 entery among the prisoners in Millbank Penitentiary, 1 
 
 Although this medicine may relieve all the symptoms considerably, 
 and although the general state of the child may be much improved, yet 
 it sometimes happens that a considerable degree both of tenesmus and 
 of purging continues. These symptoms will now be more effectually 
 soothed by an opiate enema than by any other means. Three minims 
 of laudanum will form an enema of sufficient strength for an infant a 
 year old ; and this should be given suspended in half an ounce of 
 mucilage, since a more bulky injection is almost sure to be immediately 
 expelled. Supposing the symptoms not to yield to these means, or that 
 the case presented from the first a great degree of severity, small doses 
 of Hyd. c. Creta and Dover's powder may be given every four hours, 
 in addition to the castor-oil mixture ; which, however, should now be 
 given without the laudanum. 
 
 In some cases the irritability of the stomach is so great that almost 
 everything taken is speedily rejected ; and when this condition is present, 
 none of the medicines already mentioned can be borne. In these cir- 
 cumstances a small mustard poultice should at once be applied to the 
 epigastrium, the child should be taken from the breast, a teaspoonful of 
 cold water or cold barley-water should be given at intervals, and a powder 
 of a third of a grain of calomel, and a twelfth of a grain of opium, 
 should be laid upon its tongue every three hours for three or four 
 times. The sickness will generally subside in four or five hours, though 
 the stomach often remains too irritable to bear any change in the 
 remedies, and the greatest caution will be needed in restoring the infant 
 
 1 (No. 31.) 
 R. 01. Eicini, £j. 
 
 Pulv. Acacise, tt£xx. 
 Sacchari albi, ^ss. 
 Tinct Opii, n^'iv. 
 Spt. Myristiea?, tr^xx. 
 Aquae Flor. Aurant., gxi. M. 
 A teaspoonful every four hours. For a child a year old. 
 
534 USE OF STIMULANTS. 
 
 to the breast. It may be necessary indeed, to confine the child for 
 twenty-four or thirty-six hours to cold barley-water, cold water thick- 
 ened with isinglass, the white decoction of Sydenham, or equal parts of 
 cold milk and water ; and when the child has been seen early in the 
 disease, I have never observed any evil to follow the perseverance for 
 this short period in a rigorous diet. 
 
 The tepid bath employed twice a day, or even more frequently, will 
 be found of great service in soothing that general irritability of the 
 nervous system which often continues through the whole course of the 
 affection, and. which sometimes issues in convulsive seizures, or in other 
 symptoms that are occasionally mistaken for the indications of real 
 cerebral disease. It cannot be necessary to reiterate here the often-re- 
 peated caution against regarding the symptoms of disturbance of the 
 nervous system as being always the signs of active cerebral disorder 
 calling for depletion to relieve the congestion of the vessels of the brain, 
 and for antiphlogistic measures to moderate the excited state of the cir- 
 culation. At the very commencement of this course of lectures, 1 I en- 
 deavored to set before you the various circumstances in which convul- 
 sions come on in early life ; and some days ago 2 I tried to delineate the 
 characteristic features of spurious hydrocephalus. On that occasion I 
 related the history of two children, both of whom had been attacked 
 by severe diarrhoea. In one case, the child passed every few minutes 
 from a state of listless drowsiness to a condition of extreme restlessness 
 and alarm ; the tendons of the forearm were in a state of subsultus, and 
 general convulsions seemed impending. In the other case, the irrita- 
 bility of the nervous system was rapidly subsiding under the general 
 exhaustion of the vital powers, and probably in a few hours more the 
 infant would have sunk into a profound coma, from which no means 
 would have been adequate to rouse it. The tepid bath and an opiate 
 enema in the first-mentioned case, and the free employment of stimu- 
 lants in combination with small doses of Dover's powder in the second, 
 speedily averted dangers that had seemed so threatening. I need not, 
 however, tread again over all the ground we have already passed, but 
 will content myself with repeating the remark I then made — that if, in 
 cases of this kind, you fall into the error of regarding the cerebral 
 symptoms as the signs of active disease, and withhold the Dover's 
 powder or the opiate enema, that might have checked the diarrhoea and 
 soothed the irritability, while you apply cold lotions to the head, and 
 give the child nothing more nutritious than barley-water in small 
 quantities, because the irritability of the stomach, which results from 
 weakness, seems to you to be the indication of disease of the brain, the 
 restlessness will before long alternate with coma, and the child will die 
 either comatose or in convulsions. 
 
 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 ; 
 
 1 Lecture III, p. 43. 2 Lecture XI, p. 131. 
 
TREATMENT OF CHRONIC DIARREKEA. 535 
 
 while the infant's state in the morning affords, in cases of severe diar- 
 rhoea, no sure criterion by which to judge what its condition 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 
 a large number of instances. I have, however, met with some instances 
 in which they were absolutely necessary as early as the second or third 
 day of the disease. This has occurred in cases in which there was 
 great irritability of the stomach, as well as violent action of the bowels ; 
 in which no medicine could be borne except the calomel and opium 
 powders, nor any drinks except such as were given cold. In such cir- 
 cumstances a state of extreme debility is sometimes very rapidly in- 
 duced, and the vomiting, which at first was a sign of the gastric dis- 
 order, continues when it is nothing else than an effect of the general 
 exhaustion. 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 arresting 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. Occasionally, however, when it 
 has been necessary to continue it for some time, it has seemed to pro- 
 duce pain in the stomach, and even to nauseate the child ; and in this 
 case the compound tincture of bark, or the aromatic spirits of ammonia, 
 or the two together, may be substituted for it ; and there is seldom 
 much difficulty in administering them, if they are mixed with milk and 
 sufficiently sweetened. 
 
 The proper time for the employment of aromatics and astringents is 
 not during the acute stage of the affection ; but when the disease has 
 already begun to decline, these remedies will be found of most essential 
 service in checking that looseness of the bowels which otherwise is 
 very apt to degenerate into a state of chronic diarrhoea. In these cir- 
 cumstances the logwood and catechu mixture, mentioned at an early 
 part of this lecture, is a very valuable medicine, or the watery extract 
 of Bael, and the syrup of the Australian Red Gum. 1 If, notwithstand- 
 ing its employment, the bowels still continue to act with excessive fre- 
 quency, small doses of the compound powder of chalk and opium may 
 be given twice a day, 2 or the use of the opiate enema may be continued 
 if there be much tenesmus. By these means, coupled with the most 
 
 1 (No. 32.) 
 
 R. Extr. Belseliquidi, giij. 
 Syr. Gummi rubri, giss. 
 Tinct. Camph co., ^ij. 
 Tinct. Aurantii, ^ij. 
 Glycerina purificati, giij. 
 Aquae Anisi, gvj. 
 Aquae purse, ad 3jiij. M. ft. Mist. 
 Two teaspoonfuls every six hours. For a child a year old. 
 
 2 (No. 33.) 
 
 R. Pulv. Cretae co. c. Opio, J}j. 
 Inf. Catechu Co., ^iss. M. 
 A teaspoonful two or three times a day. For a child a year old. 
 
536 TREATMENT OF CHRONIC DIARRHCEA. 
 
 sedulous attention to the child's diet, and the greatest care in allowing 
 either animal broths or meat or other solid food, a complete cure will 
 usually be brought about in the course of two, or at the latest of three 
 weeks. 
 
 There are some cases in which, after the disease has passed its acute 
 stage, it still retains much of its dysenteric character ; the bowels not 
 merely acting with undue frequency, but the evacuations containing 
 mucus, pus, or blood, and their expulsion being attended with very 
 considerable tenesmus. The strength in such chronic cases is very 
 greatly reduced, and emaciation goes on to a greater degree than in 
 almost any other affection with the exception of phthisis and mesen- 
 teric disease ; while the bowels are excited to almost immediate action 
 by even the simplest food. The treatment of these cases is attended 
 with considerable difficulty ; recovery, when it does take place ( and it 
 is consolatory to know that it often does, even from a condition appar- 
 ently desperate), is brought about very slowly, and each remedy 
 employed seems speedily to become ineffectual. Throughout their 
 course two objects are to be borne in mind, — one being to check the 
 diarrhoea ; the other to support the child's strength during the time 
 required for nature to effect the cicatrization of the ulcerated mucous 
 membrane, and to restore it to a state of health. The utility of mer- 
 curial preparations has appeared to me to be almost exclusively confined 
 to the early stage of dysentery, and to cease when the disease has passed 
 into the chronic form. On the other hand, astringents may now be 
 employed with the most marked benefit, and when one fails, another 
 may be substituted for it. In cases where the stomach has been very 
 irritable, so that almost everything has been speedily rejected, I have 
 sometimes employed the gallic acid in combination with laudanum, 1 
 and have seen much benefit from its use. At other times I have given 
 the acetate of lead with opium, 2 — a combination which retains its effi- 
 cacy when given in the form of mixture, notwithstanding the decom- 
 position that takes place. The sulphate of iron combined with opium 3 
 
 1 (No. 34.) 
 
 &. Acidi Gallici, gr. viij. 
 
 Tinct. Cinnamomi co., ^j. 
 Tinct. Opii, n^viij. 
 Syrupi, gij. 
 Aqua? Cinnamomi, %v. 
 Aqua? purse, giv. M. 
 Two teaspoon fuls every six hours. 
 
 2 (No. 35.) 
 
 R. Plumbi Aeetat., gr. vj. 
 Aceti destillati, ttj?xx. 
 Tinct. Opii, T^viij. 
 Muc. Acaciae, 31J. 
 S\'rupi Zingib., gj. 
 Aquae purse, ^xiij. M. 
 Two teaspoonfuls every six hours. 
 The above are all suited for children one year old. 
 
 3 (No. 36.) 
 
 R. Ferri Sulphatis, gr. iv. 
 Tinct. Opii, rijjyj. 
 Syrupi Aurantii, gij. 
 Aquae Carui, £x. M. 
 Two teaspoonfuls every six hours. For a child a year old. 
 
DIET IN CHRONIC DIARRHOEA. 537 
 
 is another highly useful remedy in these cases, and appears to have the 
 advantage over the sulphate of zinc, which has likewise been used in 
 similar cases, of not exciting the irritability of the stomach. 
 
 Our remedies are not to be confined to those administered by the 
 mouth ; for much may be done towards relieving the symptoms and 
 curing the disease by suitable enemata. In some cases of unmanageable 
 diarrhoea, M. Trousseau employed an enema of nitrate of silver in the 
 proportion of a grain to an ounce of distilled water, which I have 
 sometimes tried in combination with a few drops of laudanum, with 
 very good effect. I have employed the gallic acid in enema in a 
 similar manner; and throughout any case of chronic diarrhoea, occa- 
 sion will often arise for altering our remedies in various ways, not so 
 much to meet any changes in the character of the symptoms, as be- 
 cause all medicines, even the most appropriate, after having been em- 
 ployed for a time, seem to lose their power. In the majority of in- 
 stances I have begun with the administration of clysters of laudanum 
 diffused in mucilage, or in a small quantity of starch, while occa- 
 sionally, in protracted cases, where the tenesmus was very distressing, 
 I have used the black wash as a vehicle for the laudanum ; and on one 
 occasion, in which a copious discharge of pus continued for several 
 days in a little boy two years old, this symptom was greatly relieved 
 by the administration, twice a day, of an enema containing two grains 
 of sulphate of zinc. 
 
 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 nourishment of 
 all kinds, often render it necessary to continue the use of brandy for 
 several days, or even for several weeks. For an infant not weaned, 
 there can be no better food than that which is furnished by the breast 
 of a healthy nurse. In the majority of cases, however, the child has 
 been either in great measure or altogether weaned before the affection 
 came on, and consequently it is a less easy matter to supply it w T ith 
 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 infrequently pass through the alimentary canal un- 
 changed. Milk, too, does not always agree, and is sometimes rejected 
 almost at once, unless it be given in a state of extreme dilution ; and 
 in many of these cases whey may be advantageously substituted for it. 
 In 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 is 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 nutriment. 
 I may add that, when prepared with care, and quite free from salt or 
 any seasoning, and when given cold, I have seldom observed any 
 serious increase of the diarrhoea to follow their use in these circum- 
 stances. In some instances, too, beef tea prepared cold by means of 
 hydrochloric acid is retained by the stomach, which rejects almost every- 
 thing else. In some of these cases, however, we encounter an addi- 
 tional difficulty, owing to the child's distaste for almost every kind of 
 
538 TREATMENT OF INTERTRIGO 
 
 food, which it either positively rejects, or having taken a little seems 
 to be nauseated by it, and refuses any more ; and this, even though its 
 eager manner and its plaintive cry plainly announce its hunger. In 
 these circumstances there is still one article of food — raw meat — which 
 is often eagerly taken, and almost always perfectly digested. 1 Prof. 
 Weisse, of St. Petersburg, 2 first recommended its employment in chil- 
 dren suffering from diarrhoea after weaning, and it has since then been 
 very frequently given by other physicians in Germany in cases of long- 
 standing diarrhoea. The lean, either of beef or mutton, very finely 
 shred, pounded to a pulp in a mortar, and if the stomach be very 
 irritable, rubbed through a fine sieve, may be given in quantities at 
 first of not more than an ounce in the course of the day ; and this in 
 small quantities at a time to children of a year old ; and afterwards, if 
 they crave for more, an ounce and a half even may be allowed. I have 
 seldom found any difficulty in getting children to take it — often, 
 indeed, they are clamorous for it ; it does not nauseate if given in small 
 quantities, neither does it ever aggravate the diarrhoea, while in some 
 instances it has appeared to have been the only means by which the 
 life of the child has been preserved. With returning convalescence, 
 the desire for this food subsides, and the child can without difficulty 
 be placed again on its ordinary diet. 
 
 Two accidents are occasionally met with in connection with pro- 
 tracted diarrhoea in infants and young children, concerning each of 
 which a few words must be said. It is not unusual to observe a gen- 
 eral erythematous redness of the buttocks and nates in infants suffering 
 from severe diarrhoea, and sometimes the irritation of the acrid fseces 
 produces an attack of intertrigo, and a serous fluid exudes abundantly 
 from the inflamed skin. This condition, which is the occasion of very 
 considerable suffering to the child, almost always depends upon a 
 neglect of that most scrupulous cleanliness which is of such essential 
 importance in early life. In order to prevent its occurrence, the nates 
 and buttocks must be sponged with warm water immediately after each 
 evacuation ; the surface may afterwards be smeared with a little zinc 
 ointment, while any part at which the skin seems disposed to crack 
 should be dusted over with the oxide of zinc in powder. These simple 
 precautions will usually suffice to prevent a condition which, in some 
 of the hospitals of Paris, where such sedulous care is almost impossible, 
 
 1 The greater digestibility of raw meat than of that which has been cooked, con- 
 stitutes doubtless its great advantage in these cases. The fact, though contrary to 
 the opinions formerly entertained on the subject, appears to be substantiated, not 
 merely by carefully conducted experiments on artificial digestion, but also by 
 observations on the subject, for which opportunity was afforded by a case resembling 
 that of the Canadian, who was for so long a time under the notice of Dr. Beaumont. 
 See a dissertation, Succi G-astrici Humani Vis Digestiva ope Fistula? Stomachalis 
 Indagata. Auctore Ernesto de Schrceder. Dorpat, 1853. The author comes to the 
 conclusion, " carnem crudam in ventriculo hominis facilius quam carnem coctam dis- 
 solutam esse." M. Trousseau, at p. 123 of vol. iii, of the 2d edition of his Clinique 
 Medicale, bears the strongest testimony to the utility of raw meat in cases of diar- 
 rhoea, and more especially of that form which succeeds to weaning. 
 
 2 Journal f. Kinderkrankheiten, vol. iv, 1845, p. 99. 
 
AND OF PROLAPSUS ANI. 539 
 
 degenerates into a state of unhealthy ulceration that exhausts the in- 
 fonts powers, and sometimes contributes to its destruction quite as 
 much as the diarrhoea in the course of which it came on. 
 
 Prolapsus of the anus is another troublesome accident which some- 
 times takes place in the course of protracted diarrhoea. It abates, how- 
 ever, almost always, as the diarrhoea diminishes, and generally ceases 
 altogether as the child regains its strength. When there is a disposi- 
 tion to it during the acute stage of the affection, this may often be 
 controlled if the nurse be instructed to support the margin of the anus 
 during each evacuation, and thus to prevent the descent of the bowel, 
 while the opiate enema which relieves the tenesmus is of most essential 
 service, by thus removing the cause of the prolapse. The child's at- 
 tendant should also be taught how to return the bowel if it should 
 come down ; and this is best effected by means of gentle pressure with 
 a napkin wrung out of cold water. If, as the diarrhoea abates, the 
 prolapse should still continue, the nurse must still support the edge of 
 the bowel during each effort at defecation, if the child cannot be in- 
 duced to pass its evacuations lying down. If, however, the gut should 
 come down independent of efforts at defecation, it may be necessary to 
 confine the child to bed for some little time, while the buttocks may 
 be kept close together by a couple of broad strips of plaster passed 
 round from one hip to the other. I have seen many cases which, as 
 out-patients, were most rebellious to all treatment, completely cured 
 by a few weeks' stay in bed. When the child begins to go about again 
 it may be wise to let it wear a pad and bandage for a short time, while 
 some advantage may be gained by the daily employment for a week 
 or two of a small enema of cold water or of the decoction of tormen- 
 tilla, or of some other astringent. 1 
 
 1 It does not come within my province to discuss the surgical treatment of long- 
 standing prolapsus ani. Cold enemata, however, or any proceedings not addressed 
 to the paralyzed state of the sphincter itself, are in such cases entirely useless; and 
 the removal of some of the folds of skin at the margin of the anus, or the applica- 
 tion of the actual cautery at four opposite points in that situation, are the only 
 measures likely to be of service. With reference to the latter proceeding, which 
 has the advantage of being the less severe, and in the young child is said to be 
 generally effectual, see a paper by M. Duehaussez, in the Archives de Medecine, 
 September, 1853. See also Holmes, op. cit., p. 577. 
 
540 PERITONTTIS IN EARLY LIFE, 
 
 LECTURE XXXVIII. 
 
 Peritonitis. — Sometimes occurs duriner foetal existence, or in very early infancy — 
 Is then possibly dependent on syphilitic taint — When epidemic in large insti- 
 tutions, is often connected with infantile erysipelas. 
 
 Peritonitis in after childhood — A rare occurrence — Generally secondary to some 
 febrile attack — Case illustrative of its symptoms, which are much the same as 
 in the adult — Occasional escape of the fluids effused, through the abdominal 
 walls, and recovery of the patient — Inflammation sometimes circumscribed, 
 especially in connection with disease about the appendix caeci — Illustrative 
 cases — Treatment of peritonitis. 
 
 Chronic peritonitis — Almost always a tubercular disease — Morbid appearances — 
 Symptoms — Their vagueness — E'auses in the advance of the disease — Various 
 and often obscure forms which it assumes — Close analogy between its symptoms 
 and those referred to tubercular disease of the mesenteric glands. 
 
 Tabes Mesenterica. — Rarity of extensive disease of the glands — Slightness of its 
 sj'mptoms when uncomplicated — Treatment of it, and of tubercular peritonitis. 
 
 From the study of the affections of the mucous lining of the intes- 
 tinal canal, we pass by a natural transition to that of the disease of its 
 serous investment. Peritonitis, however, which is not very common 
 as an idiopathic affection at any period of life, is still more rare during 
 the greater number of the years of childhood ; while its symptoms do 
 not deviate in any important respect from those which characterize it 
 in the adult. It would be idle to spend our time in speculating on the 
 reasons for the rarity of inflammation of the peritoneum in early life. 
 Some connection may perhaps be thought to subsist between the great 
 irritability of the intestinal mucous membrane, and its proneness to 
 disease during the greater part of childhood on the one hand, and the 
 immunity from disease which the peritoneum exhibits during the same 
 period. At any rate, it is certain that in the new-born infant, in whom 
 the former peculiarity has not yet become developed, inflammation of 
 the peritoneum is of more common occurrence than in subsequent child- 
 hood. 
 
 Inflammation of the peritoneum, giving rise to adhesions between the 
 intestines, and to the effusion of lymph and serum into the cavity of 
 the abdomen, occurs sometimes even during intra-uterine life, and occa- 
 sions the death of the foetus. It is not possible to say with certainty 
 to what cause the disease should be attributed at a time when the being 
 is sheltered from all those influences from without which may excite 
 inflammation after birth ; but it is worthy of notice that in many in- 
 stances of peritonitis in the foetus, traces of syphilitic disease are observed 
 upon it; or there is clear evidence of the existence of venereal taint in 
 the mother. In such cases, the inflammation of the serous lining of 
 the abdomen is probably due to the altered state of the circulating fluid ; 
 a cause to which, in after life, inflammation of the serous membranes 
 is frequently owing. 
 
PERITONITIS IN EARLY LIFE. 541 
 
 My own experience of non-congenital peritonitis in early infancy is 
 extremely small, and consists of only two cases ; in one, which recov- 
 ered, it was obviously connected with syphilitic taint, but in the other, 
 which proved fatal, and which ran an acute course, it was impossible 
 to assign any cause whatever for its occurrence. In this instance, the 
 infant, seven months old, who had been brought up by hand since the 
 age of four months, was put to bed perfectly well, but awoke in the 
 night screaming with pain. The child became very sick, its abdomen 
 was tense and tender, and the urinary secretion exceedingly scanty. 
 In six days the child died under a continuance of these symptoms, and 
 after death there was found a large quantity of sero-purulent fluid in 
 the abdomen ; the intestines and the abdominal peritoneum were coated 
 with a thin layer of lymph, and their vessels w T ere congested. There 
 was no tubercle in any organ, no obstruction of any kind ; and, indeed, 
 the bowels had acted from mild aperients ; no disease was to be found 
 except the simple acute peritonitis. 
 
 The other case was that of a little boy, five weeks old (whose 
 mother had twice before been confined prematurely with stillborn 
 children), who began to have snuffles at the age of three weeks. In 
 the course of the next week a few copper-colored spots appeared about 
 his face ; his scrotum next grew sore, then his voice became hoarse and 
 his lips cracked ; and at the end of the fourth week he grew sick and 
 his abdomen enlarged and became tender. When brought to me, the 
 child was extremely small ; he was greatly emaciated ; the skin of his 
 face wrinkled ; his appearance distressed ; his chin covered with copper- 
 colored blotches ; the angles of his mouth were ulcerated ; his lips 
 cracked ; and small sores beset his scrotum. His abdomen likewise was 
 very large ; it was remarkably prominent about the umbilicus, and 
 its superficial veins were much enlarged. It was extremely tense, 
 somewhat tympanitic, and though dull in places, it yet did not yield 
 the impression of distinct fluctuation anywhere. The abdomen was 
 exceedingly tender to the touch, but the child seemed in pain also 
 even when quite quiet ; he had been very sick for nearly a week, and 
 vomited almost immediately after sucking, besides which he threw up 
 a yellow fluid at other times. His bowels were purged several times 
 a day. His mother, who did not suffer at that time from any syphil- 
 itic symptom, was put upon a mild mercurial course, with iodide 
 of potassium and sarsaparilla ; and the mercury with chalk was like- 
 wise administered to the child. By degrees, as the syphilitic spots 
 faded, the abdomen grew less tender, and less swollen — it became soft ; 
 and in the course of time the infant regained perfect health. 
 
 The symptoms in this case ran a chronic course ; but peritonitis of 
 an acute character, and tending to a rapidly fatal termination, is some- 
 times observed to occur among very young infants when collected 
 together in large' numbers, and under conditions unfavorable to health. 
 A French physician, M. Thore, 1 during a year's observation at the 
 Hospice des Enfans Trouves at Paris, found that acute peritonitis 
 
 1 De la Peritonite chez les Nouveau-nes, in the Archives Gen. de Med. for 
 August and September, 1846. 
 
542 SYMPTOMS OF ACUTE PERITONITIS IN CHILDHOOD. 
 
 existed in about six per cent, of the infants who died at that institu- 
 tion. The disease, such as he observed it, seems to be exclusively an 
 affection of early infancy, since, though the hospice contains children 
 of all ages, yet no child above the age of ten weeks was attacked by 
 it, while thirty-five out of fifty-nine were less than a fortnight old. 
 The previous health of the children had in some instances been good, 
 but in many cases the peritonitis appeared as a consequence or compli- 
 cation of some other affection. A sudden tympanitic swelling of the 
 abdomen was often the first symptom of the disease, and was soon 
 associated with vomiting of a greenish matter ; which phenomenon, 
 however, was seldom of long continuance. The bowels were generally 
 constipated throughout, the respiration and pulse soon became acceler- 
 ated, and the heat of the skin increased, while the child evidently 
 suffered pain in the abdomen. With the advance of the disease the 
 countenance altered, the skin grew cold, and the pulse feeble ; and in 
 the majority of cases the child died within twenty-four hours, while 
 life was not in any instance prolonged beyond the third day. 
 
 The appearances found after death were much the same as those 
 which characterize peritonitis in the foetus. In none of the sixty-three 
 cases which were examined was there any puriform matter in the ab- 
 dominal cavity, but only a dirty serous fluid, in which flocculi of 
 lymph were often floating; while the intestines were more or less 
 coated with false membrane, which was especially abundant about the 
 spleen and liver. Pleurisy was found associated with the peritonitis 
 in a third of the cases ; and the frequency of this complication is an- 
 other point of resemblance between the disease as it occurs during 
 foetal life and in early infancy. Its causes, too, appear to be such as 
 act through the medium of the circulating fluid ; for in seventeen out 
 of sixty-three cases the peritonitis followed upon erysipelas, and in four 
 upon phlebitis of the umbilical vein — affections which, it is known, 
 are immediately dependent on epidemic causes, and are excited by the 
 same atmospheric conditions as induce puerperal fever in lying-in 
 women. The influence of such agencies is still further shown by the 
 fact that forty-two per cent, of the cases of peritonitis recorded by 
 M. Thore occurred during the months of April and May, while the 
 others were somewhat unequally distributed over the remainder of the 
 year. 
 
 When the child grows older it is no longer so susceptible of noxious 
 influences as before; and when they come into play, the mucous mem- 
 brane of the bowels suffers, rather than their serous investment. Hence, 
 acute idiopathic peritonitis becomes a very rare disease in childhood; 
 and peritoneal inflammation usually occurs as a sequela of some affec- 
 tion which has been attended with considerable alteration in the cir- 
 culating fluid. It sometimes succeeds to an attack of scarlatina; and 
 the possibility of its occurrence should lead us to look with great sus- 
 picion upon any complaint of pain in the abdomen made by children 
 during their convalescence from that disease ; while, though the danger 
 of its supervention after other febrile affections is less considerable, the 
 risk is by no means to be forgotten. 
 
 The symptoms and course of the disease appear to be much the same 
 
CASE OF ACUTE PERITONITIS. 543 
 
 whether it occurs as a primary or as a secondary affection ; but there is 
 a great difference between the severity of the symptoms and the amount 
 of danger to which the patient is exposed, in different cases. 
 
 I do not recollect ever to have witnessed more intense suffering than 
 was endured by a little boy, nine years old, who, after recovering from 
 fever, yet seemed to regain his health by but slow degrees, and had 
 almost habitual constipation. He came under my notice on May 25, 
 and was much benefited by alterative and slightly aperient medicines; 
 when he was suddenly, and without any known cause, seized on the 3d 
 of June with profuse diarrhoea, and severe pain in the abdomen. On 
 the following day, when I saw him, his face was haggard and anxious, 
 and his abdomen excessively tender ; while the diarrhoea continued even 
 more profusely than before. Some leeches were applied to the abdomen 
 and calomel and Dover's powder were given every four hours ; but the 
 leeches drew but little blood, and though the purging ceased, the pain 
 in the abdomen increased in severity. On the 5th of June I found the 
 boy lying on his back, with his legs stretched straight out ; w T hile the 
 slightest movement, or any attempt to sit up, produced excruciating 
 pain. The abdomen was tympanitic, very tender to the touch, and 
 especially so just below the umbilicus. The pulse was frequent and 
 sharp ; the tongue moist, and uniformly coated with yellow fur. Leeches 
 were again applied, in greater numbers than before; and the mercurial 
 was given every three instead of every four hours. Towards evening 
 he was rather better, but the pain, which was referred especially to the 
 neighborhood of the umbilicus, came on severely during the night, and 
 was aggravated in paroxysms. He had passed no urine for many 
 hours, but only half a pint was drawm off by the catheter, and this was 
 dark-colored, and had a very strong smell. The bowels had acted only 
 once, and then scantily. The same remedies were continued, but the 
 child's condition continued to grow worse; and during the night he 
 was in such pain that he frequently shrieked aloud, so as to alarm the 
 neighborhood. On the morning of the 7th he had turned round upon 
 his right side, and lay with his knees drawn up towards his abdomen, 
 his head supported in his mother's lap ; his face expressed the most in- 
 tense suffering, and he shrieked frequently with pain. The abdomen 
 was much distended, and so tender that it could not endure the slightest 
 touch. The pulse had become frequent and thready. He had made water 
 twice of his own accord. The abdomen was now covered with a large 
 blister ; beef tea and brandy were given to support the vital powers ; 
 and while the mercurial was continued, air endeavor was made by a full 
 dose of opium, to procure a temporary abatement of the child's suffer- 
 ings. When seen at 6 p.m. he had vomited frequently a dark green 
 fluid, and had passed three natural liquid evacuations. He was lying 
 in the same attitude as before, dozing with half-closed eyes, his forehead 
 wrinkled, the corners of his mouth drawn down, terror and pain stamped 
 on his countenance, — seeming as if dying, till roused by a return of pain, 
 when he called with loud and piteous cries on his mother for help. His 
 pulse was now smaller and more thready. During the night his suffer- 
 ings were unceasing ; towards morning he became quieter, and died 
 quietly at 9 A.M. on June the 8th. « 
 
544 ACUTE GENERAL PERITONITIS. 
 
 On opening the abdomen, thin pus, unmixed with lymph, poured 
 forth in great abundance. It quite concealed the intestines from view, 
 and must have amounted to at least a quart. The peritoneum lining 
 the abdominal walls was highly vascular, especially in the hypogastric 
 region ; that covering the intestines had lost its natural transparency, 
 was softer, and seemed thicker, but was not much injected. There was 
 no lymph effused on any part of the parietal peritoneum, nor were 
 there any adhesions between tbe intestines ; but the spleen and liver, 
 the latter especially on its convex surface, were coated with lymph. 
 The whole tract of the intestines was examined with great care, and 
 was found to be quite healthy ; the mucous membrane being rather 
 pale. There was some crude tuberculous matter in the mesenteric 
 glands. The right side of the chest contained a pint of pus, similar to 
 that in the abdomen ; the right pleura was intensely vascular ; and this 
 condition was especially remarkable in that part of it which lined the 
 diaphragm ; a patch of lymph, of small extent, formed a connection 
 between the two surfaces of the lung, while the right lung generally 
 had a rather thick coating of false membrane. Some tubercles in the 
 bronchial glands, and a compressed state of the substance of the right 
 lung, formed the rest of the morbid appearances. 
 
 There can be no doubt but that, in the early stages of this case, a 
 more active plan of treatment ought to have been adopted. It is re- 
 lated, however, not as an illustration of the therapeutical principles by 
 which you should be guided, but as affording a remarkably good speci- 
 men of the symptoms of acute peritonitis. The inflammation of the 
 pleura was doubtless secondary to that of the peritoneum, and the 
 effusion into the cavity of the chest probably coincided with the time 
 when the child assumed the position on his right side. AVe learn from 
 this case, that pain, coming on suddenly, referred particularly to one 
 part of the abdomen, but extending over the whole, greatly aggravated 
 on pressure, or on the slightest movement, so as to compel the patient 
 to remain in the recumbent posture, with the legs extended and mo- 
 tionless, characterizes the disease. The abdomen before long becomes 
 tympanitic, and this tympanitis, if considerable, greatly aggravates the 
 patient's sufferings. The state of the bowels varies : frequently they 
 are relaxed at the outset of the illness ; sometimes they continue so 
 throughout, while they are but rarely constipated. Vomiting is not a 
 constant symptom ; and when it does occur, the irritability of the 
 stomach varies, both in its degree as well as in the time at which it 
 appears. The symptoms sometimes continue to increase in severity 
 until death takes place ; at other times they undergo a sudden dim- 
 inution, or even cease altogether ; though this seeming amendment is 
 attended, or rapidly followed, by sinking of the vital powers, and 
 soon afterwards by the patient's death. 
 
 Acute general peritonitis is fortunately very rare in childhood, — 
 only four other instances of it as an idiopathic affection have come 
 under my notice ; and still rarer is its termination by the effusion of 
 pus into the cavity of the abdomen. Even in these apparently hope- 
 less circumstances, however, nature does sometimes make an effort 
 at cure. The active symptoms diminish in intensity ; the abdominal 
 
ACUTE GENERAL PERITONITIS. 545 
 
 parietes grow thin at some spot, where a passage at length is formed 
 through which the 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. Aid is, at a meeting of the Medico-Chirurgieal 
 Society, in November, 1846. * A few similar cases may be found in 
 medical journals f and three have come under my own observation, — 
 one in the person of a little child, whose history I formerly related 3 
 as affording an illustration of that rare affection, thrombosis of the 
 sinuses of the dura mater ; a second in a little girl aged six and a half 
 years, in whom puncture of the prominent umbilicus on the 27th day 
 from the attack of acute peritonitis was followed by the discharge of 
 forty-eight ounces of pus ; a renewal of the puncture on the 33d day 
 was again succeeded by the escape of twenty-four ounces, and some 
 discharge continued from this time until the death of the patient, 
 from exhaustion, fifty-three days after the onset of her illness. In the 
 third case, that of a girl aged eight years, the peritonitis was chronic 
 in its character, and associated with tubercular disease. 
 
 The peritoneal inflammation which comes on during scarlatinal 
 dropsy is not in general of a very active character, and seldom pro- 
 duces any morbid appearance of greater gravity than numerous slight 
 adhesions between the intestines. It generally succeeds to ascites ; and 
 the abdominal affection seldom exists alone, but is usually associated 
 with pleurisy, and abundant serous effusion into the chest ; and the 
 symptoms of disease of the respiratory organs very often mask those 
 of abdominal inflammation, which latter indeed seem in many instances 
 to have but a very subsidiary share in bringing about the patient's 
 death. But to this there are occasional exceptions; and I have seen 
 a few instances of peritonitis of a most acute character coming on in 
 the course of scarlatina independent of dropsy, but as one of the sec- 
 ondary results of the disease, due in short to blood-poisoning, and 
 belonging to the same category with cervical bubo, and the inflamma- 
 tion of the joints. This form of peritonitis is not in general attended 
 with severe pain ; but is accompanied by great depression, and is char- 
 acterized after death, which takes place in the course of two or three 
 days, by abundant effusion of sero-purulent fluid just like that which 
 one meets with in cases of fatal puerperal fever. Like many of the 
 sequelae of scarlet fever, the frequency of the condition varies much in 
 different epidemics ; not occurring, perhaps, for several years, and then 
 being met with on several occasions, within a few weeks. I have never 
 seen it, however, except during the time of epidemic prevalence of 
 scarlet fever. 
 
 Besides those cases in which the peritonitis is general, there are 
 
 1 Reported in the London Medical Gazette, November, 1846. 
 
 2 For instance, Bernhardt in Preuss. Med. Zeitung, 1842, No. 10; and Beyer, 
 Casper's Woch^nsehr., 1842, No. 5. 
 
 3 See Lecture VIII, p. 108. 
 
 35 
 
546 PERITONITIS FROM INFLAMMATION OF THE C^ICUM. 
 
 others in which the inflammation is circumscribed to a part, and some- 
 times to a small part of the peritoneum. Now and then, peritonitis 
 affecting only a very small extent of surface proves rapidly fatal 
 (though no such instance has come under my own notice) ; but usually 
 there is correspondence between the severity of the symptoms and the 
 extent of the disease. I imagine the inflammation to have been circum- 
 scribed in some cases in which the principal pain was referred to one 
 part of the abdomen, while the tenderness was almost limited to that 
 situation, in which, moreover, the abdomen did not become generally 
 tense or tympanitic, and all the symptoms yielded with tolerable readi- 
 ness to the employment of remedies, though the disposition to pain and 
 tenderness in one spot was some time before it wholly disappeared. 
 
 Lastly, some notice must be taken of a highly dangerous form of 
 peritonitis, circumscribed in some cases, but general in others, which 
 succeeds to inflammation of the caecum, or of its vermiform appendix. 
 This affection, however, of comparatively rare occurrence at any age, 
 presents no such peculiarities in early life as to require any very 
 lengthened description. It has come under my observation eight 
 times; the patients in every instance were male children, of the respec- 
 tive ages of seven, eight and a half, six and a half, nine, and three 
 and a half years; and the remaining three were all ten years old. In 
 the first three cases it terminated fatally ; in the fourth it ended, after 
 protracted suffering, in the formation of an abscess in the right iliac 
 region, which was opened a little above the centre of Poupart's liga- 
 ment, the child eventually recovering; while I am ignorant of the 
 issue of the fifth case. In the first fatal case, no foreign body, nor any 
 intestinal concretion was discovered ; but in the second, a small con- 
 cretion, which weighed two grains, was found impacted in the extrem- 
 ity of the vermiform appendix, which was ulcerated around it, al- 
 though no escape of the intestinal contents had taken place. In the 
 third fatal, case, permission was not obtained to make a post-mortem 
 examination. 
 
 The main symptoms are the same in all cases. First, there is dis- 
 order of the bowels, which sometimes are constipated, less often re- 
 laxed ; but in either case there is pain in the abdomen, which passes at 
 first for that of ordinary stomach-ache, though a little inquiry will 
 ascertain that it is more abiding, and that besides it is chiefly referred 
 to the right side, and is still experienced there, even when every- 
 where else it has ceased for a season. Next, there comes, it may be in 
 one day, or it may be not until after four or five, an increase in the 
 severity of the pain, attended with tenderness on pressure over the 
 abdomen, and this tenderness is more marked on the right side than 
 elsewhere. Treatment perhaps mitigates it ; but as it does so, serves 
 at the same time to bring out more clearly the characteristic features 
 of the ailment. The right side of the abdomen now becomes tense 
 and swollen, and hard, and dull on percussion, which, though borne 
 elsewhere, causes much pain in this situation. The prominence of the 
 right side sometimes assumes the form of a distinct, somewhat elon- 
 gated tumor, reaching down to the ramus of the pubes, upwards nearly 
 into the right hypochondrium, and backwards towards, but not in 
 
INFLAMMATION OF THE CMCUM. 547 
 
 general into, the lumbar region, while the integument above it presents 
 a peculiar unyielding, brawny hardness. In addition to the swelling 
 in this situation, it will now be observed, that while the child is able 
 to extend the left leg without pain, so much suffering is induced by 
 any attempt to stretch out the right, as to compel him at once to desist, 
 and the posture which he adopts is accordingly peculiar, — one leg 
 usually extended, the other drawn up towards the abdomen, and all 
 the abdominal muscles kept as rigidly immovable as those of a marble 
 statue. 
 
 While these peculiarities stamp, almost beyond the possibility of 
 error, the nature of the ailment, it may yet run its further course in 
 different ways, and to various issues. The extension of the inflamma- 
 tion to the general peritoneum may speedily prove fatal ; having be- 
 trayed its existence, not by intense pain, but by a state of general col- 
 lapse, in which, while the skin is cold and the pulse scarcely perceptible, 
 the intellect is clear and the temper unruffled. It was thus I saw a 
 little boy die, who was eight and a half years old, and who, though 
 liable to constipation, was as well as usual till August 11th. He then 
 had stomach-ache, which was not relieved by an aperient, and on the 
 next day was more severe, though chiefly referred to the right side of 
 the abdomen. On the 13th some leeches mitigated the pain, but their 
 application produced extreme faintness. On recovering from this 
 faintness there was no longer any tenderness of the abdomen, but the 
 two most remarkable symptoms were a peculiar tension of the abdomi- 
 nal muscles, and inability to move the right leg without pain. Swell- 
 ing, too, was now apparent in the right pubo-iliac region, and on the 
 14th this was ^till more marked, while, though there was no increase 
 of pain, the pulse had risen in frequency to 130. In the afternoon of 
 that day, after scanty relief from the bowels, consequent on the admin- 
 istration of an enema, the child, without pain, sank into a state of col- 
 lapse, in which his pulse became almost imperceptible, and his surface 
 was bathed with cold sweat. In four hours he rallied somewhat, and 
 his face, though pale and anxious, by no means suggested that dissolu- 
 tion was impending, for his manner was quite calm, and his gentle 
 consideration for others, which had formed part of his very lovely 
 character, was quite remarkable. His pulse, however, was like a thread, 
 and his surface cold like that of a cholera patient. He said that he 
 had scarcely any .pain, and that his great distress was from thirst, which 
 no fluids quenched, though he took water abundantly, and very seldom 
 vomited. He grew colder and colder, his pulse became more and more 
 feeble : now and then he wandered for a moment, but was self-possessed 
 the moment he was spoken to, and the last words that he spoke just 
 before his death, which took place eight hours after the state of collapse 
 came on, were, " Thank you, sir," to one who gave him a draught of 
 water. The death which came so gently though so quickly, seemed 
 due in this case not to the intensity of the inflammation, but to its ex- 
 tension over the whole of the peritoneum. This, however, does not 
 appear to be the most common issue of the affection, but more generally 
 the mischief remains circumscribed to the neighborhood in which it 
 originated. It did so in another fatal case to which I have referred, 
 
548 TREATMENT OF PERITONITIS. 
 
 though the irritation extended to the chest, and pleurisy of the right 
 side, which issued in abundant sero-purulent effusion, contributed 
 largely to bring about the death of the child. Sometimes the inflam- 
 mation subsides, the tenderness abates, the swelling disappears, and 
 convalescence gradually takes place. I believe, however, that unless 
 the mischief is slight, resolution is a rare occurrence, and that suppura- 
 tion of the cellular tissue about the caecum, and the formation of an 
 abscess, which points either in the lumbar or the iliac region, is the 
 mode in which recovery is usually effected ; a mode tedious indeed and 
 painful, but one that, judging from one's experience of iliac abscesses 
 in the female sex, one would count on as almost always certain, though 
 slow. 1 
 
 The indications for treatment in cases of acute peritonitis, are so clear, 
 that it would be- superfluous to occupy much time in laying down rules 
 for your guidance. You have to deal with the active inflammation of 
 parts in which acute disease cannot go on long without destroying life. 
 Depletion, both general and local, and the employment of mercury, 
 combined with opium or Dover's powder, in order to mitigate the suf- 
 fering which- attends on the disease, are the remedies to which you 
 must have recourse, and which you must employ with an unsparing 
 hand. When the abdominal tenderness has been mitigated by bleeding, 
 a warm poultice, frequently renewed, will often afford considerable 
 comfort; and in some cases of local peritonitis I have seen the warm 
 hip-bath give much relief. The error into which you are likely to fall 
 in the management of these cases is not that of pursuing a wrong course, 
 but of following the right one with too little vigor. 
 
 In the peritonitis that follows scarlatina, the symptoms are often less 
 urgent than in other circumstances; but you will bear in mind, that 
 when the function of the kidneys is disturbed, and urea is circulating 
 in the blood, the serous membranes are very apt to become inflamed, 
 and you will, therefore, keep on the lookout for any indication of their 
 suffering. I shall hereafter have to point out to you, that in this, as 
 well as in so many other cases, prevention is not only better, but easier 
 than cure; and that if, on the first appearance of the dropsy consecutive 
 on scarlet fever, you have recourse to active antiphlogistic measures, 
 you will, in the large majority of cases, escape the risk of these secon- 
 dary inflammations. Concerning the treatment of the peritoneal in- 
 flammation wmich I have referred to as an occasional complication 
 rather than sequela of scarlet fever, I have little indeed to say. The 
 secondary inflammations which attend on blood-poisoning run their 
 course to a fatal issue, as we know but too well, unchecked by any 
 treatment which we can devise. 
 
 The circumscribed inflammation of the peritoneum which is associ- 
 ated with mischief in the caecum or its appendix, calls for very guarded 
 treatment. The tendency of the ailment even when it terminates most 
 favorably, is to run a slow course, and unless you could remove the 
 
 1 The papers of Dr Burne, in vols xx and xxii of the Medieo-Chiriir«;ical Trans- 
 actions, still contain the most valuable information of which we are possessed on 
 this subject. 
 
MORBID APPEARANCES IN TUBERCULAR PERITONITIS. 549 
 
 local irritation in which it originated, it would be idle to expect that 
 you could cut it short by heroic measures. The application of a few 
 leeches over the caecum, and their repetition once or twice at intervals 
 of two or three days, the sedulous employment of a warm poultice and 
 the administration of small doses of calomel with opium or Dover's 
 powder, while the bowels are kept regular by castor oil, and the diet 
 consists entirely of milk and farinaceous substances, constitute all that 
 we can venture on during the active stage of the inflammation. When 
 that has passed, and the abiding swelling, hard and tense and tender, 
 remains behind, indicating that the inflammation has ended in the 
 formation of matter, the support of the patient's strength, the employ- 
 ment of bark, the use of wine and animal broths (though still we must 
 be most careful in allowing solid food), are no less indicated ; while, 
 even at the best, we must not look for the speedy approach of the mat- 
 ter to the surface, or expect other than a very tedious convalescence. 
 
 Acute peritonitis indeed, in all its forms, like the acute inflammation 
 of any other tissue, may subside, but not altogether cease; it may pass 
 into a chronic state, and the patient may still suffer from the conse- 
 quences of the disease long after the disease in its original form has 
 disappeared. But it is not to an affection of this kind that I w T ish to 
 call your notice in speaking of chronic peritonitis ; but to a disease, the 
 progress of which is slow from its commencement, which is weeks or 
 months in running its course, but which yet demands your closest 
 attention, since in a very large number of cases that course is to a fatal 
 issue. 
 
 It is not, however, its tardy progress which alone distinguishes the 
 chronic from the acute inflammation of the peritoneum, but the former 
 is almost invariably associated with the tuberculous cachexia, and, 
 indeed, generally succeeds to the deposit of tubercle upon the serous 
 membrane of the abdomen. The occasional recovery of a child in 
 whom the symptoms of chronic peritonitis have existed, by no means 
 disproves that connection between it and the phthisical disease, of which 
 dissection in fatal cases affords such convincing proof. 
 
 The bodies of children ivho have died of this affection are usually found 
 to be exceedingly emaciated ; and their face retains after death the 
 suffering expression which it had worn during their protracted illness. 
 The lungs and bronchial glands contain tubercle in greater or less 
 abundance, and the pulmonary disease is sometimes so far advanced as 
 to have obviously had no small share in bringing about the fatal event. 
 On dividing the abdominal parietes, long, slender, cellular adhesions 
 are often found connecting the peritoneum and the subjacent viscera ; 
 while in other instances the peritoneum and intestines are agglutinated 
 together, so as to render it difficult thoroughly to expose the abdominal 
 cavity. The intestines, too, are closely connected by adhesions, some 
 of which are very easily broken down, while others are so firm that 
 the coats of the bowels give way in the attempt to separate them. This 
 difference does not depend on the age of the adhesions (although in this 
 respect they vary greatly, some being apparently of very recent date, 
 others of long standing) so much as on their nature. Those connections 
 
550 MORBID APPEARANCES IN TUBERCULAR PERITONITIS. 
 
 which are formed by the mere effusion of lymph, even when from age 
 they have acquired considerable firmness, can generally be broken down 
 without much difficulty; and at any rate the attempt will not produce 
 rupture of the intestines. When, however, different portions of the 
 bowel are matted together so inseparably that it is easier to lacerate 
 than to detach them from each other, it will be found that something 
 more than the mere effusion of lymph has produced this union. It 
 will be seen to have been effected by means of a yellow granular mat- 
 ter, like that which connects the opposite surfaces of the arachnoid in 
 a case of tubercular meningitis, and made up like it in part of lymph, 
 in part of tubercular deposits. Adhesions are thus formed between the 
 opposite surfaces of the peritoneum, at first of small extent, but fresh 
 deposits of tubercle soon take place in the vicinity, and the attendant 
 inflammatory process unites together a still greater extent of intestine. 
 Nor is this all ; but in time, the tubercle thus deposited undergoes a 
 process of softening, in the course of which the muscular tissue of the 
 intestines becomes destroyed, and their mucous membrane may thus 
 eventually be perforated, so that distant parts of the intestinal canal, 
 which at first were merely adherent together, are sometimes brought 
 by this means into direct communication with each other. The abdo- 
 men generally contains a small quantity of transparent serum; but if, 
 as sometimes happens, life should have been cut short by the super- 
 vention of acute peritonitis upon the old disease, the effusion may be 
 of a puriform or sero-purulent character ; though this is seldom abun- 
 dant. 
 
 In addition to the evidences of inflammatory action presented by the 
 peritoneum, that membrane and the various abdominal viscera are the 
 seat of a more or less generally diffused tubercular deposit. In some 
 instances the peritoneum lining the abdominal walls is greatly thickened, 
 and abundantly beset with small gray semitransparent granulations, 
 or even with yellow tubercle, usually in the miliary form, though 
 sometimes small distinct patches of tubercle are interspersed. In the 
 majority of cases, however, the affection of the parietal peritoneum is 
 less' considerable, and almost invariably the deposit on it is greatly ex- 
 ceeded by that on other parts of the membrane. That part of the peri- 
 toneum which lines the diaphragm or the abdominal walls in the im- 
 mediate vicinity of the spleen, is one of the favorite seats of tubercular 
 deposit. In some instances the omentum is the seat of the chief 
 tubercular deposit ; and though it usually assumes the miliary form, 
 yet now and then masses of crude tubercle of considerable size are met 
 with in this situation. The peritoneum covering the liver and spleen 
 seldom fails to show an abundant deposit of tubercle ; and tubercles 
 usually abound in the substance of the latter organ. The mesenteric 
 glands likewise are tuberculous, though the degree of their degeneration, 
 and the size which they have in consequence attained, vary much in 
 different cases. The same remark holds good with reference to the 
 amount of tubercular disease in the interior of the intestines, which, 
 though in some cases very considerable, yet is not so in by any means 
 the majority of instances, while it bears no invariable relation either to 
 
SYMPTOMS AND COURSE OF TUBERCULAR PERITONITIS. 551 
 
 t'ie degree of the affection of the peritoneum, or to that of the mesen- 
 teric glands. Perforation of the intestines, too, is produced in these 
 cases from without inwards, not by destruction of the coats of the bowel 
 by tubercular ulceration on its interior. 
 
 In cases of this affection, those vague indications of decaying health 
 which characterize the early stages of the tuberculous cachexia often 
 precede any symptom of special disorder of the abdominal viscera. But 
 this is not always the case; for in some instances the child begins, with- 
 out any previous indisposition, to complain of occasional pains in the 
 abdomen, which last but for a moment, and which cause the less anxiety 
 from the appetite being good, the bowels regular, and the general cheer- 
 fulness undisturbed. In the course of a short time, however, the appe- 
 tite fails, or becomes capricious; the bowels begin to act irregularly, 
 being alternately constipated and relaxed ; while the motions, always 
 abundant, are usually unnatural in character, — dark, loose, and slimy. 
 The child now grows restless and feverish at night, its thirst is con- 
 siderable, and the abdominal pain becomes both more severe and more 
 frequent in its recurrence. Sometimes the stomach grow T s very irrita- 
 ble, and food taken is occasionally vomited ; but this syrrtptom is often 
 absent ; while the tongue, throughout the early stages of the affection, 
 continues for the most part clean and moist, and deviates but little from 
 its appearance in health. The symptoms just enumerated seldom con- 
 tinue long without being accompanied by a marked change in the size 
 of the abdomen ; and sometimes the alteration in the abdomen takes 
 place rather suddenly, and is one of the earliest signs of the affection 
 from whjch the child is suffering. The abdomen becomes large, tense, 
 and tympanitic, while its parietes often seem glued to the subjacent 
 viscera; and that manipulation which causes no discomfort, even when 
 practiced somewhat roughly on the big abdomen of a rickety child, is 
 sure to occasion uneasiness, often even considerable pain, when tried 
 with ever so much gentleness in the child suffering from chronic peri- 
 tonitis. 
 
 In this, as in other forms of tubercular disease, the progress from 
 bad to worse seldom goes on uninterruptedly. Pauses take place in 
 its course, though each time they become shorter ; and signs of amend- 
 ment now and then appear — but they too promise less and less with each 
 return. The child loses flesh ; the face grows pale, and sallow, and 
 anxious; the skin becomes habitually dry, and hotter than natural, and 
 the pulse is permanently accelerated. The abdomen does not grow pro- 
 gressively larger; often, indeed, it shrinks in the more advanced stages 
 of the disease, and at the same time it becomes more and more tense, 
 although this tension varies without any evident cause, and sometimes 
 disappears for a day or two, to return again as causelessly as it disap- 
 peared. When the tension is diminished, the abdomen yields a solid 
 and doughy sensation, and the union between the contents of the abdo- 
 men and the abdominal walls becomes very perceptible. In many cases, 
 too, a vague sense of fluctuation may be detected in the hypogastric 
 region, which seems more distinct atone time than at another, is never 
 as marked as is the fluctuation in cases of ascites, and is doubtless due, 
 
552 COURSE OF TUBERCULAR PERITONITIS. 
 
 as suggested by MM. Rilliet and Barthez, 1 in some measure, to the 
 transmission of the shock by the agglutinated mass of intestines from 
 one side of the abdomen to the other. The superficial abdominal veins 
 now become enlarged in many instances, and the skin grows rough, 
 desquamates, and looks as if it were dirty. The pain in the bowels re- 
 tains the same colicky character as before, but it returns very frequently, 
 and is sometimes exceedingly severe, while the child is never free from 
 a sense of uneasiness. The tenderness of the abdomen, however, but 
 seldom increases in proportion to the increase of pain. The bowels are 
 in general habitually relaxed, though the degree of the diarrhoea, as 
 well as the severity of the abdominal pain, vary much in different cases. 
 As the disease advances, the child becomes confined to bed, and is at 
 length reduced to a state of extreme weakness and emaciation. Death 
 is often hastened by the concomitant affection of the lungs, or more 
 rarely by the occurrence of tubercular meningitis ; but should this not 
 be the case, the patient may continue for many weeks in the same con- 
 dition, till life is destroyed, after a day or two of increased suffering, by 
 some renewed attack of peritoneal inflammation, or till, in other in- 
 stances, the child sinks, almost painlessly, from sheer exhaustion. 
 
 Such, now, is the ordinary course of tubercular peritonitis ; but just 
 as it would not be possible to draw a picture of pulmonary phthisis 
 which would represent with perfect accuracy every case of the disease, 
 so it is with our attempt to delineate the features of this malady. Its 
 main diversities, of which the differences in the appearances found after 
 death are far from affording a satisfactory explanation, consists in 
 the various degrees in which pain is experienced, in the rapidity of 
 the course of the affection, and in the alternation of constipation with 
 diarrhoea, or sometimes in the complete substitution of the one condi- 
 tion for the other. One form of tubercular peritonitis, in which its 
 early stages are very likely to be unnoticed, is that which it assumes 
 when it supervenes upon one of the eruptive fevers — usually upon 
 measles ; the diarrhoea, the feverishness, the loss of flesh, are regarded 
 merely as attendants upon a tardy convalescence ; the abdominal pain, 
 probably by no means severe, is supposed to be of little moment ; and 
 the abiding tenderness is altogether overlooked. The chief safeguard 
 against this error is found in our being fully alive to the possibility of 
 the danger, and in the most sedulous watching of every child whose 
 convalescence is tedious. Another class of symptoms which should ex- 
 cite our suspicion are those which are sometimes presented by children 
 who, having suffered from dyspepsia, become liable to occasional attacks 
 of colic and constipation, the severity of the pain being out of propor- 
 tion to the duration of the previous constipation, the effect of purgatives 
 in inducing action of the bowels being uncertain, and the relief which 
 follows their operation neither immediate nor complete. Lastly, the 
 disease is sometimes observed attended by scarcely any pain : the child 
 grows pale and thin, and has occasional diarrhoea but makes no com- 
 plaint of pain, or at most of nothing beyond a sense of stuffing and ful- 
 ness of the belly ; but emaciation goes on, perhaps rapidly ; the diarrhoea 
 
 1 Op. cit., tome iii, p. 784. 
 
TABES MESENTERICA — A RARE AFFECTION. 553 
 
 becomes habitual, and medicine loses much of its control over it ; the 
 Strength fails, and the little one dies, worn out and weary, but quietly 
 and without pain. It would be easy, but I do not think it necessary, 
 to relate a history illustrative of each of these varieties of the disease ; 
 they would each point to the same moral, — that, under all modifications 
 of symptoms, when a child loses flesh, and has in conjunction with that 
 emaciation, abiding even though but slight tenderness of the abdomen 
 on pressure, you are to suspect the existence of tubercular peritonitis. 
 
 Some of you have probably been struck by the many points of resem- 
 blance between the symptoms that have just been described and those 
 which are often enumerated as characteristic of mesenteric disease. Nor 
 is it at all surprising that a very close analogy should subsist between 
 chronic peritonitis and tabes mesenterica, since not only are both affec- 
 tions the results of the tubercular cachexia, but in both the abdominal 
 viscera are chiefly involved in the disease, and both are in consequence 
 characterized by a remarkable impairment of the functions of nutrition. 
 It was natural, too, that in former times, when morbid anatomy was less 
 carefully cultivated than at present, the attention of the observer should 
 have been chiefly drawn to the increased size and altered structure of 
 the mesenteric glands — appearances which must have been often dis- 
 covered on an examination of the bodies of children who had died after 
 a slow wasting of their flesh, attended with more or less enlargement 
 of the abdomen and disturbance of the bowels. The physiology of 
 those days, too, knew of no means whereby the absorption of the chyle 
 could be effected except through the medium of the mesenteric glands; 
 and the coarse appliances which then subserved the purposes of ana- 
 tomical investigation did not suffice to show that, even when these 
 glands outwardly present a considerable degree of tuberculization, their 
 lymphatics in many instances are still pervious. 
 
 We know that the nutrition of children is often much impaired 
 from other causes besides tubercular disease; and that, w T hen the diges- 
 tive organs perform their functions ill, nothing is more common than 
 for the abdomen greatly to exceed its natural size. Our predeces- 
 sors had observed similar facts ; but, owing to the imperfection of their 
 physiological knowledge, they drew from them erroneous conclusions. 
 Disease of the mesenteric glands was in their eyes the almost exclusive 
 cause of the atrophy of children, and a preternatural enlargement of 
 the belly was looked upon by them as an almost infallible sign that such 
 disease had already begun. Tabes mesenterica was consequently re- 
 garded as a very common affection ; and though its frequency is now 
 well known to have been much overrated, yet the appearance of those 
 symptoms that were once supposed to be characteristic of it, still 
 excites much needless alarm among non-professional persons. 
 
 The mere presence of tubercle in the mesentery is, it must be owned, 
 of very common occurrence, since MM. Rilliet and Barthez met with 
 it in nearly half of all children in whom that morbid deposit existed in 
 some one or other of the viscera. But though the existence of tubercle 
 in the glands is thus frequent, its presence in any considerable quantity 
 is extremely rare, since, according to the same authorities, it was found 
 
554 TABES MESENTERICA. 
 
 in abundance in only one out of every sixteen children, some of whose 
 organs contained tubercle. 
 
 The general character of tuberculous mesenteric glands is much the 
 same with that of tuberculous bronchial glands, but the former are 
 usually surrounded by a more delicate cyst ; and although their size 
 seldom exceeds that of a chestnut, yet they occasionally undergo a 
 degree of development which far exceeds that of tuberculous bronchial 
 glands, and three or four of them coalescing together, sometimes form 
 a mass as big as the fist, or even bigger. 
 
 The effects produced even by an advanced degree of tuberculization 
 of the mesenteric glands are smaller than might be anticipated, and 
 much smaller than those which result from a considerably less amount 
 of disease of the bronchial glands. Nor will this at all surprise us, if 
 we bear in mind the difference between their anatomical relations. 
 The bronchial glands are not merely situated in a cavity which is 
 bounded by comparatively unyielding parietes, but the viscera with 
 which they are in contact are solid and resisting, and they are, moreover, 
 adherent to the trachea and the larger air-tubes, so that any increase of 
 their size is sure to produce compression of parts whose functions are of 
 vital importance. The mesenteric glands, on the contrary, are con- 
 tained in a cavity whose yielding walls allow them to increase readily 
 in size, while the loose attachments of the mesentery still further per- 
 mit them to attain even to considerable dimensions, without pressing 
 upon any viscus ; so that it is an exceedingly unusual occurrence for 
 them to cause the perforation of any part of the intestines, or even for 
 them to contract adhesions to their exterior. 
 
 To these causes it must be attributed that there is no symptom pa- 
 thognomonic of tubercle of the mesenteric glands, except their being 
 perceptible through the abdominal parietes. This, however, they 
 never are during the early sta^e of the affection ; and though on a few 
 occasions I have felt a tumor in the abdomen, which, from its being 
 associated with the evidence of tuberculous disease in other organs, I 
 have been led to attribute to the enlarged mesenteric glands, yet I 
 have only once had the opportunity of confirming the diagnosis by an 
 examination after death. There can, however, be no doubt but that 
 they do sometimes become perceptible through the abdominal walls, 
 though at a season when, their cure being hopeless, little practical use 
 can be made of the certainty of our diagnosis. In its earliest stages 
 no symptoms at all are present, or only the indications of that general 
 tuberculous disease of which the affection of the mesentery is usually 
 but a subordinate part. At a later period, when the disorder of the 
 digestive organs attracts attention, the symptoms are generally much 
 the same with those of chronic peritonitis, save that, if the peritoneum 
 be free from disease, the abdomen is in most cases both less tense and 
 less tender. 
 
 I the less regret that so little time remains for the consideration of 
 the treatment of chronie peritonitis and of tabes mesenterica, since the 
 subject may be dismissed in a few words. In each of these affections 
 two periods may be distinguished. During the first, while our diagno- 
 sis is still uncertain, general principles guide our conduct, and lead us 
 
TREATMENT OF IT AND OF TUBERCULAR PERITONITIS. 555 
 
 to subject the child to the same dietetic and hygienic management as 
 we should adopt if we feared the approach of any other form of phthisis. 
 In the second, the advancing mischief has removed all doubt from our 
 minds, but at the same time has chased almost all hope from our 
 spirits ; and we now minister to symptoms as they arise, and try to 
 mitigate sufferings which we can seldom cure. 
 
 The dyspeptic symptoms, the unhealthy appearance of the evacua- 
 tions, and the frequency with which diarrhoea occurs, enforce the neces- 
 sity for the diet being as mild and unstimulating as possible. The 
 abdominal pain which is experienced in tubercular peritonitis is almost 
 always relieved by the application of a few leeches; but even local de- 
 pletion must not be practiced without absolute necessity ; and in many 
 instances a large poultice to the abdomen, frequently renewed, will 
 remove pain the severity of which at first seemed to call for the abstrac- 
 tion of blood. Now and then, however, symptoms of acute peritonitis 
 come on in children who have previously manifested unmistakable signs 
 of tubercular disease, and nevertheless yield to free local depletion, and 
 the administration of mercury. I would therefore advise you not to 
 allow any notion, how well founded soever, of the probable connection 
 of the symptoms with tubercular disease, to betray you during their 
 presence in an acute form into an inert course of treatment ; nor, I may 
 add, into the too positive expression of a gloomy prognosis. Still these 
 are exceptional cases; and our treatment in the majority of instances is 
 confined to relieving the more urgent symptoms. Next in importance 
 to the pain, or sometimes even more important, is the diarrhoea, which 
 we must try by all means to keep in <:heck ; and for this purpose few 
 astringents are better than the logwood and catechu mixture men- 
 tioned in the last lecture. Sulphate of iron and opium, in the form 
 either of pills or of mixture, may be given if the diarrhoea is very ob- 
 stinate, though we may be compelled to abandon their use, from find- 
 ing that they add to the fever, and thus aggravate the patient's illness; 
 but I have not observed the mere suppression of the diarrhoea by astrin- 
 gents to be followed by any exacerbation of the other abdominal symp- 
 toms. Astringents, however, are far from being the only remedies to 
 be employed; but mercurials in a mild form, and continued for a long 
 period, have often seemed to be of much service. When the tenderness 
 of the abdomen has been sufficiently relieved to admit of it, I generally 
 direct the use of a liniment twice a day, consisting of the Linimen- 
 tum Hydrargyri, soap liniment, and olive oil, in equal parts, which has 
 seemed useful as a counter-irritant even independent of the mercury 
 which enters into its composition. It is generally better to apply the 
 liniment by soaking a piece of lint in it twice a day and spreading it 
 over the abdomen ; covering it with oiled silk ; or, if the pain is con- 
 siderable, an ointment of two drachms of the extract of belladonna and 
 six drachms of mercurial ointment may be applied in the same man- 
 ner, and often with much benefit. Besides this I usually give equal 
 parts of the Hydr. c, Creta and Dover's powder once or twice a day. 
 The Dover's powder prevents the mercurial from irritating the bowels, 
 and also allays the restlessness and feverishness at night — an end to 
 
556 TREATMENT OF TABES MESENTERICA. 
 
 which the use of the tepid bath every evening likewise conduces, often 
 in an eminent degree. The comfort of the child is frequently much 
 promoted by wearing a well-adapted flannel bandage over the abdomen 
 both by night as well as by day ; and the support this affords may be 
 increased with advantage by a piece of thin whalebone at either side. 
 
 If diarrhoea is absent, or if, though it is present in a slight degree, 
 the skin is very hot and dry, and the child very thirsty and feverish, 
 the tepid bath, the mercurial with Dover's powder, and small doses of 
 liquor potassse and ipecacuanha, are the remedies on which I chiefly 
 rely ; and to these the extract of dandelion may often be added with 
 advantage. If it seems likely that a mild tonic will be borne, a mix- 
 ture containing the extract of dandelion, extract of sarsaparilla, and 
 sesquicarbonate of soda, 1 may be given ; or the liquor cinchonas, or the 
 infusion of calumba may be employed for the same purpose; or the com- 
 bination of the bichloride of mercury with bark, which I recommended 
 a short time ago. 2 It is only with much caution that we can admin- 
 ister chalybeates in these cases, and after having found that the milder 
 vegetable tonics are well borne. The ferrocitrate of quinine, or the 
 citrate of iron, are the preparations which it will generally be desirable 
 to employ in the first instance; and even their eifect should be watched 
 attentively. When well borne the cod-liver oil is, I think, more use- 
 ful in this than in any, other form of the tuberculous cachexia in early 
 life. The cases in which it causes nausea or diarrhoea are comparatively 
 few, and its effects in fattening children who were greatly emaciated 
 are sometimes very remarkable. In conclusion, I need hardly mention 
 the importance of change of air, and the benefits likely to arise from 
 a sojourn on the seacoast; for you know how much more powerful 
 nature's remedies are in diseases of this kind than the remedies of man's 
 devising. 
 
 1 (No. 37.) 
 R. Extracti Taraxaci, £ij. 
 Sodae Sesquicarbonatis, ^j. 
 Extr. Sarza?, giv. 
 Syr. Aurantii, ^iv. 
 Decoct Sarzse Co., ^v. M. 
 A tablespoonful three times a day in a little milk. For a child four years old. 
 2 See Formula 29, p. 507. 
 
INTESTINAL WORMS. 557 
 
 LECTURE XXXIX. 
 
 Intestinal Worms. — Their varieties, symptoms, and treatment. 
 
 Diseases of the Urinary Organs. — Inflammation of the kidneys — Albuminous 
 nephritis — Generally follows one of the eruptive fevers, often est scarlatina — Its 
 symptoms — Modes in which it proves fatal — Condition of the urine — Appear- 
 ances after death — Essential nature of the changes in the kidneys — Treatment. 
 
 Calculous disorders. — Frequent in early life — Deposits in the urine in childhood 
 almost always consist of the lithates — Other causes of dysuria besides gravel 
 and calculus — Congenital phimosis as a cause of dysuria — Treatment of dysuria 
 in early life — Lithic acid deposits connected with chronic rheumatism in chil- 
 dren — Symptoms of ill health associated with them — Importance of not over- 
 looking them. 
 
 Diabetes. — True saccharine diabetes very rare in early life — Simple diuresis less 
 uncommon — Symptoms of disordered health that attend both affections. — 
 Treatment. 
 
 Incontinence of urine. — Circumstances in which it occurs — Treatment. 
 
 Our study of the diseases of the digestive organs would be incom- 
 plete if we took no notice of those parasitic animals which frequently 
 inhabit the alimentary canal in children. It will not, indeed, be neces- 
 sary to say much respecting them ; for we know that the older medical 
 writers greatly overrated their frequency and importance, when they 
 saw the proofs of their existence in almost every variety of gastric and 
 intestinal disorder, and even commonly attributed to their presence 
 many forms of serious disturbance of the nervous system. Still, they 
 are in many instances the occasion of considerable discomfort; they 
 often aggravate, or even give rise to, disorder of the digestive organs, 
 while the irritation excited by their presence, being propagated to the 
 spinal cord, sometimes produces convulsions or other formidable ner- 
 vous symptoms. 
 
 Although intestinal ivorms are much more common in early life than 
 in adult age, yet no species of them is peculiar to the child, but they 
 belong to one or other of the five sorts ordinarily met with in the 
 grown person. 1 
 
 The ascaris vermieularis, or small threadworm, which lives princi- 
 pally in the rectum, is by far the most common of all these entozoa, 
 and is very troublesome, from the local irritation which it excites. 
 The long threadworm, the tricocephahis dispar, appears much less 
 frequently in the evacuations ; it inhabits the upper end of the large in- 
 testines, and in some cases coexists with the presence of ascarides in the 
 rectum. When it is present alone, I am not aware that it gives rise 
 to any unpleasant symptoms. The ascaris himbricoides, or round- 
 
 1 The work of Dr. Kiichenmeister, Die Parasiten, &c, 8vo., Leipsig, 18^)5, con- 
 tains the fullest details concerning the anatomy and physiology of intestinal worms, 
 and particularly all those ingenious observations by which the development of the 
 ta?nia from the eysticercus cellulosae has been established. Its translation by the 
 Sydenham Society has rendered the book accessible to all readers. 
 
558 SYMPTOMS OF INTESTINAL WORMS. 
 
 worm, is of much less common occurrence than the small threadworm, 
 though observed more frequently than the tricocephalus ; it dwells in 
 the small intestines, and sometimes, entering the stomach, is rejected 
 by vomiting. Occasionally only one of these worms is present; and 
 though there are oftener several, yet it is but seldom that they exist 
 in the child in very considerable numbers. The tapeworm, of which 
 there are two kinds, the tcenia solium and tcenia lata, is much the rarest 
 of these entozoa in early life, and is seldom met with in children under 
 seven years of age, though once or twice I have known it to exist in 
 infants who were still in part nourished at the breast ; and I appre- 
 hend it is altogether more frequent in early life in this country that in 
 France, 1 or at least than in Paris. 
 
 Various symptoms have been said to indicate the presence of worms 
 in the intestines, but most of them are of small value; and nothing 
 short of actually seeing the worms can be regarded as affording con- 
 clusive evidence of their existence. No one who is at all familiar with 
 the disorders of early life will be disposed to attach much weight to 
 symptoms such as the altered hue of the face, the appearance of a livid 
 circle around the eyes, the loss of appetite, or its becoming irregular 
 or capricious. Many causes besides the presence of worms give rise to 
 a tumid state of the abdomen, to colicky pains, and to occasional sick- 
 ness and vomiting; and itching of the nose or anus, though often pres- 
 ent when the intestinal canal is infested with worms, yet is sometimes 
 the occasion of much annoyance independently of their existence. An 
 irregular or intermittent pulse, widely dilated pupils, occasional drowsi- 
 ness, with uneasy rest at night, and starting during sleep, are evidences 
 of disturbance of the nervous system, but do not specially indicate the 
 presence of worms as the cause of such irritation. 
 
 The small threadworms, which are of all the most frequent, pro- 
 duce a most distressing itching and irritation about the anus, which 
 always become more troublesome at night than they are in the day- 
 time, and frequently prevent the child for hours from getting to sleep. 
 Sometimes, too, they give rise to a troublesome diarrhoea, attended 
 with considerable tenesmus ; while in female children they occasion- 
 ally creep up the vulva, and not merely cause much irritation there, 
 but excite a leucorrhoeal discharge, which ceases on their expulsion. 
 
 The roundworms often give no evidence at all of their presence, so 
 long as they are but few in number, and as the child affected by them 
 is otherwise healthy ; the discharge of a lumbricus by stool, or its 
 expulsion by vomiting, being often the first indication of their exist- 
 ence. The common opinion, indeed, which associates inordinate appe- 
 tite with the presence of lumbrici, is probably not devoid of truth, 
 since these creatures appear to live on the contents of the intestines, 
 not, as the tapeworm does, on the juices of the living structures them- 
 
 1 ]NJM. Rilliet and Bnrthez, op. cit., 2d ed., vol. iii, p. 862, pass over tapeworm 
 without notice, on account of its extreme rarity in early life. At Geneva, how- 
 ever, M. Rilliet states that he has seen it several times, even in an infant of fifteen 
 months; while, though I have kept no exact account of the instances of it which 
 have come under my notice, the occurrence of tapeworm in children from five to 
 ten years old is far from having been extremely uncommon. 
 
SYxMPTOMS OF INTESTINAL WORMS. 559 
 
 .selves. The more marked symptoms of gastro-intestinal disorder are 
 dependent either on the presenee of a great number of these parasites 
 (an occurrence which seems to be far rarer in this country than in 
 many parts of the Continent, especially in Italy), or on some circum- 
 stance exciting in them an unusual restlessness, and causing them to 
 wander from one part of the intestines to another. According to the 
 excitability of the patient, and according also to the course taken by 
 the worm, the symptoms thus produced will be more or less formida- 
 ble. The diarrhoea that sometimes attends the expulsion of lumbrici 
 is of all the accidents the least serious, or rather it is by the superven- 
 tion of diarrhoea, or its artificial induction, that these intruders are 
 most frequently got rid of. Much discomfort often precedes their 
 expulsion by vomiting, though sometimes I have known a worm to 
 be rejected almost without warning, and with very little difficulty or 
 annoyance. Strange instances, indeed, are on record of these worms 
 getting into the oesophagus, and thence passing out of the nostrils; and 
 of death being produced by their entering the larynx ; but such are 
 wholly exceptional accidents, from which no inference can be deduced 
 as to the ordinary consequences of their presence. Violent convulsions, 
 and other cerebral symptoms, are alleged to be more frequently pro- 
 duced by the presence of lumbrici than of any other varieties of these 
 entozoa. It chances, however, that the most formidable convulsions 
 which I ever observed to be excited by worms, were due to the pres- 
 ence of an immense number of small threadworms, and ceased im- 
 mediately on their expulsion. M. Legendre, 1 too, has called attention 
 to the great frequency of symptoms of disorder of the nervous system 
 in connection with the presence of tapeworm ; "such symptoms having 
 been present in twenty out of thirty-three cases. They consisted, in 
 twelve instances, of more or less frequently repeated convulsive seizures, 
 which eight times assumed the character of epilepsy, four times of 
 hysteria; while on eight occasions the convulsive movements were par- 
 tial, and affected either the face or one of the limbs." 
 
 It would seem, then, that the presence of worms of any kind, just 
 like any other source of irritation, may excite convulsions, or may 
 disturb in other ways the functions of the nervous system. In the 
 symptoms themselves, there does not seem to be anything which could 
 enable us at once to distinguish between convulsions produced by the 
 presence of worms and those dependent on some other cause. In most 
 instances, however, it will be found that the child has passed worms 
 frequently before the cerebral symptoms made their appearance, while 
 the absence of any other adequate cause for their occurrence should at 
 once direct our attention to the possibility of their arising from this 
 source ; and an examination of the evacuations will seldom fail to dis- 
 cover evidence to justify our suspicions. 
 
 The symptoms of taenia are not pathognomonic of that peculiar form 
 
 1 Si ir les Syrnptomos .Nerveux que determine le Taenia: tire des Archives de 
 Medecine, 1850, and a second paper in the Archives for December, 1854. In this 
 latter paper he gives the particulars of several eases of convulsions in children from 
 the presence <-f taenia, and has collected statistics to show that the rarity of this 
 worm in early life has been somewhat exaggerated. 
 
560 TREATMENT OF INTESTINAL WORMS. 
 
 of entozoon, but are common to it and to the lumbrici, with the excep-* 
 tion, perhaps, that tapeworm is apt to produce a more decided impair- 
 ment of the general health, and that from the difficulty in obtaining 
 its complete expulsion its symptoms are usually more persistent. When 
 once, however, our suspicions are excited, we are seldom long without 
 receiving complete confirmation of them in the appearance of joints of 
 the worm intermingled with the evacuations, since, when the creature 
 has attained to maturity, the spontaneous detachment of portions of it 
 from time to time is a purely physiological occurrence. 
 
 The different varieties of worms are not to be got rid of by the same 
 treatment; nor is the cure of all equally easily effected. Internal 
 remedies are of comparatively little use against the small threadworms, 
 though their destruction is by no means difficult if they are attacked 
 by enemata in the lower bowel, which they chiefly inhabit. Enemata 
 of lime-water usually answer for this purpose extremely well ; or if the 
 ascarides are very numerous, or have been frequently reproduced, the 
 remedy may be made more efficacious by the addition to six ounces of 
 lime-water of two drachms of the solution of perchloride of iron. 
 Kiichenmeister, to whose elaborate treatise on helminthology I have 
 already referred, speaks of having employed santonin in an enema in 
 the proportion of from four to eight grains ; but I have no experience 
 of its employment in this manner. He further gives a hint as to the 
 expediency in cases which are at all obstinate of introducing a long 
 elastic tube, in order that the fluids injected may reach such of these 
 creatures as have travelled high up beyond the sigmoid flexure of the 
 colon. Though I have never employed santonin in an enema, being 
 satisfied with the results obtained by lavements of lime-water and iron, 
 I very generally employ it as a vermifuge, giving three or four grains 
 twice a week, at bedtime, to children of five years of age, and following 
 it by any simple aperient in the morning. It is always well to warn 
 the parents of the peculiar change in the color of the urine which san- 
 tonin sometimes produces, imparting to it a greenish-yellow, or in other 
 instances a scarlet hue, such as might be supposed due to the presence 
 of blood in the urine. During the continuance of the treatment, as 
 well as afterwards, when the threadworms have been got rid of, prep- 
 arations of iron are also of much service. I believe the remedy acts in 
 these cases, not merely as a tonic, but also, by its admixture with the 
 secretions, it renders the intestinal mucous membrane unsuitable to 
 serve as a nidus for the reproduction of the worms. 
 
 A vast number of remedies have been employed for the cure of the 
 roundworm and tapeworm, some of which are mere drastic purgatives, 
 and act by dislodging the worms, while others exercise a directly poi- 
 sonous influence on them, and destroy as well as expel them. In the 
 treatment of tsenia, remedies of the latter class are absolutely necessary, 
 since, unless the head of the creature be detached from its hold on the 
 intestinal mucous membrane, no permanent cure is effected, and the 
 detached joints are speedily reproduced. Mere mechanical irritants, 
 such as tin filings, appear, according to Dr. Kuchenmeister's researches, 
 to be absolutely useless as far as the destruction of worms is concerned, 
 though by no means without a mischievous influence on the coats of 
 
TREATMENT OF INTESTINAL WORMS. 561 
 
 the intestines. For the roundworm, a very efficacious proceeding, and 
 one which has the advantage of not distressing the child, consists in 
 giving a small dose of santonin, as two or three grains for a patient six 
 years old, over night, and a full dose of castor oil the next morning, 
 and repeating this two or three times in succession ; and I have never 
 myself seen from the use of santonin any of the unpleasant symptoms 
 which some persons have experienced from its employment. 
 
 I have not satisfied myself that santonin exercises any very decided 
 influence upon tapeworm; for the cure of which, as well as of lum- 
 brici, when the persistence of the symptoms leads to the suspicion that 
 they have not all been got rid of, the kousso, the oil of male fern, or 
 the kamella, is far more effectual. For the success of any of these 
 remedies against tapeworm it is, however, very necessary that the in- 
 testines should be previously well emptied of their contents. This is 
 best accomplished by giving a dose of castor oil some three hours after 
 an early dinner, and afterwards allowing the child only a small cupful 
 of milk during the remainder of the day, the vermifuge being given on 
 the following morning fasting. The great bulk of the kousso almost 
 excludes it from use when our patients are children, and it may be 
 added that Kuchenmeister's investigations seem to show that it is actu- 
 ally inferior in efficacy to several other anthelmintics. The same draw- 
 back, too, attends the use of the seeds of the pumpkin, which in their 
 fresh state have much, and apparently well-merited, reputation as an 
 anthelmintic in America and in parts of Southern Europe. For a 
 child of ten years old three ounces made into a paste with honey or 
 sugar is the dose. I imagine it acts simply by its irritant properties. 
 I have tried the dried seeds bruised and mixed with sugar, but without 
 result; though I have seen the use of the fresh seeds followed by the 
 expulsion of a worm which every other remedy had failed to dislodge. 
 I believe turpentine to be a very efficacious remedy, but the violent 
 effects which it sometimes produces, as well as the temporary intoxica- 
 tion which follows its administration in a large dose, have withheld me 
 from giving it to children. Still it is to be borne in mind as a most 
 energetic vermifuge ; w 7 hile the unpleasant symptoms that follow it are 
 not dangerous, and soon pass away, especially if the turpentine be given 
 with an equal quantity of castor oil. The oil of male fern has proved 
 itself more efficacious in my hands than any other medicine in cases of 
 taenia ; and the sickness which it sometimes causes seems to me to be 
 the chief drawback from its employment. 1 I have almost completely 
 abandoned the use of the pomegranate bark, in spite of the strong evi- 
 
 1 I subjoin a formula, according to which the remedy is tolerable. 
 
 (No. 38.) 
 R. Olei Eilicis Maris, £j. 
 Pulv. Acaciae, gr. xl. 
 Spt. Myristicse, ^v. 
 Syr. Tolutan , giv. 
 Aq. Cinnamomi, ad Jj. M. 
 
 To be taken mixed with an equal quantity of hot milk. For a child of eight or 
 ten years old. 
 
 36 
 
562 DISEASES OF URINARY ORGANS — ALBUMINOUS NEPHRITIS. 
 
 dence borne to its utility/ in consequence of the bulk of the decoction, 
 which I have found it impossible to induce children to take in suffi- 
 cient quantity and sufficiently often repeated to be of much service. 
 Kiichenmeister, however, speaks of a watery extract which is prepared 
 in India, and which possesses great efficacy; but of this I have had no 
 experience. 
 
 Closely connected with the disorders of the digestive organs are those 
 affections to ivhich the urinary apparatus is liable. Unfortunately, 
 special difficulties attend their investigation in early life, and hence the 
 information which it is in my power to give you with reference to these 
 diseases is less complete than I could have desired. 
 
 In childhood, as in adult age, congestion and inflammation are the 
 exciting cause of by far the greater number of affections of the kidney, 
 and the proof of their existence is furnished by an albuminous state of 
 the urine. Hence the designation of albuminous nephritis, which it 
 seems to me convenient to retain in speaking of the disorder as it com- 
 monly occurs in childhood; sometimes as dependent primarily on some 
 altered state of the blood, as in diphtheria, pyaemia, and the acute stage 
 of scarlatina ; sometimes as produced by the direct influence of cold 
 when checking of the action of the skin is followed by congestion of 
 the kidney ; or in other instances, and those the most frequent of all in 
 early life, where the urinary tubules become choked by the accumula- 
 tion of their epithelium during the desquamative stage of scarlatina. 2 
 
 It is after scarlatina that we meet with three-fourths of the cases of 
 albuminuria that occur in early life; and the peculiar condition which 
 I have referred to as then producing it has led to the adoption of the 
 term desquamative nephritis by Dr. G. Johnson to distinguish it from 
 other forms of the disease dependent on a different cause. It might at 
 first be expected that this condition would be found to occur after scar- 
 latina with a tolerably uniform regularity, or at any rate that it w r ould 
 be easy to determine the peculiarities of the disease which govern it: 
 But neither the one nor the other is the fact. Its varying frequency is 
 shown by a statement of Dr. Vogel, that, "while in some epidemics of 
 scarlet fever almost every patient becomes dropsical, in others the 
 number is so small as not to amount even to 1 per cent. 
 
 1 See paper by Mr. Breton, in Med.-Chir. Trans., vol. xi, p. 301; and Kiichen- 
 meister, op. cit., p. 122. 
 
 2 Of 120 cases of albuminuria of whicb I cbance to bave preserved a record (tbose 
 in wbicb it complicated dipbtberia not included, since examination of tbe urine was 
 sometimes omitted), 
 
 85 succeeded to Scarlatina. 
 
 1 
 
 u 
 
 Measles. 
 
 3 
 
 It 
 
 Typhoid fever. 
 
 1 
 
 it 
 
 Ague. 
 
 1 
 
 a 
 
 Acute rheumatism. 
 
 2 
 
 a 
 
 Empyema. 
 
 1 
 
 a 
 
 Pyaemia. 
 
 2 
 
 it 
 
 Pneumonia. 
 
 1 
 
 (( 
 
 application of a blister. 
 
 In 14 th( 
 
 3 disease 
 
 was acute and idiopathic. 
 
 " 9 
 
 « u 
 
 chronic " 
 
 120 
 
SYMPTOMS OF ALBUMINOUS NEPHRITIS. 563 
 
 In an epidemic described by Haidenheim, albuminuria occurred in 80 per cent. 
 " " James Miller, " » 27 " 
 
 " " Wood, in Edinburgh, <' " 12J- " 
 
 " »< Rosch, " " 10" : < 
 
 (i a Frerichs, " » 4 » 
 
 Scarlet fever has now for many years been endemic in Munich, but 
 only slightly contagious. I have treated at least 50 or 60 cases, but 
 have only twice met with albuminuria out of this number, and in both 
 of them it was very temporary." l 
 
 The common opinion that albuminuria is rare after severe scarlet 
 fever, and frequent after cases of the disease in a mild form, is, I 
 believe, correct ; but my impression is, that in other respects there is 
 no constant relation between the characters of the disease and liability 
 to dropsy or immunity from its occurrence. It is an accident, not only, 
 as I have already shown, rare in some epidemics of scarlet fever, fre- 
 quent in others; 2 but its fatality is liable to at least as great variations 
 as its frequency ; for it appears that while in the first quarter of 1848 
 only 7 per cent, of the mortality of scarlatina was owing to the con- 
 secutive dropsy, 20 per cent, of the deaths from scarlet fever in the last 
 quarter of the same year were due to that cause. 3 
 
 That cold and interruption of the cutaneous function favor the 
 occurrence of dropsy after scarlatina, is a fact supported by universal 
 testimony ; and that the maintenance of the functions of the skin, and 
 the securing an unvarying temperature about the patient during con- 
 valescence from the fever, will go far to prevent it, is also abundantly 
 proved. The early adoption of a stimulating plan of diet or treatment 
 during convalescence from scarlet fever is also reputed to have a marked 
 influence in inducing dropsy after it. It must be remembered, how- 
 ever, that injudicious management in this respect seldom goes alone, 
 but is usually associated with carelessness in other points ; so that the 
 influence of this cause cannot be exactly estimated. I am, however, 
 quite sure that the employment of stimulants in such cases of severe 
 scarlatina as appear to indicate their administration, and even the freest 
 use of wine in such circumstances, in no respect increases the risk of 
 dropsical effusion occurring subsequently. 
 
 The date of appearance of the dropsy is liable to very considerable 
 variation, occurring sometimes within the first week, at other times as 
 late as the end of the third week, or even later. In the great majority 
 of instances, however, its symptoms appear after the end of the first, 
 but before the completion of the second week ; while it but seldom 
 happens, if its appearance is delayed till far into the third week, that 
 its symptoms are formidable, or that its course is acute. It sometimes 
 
 1 Vogel, lib. cit., p. 370. 
 
 2 M. Jaccoud's able article, Albuminuric, in the Nouveau Dictionnaire de Mede- 
 cine et de Chirurgie, 8vo., Paris, 1864, abundantly confirms, by a reference to 
 numerous authorities, the above statement as to the varying prevalence of albumi- 
 nuria in different epidemics of scarlatina. 
 
 3 As deduced from data in the Registrar-General's office, by Dr. Tripe, whose 
 papers on Scarlatinal Dropsy, in the British and Foreign Medico-Chirurgical Re- 
 view for January and July, 1854, are models for inquiries of this kind in laborious 
 research, lucid arrangement, and cautious inference from well-ascertained premises. 
 
564 SYMPTOMS OF ALBUMINOUS NEPHRITIS. 
 
 sets in with considerable febrile disturbance, but even then has a great 
 tendency to assume a chronic character ; while in by far th© majority 
 of cases its attack is gradual, and its advance is slow. In these cir- 
 cumstances, the child who has passed through the fever perhaps with 
 less than the average amount of suffering, and who for a day or two 
 had seemed rapidly advancing to convalescence, begins to droop, grows 
 languid, feverish, and restless. The skin becomes dry and hot; the 
 process of desquamation is arrested while still incomplete ; the appetite 
 is lost, though the thirst is often considerable ; the bowels become con- 
 stipated and the urine diminished in quantity, although the desire for 
 voiding it is very frequent. After these signs of interrupted convales- 
 cence have continued for two or three days, or even longer, the face 
 becomes slightly swollen, a puffiness appearing about the eyelids in the 
 morning, which probably disappears later in the day ; so that in many 
 instances the attention of the parents is not particularly directed to the 
 child's condition until oedema has extended to the hands and feet. 
 The degree of anasarca varies much in different cases, and likewise 
 fluctuates at different periods in the same patient. Usually, though by 
 no means invariably, there is a distinct relation between the degree of 
 swelling and the severity of the general symptoms; and in most cases 
 which terminate fatally there is considerable serous effusion into the 
 different cavities of the body. In very mild cases the febrile disturb- 
 ance is inconsiderable, the anasarca slight, and confined to the face ; 
 and after a few days of poorliness the kidneys resume their proper 
 functions, the anasarca disappears, and the child's health returns. In 
 severe cases the symptoms exist for a longer time ; the swelling extends 
 to the cellular tissue of most parts of the body, the secretion of urine 
 is extremely scanty, and sometimes, though certainly in the smallest 
 number of instances, there are complaints of pain in the back, or more 
 frequently of tenderness on pressure in the lumbar region. The danger 
 of the affection, however, depends almost entirely on its complications; 
 for if they do not destroy the patient, amendment generally becomes 
 apparent in the course of a week or ten days, the urine gradually in- 
 creasing in quantity and becoming less albuminous, the anasarca next 
 diminishing, and the patient regaining health ; though in cases where 
 the attack has been severe, traces of albumen often remain in the urine 
 long after all signs of ailment, with the exception of those of simple 
 debility, have disappeared ; and I have occasionally found the urine to 
 be still albuminous even one or two years after an attack .of scarlatina. 
 I have spoken of the dropsy, which is only one of the symptoms, and 
 of the albuminuria, almost as if they were convertible terms ; and in 
 the earlier years of my practice, when my patients were seen only at 
 their own homes, I thought them so to be. This, however, has been 
 abundantly proved not to be the case ; serous effusion is sometimes en- 
 tirely absent ; in other instances it is but slight and temporary ; and in 
 the great majority of cases the presence of albumen in the urine pre- 
 cedes by a day or two not merely the occurrence of the dropsy, but even 
 any indication of increased constitutional disturbance, except perhaps 
 some elevation of temperature, though observations are not at present 
 sufficiently numerous to determine whether this takes place invariably. 
 
MODES IN WHICH IT PROVES FATAL. 565 
 
 It must further be added, that while the rule unquestionably is for 
 the amount of dropsy and the degree of danger to bear some relation to 
 each other, the rule is subject to numerous exceptions ; for of 35 fatal 
 cases of scarlatinal albuminuria, dropsy was present in 26, absent in 9. 
 
 In the 26 cases associated with dropsy, 
 
 Death took place from effusion into the serous .caviiies in 11 cases. 
 
 " " the same cause associated with pleu- 
 
 risy or pneumonia, or both, in 6 
 
 11 " pleurisy or pneumonia independent 
 
 of considerable effusion, in . 4 
 
 " " convulsions or other ursemic symp- 
 
 toms, in ... . .5 
 
 2G 
 
 In the cases which were unassociated with dropsy, 
 
 Death took place from the direct effect of the fever in . 2 cases. 
 " " pleurisy or pneumonia, or both, in . 4 
 
 " " intercurrent diphtheria, in .. . 2 
 
 " ; ' ursemic convulsions, in . . .1 
 
 9 
 
 When death takes place from effusion into the chest, the anasarca 
 has usually been considerable from the outset, and in the course of a 
 few days, after having undergone apparently causeless variations, it 
 becomes extreme as well as universal : the features are disfigured by the 
 dropsy, the legs greatly swollen, and the abdominal parietes much in- 
 filtrated, while fluctuation often becomes perceptible in the abdomen. 
 The quantity of water voided is very scanty ; it is high-colored, very 
 albuminous, and generally contains blood, while it is now and then 
 suppressed for several hours together, and in one instance none what- 
 ever was secreted for thirty-six hours before the patient's death. Pain 
 in the back is sometimes complained of, but the chief suffering is re- 
 ferred to the chest ; the respiration is labored and accelerated, the child 
 is distressed by a frequent, short, hacking cough, and becomes unable 
 to assume the recumbent posture. In these circumstances life is some- 
 times prolonged for several days, though in a state of great suffering, 
 remedies proving unable either to relieve the dropsy or to increase the 
 action of the kidneys ; death at length taking place under a sudden but 
 usually short aggravation of the disorder of the respiratory organs — 
 an abundant effusion of serum into the pleura generally associated with 
 oedema of the pulmonary tissue being the most important appearances 
 discovered on a post-mortem examination. This effusion sometimes 
 takes place with so little previous warning as to occasion the sudden 
 death of children whose symptoms had not presented any special 
 urgency, and had not seemed to warrant serious anxiety. It was so in 
 the case of a little boy eight years old, in whom slight anasarca appeared 
 on the nineteenth day after a moderately severe attack of scarlet fever. 
 On the third day from the appearance of the dropsy the child walked 
 to and from the Infirmary for Children — a distance of two miles ; and 
 though he appeared oppressed and exhausted, he yet manifested no 
 
566 MODES OF DEATH FROM ALBUMINOUS NEPHRITIS. 
 
 symptom of particular urgency. He had a somewhat restless night, 
 but seemed better rather than worse in the morning, when he arose to 
 relieve his bowels, which acted scantily. Soon after being replaced in 
 bed he began to struggle faintly, and in less than five minutes was dead. 
 The presence of half a pint of fluid in the cavity of each pleura, and the 
 consequent compression and condensation of the lower part of each lung, 
 were the only appearances which could account for the child's sudden 
 death. Other instances of almost equally sudden death in cases of 
 dropsy after scarlet fever have come under my observation. The pos- 
 sibility of such an occurrence should lead us always to watch a patient 
 with great care, in whom the want of due resonance, or the absence of 
 clear respiration in either infra-scapular region, informs us that fluid is 
 present in the chest ; since the scanty effusion may increase with ex- 
 treme rapidity, and symptoms which had seemed of little moment may, 
 in a few hours, jeopardize life, or even destroy it. 
 
 A slight degree of inflammation of the pleura giving rise to increase 
 of its vascularity, or to a scanty deposit of lymph on its surface, is very 
 often observed in connection with the abundant effusion of fluid into 
 the cavity of the chest. Acute pleurisy terminating in the formation 
 of pus, or pneumonia running rapidly into the third stage of the disease, 
 is a less frequent but by no means a less formidable complication of 
 albuminous nephritis. The occurrence of either of these affections is 
 often independent of the existence of anasarca, though it is, I believe, 
 always associated with an albuminous state of the urine, and preceded 
 by those general febrile symptoms which almost invariably accompany 
 that affection when it succeeds to scarlatina. Both diseases run in these 
 circumstances an exceedingly rapid course ; and I have known death 
 take place, and nearly the whole of one lung pass into the second and 
 third stages of pneumonia, within thirty -six hours from the appearance 
 of the first symptom of disorder of the respiratory organs — a fact which 
 gives a peculiar gravity to all affections of the chest succeeding to scarlet 
 fever. 
 
 Lastly, death is sometimes due to convulsions, similar to those which 
 take place occasionally in the adult in the course of granular degenera- 
 tion of the kidneys. In the child, however, this accident is very un- 
 usual ; while, even when it does take place, it does not in general lead 
 to a fatal result : inasmuch as, of twelve cases which came under my 
 own observation, seven recovered ; and of thirteen, particulars of which 
 are collected by M. Rilliet, 1 ten issued in the recovery, only three in 
 the death, of the patient. These convulsions are sudden in their occur- 
 rence, coming on without any premonitory symptoms, except the almost 
 invariable great diminution of the urinary secretion for at least twenty- 
 four hours. They are sometimes immediately preceded by violent 
 headache; and are followed by a more or less complete unconsciousness, 
 and a repetition of the attack takes place almost ahvays in the course 
 of from one to three hours. The violence of the fits varies : the first 
 is not, in general, so severe as those which succeed to it, and the degree 
 
 1 Op. cit., 2d ed., vol. iii, p. 185. 
 
CHANGES IN THE URINE. 567 
 
 to which consciousness returns in the intervals between the fits is un- 
 certain ; though, whenever recovery takes place, the complete restora- 
 tion of all the powers, both of mind and body, proves that no abiding 
 injury has been inflicted on the brain. When recovery takes place, the 
 restoration of the cerebral functions is not only complete, but rapid ; 
 and if the child survive twenty-four hours from the first convulsive 
 seizure, we may, I think, look upon the danger from that source as at 
 an end, though it must not be forgotten that the same state of blood as 
 predisposes to the convulsive attack is a very influential cause of in- 
 flammation of the serous membranes, and that, as happened in one case 
 which came under my own observation, the patient may outlive danger 
 from the one source only to sink under that arising from the other. 
 
 Supposing the patient to escape the dangers arising from these vari- 
 ous causes, convalescence eventually takes place, the dropsy seldom 
 persisting, at the longest, above a fortnight or three weeks ; though the 
 child often remains long afterwards languid and feeble, with a weak 
 pulse and an anaemic aspect, while any serious complication may ob- 
 viously enough retard recovery almost indefinitely. Accidental ex- 
 posure to cold, too, may suffice, even months after apparent convales- 
 cence, to disorder once more the functions of the kidneys, to reproduce 
 an albuminous condition of the urine, attended as before with anasarca, 
 though the dropsical symptoms are not in general considerable. 
 
 The symptoms of constitutional disturbance already described, and 
 which in the main are those of inflammatory dropsy, are associated 
 with changes in the composition of the urine, as well as, in most in- 
 stances, with a diminution in the quantity of the secretion. In very 
 slight cases, in which the dropsical symptoms are scarcely indicated, 
 or in which there is simply a little poorliness retarding the rapid ad- 
 vance of convalescence, the urine may be a little less transparent than 
 natural, and present very slight traces of albumen on examination. 
 It has, indeed, been doubted whether the presence of slight traces of 
 albumen for a very short time, possibly not more than twenty-four 
 hours, is not invariable during some period or other of the convales- 
 cence from scarlet fever ; and the tendency of recent researches is to 
 lend increased probability to the supposition. Be this as it may, how- 
 ever, the changes in the urine are from the first much more consider- 
 able, or very speedily become so, in all instances in which' any marked 
 constitutional disorder is present. Though transparent when passed, 
 it is of a deeper color than natural, and speedily becomes turbid on 
 cooling, when it deposits a more or less abundant precipitate. It has 
 a strong acid reaction; somewhat exceeds the usual specific gravity of 
 healthy urine ; is at first rendered clear by the application of heat, but 
 again becomes cloudy, as the albumen which it contains is coagulated, 
 and falls down in a flocculent precipitate. If the attack is more severe, 
 the urine, which is very scanty, is of a^ brown or smoke color, deep 
 red, or coffee-colored, and throws down a deposit chiefly of a reddish- 
 brown color ; which, however, does not entirely disappear when heated, 
 while albumen is present in it in extreme abundance.. It is to the 
 presence of the coloring matter of the blood that this dark hue of the 
 
568 ALTERATIONS IN THE KIDNEYS. 
 
 urine is partly to be attributed ; but in many instances blood is present 
 in great abundance, and for a season the case is strictly one of hema- 
 turia ; though the symptom in this extreme degree is usually transitory, 
 not continuing for above thirty-six or forty-eight hours at a time, but 
 recurring sometimes causelessly more than once during the patient's 
 illness. Usually, though not invariably, the presence at any time of a 
 large quantity of blood in the urine indicates a very serious disturbance 
 of the functions of the kidney, and forebodes a slow and imperfect 
 convalescence. On the other hand, an extreme degree of anasarca and 
 hematuria are by no means generally associated ; nor does the complete 
 disappearance of blood from the urine constantly imply a corresponding 
 improvement in the patient's general condition. Of all indications 
 furnished by the urine none is of such constantly evil import as a 
 marked diminution *in the quantity of that secretion, especially when 
 such diminution takes place suddenly ; and in whatever other respects 
 the state of a patient may differ, complete suppression of urine for a 
 period much exceeding twelve hours almost invariably announces the 
 speedy approach of death. 
 
 Microscopic examination of the urine in cases of this disease discovers 
 crystals of lithate of ammonia, mucus corpuscles, scales of epithelium, 
 casts of the urinary tubules, and in many instances blood-globules but 
 very little altered. These matters, however, disappear by degrees as 
 the patient's symptoms abate, as the quantity of the urine increases, 
 and its natural appearance returns : though long after it looks healthy, 
 and has ceased to throw down any deposit, it may be shown by chemi- 
 cal reagents not to be entirely free from albumen ; and I have found 
 traces of its presence more than two years and a half after an attack of 
 scarlatinal dropsy. 
 
 The degree of alteration presented by the kidneys in fatal cases appears 
 to depend partly on the duration of the disease, partly on the immedi- 
 ate cause of the patient's death, being more considerable when it has 
 resulted from the dropsy itself than when it has been produced by 
 some intercurrent inflammation. When least affected, the kidneys are 
 swollen, dark, heavy, and gorged with venous blood; but not otherwise 
 altered. In a more advanced stage of disease their surface presents a 
 pale color and mottled appearance, and is sometimes distinctly gran- 
 ular, while spots of vascularity, remarkable for the stellated arrange- 
 ment of the small vessels of which they are composed, are dispersed 
 over it. On a section being made, a marked contrast is observable 
 between the pale, fawn-colored, cortical -structure of the organs, and 
 their deeply injected tubular parts; whilst the lining of their pelvis 
 and infundibula generally displays a greatly increased vascularity. 
 The granular appearance characteristic of the second stage of Bright's 
 disease is also still more obvious on a section of the organs than it was 
 on the examination of their surface, while the change in their tissue is 
 further shown by the facility with which it tears or breaks down under 
 the finger. The time required for the production of these changes in 
 the kidneys varies much. I have seen them present in a remarkable 
 degree in the case of a little boy aged five and a half years, who died 
 
TREATMENT OF ALBUMINOUS NEPHRITIS. 569 
 
 of serous effusion into his chest on the twenty -second day from the 
 appearance of the rash of scarlet fever, and the thirteenth from the 
 commencement of the dropsy ; but this is the only occasion, in my ex- 
 perience, on which such extensive alterations have been wrought within 
 so short a period. No instance has offered itself to my notice in which 
 the changes characteristic of the third stage of Bright's disease have 
 been found after death ; for though children may continue feeble and 
 much out of health long after the acute stage of the disease has passed 
 away, and may even die of its remoter consequences, yet I believe that 
 the fatal issue, in such circumstances, is usually brought about by the 
 development of tuberculosis, not by the progressive advance of disor- 
 ganization of the kidney. 
 
 The use of the microscope has of late enabled us to advance a step 
 farther than we otherwise could have done towards understanding the 
 pathology of this disease. It has shown us that the morbid process 
 begins in the cortical part of the inflamed kidney, the urinary tubules 
 of which are stimulated to an increased production of their epithelial 
 lining, or even to a pouring out of solid fibrinous matter into their 
 cavities. The urine carries away with it some of these matters, and 
 thus frees the tubules for a time : but as their contents are reproduced 
 in quantities too large to be thus eliminated, some of the tubules become 
 plugged and impervious, sometimes even so overdistended that they 
 give way, and are completely destroyed. Nor is this all, but the capil- 
 laries of the organ necessarily bear a part in the mischief. At first, 
 from overcongestion, they become dilated and varicose, and afterwards 
 (in part, probably, from the formation of fibrinous clots within them, 
 in part as the result of a process of adhesive inflammation) they become 
 obstructed or even obliterated. Supposing this morbid process to have 
 gone on to any considerable extent, the kidney must be left by it prem- 
 aturely injured; while even its slighter degrees must for a time seri- 
 ously 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, 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 serious injury has been 
 inflicted on the organ. At the same time, the reparative power char- 
 acteristic of early life tends, I believe, to the ultimate removal of the 
 mischief, and warrants a more hopeful prognosis as to the ultimate com- 
 plete recovery of a (#iild from the effects of scarlatinal dropsy, than 
 would be justifiable in a case of albuminuria in the adult. 
 
 The treatment of this affection is, on the whole, that of inflammatory 
 dropsy, from what cause soever it may arise. If it has set in with 
 severity, the urine being high-colored, extremely scanty, and loaded 
 with albumen, I am satisfied that the abstraction of blood is most 
 serviceable, and believe that the employment of leeches, or the applica- 
 tion of cupping-glasses to the loins, is but an indifferent substitute for 
 the abstraction of blood from the arm. Whether bleeding is requisite 
 or not, the great object to which our treatment must be directed is the 
 
570 TREATMENT OF ALBUMINOUS NEPHRITIS. 
 
 re-excitement of the cutaneous function ; and in proportion as we suc- 
 ceed in this shall we avert danger and expedite convalescence. For 
 this purpose the hot-air bath is one of the most efficacious means with 
 which I am acquainted ; it not only stimulates the skin much more 
 powerfully than the warm-water bath, but has the further advantage 
 that it can be employed without removing the patient from bed, and 
 consequently without the risk of catching cold. It may be used once 
 or twice in the twenty -four hours, and seldom fails, even wdien its ac- 
 tion is most transitory, in inducing, for the time at least, a copious per- 
 spiration. Among internal remedies, the tartar emetic deserves to hold 
 the highest rank ; and I know of no medicine to the utility of which, 
 in the acute stage of scarlatinal dropsy, there are so few exceptions. It 
 should be given in nauseating doses every four hours, and at bedtime; 
 if headache or a constipated state of the bowels does not contraindicate 
 its use, a small dose of Dover's powder may be advantageously com- 
 bined with it. When, by the employment of these means, the skin has 
 been excited to action, the anasarca has ceased to increase, and the albu- 
 men in the urine has much diminished, some of the milder diuretics 
 may be combined with the mixture — as the acetate of potash, the ex- 
 tract of taraxacum, the spirits of nitrous ether, or the benzoic acid, of 
 which latter remedy I have recently made much use, while at the same 
 time the dose of the tartar emetic may be reduced; but any change of 
 the urine to a darker color, or the increase of albumen, in it should be 
 regarded as indicating the propriety of discontinuing them, and of re- 
 turning to the previous treatment. 
 
 The obvious desirability of increasing the quantity of urine without 
 irritating the kidney, led Dr. Dickinson 1 to suggest the administration 
 of a large quantity of water, on the principle on which Dr. Wade has 
 advocated a similar proceeding in diphtheria. There is not in scar- 
 latinal albuminuria the difficulty in its employment which is presented 
 by the sore throat in diphtheria; and there is no doubt but that in some 
 instances the plan is very serviceable, producing an increase in the 
 quantity of the urine, a diminution in its specific gravity, and also an 
 absolute lessening of the albumen. The limit of this latter result, how- 
 ever, seems to be speedily arrived at ; and, those mild cases excepted 
 in which the ailment tends spontaneously to pass away, nothing what- 
 ever that was observed during its use among my patients at the Chil- 
 dren's Hospital seemed to justify one's regarding the drinking of two 
 or three pints of cold water in the twenty -four hours as more than a 
 useful adjunct to the treatment. 
 
 My experience does not lead me to form a favorable opinion of the 
 utility of cathartics in the treatment of this affection. They are uncer- 
 tain in their action, their operation is often attended by much distress 
 to the child, and by unavoidable risk of catching cold, while the occur- 
 rence of diarrhoea is a very troublesome and very unmanageable com- 
 plication. On this account, therefore, I think it preferable to give 
 
 1 In a paper read before the Medico-Chirurgical Society in March, 1864; and re- 
 ported in abstract at p. 355 of vol. iv of its Proceedings. 
 
TREATMENT OF ALBUMINOUS NEPHRITIS. 571 
 
 aperients only when a constipated condition of the bowels absolutely 
 requires their employment. 
 
 In very mild cases of dropsy it suffices to give the antimony in small 
 doses, so as to produce merely its diaphoretic effects; while in cases of 
 long standing the feebleness of the patient's pulse and the occasional 
 irritability of his stomach often completely contraindicate its use. In 
 those instances too in which the quantity of blood in the urine is con- 
 siderable, the restraining its discharge from the kidneys becomes the 
 first indication. For this purpose the gallic acid, in doses of five grains 
 every four hours for a child of five years old, is the best remedy that 
 we can employ; while a small dose of antimony may still be given in 
 the evening, at the time when the hot-air bath is used, with the view 
 of helping to keep up the proper action of the skin. In the chronic 
 stage of the disease, even though no blood be present in the urine, yet 
 if the quantity of albumen is large, the gallic acid will again be indi- 
 cated in preference to any other remedy. 
 
 With reference to the complications of the disease, I do not know 
 that their association with scarlatinal dropsy furnishes any special in- 
 dications for their treatment, though it certainly destroys much of the 
 hopefulness which we might otherwise feel with reference to the success 
 of our remedies. This remark applies with especial force to the inflam- 
 matory affections that sometimes supervene in its course, and more par- 
 ticularly to the pneumonia, which though not a very frequent, is a most 
 dangerous accident, and one in which, if depletion and tartar emetic 
 fail, I know not to what remedy to have recourse. In four of the cases 
 of convulsions which recovered, large depletion was resorted to; but of 
 late years, since I have been conversant with the employment of chloro- 
 form in puerperal convulsions, I have also used it in those which suc- 
 ceed to scarlatina, and have done so with manifest advantage, arresting 
 in some instances convulsions which had previously been going on for 
 hours. As in puerperal convulsions too, so here, the chloroform has 
 seemed to enable me to dispense with the very copious abstraction of 
 blood, wdiich, how useful soever in some cases, yet at the best weakened 
 the child, and rendered its subsequent convalescence tedious. I now, 
 therefore, always try chloroform first as a means of controlling the at- 
 tack, and limit the depletion to such an amount as the state of the child 
 subsequently may seem to require, being guided by the persistence of 
 the coma, and the character of the pulse. 
 
 The convalescence from scarlatinal dropsy requires much care in re- 
 storing the child to its usual diet, and long-continued precaution against 
 cold and damp, together with great attention to maintain the active 
 performance of the cutaneous functions ; on which account it is always 
 desirable that flannel be worn next the skin. In mild cases the obser- 
 vance of these precautions is all that is needed ; but in many instances 
 the child is left weak and bloodless, and with its digestive powers much 
 enfeebled. In these circumstances tonic remedies are always indicated, 
 and either the extract of bark or the tincture of the perchloride of iron 
 will generally be found most appropriate, while wine is not infrequently 
 needed to restore the appetite, which in many instances seems com- 
 pletely lost. I need not, however, pursue this subject in minute detail : 
 
572 CALCULOUS DISORDERS. 
 
 the great principles which should govern your conduct must already 
 be sufficiently obvious. 
 
 I have dwelt thus at length on albuminuria as it succeeds to scarla- 
 tina because that is by far the most frequent, and by far the most im- 
 portant form of the disease. We meet with it, however, sometimes, as 
 we do in the adult, in consequence of exposure to cold; though acute 
 rheumatism, pneumonia, or pleurisy are produced by this cause in 
 childhood with far greater frequency than acute dropsy. Cases of acute 
 dropsy from cold generally recover more quickly, and, I may add, 
 more completely than in the adult ; I suppose because the organs are 
 in general more healthy, and the powers of repair greater in the child. 
 
 Chronic albuminuria is very rare, and, I believe, dates back, in the 
 great majority of instances, to some attack of scarlatina ; so mild per- 
 haps as scarcely to have been noticed, and of which the sequelae were 
 so slight as to have been altogether forgotten. Now and then albumi- 
 nuria occurs in the course of the so-called albuminoid disease of the 
 liver ; and is then an evidence of the kidney having become the seat of 
 the same kind of interstitial deposit as that to which the enlargement 
 of the liver was due. Chronic albuminuria is also now and then met 
 with in connection with a state of general tuberculosis ; but the kidney 
 disorder plays, in these cases, a subordinate part in the production of 
 the symptoms which seem to be due to disturbance of function rather 
 than to alteration of structure. The same applies, too, to cases of albu- 
 minuria coming on in the course of disease of the heart in childhood. 
 In the few instances of uncomplicated idiopathic chronic albuminuria 
 in childhood which I have met with, anasarca has been almost invaria- 
 bly present ; calling attention at once to the kidney and its functions, 
 and with scarcely an exception, this anasarca has been the first symp- 
 tom to arouse the attention of the friends to the health of the child. It 
 is in accordance with this, that the large white kidnev is the form of 
 degeneration of the organ, which I believe is almost always met with 
 in fatal cases of chronic idiopathic albuminuria in early life. 
 
 Although most diseases of the urinary organs are less common in 
 children than in grown persons, yet calculous disorders are far more 
 frequent in early life than in adult age. It appears, indeed, from some 
 statistical data furnished by Dr. Prout, that out of 1256 patients re- 
 ceived into the Bristol, Leeds, and Norwich Hospitals, for the purpose 
 of being operated on for stone, 500, or nearly 40 per cent., were under 
 ten years of age. If w T e bear in mind the intimate connection that sub- 
 sists between the assimilative and the excretory functions, it will not 
 surprise us that in early life, w T hen the former, though so active, are so 
 readily disturbed, the latter should be often thrown into disorder. 
 
 Very slight and very temporary causes often suffice to occasion de- 
 posits in the urine of children ; and these deposits almost always con- 
 sist either of the amorphous lithate of ammonia, or of the small red- 
 dish-brown crystals of lithic acid. These deposits, indeed, are not of 
 much moment, and one might perhaps say that the younger the infant 
 the less is their importance, since the presence of lithic acid in consid- 
 erable quantity in the kidneys of new-born children seems to be almost 
 a physiological condition. Its frequency was first noticed, some years 
 
VARIOUS CAUSES OF DYSURIA. 573 
 
 ago, by Professor Schlossberger ; and his original statements have been 
 confirmed both by his own subsequent researches, as well as by those 
 of Professor Martin, of Jena. 1 Dr. Schlossberger, on an examination 
 of 199 children who died within thirty days from birth, found lithic 
 acid gravel in the tubuli uriniferi of 32 per cent, of the number, in 
 many but not all of whom some degree of icterus had existed. The 
 frequency of this condition is probably connected with the peculiar 
 changes in the processes of assimilation which take place after birth ; 
 and any interruption to their performance, or any disturbance of the 
 cutaneous function, increases, as in the case of infantile icterus, the 
 probability of its occurrence. The same causes exert a similar influence 
 both in infancy, and also to a considerable degree even in subsequent 
 childhood. A trifling cold, slight gastric disorder, or the feverishness 
 and general irritation which sometimes attend upon dentition, not in- 
 frequently produce these deposits, while they disappear as soon as the 
 brief constitutional disturbance subsides. While it lasts, however, the 
 condition of the child is often one of very considerable suffering, each 
 attempt to make water being attended by much pain, the patient crying 
 and drawing up its legs towards its abdomen ; while frequently a few 
 drops only of urine are voided at each time. Now and then, the sup- 
 pression of urine is complete for twelve, eighteen, or twenty -four hours; 
 but this seldom happens, except in children previously much out of 
 health, and in whom, in these circumstances, the febrile symptoms and 
 the constitutional disturbance are very severe, the bowels usually con- 
 stipated, and the evacuations very unnatural in appearance. But be- 
 sides cases of this acute kind, which occur almost exclusively in infants 
 in whom the process of dentition is not yet complete, similar symptoms 
 are often observed in older children ; and though at first of a much less 
 urgent character, they are yet of more serious import, since they fre- 
 quently indicate the existence of a calculus in the bladder, instead of 
 betokening a merely temporary excess of lithic acid deposits in the 
 urine. 
 
 In many instances the formation of lithic acid in the kidneys goes 
 on without giving rise to any very obvious symptoms ; and I have but 
 rarely seen a child suffer from pain of that severe character which in 
 the adult not infrequently accompanies the descent of a calculus from 
 the kidney to the bladder. Sometimes, however, after frequent attacks 
 resembling seizures of ordinary colic, a child begins to manifest the 
 symptoms of stone in the bladder ; and in these circumstances it is 
 probable that the previous attacks of abdominal pain w r ere due to the 
 disordered function of the kidneys, rather than to any primary affec- 
 tion of the intestinal canal. The occurrence of colic in children of 
 three or four years old indeed, should always direct our most sedulous 
 attention to the state of the urine, which will very often be found 
 to deviate widely from a healthy condition, — frequently to abound in 
 lithic acid gravel. 
 
 The symptoms of stone in the bladder are much the same at all ages ; 
 
 1 Archiv f. physiol. Heilkunde, vol. ix ; also Schmidt's Jahrbiicher, Dec. 1850, 
 p. 333. 
 
574 TREATMENT OF DYSURIA. 
 
 the pain in voiding urine, and immediately afterwards, the frequent 
 desire to pass water, the occasional abrupt stoppage of the stream of 
 urine, and the irritation about the penis, owing to which the child 
 keeps its hand almost constantly on its genitals, can hardly fail to 
 awaken suspicion as to the nature of the case. 
 
 In the child, however, we sometimes find the symptoms produced 
 by difficulty in making water owing to the length of the prepuce and 
 the extreme narrowness of its orifice, which may even be scarcely 
 large enough to admit the head of a pin. This congenital phimosis 
 is, I may add, not an infrequent ' occasion of incontinence of urine in 
 children, and also an exciting cause of the habit of masturbation owing 
 to the discomfort and irritation which it constantly keeps up. In 
 every case, therefore, where any difficulty attends the passing or the 
 retention of the urine, or where the practice of masturbation is sus- 
 pected, the penis ought to be examined, and circumcision performed if 
 the preputial opening is too small. This little operation, too, ought 
 never to be delayed, since, if put off, adhesions are very likely to form 
 between the glans and the foreskin, which render the necessary surgi- 
 cal proceeding less easy and more severe. Another occasional cause of 
 irritation of the bladder, and of difficult, painful, or even frequent 
 micturition is furnished by the presence of ascarides in the rectum, and 
 against this possible source of error it behooves us to be likewise on 
 the watch. 
 
 The treatment of dysuria in early life, connected, as the affection 
 almost always is, with an excess of lithic acid in the urine, is sufficiently 
 simple. Those acute attacks which come on during infancy, and for 
 the most part during the period of teething, and which are attended 
 with much fever, with a constipated or otherwise disordered condition 
 of the bowels, and with severe suffering, obviously call for antiphlo- 
 gistic and soothing measures. The warm bath is often very service- 
 able in these cases in relieving the febrile symptoms; besides which, 
 the occasional immersion of the child in hot water, as high as the hips, 
 soothes the pain which is so apt to attend upon every attempt to empty 
 the bladder. The bowels should be acted on freely by castor oil ; and, 
 afterwards, no medicine has appeared to me to afford so much relief to 
 pain, or so effectually to excite the kidneys to action, as the castor oil 
 mixture which I have already mentioned to you, in combination with 
 small doses of liquor potassse, laudanum, and nitrous ether. Barley- 
 water, milk and water, and thin arrowroot, should constitute the child's 
 nourishment during the severity of its attack ; and, even when the 
 symptoms are on the decline, much prudence must still be exercised 
 in keeping to a very mild and unstimulating diet. It is generally 
 wise to continue the use of alkalies for some time after the active symp- 
 toms have subsided ; and small doses of liquor potassae, either alone or 
 in combination with the vinum ipecacuanha?, may be given three or 
 four times a day in a little milk. Once or twice I have seen a sudden 
 suppression of urine, attended with great aggravation of the child's 
 sufferings, follow after the existence of severe dysuria for two or three 
 days ; and have found this occurrence to be due to the mechanical ob- 
 struction of the urethra by a small calculus which had become im- 
 
EXCESS OF LITHATES IN THE URINE. 575 
 
 parted in its canal. The dysuria which is produced by the excessive 
 length and extreme narrowness of the orifice of the prepuce can be 
 relieved only by the removal of a portion of the superfluous foreskin ; 
 while, when it is excited by ascarides, an enema of liquor calcis, with 
 a dose or two of castor oil, will often produce an immediate cure of 
 symptoms which had been very troublesome. 
 
 The treatment of calculus in the bladder hardly requires special 
 notice here ; but you will bear in mind that the calculi which form in 
 childhood are just of that kind on which medicinal agents are best 
 calculated to act ; and that we have but little reason for dreading those 
 changes in the precipitate thrown down from the urine which take 
 place in later life. The deposits that occur and the calculi that 
 form in childhood consist almost invariably of the lithates, and hence 
 we may employ the alkaline carbonates without apprehension ; and 
 under their continued use I have seen very copious sediments com- 
 pletely and permanently disappear from the urine. Their action, 
 however, is far too slow to be relied on in any case where unequivocal 
 signs are present of the existence of a stone of considerable dimensions; 
 while, fortunately, the anaesthetic agents which we now possess, by 
 depriving the operation of lithotomy of the pain that once attended it, 
 have robbed it of many of its terrors. 
 
 The importance of lithic acid deposits in the urine is, however, by 
 no means dependent on the temporary suffering associated with its 
 elimination in some instances, or the dangers of the formation of vesical 
 calculus in others. Deposits of lithic acid are observed in the urine of 
 children, as the consequence and the indication of a state of general 
 constitutional disorder, which manifests itself by dyspeptic symptoms 
 and imperfect nutrition, and is often associated with chronic cutaneous 
 affections. Not infrequently the deposits in the urine and the state of 
 general ailment succeed to some attack of rheumatism. I have already 
 told you that rheumatism in the child runs its course frequently with 
 a much smaller amount of local pain, and with less swelling of the 
 joints than generally attend it in the adult. Its remote effects also very 
 seldom show themselves in those abiding pains which characterize chronic 
 rheumatism in the grown person, but in a state of general ill-health 
 such as that to which I have just referred. A child is brought to you 
 with a vague history of failing health ; or loss of flesh, of variable 
 appetite, sluggish bowels, and occasional night perspirations. On fur- 
 ther inquiry you learn that he is nervous and excitable in the highest 
 degree; sometimes depressed and sullen, at other times so high-spirited 
 as, to be almost uncontrollable : each of these fluctuations in his condi- 
 tion, whether for better or for worse, is found to be more marked at 
 some seasons of the year than at others ; and often also modified by 
 change of residence, his health being manifestly worse in cold weather, 
 and in exposed situations, than in a sheltered spot, and during the sum- 
 mer season. Anxiety lest consumptive disease should be impending is 
 often needlessly entertained in these cases; but if you examine the urine 
 you will at once discover the clue that will help you to their thorough 
 understanding. The urine will be found acid, of a very high specific 
 gravity, 1025° or upwards, depositing on cooling abundant red crystals 
 
576 DIABETES. 
 
 of lithic acid, and on the addition of nitric acid giving evidence, by the 
 speedy crystallization that takes place, of the presence of an excess of 
 urea. On close inquiry you will probably learn that some months pre- 
 viously the child had had an attack of rheumatism, not necessarily 
 very severe, and that since then his health had never been so good as 
 before ; or, if not, you will almost certainly find that rheumatism is a 
 disease from which, in some one or other of its numerous forms, mem- 
 bers of his parents' family have suffered. It is to cases such as these 
 that the term of the lithic acid diathesis 1 is applicable. 
 
 The treatment of this condition does not require much notice. A 
 residence in a sheltered and warm situation, and the habitual wearing 
 of flannel next the skin, are two points of much importance. A third, 
 of at least equal moment, is the careful regulation of the diet, which 
 should be simple, unstimulating, and moderate in quantity. With ref- 
 erence to medicine, the alkalies and alkaline carbonates may be given 
 with a vegetable bitter if some decided tonic appears necessary ; but 
 you must bear in mind, and clearly explain to your patient's friends, 
 that the condition is not one to be overcome in a short time by a few 
 potent remedies, but one which will require watching and care, and a 
 well-considered system of diet and regimen, to be carried on for months 
 and years, and from which it is scarcely safe to depart before the time 
 of puberty has been passed in safety. I referred to it, not because I 
 had any special cautions to give you about its treatment, but to call your 
 attention to a set of symptoms, the real signification of which may be 
 readily overlooked. 
 
 An unnaturally profuse flow of urine occurs at all ages as a temporary 
 symptom in the course of many disorders. Its permanent increase, 
 when associated with certain changes in the composition of the fluid, 
 and the presence of saccharine matters among its elements, constitutes 
 diabetes. This disease, although not common at any period of life, yet 
 occurs in the adult sufficiently often for us to become familiar with its 
 characters, and to dread it as one of the most formidable results of dis- 
 order of the assimilative processes. In the child, however, it is an 
 exceedingly rare affection, for Dr. Prout, out of his immense experience 
 in diseases of the urinary organs, states that he has seen but one instance 
 of it in a child of five years old, and only twelve in young persons 
 between the ages of eight and twenty years, out of a total of 700 cases 
 of diabetes. 2 Five cases only of it have come under my observation 
 whether in hospital or in private practice ; one in a little girl aged 
 three years and a half, whose brother had died at the age of two years, 
 and her sister at two years and a half, with precisely the same symp- 
 toms as she presented, and from the first appearance of which to their 
 fatal termination in both cases only six weeks elapsed. The child 
 whom I saw had been drooping for about two months and was losing 
 flesh very rapidly, but had not then begun to experience the urgent 
 thirst of a diabetic patient. She was pale, thin, and rather sallow ; her 
 
 1 It is almost superfluous to remind the reader of Dr. Todd's remarks on this 
 subject in his Croonian Lectures — On Gout. Kheumatism, &c. 
 
 5th edit., 8vo, p. 36, note. 
 
SIMPLE DIURESIS. 577 
 
 tongue was slightly coated, but not at all characteristic of her disease. 
 Her urine, of which she passed about four pints in the twenty-four 
 hours, had a specific gravity of 1045, became of a dark color when 
 boiled with liquor potassse, and yielded with Trommer's test indications 
 of sugar in abundance. The parents, who had lost all heart, in conse- 
 quence of the death of their other children, could not be persuaded to 
 restrict her diet, or to put her on any plan of treatment, and I never 
 saw the child but on one occasion. The second case I saw but twice. 
 It was that of a girl ten years old in whose family a phthisical taint 
 existed ; and in whom the first symptom of diabetes had appeared on 
 convalescence from measles eighteen months before. She had at one 
 time voided as much as ninety ounces of urine of a specific gravity of 
 1035; and it had ranged as high as 1040 to 1050. Judicious treat- 
 ment, however, had reduced the quantity to fifty ounces, and the specific 
 gravity to 1036 ; while the urgent thirst had ceased ; and a gain of 
 several pounds in weight justified the hope that the child might survive, 
 though the urine was still laden with sugar. Of the three other cases : 
 one, a girl, aged ten, died suddenly four months after the commence- 
 ment of her illness, and apparently as the immediate result of mental 
 shock ; the second, aged seven years and nine months, sank from gen- 
 eral tuberculosis at the end of six months ; while the third, a boy seven 
 years of age, has now been kept in moderate health for fifteen months 
 since the nature of his illness was discovered ; but only by the most 
 unremitting attention to his health, by the use of iron and cod-liver 
 oil : while the slightest relaxation of rules with reference to his diet is 
 followed by the reappearance of sugar in his urine, and the return of 
 all the signs of diabetes. Simple diuresis, or diabetes insipidus indeed, 
 is less rare than true saccharine diabetes ; and though where it exists 
 in" a marked degree, it is most rebellious to all treatment, yet it has no 
 such decided or rapid tendency to a bad issue as the saccharine form of 
 the disease. Cases, too, are sometimes met with in which there is a 
 great increase of the quantity of urine voided, though not so extreme 
 as to constitute diabetes and not accompanied with the intense thirst of 
 the diabetic patient, but associated with considerable disorder of the 
 digestive organs. In these cases the gastro-intestinal disorder usually 
 precedes for some time the excessive flow of urine; and Dr. Prout states 
 that in the earlier stages of infantile diuresis the urine is loaded with 
 lithates and diminished in quantity, though as the disease advances the 
 quantity of urine becomes considerably increased ; and it sometimes 
 contains albumen, or more rarely yields signs of sugar. So far as my 
 observation goes, indeed, the disturbance of the functions of the kidney 
 is in these cases purely secondary, and subsidiary to the gastric and 
 intestinal disorder. The quantity of urine has either been speedily 
 diminished under a due attention to diet and the regulation of the 
 digestive organs, or the symptoms have become merged by degrees in 
 those of phthisis, which has gradually developed itself. My experience 
 concerning these affections amounts, in short, to this, — that whenever 
 the processes of digestion and assimilation are seriously disturbed for 
 any considerable time in early life, the functions of the kidney are very 
 apt to become excessive in degree as well as disordered in kind. Fur- 
 
 37 
 
578 DIABETES, AND ITS TREATMENT. 
 
 ther, such disorder is especially likely to occur just at that period when 
 the simple but highly anirnalized food of the suckling is exchanged for 
 the more varied diet of the infant after weaning. And, lastly, its ex- 
 istence may be suspected, whenever, coupled with more or less marked 
 indications of gastro-intestinal disorder, there is a rapidly increasing 
 emaciation, for. which no adequate cause appears. It will, however, 
 often happen, even when the amount of urine greatly exceeds the healthy 
 average, that the parents of an infant take no notice of the circumstance, 
 imagining it to be either an accidental and unimportant occurrence, or 
 accounting for it as the natural result of the thirst, which induces the 
 child to drink very abundantly. Hence, unless you make special in- 
 quiries with reference to this point, you may remain in ignorance of a 
 very important symptom. 
 
 When once you have become aware of the existence of this affection, 
 its treatment is attended by no particular difficulty, and, if undertaken 
 sufficiently early, will often prove successful. The state of the bowels 
 requires most careful attention : mild alteratives are frequently service- 
 able, but drastic purgatives are very unsuitable. The Hydr. c. Creta, 
 in combination with Dover's powder, is often very useful in promoting 
 a healthy condition of the evacuations ; while the Dover's powder alone 
 is also beneficial in calming the child's excessive irritability, as well as 
 in diminishing the amount of urine secreted. Dr. Prout adds a caution, 
 however, with reference to the use of opiates in these cases, as well as 
 to the sudden withdrawal of fluids, since a suppression of urine may 
 follow the incautious adoption of these measures, and that condition is 
 almost sure to end in coma and death. Change of air to a dry and 
 temperate situation, especially on the seacoast, is of much importance, 
 and the tepid or warm sea-water bath is often beneficial ; while tonics 
 of various kinds are generally of service. The different preparations of 
 iron appear to have advantages over other medicines ; and Dr. Yena- 
 bles, who was the first to call the attention of the profession to this 
 affection, bestows high commendation on the phosphate of iron. Dr. 
 Prout insists, moreover, on the importance of a suitable diet, into which 
 albuminous matters should enter freely, in preference to, though not to 
 the entire exclusion of, those which contain gelatin. Milk should form 
 a chief element in the diet ; while of farinaceous matters, those are to 
 be preferred which have undergone the fermentative process. These 
 precautions too must be observed, not for a short period only, but until 
 the child has for some time regained its health, since a slight error is 
 very likely to be followed by a serious relapse. I need not add that 
 these remarks of mine apply to cases of simple diuresis, not to estab- 
 lished diabetes, whether in the form of diabetes insipidus, or the saccha- 
 rine diabetes. In them, however, the principles of treatment are the 
 same, although the prospects of a successful issue are very slender. 
 
 Incontinence of urine is a very distressing infirmity from which chil- 
 dren sometimes suffer, and which, in many instances, it is found very 
 difficult to cure. In most cases this inability to command the flow of 
 urine exists only in the night-time, but sometimes it is present- also by 
 day ; and both forms of the affection are met with in children of both 
 sexes and of all ages, even up to the period of puberty. The nocturnal 
 
INCONTINENCE OF URINE. 579 
 
 incontinence of urine is often associated with the presence of an excess 
 of lithic acid in the secretion ; and in such cases the first step towards 
 remedying the infirmity consists in correcting the morbid state of the 
 fluid. Now and then it appears to be dependent upon the irritation 
 produced by ascarides in the rectum, while in the majority of cases, so 
 long as the affection is recent, a connection may be clearly traced between 
 it and gastro-intestinal disorder. If not remedied, however, all the 
 functions of the body may return to a healthy state, while yet the in- 
 continence is perpetuated by a kind of habit which it is found very dif- 
 ficult to break through. 
 
 The involuntary discharge of urine by daytime as well as at night 
 is a still more troublesome affection, except when it depends, as is by 
 no means seldom the case, on the child's indolence and indifference, 
 when one or two judicious whippings cure an apparently deep-rooted 
 evil. We must, however, in every instance examine a case with the 
 greatest care before w r e come to the conclusion that the apparent in- 
 firmity is within the power of the child to prevent. Sometimes there 
 is an absolute want of control over the bladder, so that the urine is 
 almost constantly dribbling away ; while in other cases the desire to 
 pass water is distinctly felt at certain short intervals, but the patient is 
 unable to resist this desire even for a minute. This affection, too, is 
 sometimes associated with a morbid condition of the urine : in other in- 
 stances it seems to depend on a state of general weakness ; while in 
 some cases there is no apparent cause, either general or local, to which 
 it is possible to ascribe it. Cases of this last kind are of all the most 
 troublesome; they are sometimes met with in several members of the 
 same family, especially in girls, though, according to my experience, 
 the other more curable forms of incontinence are much more common 
 in male children. 
 
 In the cure of nocturnal incontinence of urine much may often be 
 gained by attention to certain precautionary measures ; such as limit- 
 ing the quantity of drink taken at the last meal, preventing the child 
 from lying on his back when in bed (a position which seems greatly to 
 favor the occurrence of the accident) and rousing him from bed to empty 
 his bladder two or three times in the night. To gain any good, how- 
 ever, from this the child must each time be awoke completely so as to 
 put forth a conscious effort of the will. The mere mechanical empty- 
 ing of the bladder, which the child soon gets a habit of doing, while 
 still fast asleep, is absolutely useless. If the urine is loaded with 
 lithates, the diet must be most carefully regulated, and medicines must 
 be given to restore the urine to a healthy state, and to insure the due 
 performance of the functions of the digestive organs. Tonics are often 
 extremely useful afterwards ; and there is none from which I have seen so 
 much benefit as from the tincture of the perchloride of iron. At the same 
 time cold sponging to the back and loins is often decidedly serviceable, 
 and, if the case resists these milder measures, the frequent application of a 
 blister to the sacrum seldom fails to do great good. But there are two 
 remedies which seem to have a special influence over this infirmity, and 
 one which they seldom fail to exert, though in very different ways. The 
 one of them is strychnine, or nux vomica, the latter of which I generally 
 
580 ABDOMINAL TUMO&S. 
 
 prefer on account of the greater safety of its administration in children ; 
 the other is belladonna. The nux vomica has appeared to me to be 
 most suitable in those cases where there is manifest general debility, 
 and I commonly give it in combination with iron about every six hours; 
 and this combination often succeeds in cases where iron alone had pre- 
 viously been given without result. Belladonna has proved most useful 
 in those cases where the incontinence of urine was quite a chronic evil, 
 and was unassociated with any manifest constitutional disorder. It 
 must of course be given carefully and in doses gradually increased, four 
 times in the twenty-four hours, and very large doses are sometimes 
 taken before the specific influence of the drug is exerted, and this with- 
 out the production of any of its poisonous effects. It must be borne in 
 mind, that whatever be the remedies used or the precautions taken to 
 overcome the ailment, it is quite essential for the permanence of the 
 cure that they should be continued for some weeks after the child's ap- 
 parent recovery. 
 
 Lastly I must just mention an ingenious suggestion of Sir Dominic 
 Corrigan, 1 which I regret that I have never had a fair opportunity of 
 putting to the test. Regarding the inability to retain the urine at 
 night as dependent usually on relaxation of the sphincter vesica? or on 
 a lax condition of the urethra, he advises that the child should lie with 
 the feet raised higher than the pelvis, so that the urine may collect 
 towards the fundus, not towards the neck of the bladder, and next that 
 the edges of the prepuce, or still better the lips of the urethra should 
 be stuck together with collodion which can easily be removed in the 
 morning. How far a radical cure may be thus effected I cannot say, 
 but I should fear the evil would be left unmitigated ; though even then 
 something is gained by preventing the bed from being wetted. At 
 any rate the plan deserves a trial. 
 
 LECTURE XL. 
 
 Abdominal Tumors. — Large abdomen natural in childhood — Causes of its spe- 
 cial enlargement various, as rickets, disorders of digestive organs, enlargement 
 from flatus, from fluid. 
 
 Distinct Tumors. — From enlarged liver. — From simple hypertrophy — Fatty de- 
 posit — Albuminoid deposit — Hydatid cysts — Malignant disease — From enlarged 
 spleen — Its connection with leucsemia, and disposition to hemorrhage — From 
 enlarged kidney, which is almost always due to malignant disease — From 
 enlargement of mesenteric glands — From disease of intestines, or from ovarian 
 tumor — From abscess in abdominal walls. 
 
 I propose to devote this lecture to a brief notice of some conditions 
 very various in their nature and in their importance, which have this 
 
 1 Dublin Quarterly Journal, vol. xcvii, p. 113, referred to in Oesterr. Jahrb. f. 
 Padiatrik, 1871, vol. i, p. 84. 
 
CAUSES OF LARGE ABDOMEN IN CHILDHOOD. 581 
 
 in common, that they produce enlargement of the abdomen ; and this 
 abdominal enlargement is usually the first thing which excites the 
 anxiety of the friends, and which leads to the patient being brought 
 under your notice. 
 
 But before speaking of abdominal tumors in children, I must say 
 something concerning tumors which are no tumors; apparent, not 
 real ones. 
 
 If you go into a gallery of the old masters, and look at any of the 
 pictures of angels, which are generally to be seen there in such abun- 
 dance, you will probably be struck in the case of all the child angels, 
 by what will seem to you to be the undue size of their abdomen. You 
 will notice this even in the works of painters, who, like Raphael, most 
 idealize their subjects, while in those of others, who, like Rubens, 
 interpret nature more literally, the apparent disproportion becomes 
 grotesque ; or in the coarser hands of Jordaens, even repulsive. 
 
 But these painters are after all true interpreters of nature. In in- 
 fancy and early childhood, the abdomen is much larger comparatively, 
 than in the adult. Two causes chiefly conduce to this ; the one, the 
 much smaller size of the pelvis, the other the greater size of the liver, 
 which Frerichs 1 estimates as being in proportion to the weight of the 
 whole body 
 
 as 1 : 17 in the 7 months' foetus. 
 
 1 : 20 at birth, and in early infancy. 
 1 : 40 in adult age. 
 
 Now this excess in the size of the abdomen may be much exaggera- 
 ted if the child is small, weakly, or premature ; if the lungs have been 
 but imperfectly inflated at birth, and the chest is consequently ill-de- 
 veloped, and if, in addition, the general muscular power is feeble, so 
 that the intestinal gases are subjected to a smaller amount of compres- 
 sion from the coats of the bowels than would be exercised upon them 
 if the child were robust. 
 
 In cases where the child is not merely weakly but is also affected 
 by rickets, other causes come into play which greatly increase the ab- 
 dominal enlargement. 
 
 1st. The chest is not merely small and unexpanded, but it is actu- 
 ally deformed ; and this chest deformity is associated with displacement 
 downwards of the abdominal organs. 
 
 2d. Rickets arrest the development of the pelvis and of the lower 
 limbs to a very considerable degree, and thus tend to produce an en- 
 largement of the abdomen which not infrequently remains very marked 
 even in adult age. 
 
 3d. The disease is associated not only with great feebleness of the 
 muscular powers, but also with very imperfect digestion. The in- 
 testines then become distended, not merely from the contained gases 
 being subjected to but little compression, but also from the generation 
 of flatus which is the symptom and consequence of dyspepsia. 
 
 4th. In many cases the abdomen in rickets is also enlarged by a dis- 
 
 1 Klinik der Leberkrankheiten, 1858, vol. i, table at p. 20. 
 
582 ENLARGEMENT OF THE ABDOMEN 
 
 tinct tumor or tumors, produced by the amyloid or albuminoid hyper- 
 trophy of liver and spleen. This cause of abdominal enlargement, 
 however, unlike the other three, is not invariable, and the cases are 
 decidedly exceptional in which it is the chief cause of the enlargement. 
 
 In subsequent childhood the abdomen is found much enlarged 
 wholly independent of any disposition to rickets, but as a symptom 
 and a result of indigestion. 
 
 You will often be asked whether you do not think a child is suffer- 
 ing from worms, and just as often whether you do not think it is suf- 
 fering from mesenteric disease, when the only reason assigned, or in- 
 deed assignable for either suspicion, is the unusual size of the abdomen. 
 
 Now with reference to both of these points it is well to bear in mind, 
 
 1st. That there is no special condition of the abdomen in itself char- 
 acteristic of the presence of intestinal worms. 
 
 2d. That even when much larger than natural, so long as the ab- 
 domen is not tense, you need entertain no apprehension of the existence 
 of organic disease ; and 
 
 3d. That sometimes, especially in infancy, you may meet with ex- 
 treme tension of the abdomen, and even with enlargement of the super- 
 ficial veins of the abdominal walls, such as is usually associated with 
 mesenteric disease, due in reality to mere flatulent distension of the 
 intestines. 
 
 In such doubtful cases, however, you will be preserved from error 
 by observing two points : 
 
 1st. That there is no general glandular enlargement to be discovered, 
 and especially that there is no enlargement of the inguinal glands, for 
 they never fail to participate in any considerable increase in size that 
 may affect the glands of the mesentery. 
 
 2d. That the resonance on percussion of the abdomen is equal and 
 universal. In cases of tubercular peritonitis, or of at all advanced 
 mesenteric disease, this is not the case, but about or below the um- 
 bilicus there is either absolute or relative dulness on percussion, and, 
 in addition, in the case of tubercular peritonitis, a doughy feeling of 
 the abdomen in that situation owing to the adhesion of the coils of 
 small intestine to each other and to the peritoneum. 
 
 On a few occasions, almost always in young children between the 
 ages of two and three, I have found the abdomen extremely distended, 
 hard, tense, even slightly tender to the touch, and with marked en- 
 largement of the superficial veins, but yet everywhere resonant on per- 
 cussion. The enlargement has been so considerable as to force upon 
 me the conviction that some deepseated disease must underlie it, and 
 yet it has entirely disappeared, just as the phantom tumor of a hysteri- 
 cal woman does, when the child was put under chloroform. A some- 
 what similar state, too, has occasionally come under my notice in older 
 children who were subject to colic, and in whom the distinct outline of 
 a tumor seemed sometimes perceptible ; due to the spasmodic contrac- 
 tion of the abdominal muscles, and recognizable both by its outline 
 never being complete, but undistinguishable at one side, though clearly 
 perceptible at the other, by its not being invariably to be felt, and also 
 
FROM FLATUS AND FROM FLUID. 583 
 
 by its disappearance under the use of chloroform. Such cases are rare, 
 but it is well to be aware of them. 
 
 A word or two ought, perhaps, to be added with reference to the en- 
 largement of the abdomen from fluid in childhood. Though often sus- 
 pected by the friends of our patients, abdominal enlargement from the 
 collection of fluid is a comparatively rare occurrence. It is, of course, 
 met with sometimes, in cases of albuminuria, whether acute or chronic; 
 the ascites bearing some proportion to the degree of general oedema; 
 and it also occurs, though not so frequently as in the grown person, in 
 cases of disorganization of the heart from long-standing valvular dis- 
 ease; and in such circumstances no diagnostic difficulty presents itself. 
 Every now and then, too, the same exposure to cold as, more commonly, 
 gives rise to acute anasarca, occasions the outpouring of fluid into the 
 abdominal cavity, an accident by no means always associated with 
 albuminous urine; but the fluid in such cases is in general speedily 
 absorbed if the patient is kept in bed, the abdomen gently swathed in 
 flannel, the action of the skin promoted by the vapor or hot-air bath, 
 and that of the kidneys by mild diuretics. Now and then ascites 
 occurs in early life, in connection with a general state of cachexia ; the 
 fluid, however, in these cases is seldom considerable in quantity ; and 
 disappears simultaneously with the general improvement of the health 
 which tonics and chalybeates bring out. 
 
 But besides these cases, we sometimes meet with a large collection of 
 fluid in the abdomen, which has formed gradually in connection with 
 an apparently causeless failure of the general health, and which may 
 be due to cirrhosis of the liver. It is true that cirrhosis is rare in child- 
 hood ; but still not so rare that the possibility of its existence should 
 be absent from our minds. But over and above these cases I have on 
 a few occasions observed ascites with failure of the general health, an 
 ill-defined state of fever and considerable emaciation with a dry and 
 harsh skin; and symptoms of general illness, suggestive of grave or- 
 ganic disease; but in reality due to the influence of malaria; the health 
 improving, the fever ceasing, and the fluid becoming absorbed under 
 the steady employment of quinine. It is very difficult, I own, to dis- 
 criminate these cases ; but a careful inquiry into the possible exposure 
 of the child to the influence of malaria, and the fact that irregular febrile 
 attacks of a remittent if not of an actually intermittent character have 
 preceded for some weeks the effusion into the abdomen, will do much 
 to put us on our guard, and to prevent us from at once attributing to 
 hopeless organic disease symptoms that may really be due to a perfectly 
 removable cause. 
 
 In some cases of mesenteric disease fluid is effused into the abdominal 
 cavity; rarely indeed in large quantity, or so as to contribute much 
 to the enlargement of the abdomen. Still when present it is a condi- 
 tion of much moment, since I fear in any case of disorder of the diges- 
 tive organs of long continuance, associated with loss of flesh, tumefaction 
 of the abdomen, and enlargement of the inguinal glands, the presence 
 of fluctuation even though indistinct greatly adds to the gravity of our 
 prognosis. 
 
 In some few cases of tubercular peritonitis, small collections of pus 
 
584: ABDOMINAL TUMOR 
 
 form between the coils of intestines, and as already mentioned a few 
 days ago point and discharge at the umbilicus. Here, however, the 
 gravity of the other symptoms is such as rarely to leave doubt as to 
 the nature of the case, or as to the cause of the abdominal enlargement. 
 
 We have now I think disposed of all the more important conditions 
 to which enlargement of the abdomen in childhood may be due, with 
 the exception of those in which there exists some actual definite growth 
 or tumor, or some distinct collection of matter. 
 
 Such tumors may be due : 
 
 1st. To the liver. 
 
 2d. " spleen. 
 
 3d. " kidneys. 
 
 4th. " mesenteric glands. 
 
 5th. " disease of the intestines themselves ; an occurrence, how- 
 ever, of extreme rarity, or to ovarian disease. 
 
 6th. To abscesses in the abdominal parietes. 
 
 We will examine these in the order in which I have enumerated 
 them; and 
 
 1st. Of abdominal tumors due to enlargement of the liver. 
 
 1st. Sometimes we meet with very perceptible enlargement of the 
 liver in cases of heart disease, when of course we attach to it no special 
 importance, but regard it only as one of the consequences of the ob- 
 structed circulation. In these circumstances, too, the enlargement is 
 rarely so considerable as to constitute a distinct abdominal tumor, while 
 the other symptoms with which it is associated are such as to prevent 
 all risk of error. 
 
 A similar enlargement of the liver, though likewise seldom to a re- 
 markable degree is also sometimes met with in children of two or three 
 or four years old. It is accompanied by dyspeptic symptoms, with 
 white evacuations, and considerable deposits of lithates in the urine ; 
 but neither with jaundice nor with distinct tenderness in the region of 
 the liver. Some loss of flesh attends it, and general flatulent disten- 
 sion of the abdomen, but it is not associated with evidence of tubercular 
 disease, and the symptoms disappear, the abdomen grows smaller, and 
 the liver resumes its natural size, under the employment of mercurials, 
 sometimes in purgative, but oftener in alterative doses. 
 
 I refer to this condition, not so much on account of the mere enlarge- 
 ment of the liver, as on account of the general symptoms, which are 
 not infrequently regarded as those of mesenteric disease. The abdomen, 
 however, is softer, it is less tender, or not tender at all ; percussion does 
 not elicit the diminished resonance around and below the umbilicus 
 generally perceptible in cases of tubercular disease, the tongue is not 
 morbidly clean, nor are any distinct symptoms of glandular enlarge- 
 ment or of phthisical disease present. 
 
 2d. At a still earlier age ; in infancy, and early childhood, up to 
 the age of two years, we meet sometimes with an enlarged liver owing 
 to fatty deposit. In its less marked degrees, it is merely an exagge- 
 ration of the fatty liver of infancy. It sometimes, however, is more 
 considerable, is accompanied with complete non-performance of the 
 
FROM ENLARGED LIVER. 585 
 
 functions of the liver, and with extreme emaciation, and yet by no 
 means of necessity with the deposit of tubercle. 
 
 This condition of the liver, too, is sometimes found to exist in cases 
 of laryngismus stridulus, and appears to be at the root of that mal- 
 assimilation which is often the exciting cause of the convulsive affections 
 of early life. 
 
 The subject calls for and will repay further investigation than it has 
 yet received. It is, however, well to bear in mind the possible connec- 
 tion of convulsions with a state of fatty liver, and the possible existence 
 of extreme and even fatal atrophy in infancy independent of tubercular 
 deposit. The existence of this state explains, perhaps, to some degree 
 the cases in which young children have failed to be nourished by the 
 milk and farinaceous diet which commonly suits their tender age, but 
 have improved on animal broths and on the raw meat which in some 
 instances we find so extremely valuable. 
 
 I have, however, referred to these two classes of cases rather to sug- 
 gest an explanation of the conditions with which you may find hepatic 
 enlargement associated, than because the increased size of the liver is 
 such as at once to attract your notice. You discover it in the course 
 of that examination of the abdomen, which in the case of infants and 
 children you should never omit. I have merely tried to give you a 
 clue to its meaning. 
 
 3d. The albuminoid, amyloid, or waxy liver is the most common 
 form of those enlargements of the organ in which it attains such a size 
 as to force itself on the notice even of the unobservant. 
 
 It is one of the common attendants upon rickets, and is then usually 
 associated with a similar enlargement of the spleen. The latter organ, 
 indeed, is commonly the first to be affected, and its enlargement is in 
 general proportionately greater than that of the liver. 
 
 A boy three years old, but unable to walk, was admitted into the 
 Children's Hospital. His thighs and legs were much bent by rickets, 
 and his head was large and had the characteristic square form which 
 one commonly meets with in rickety children. He was emaciated, 
 was reported to have been always delicate, to have suffered at different 
 times from diarrhoea, and for the previous four months to have lost 
 much flesh, to have suffered from occasional sickness, and from general 
 dyspeptic symptoms. 
 
 On examining his big abdomen, the sharp, firm edge of the liver 
 was felt two inches below the margin of the ribs on the right side, and 
 in the middle three inches below the ensiform cartilage ; and three- 
 fourths of an inch below the tenth rib on the left side. The enlarged 
 spleen, presenting the same characters of hardness with a distinct sharp 
 edge, reached down to within half an inch of the anterior superior 
 spine of the ilium, and across the abdomen to within tw r o and a half 
 inches of the mesial line. 
 
 My business now is not to pursue the history of this case further. 
 The boy, indeed, left the hospital after a short stay somewhat better 
 in health, but with the liver and spleen as large as ever. That which 
 it behooves you to remember is that in almost all cases where the 
 cachexia of rickets is well marked, and the dyspeptic symptoms are 
 
586 ABDOMINAL TUMOR 
 
 severe, you will meet with enlargement of the liver and spleen ; that 
 this enlargement is usually associated with considerable emaciation, but 
 that it has no necessary relation to tubercular disease ; nor in the case 
 of the rickety child to any scrofulous taint in the system. 
 
 I do not know what changes take place in the albuminoid liver 
 during convalescence from rickets, nor am I prepared to say whether 
 a great degree of enlargement of the liver produces or implies such an 
 intensity of the rickety cachexia as to preclude the child's recovery. 
 Both these points require elucidation. 
 
 This state of the liver is associated with various cachexia?. It has 
 been ascertained by Dr. Gubler of Paris 1 to exist in congenital syphilis 
 whenever the constitutional symptoms are well marked, though it does 
 not occasion the same degree of enlargement of the organ as one con- 
 stantly observes in cases of rickets. 
 
 It is a not infrequent attendant on scrofulous disease of the bones, 
 and Dr. Budd, 2 who was the first to call special attention to it, believes 
 this affection of the liver to be always or almost always found in this 
 connection. This, however, is by no means invariably the case, for I 
 have met with it not only in cases of rickets, or of syphilis, but also in 
 instances where no special constitutional taint could be alleged as pro- 
 ducing it. 
 
 Some years ago the child of healthy parents came under my notice 
 at the age of fourteen months. She was healthy when born, and was 
 suckled by a healthy wet nurse up to the age of eight months. At 
 that time the wet nurse fell ill with fever at Nice, where the family 
 had been residing for half a year, and some unavoidable difficulty and 
 delay occurred in obtaining another. During this time the child 
 drooped, and a distinct enlargement of the abdomen was now noticed. 
 In spite of being restored to a healthy wet nurse emaciation went on, 
 and was not arrested either by a return to England at the age of nine 
 months, or by an attempt at artificial feeding at the age of twelve 
 months. The artificial feeding not having succeeded, and an attack of 
 convulsions having occurred, a third wet nurse was obtained, and about 
 a fortnight after I saw the child. 
 
 She was very thin, and her general aspect was like that of a child 
 w^ith tubercular disease, except that her face was less distressed and she 
 seemed even somewhat cheerful. The tongue was clean and moist, and 
 the mouth quite free from aphtha?. 
 
 The limbs were very much emaciated, but the abdomen was very 
 large. It measured twenty-one inches at the umbilicus, where six 
 weeks before its girth was but nineteen. The superficial abdominal 
 veins were much enlarged, the surface of the abdomen was smooth, not 
 tender. 
 
 The enlargement of the abdomen was due to two firm tumors. One 
 on the left side extended from below the floating ribs down into the 
 
 1 Memoires de la Societe de Biologie, Paris, 1853, 8vo., p. 25. 
 
 2 In his Treatise on Diseases of the Liver, at p. 304; where, and in Henoch's 
 Klinikder Unterleibs-Krankheiten, vol. i, Berlin, 1852, p. 130, and in Frerichs's 
 Klinik der Leberkrankheiten, vol. ii, Braunschweig, 1861, p. 165, is to be found the 
 best account of this affection. 
 
FROM ENLARGED LIVER. 587 
 
 pelvis. It had a sharp straight edge which reached very nearly to the 
 mesial line. The other tumor, which occupied chiefly the right half 
 of the abdomen, did pass over somewhat to the left, a deep notch in 
 the mesial line marking out its two halves. The edge of the right half 
 descended considerably below the umbilicus; the notch was about on a 
 level with it, while the left half sloped by degrees upwards and passed 
 out of reach below the ribs. 
 
 Six weeks afterwards the child died exhausted by diarrhoea, but never 
 having presented that peculiar pallor of the surface characteristic of 
 leucaemia, and with which splenic enlargement is frequently associated. 
 
 It is not in infancy only that this condition comes on ; it may be met 
 with at any time and unassociated with any complication, though I 
 believe for the most part, if not invariably, with a distinct history of a 
 scrofulous diathesis in the parents or in other members of the family. 
 
 A boy, eight years old, several members of whose family had died 
 of strumous ailments, began to fail in health about a year before he 
 came under my notice. At that time there was perhaps a slight fulness 
 of the abdomen, but no distinct tumor was discovered till three months 
 before I saw him, though since that time it had increased rapidly. The 
 abdominal enlargement had not been attended by any pain, but with 
 failing appetite, an irregular state of the bowels in which constipation 
 alternated with diarrhoea, pyrosis and occasional vomiting. 
 
 The boy was tall, thin, his complexion sallow, but his appearance 
 not particularly unhealthy, and his tongue clean. 
 
 His abdomen measured 22f inches at the umbilicus. Its enlarge- 
 ment was due to a tumor which came from beneath the ribs on the 
 right side, and reached down exactly to the umbilicus, about which it 
 was particularly prominent. It thence sloped up gradually to the left 
 side, and passed out of reach then under the ribs. There was no en- 
 largement of the spleen. 
 
 The boy's health fluctuated ; the tumor at first enlarged so that the 
 abdomen was an inch and a half bigger at the end of three months 
 than when I first saw him. It afterwards remained stationary, but 
 then again enlarged. It grew most where it encountered least resist- 
 ance, as all tumors do, so that at the end of a year, when I saw him 
 for the last time, although the abdomen was not increased in circum- 
 ference, the tumor extended down below the iliac crest. 
 
 These tumors are generally easily recognized by their smoothness, 
 hardness, by their sharp edge, their painlessness, and the history ob- 
 tained of their slow T growth. They are unattended by any pathogno- 
 monic symptoms as far as the disturbance of the general health is con- 
 cerned, although they are almost always associated with more or less 
 serious dyspeptic disorder. 
 
 In young children, death, when it occurs, seems to be due to the 
 general advance of the rickety cachexia ; or if rickets are not present, 
 and the liver is very large, the spleen also is almost invariably enlarged 
 too, and the symptoms under which death takes place are very much 
 those of leucaemia. 
 
 In children after the period of dentition, life does not seem to be 
 jeopardized so long as the affection is confined to the liver ; though of 
 
588 ABDOMINAL TUMOR 
 
 course some intercurrent scrofulous or tubercular disease may prove 
 fatal. Sometimes, however, while the liver disease seems to remain 
 stationary or slowly increases, the peculiar deposit invades the kidney 
 also. The urine then becomes scanty in quantity and highly albuminous, 
 evidencing the existence of a peculiarly intractable form of granular 
 degeneration of the kidneys which on one or two occasions I have met 
 with and have seen prove fatal. 
 
 4th. The liver may be enlarged by the development of cysts in its 
 substance. 
 
 These cysts, when they attain to any such size as to form a distinct 
 tumor perceptible during life, are almost if not quite invariably pro- 
 duced by the development of hydatids. 
 
 Of all causes of hepatic tumor, hydatid cysts are, according to my 
 experience, by far the rarest. I have met with them but twice, once 
 in a patient who died, and a second time in a girl in whom the puncture 
 of the cyst would seem to have been followed by the cure of the affec- 
 tion, for six years have now passed without any sign of its reappear- 
 ance. 
 
 In the fatal case the tumor, which no doubt must have existed some 
 time previously, was first discovered at the age of eleven years. It 
 formed in the right side, and its growth was unattended by general in- 
 disposition, though as it increased in size occasional attacks of very 
 severe pain came on. These attacks were, I believe, due in great 
 measure to the pressure of the enlarging cyst outwards against the chest- 
 walls as well as upwards agains the diaphragm. With these exceptions 
 the general health was not disturbed until six weeks before the patient's 
 death at the age of seventeen. Gastric disorder, occasional diarrhoea, 
 and severe abdominal pains then came on, fluid was poured out into 
 the abdominal cavity, and death took place six weeks after the com- 
 mencement of these symptoms. 
 
 I am not pursuing the subject of the pathology of these tumors, nor 
 considering the question of their treatment, though I cannot forbear 
 observing to you that the question of the puncture of the cyst ought in 
 its earlier stages to have been considered. 
 
 When death occurred the tumor had attained to such dimensions 
 that while on the left side it descended somewhat below the level of the 
 false ribs, and not quite so low on the right, it had pushed up the 
 diaphragm a little above the level of the upper margin of the third rib 
 on the right side, and the second on the left. 
 
 It did not in short obey that law of growing downwards in the direc- 
 tion where it encounters the least resistance to which I called your at- 
 tention as governing the development of the slowly growing albuminoid 
 enlargement of the* liver. 
 
 In the other case the tumor was first discovered in the left hypo- 
 chondrium of a little girl six years old, during an attack of bilious 
 vomiting ; and vomiting returned accompanied with sharp pain in the 
 tumor three months afterwards, and again to a slighter degree two or 
 three times subsequently. 
 
 I saw her when she was 6J years old. There was then a rounded 
 elevation in the left hypochondrium and in the epigastrium, which 
 
FROM ENLARGED LIVER. 589 
 
 raised the ribs and merged gradually into the liver. It resembled a 
 segment of a large orange, projected at its most prominent part about 
 two inches; was smooth, elastic, vibrating, almost fluctuating on per- 
 cussion ; and on inspiration the liver and it descended together. 
 
 The cyst was punctured, 27 ounces of fluid were withdrawn ; at the 
 end of three months the cyst appeared to be refilling, but it shrank 
 again in the course of a few months, and I hear that the child continues 
 perfectly well six years since the puncture, though I have not seen her 
 for the past five years, when a distinct firm lump was perceptible in 
 the situation of the hydatid ; but not yielding any sense as of fluid 
 within it. 
 
 The diagnosis of these tumors is not attended by much difficulty. 
 Their growth is unattended by any pathognomonic symptom, nor at 
 all constantly either by dyspepsia, disorder of the functions of the liver, 
 or by pain; while whenever pain does occur it is due almost or quite 
 invariably to mechanical pressure. 
 
 The hydatid tumor is smooth, globular, yielding fluctuation, or at 
 least a sense of tremor on percussing it. You will remember that small, 
 tense cysts often yield no distinct fluctuation, but at most a sort of sense 
 of elasticity. Your experience of the occasional diagnostic difficulties 
 in the case of small ovarian cysts situated within the pelvic cavity will 
 impress this on your minds. 
 
 It is almost needless to observe that these tumors are attended by 
 no general enlargement of the liver, but are developed in its substance 
 and to a certain degree at its expense. There is nowhere the sharp 
 edge to be felt so characteristic of the albuminoid enlargement of the 
 liver, nor the general nodosity of its surface characteristic of malignant 
 disease. There is no history of acute illness at its commencement, nor 
 any sign of cachexia from its continuance. 
 
 5th. The liver may be enlarged by malignant disease. 
 
 One of the inconveniences attendant upon the practice of medicine 
 in a large city is that many fragments of cases come under one's notice, 
 but few cases in their entirety ; that one sees the beginning of one, the 
 middle of a second, the termination of a third. It is thus that while 
 I have had several cases of what I believe to have been malignant dis- 
 ease of the liver under my notice, I have never followed but one from 
 its commencement to its end. 
 
 In that case the affection was attended by vague indications of 
 abdominal disease, in which there was nothing that pointed especially 
 to any one viscus ; while the morbid growth having originated from 
 the under surface of the right lobe of the liver was supposed to be due 
 to enlargement of the mesenteric glands. The patient was a little boy, 
 who was 8 months old when the first indications of disordered health 
 appeared in diarrhoea, fretfulness, and loss of flesh and appetite ; and 
 at the age of nine months his mother noticed some solid masses in his 
 abdomen, which from the commencement of his illness had been hard 
 and rather tender. The child lived to the age of one year ; and for 
 the last six weeks of his life, during which I had the opportunity of 
 watching him, he suffered from diarrhoea, which was occasionally very 
 profuse. He became extremely emaciated, and his skin assumed an 
 
590 ABDOMINAL TUMOR 
 
 exceedingly sallow color ■ but the evacuations, though relaxed, were 
 otherwise natural. No hemorrhage took place from the intestines, and 
 the urine was found to be perfectly natural whenever it was tested. 
 During the last month of life he had a slight cough, and wheezing 
 respiration ; but death seemed due to the constant diarrhoea and the 
 severe pain which the child suffered, his exhaustion being doubtless in 
 great measure the consequence of the blood, which should have nour- 
 ished his body, being diverted to supply the enormous mass of fungoid 
 disease of the liver. 
 
 During the six weeks that the child was under my observation, his 
 abdomen increased from 21 to 25 inches in circumference ; and the 
 tumor, the surface of which was uneven, was always much larger on 
 the left than on the right side. It turned out, however, on examina- 
 tion after death, that the left lobe of the liver was almost completely 
 healthy, but that it had been driven up under the ribs by the enlarged 
 right lobe ; while part of the organ was converted into a soft white 
 brain-like matter, intermingled with which were portions of a firmer, 
 highly vascular, fibro-cellular substance. A few deposits of medullary 
 cancer existed also in the right lung, but the other viscera were 
 healthy. 
 
 I saw once a little girl three years and four months old whose health 
 had been failing for the previous three months. She had been noticed 
 to lose flesh rather rapidly, to become indisposed to exertion, and to 
 walk with some apparent difficulty, while her skin had assumed a 
 general icteroid tinge. Her appetite had become bad, her bowels irreg- 
 ular, and her abdomen enlarged, though attention had been somewhat 
 turned away from that by a gradually increasing prominence of the 
 right eye, and next by the occurrence of ecchymosis of both eyelids 
 which gave the child a most singular appearance. The globe of the 
 right eye projected when I saw the child fully half out of its orbit ; 
 and there were two specks of extravasated blood in the conjunctiva. 
 
 The abdomen was enlarged by a tumor, firm, non-fluctuating ; its 
 surface uneven, its edge rounded, and the superficial veins of the abdo- 
 men were generally much enlarged. The tumors occupied the situa- 
 tion of the liver, passing down from the right hypochondrium to below 
 the iliac crest, then sloping up to the left side, where it passed out of 
 reach under the floating ribs, but not occupying at all the splenic 
 region, clear percussion being elicited for three inches to the left of the 
 outer edge of the swelling. 
 
 In this case the protrusion of the right eyeball and the general his- 
 tory of the patient seemed at once to direct the attention to the proba- 
 ble existence of malignant disease. 
 
 Independently of that, however, the general features of the case 
 were sufficiently characteristic. The causeless failure of health, the 
 well-marked cachexia, the rapid development of the disease, the irreg- 
 ular surface of the tumor, the rounded edge unlike the sharp well- 
 defined edge of albuminoid enlargement of the liver, and the absence 
 of the slightest enlargement of the spleen, stamped upon the case those 
 peculiarities which when well-marked will I think always justify you 
 in pronouncing on the existence of malignant disease of the liver. 
 
FROM ENLARGEMENT OF LIVER AND SPLEEN. 591 
 
 2d. Tumor of the abdomen may be produced by enlargement of the 
 spleen. 
 
 That enlargement of the organ consequent on frequent attacks of ague 
 is extremely rare in the neighborhood of London, and the only instance 
 of it which I have met with in childhood where a distinct abdominal 
 enlargement was due solely to the hypertrophied spleen was in the case 
 of a little girl aged six and a half years who had had frequent attacks 
 of fever on the west coast of Africa. The enlargement of her spleen 
 first attracted attention at the age of five years, and when I saw her, 
 her abdomen measured 21 J inches in circumference, and the spleen 
 reached from under the ribs quite down into the pelvis, and forward as 
 far as the mesial line of the abdomen. 
 
 In the great majority of instances which we meet with in this country, 
 the enlargement of the spleen is associated with enlargement of the 
 liver, and the causes which produce the one are the same as those which 
 give rise to the other. Hence we meet with it in rickets, in congenital 
 syphilis, and in the same scrofulous constitution as favors the albumi- 
 noid enlargement of the liver. In most of these instances, however, 
 the enlargement of the spleen is rather a condition found by those who 
 seek for it, than one so marked as to force itself on the unobservant. 
 
 But besides these cases we sometimes meet with great enlargement of 
 the spleen in infancy in connection with that general condition known 
 as Leucaemia from its supposed dependence on imperfect blood-forma- 
 tion, and on the predominance of white corpuscles in the blood. My 
 friend and colleague Dr. Gee informs me, indeed, that the connection 
 between the general symptoms and the microscopic state of the circu- 
 lating- fluid has not seemed to him to be so close as has been alleged. 
 
 Be this as it may the general symptoms are sufficiently marked to be 
 easily recognizable, and are just those which were observed in an in- 
 fant 8 J- months old ; the third child of tolerably healthy parents though 
 the father had been supposed at one time to have presented some of the 
 early symptoms of phthisis. The child had been nursed by its mother 
 for six weeks, and afterwards by a healthy wet-nurse up to the age of 
 six months. It was alleged to have been always healthy though re- 
 markable for its pallor. Dentition had not commenced, but save that 
 the bowels were always costive there was nothing which excited the 
 parents' anxiety until the discovery, not much above a week before, of a 
 tumor on the left side of the abdomen. 
 
 The child looked well-nourished ; but of extreme pallor — "the faded 
 hue of sapless boxen leaves," as Dydren has it in his version of the 
 Knight's Tale ; true to nature as the true poet always is. 
 
 The abdomen was remarkably full ; it was tympanitic on the right 
 side; but on the left there was a solid tumor which reached up under 
 the floating ribs, down below the crest of the ilium, and extended an 
 inch across the mesial line, but did not reach quite back into the lum- 
 bar region. The superficial abdominal veins were somewhat enlarged 
 over it ; it was hard, smooth, painless and presented a distinct sharp 
 edge, which ran almost straight downwards ; while, apart from the dif- 
 ference in history, these characters clearly distinguished it from any 
 
592 ABDOMINAL TUMOR 
 
 tumor due to enlargement of the kidney, with which alone it could 
 have been confounded. 
 
 The constitutional symptoms in these cases are, indeed, far too marked 
 to be overlooked. They would run but little risk of being misinter- 
 preted, if the simple precaution were always taken of undressing an in- 
 fant or young child who suffers from some apparently causeless cachexia, 
 and examining it carefully before forming a diagnosis. I believe that 
 this state of spleen, as well as the constitutional condition with which 
 it is associated, often date back to early infancy. I have, indeed, met 
 with them in a child only three months old, and though in the majority 
 of cases which I have observed, the age of the patients varied from nine 
 to fifteen months, yet the size that the spleen then presented, clearly 
 showed that its enlargement must have begun long before that time. 
 The early age at which this condition has been noticed, clearly nega- 
 tives its supposed dependence on protracted lactation -} while its occur- 
 rence among the children of the wealthier classes, as well as among 
 those of the poor, shows that it depends on constitutional causes, not 
 merely on bad air, or other unfavorable hygienic influences. In its 
 minor degree, the enlargement of the spleen is not infrequently over- 
 looked, owing to neglect of the precaution I have just insisted on; and 
 I have discovered it in cases where it had not been at all suspected, 
 but where the pallor of the child, the peculiar w r axen hue of its sur- 
 face, its failing strength, and loss of flesh, yet unassociated with the 
 evidences of tuberculosis, betrayed to those who were familiar with its 
 features the real nature of the ailment. In such cases the enlarged 
 spleen sometimes returns to its proper size in proportion as the health 
 of the child improves; as it often does under a tonic treatment com- 
 bined with the employment of preparations of iron and quinine. When 
 the depravation of the blood, however, is very considerable, no amend- 
 ment follows treatment; while not only does the enlargement of the 
 spleen become more and more considerable, but in very many instances 
 the liver also participates in the change; and two distinct tumors may 
 then be perceived in the abdomen ; the one of an elongated form, seated 
 on the left side, and often dipping down into the pelvis ; the other of 
 a more rounded shape, principally occupying the right side, and not 
 descending so low. When the enlargement is very considerable, the 
 circulation through the abdominal vessels is interfered with, and the 
 superficial veins in consequence become enlarged ; but it is decidedly 
 unusual for ascites to be produced. The smoothness of surface of these 
 tumors, and their equable firmness, serve to distinguish them from 
 growths of a malignant kind ; all of which, by the by, are of far greater 
 rarity than those of which I am now speaking. 
 
 It now and then happens in connection with this affection that a 
 great disposition to hemorrhage manifests itself; and this not only in 
 the appearance of petechia; on the surface, but also in the occurrence 
 
 1 An idea suggested by Dr. Battersby, to whose article on Enlargement of the 
 Liver and Spleen in Children, in Dublin Med. Journal, May, 1849, p. 308, we are 
 indebted for calling the attention of the profession to cases of this description. 
 
FROM ENLARGED KIDNEY. 593 
 
 of formidable or even fatal epistaxis, or hamiateroesis. 1 I believe, 
 however, that this accident is to be looked for in children of five years 
 old and upwards rather than in infants. They indeed generally fade 
 away with no very definite symptoms, but grow feebler and feebler, 
 just as women with large ovarian tumors may often be observed to do, 
 when the blood which should nourish the body is diverted to the 
 supply of the morbid growth. The appetite usually keeps up, and not 
 infrequently the bowels continue regular, though diarrhoea occasionally 
 takes place; and the loss of strength, the increasing pallor, and the 
 more and more waxen hue of the surface, are in general more remark- 
 able than even the loss of flesh, though towards the end of life that 
 too is often very considerable. Slight irregular febrile disturbance is 
 seldom absent as the disease advances, and seems, just as in cases of 
 general tuberculosis, to contribute not a little to exhaust the patient. 
 I do not know indeed how more shortly or more correctly to sum up 
 the symptoms of this aifection, than by saying that they are those of 
 general tuberculosis, but with greater pallor of the surface, less apparent 
 suffering or distress, less disturbance of any one set of functions, less 
 rapid loss of flesh ; and with an enlargement of the spleen, which gives 
 a clue to the understanding of the whole train of phenomena. 
 
 3d. Enlargement of the kidney, producing abdominal tumor, is usu- 
 ally, though not quite invariably, due to malignant disease ; and of this 
 I have the record of seven instances, of which four occurred in male, 
 three in female children. Their respective ages at death, or when so 
 ill that life could obviously be prolonged only for a few weeks, were 
 in two, between one and two years ; in one, between two and three ; in 
 two, between three and four ; in one, between six and seven ; and in 
 one, between seven and eight years. 
 
 The cases all presented very remarkable similarity to each other - 
 and in all, though there may have been some slight failure of the 
 general health, the discovery of a tumor in the lumbar region was the 
 first thing that excited real solicitude about the patient. The characters 
 of the tumor were in every instance sufficiently well marked ; though 
 
 1 I have seen five cases of that tendency to hemorrhage which, while sometimes 
 associated with splenic enlargement, is not so by any means invariably, and which 
 the Germans have described as a distinct and independent form of disease. 
 
 My patients, of whom the youngest was a boy aged six weeks, the other four, 
 girls aged seven, eight, ten and eleven years respectively, died of hemorrhage, 
 which took place from the bowels, the stomach, and, in the four elder children, 
 from the nose also. In three of the girls the hemorrhage was .accompanied by a 
 general purpurous eruption, and ecchymoses appeared on the infant. In one girl 
 the attack succeeded to measles, but there was no assignable cause for it in the 
 others. 
 
 1 do not dwell further on these cases here, because their occurrence is not limited 
 to early life, and because, be their cause what it may, it is by no means identical 
 with that which constitutes leucaemia 
 
 With reference to leucaemia, the reader may consult with advantage a paper by 
 Loschner, at p. 265 of his Aus dem Franz Joseph Kinder-Spitale, 8vo., Prag., 1860. 
 ■Concerning the hemorrhagic diathesis, the best account is still that given by Lange, 
 in Oppenheirn's Zeitschrift, Oct. 1850. See also Virchow's Specielle Pathologie, 
 vol. i, p. 263 ; two papers by Leudet, in the Memoires de la Societe de Biologie 
 for 1858 and 1859; and two others by Veit, in Virchow's Archiv for 1858. 
 
594: ABDOMINAL TUMOR FROM ENLARGED KIDNEY. 
 
 when it is situated on the left side, a doubt may be entertained as to 
 whether it is formed by the kidney or by the enlarged spleen. I be- 
 lieve, however, that error may be avoided, if it is borne in mind that 
 the spleen presents a sharp edge towards the mesial line, while the 
 contour of the kidney is rounded ; and further, that while the spleen 
 reaches higher up under the floating ribs, it does not extend into the 
 lumbar region so completely as the kidney, but always leaves an inter- 
 space close to the spinal column, where percussion yields a clear sound. 
 
 The history of the cases, too, is widely different. Generally, proba- 
 bly always, if one had the opportunity of continually watching the 
 cases, the urine at some period or other would be found tinged with 
 blood. My own experience would lead me to believe that this is 
 oftener an early symptom, than one of the disease in an advanced stage ; 
 while most certainly it is never constantly present; nor, indeed, does 
 disorder of the urinary function play the important part which might 
 be expected in such circumstances. General causeless failure of health 
 is sometimes associated with the development of the disease ; but even 
 when the growth has attained a large size, the peculiar waxen hue of 
 the surface already referred to, as attendant on splenic hypertrophy, is 
 absent; and cachectic symptoms are less marked, and less speedily 
 developed than in those cases in which the liver is the seat of malignant 
 disease. 
 
 The bulk of the tumor, the diversion to its nutrition of the blood 
 which should supply the body generally, the consequent wasting of the 
 tissues, and general loss of vital power, and all the discomfort produced 
 by mechanical pressure on the other abdominal viscera, have seemed to 
 me to be the causes which destroyed the patients' health and eventually 
 occasioned their death. Severe pain is not frequent, and when experi- 
 enced has seemed to be due to mechanical pressure rather than to suf- 
 fering seated in the tumor itself. 
 
 To sum up, I think I may say, that an abdominal tumor developing 
 rapidly in one or other side of the abdomen, neither preceded nor ac- 
 companied by any grave constitutional disturbance, though sometimes 
 associated with intermittent hematuria, ovoid in shape, apt to descend 
 into the pelvis rather than to rise under the ribs; solid to the touch, 
 but smooth on its surface ; rounded at its edge, and projecting back 
 completely into the lumbar region, may be assumed with almost abso- 
 lute certainty to be a tumor, and that malignant in its character, of one 
 or other kidney. 
 
 Such tumors belong to the class of fungoid cancer, into which the 
 whole substance of the enormously enlarged kidney becomes converted ; 
 and, in obedience to the law which seems to govern fungoid cancer in 
 general, they are very rapid in their growth, and usually bring a fatal 
 issue within six months, while I have not known any instance of the 
 prolongation of life beyond a year. 
 
 It would appear that cystic disease of the organ runs a somewhat 
 slower course, for I once saw a male child in which a tumor, recognized 
 as the enlarged left kidney, was first discovered at the end of 3 months, 
 but did not prove fatal until 17 months. 
 
 The post-mortem examination alone made manifest the difference 
 
ABDOMINAL TUMOR FROM LUMBAR ABSCESS. 595 
 
 between it and malignant disease of the kidney, but, 1 believe that, at 
 no period in the history of the case had hematuria been noticed. With 
 this exception, however, there was nothing to distinguish the case during 
 life from one of malignant disease. 
 
 The disease which occupied the left kidney weighed 14 pounds. It 
 was non-adherent to any of the surrounding structures, and on examin- 
 ation, the kidney, flattened out but unaltered in texture, was found on 
 its posterior surface. 
 
 On dividing its substance, it presented an alveolar texture, in the 
 meshes of which there was a clear fluid. 
 
 Some parts were much more solid than others, and projected, when 
 cut, so as to look like medullary cancer. 
 
 In connection with this subject, I must warn you of the possibility 
 of mistaking the swelling formed by a psoas abscess for that produced 
 by enlargement of the kidney. When psoas abscess occurs in young 
 children, its early stages may readily be overlooked, partly because the 
 patient is unable to describe those vague sensations of uneasiness in the 
 loins by which it is attended, — partly because impairment or loss of 
 the power of walking is so common a result of indisposition of any 
 kind in early life that it seems scarcely necessary to seek for any special 
 cause to explain its occurrence. The gradual failure of the health, the 
 loss of flesh, and the occasional disturbance of the bowels, are symptoms 
 that attend upon various disorders of the abdominal viscera, and that 
 present nothing pathognomonic of any. The tumor, like that formed 
 by enlargement of the kidney, occupies the lumbar region, projecting 
 forwards into the abdomen ; while fluctuation in the abscess is often so 
 obscure as to be scarcely, if at all, perceptible. The tumor of psoas 
 abscess, however, reaches less high up in the abdomen than that formed 
 by enlargement of the kidney ; its contour is usually more circular, 
 less oval, and the tenderness over it is in general greater, than in cases 
 of malignant disease of the kidney. As the aifection advances, and the 
 matter gravitates into the thigh, or points in the lumbar region, its 
 nature becomes clearly manifest ; but though, as far as the final issue 
 of the case is concerned, an error of diagnosis is but of little import, it 
 is yet very desirable for your own reputation that you should not at 
 any period have fallen into a mistake as to its nature. A somewhat 
 similar error, too, I have sometimes seen committed in cases where in- 
 flammation going on to the formation of matter has attacked the cellu- 
 lar tissue beneath some part or other of the abdominal viscera just as 
 one often sees it do in women after delivery. In these circumstances 
 there is a hard, imperfectly circumscribed swelling, slow in its progress, 
 and attended by but little suffering. Its real nature is indeed obvious 
 enough if the swelling is carefully examined, but if the possibility of 
 the accident is not borne in mind, its nature is likely to be misinter- 
 preted. 
 
 Every case of enlargement of the kidney is not due to malignant 
 disease : for once I saw a large abscess, which had distended the kidney 
 by slow degrees, point at last iri the lumbar region, death taking place 
 from exhaustion a few days after a puncture had been made and the 
 pus evacuated. For some months, too, I watched a case of hydrone- 
 
596 ABDOMINAL TUMORS 
 
 phrosis in the Children's Hospital, under the care of the late Dr Hil- 
 lier ; but it is needless to dwell on cases whose chief interest consists in 
 their great rarity. 
 
 4th. The abdomen may become enlarged in consequence of disease 
 of the mesenteric glands. I must, however, repeat what I have already 
 said, that in no instance have I found tumors of the abdomen due solely 
 or even in any considerable degree to enlargement of the glands. One 
 may meet, indeed, with a big abdomen in cases of mesenteric disease, 
 and may be able by firm pressure to distinguish the irregular lumps of 
 enlarged glands, though this even is exceptional ; but the bulk of the 
 enlargement is due either to the presence of flatus in the intestines, or 
 to the tubercular peritonitis with which mesenteric disease is commonly 
 associated. The enlarged abdomen from tubercular peritonitis is due 
 either to matting of the intestines together about and below the umbili- 
 cus, or to the effusion of seropurulent fluid between their coils, or to 
 both of these causes combined. The shape of the abdomen in such 
 cases is sufficiently characteristic. The enlargement is most marked 
 in the hypogastrium, and the greatest prominence is about and around 
 the umbilicus, which not seldom projects a little. A dull sound is 
 elicited everywhere on percussion, the abdominal walls are found agglu- 
 tinated to the intestines, and pressure is painful, often extremely so. 
 All these conditions may, and frequently do, coexist with tubercle of 
 the mesenteric glands, but are not due to it alone. 
 
 5th. Rare cases are now and then met with in which a distinct tumor 
 is produced by disease of the intestines themselves, or in the female child 
 long before puberty by ovarian disease. Thus I once saw a boy ten 
 years old in whom an irregular nodulated tumor in the left iliac fossa, 
 and extending across the mesial line, was due to cancerous disease of 
 the descending colon, and cancerous outgrowth from its walls. The 
 tumor in this case was very rapid in its growth, accompanied with great 
 failure of general health, but with no interference with the action of the 
 bowels. Death took place under an attack of peritonitis within a month 
 after the first discovery of the tumor, the real seat and nature of which 
 were discovered only on a post-mortem examination. It can scarcely 
 be necessary for me to remind you of the deceptive characters sometimes 
 presented by fecal accumulation in the child as in the adult, or of the 
 necessity to clear out the intestines both by aperients and by enemata, 
 before attempting to settle the nature of any obscure abdominal enlarge- 
 ment. 
 
 Two years since, a little girl, seven years of age, died after a year's 
 illness of medullary cancer of the right ovary, which burst into the 
 abdominal cavity. The tumor had been observed for four months be- 
 fore the child came under my notice, and she continued in the hospital 
 for a month, when she died apparently from exhaustion. 
 
 The nature of the case was diagnosed during life, and, indeed, no 
 special difficulty attended the discrimination of its nature. The physical 
 signs were the same as one would meet with in ovarian disease in the 
 adult ; the mass manifestly sprang from within the pelvis, although it 
 reached up to the under surface of the liver. The mass weighed 5 J 
 
FROM VARIOUS CAUSES. 597 
 
 pounds, and it was limited entirely to the right ovary. There were 
 some secondary deposits in the omentum but none elsewhere. 
 
 Two or three similar cases have been in the Children's Hospital 
 within the past twenty-two years. I have mentioned them, and the 
 case of cancer of the intestines, in order that in a doubtful case you 
 may have the various possibilities present to your minds. 
 
 6th, and lastly. Abscesses in the abdominal walls may give rise to 
 distinct circumscribed enlargements which it may not always be easy 
 to distinguish from tumors seated within the cavity of the abdomen. 
 I have indeed seen much uncertainty in the minds of very experienced 
 practitioners with reference to the nature of swellings of this kind, and 
 the rather since they come on in many instances without any definite 
 exciting cause, and are also extremely chronic in their course, and often 
 almost or altogether painless. They may be seated almost anywhere. 
 I have seen one follow a subacute attack of rheumatism in a boy seven 
 years old, occupying the crest of the left ilium. I have seen another 
 on the right side just over the region of the liver, and concerning which 
 the question arose whether it was not a swelling formed by a hydatid, 
 since there was no history of injury, and the swelling had remained 
 stationary for many weeks. 
 
 I once observed a swelling which had formed beneath the rectus ab- 
 dominis on the left side, and had not altered at all for many months; 
 concerning the nature of which most conflicting opinions had been 
 hazarded. I expressed my belief that it was a chronic abscess, and 
 heard some long time afterwards that I had been right. It is, how- 
 ever, in one or other iliac region, or on the right side of the abdomen 
 in the neighborhood of the caecum, that these collections of matter are 
 most frequent, and at the same time that their diagnosis is the least 
 difficult, for they will generally be found to have succeeded to some 
 inflammatory symptoms not in general either acute or formidable, but 
 referred to the abdomen, and accompanied with constipation, painful 
 defecation, and other evidences of peritoneal or of intestinal mischief. 
 
 ]S"ow and then, if the nature of such abscess has been altogether mis- 
 apprehended until the matter has approached near the surface, I have 
 known the abdominal swelling covered by the tense and shining skin, 
 through which large veins were seen meandering, raise the suspicion 
 that the case was one of some malignant tumor. 
 
 I do not think, however, that with due care there is much difficulty 
 in the diagnosis of these cases. Something, indeed, of the probability 
 of your coming to a correct conclusion depends, as on so many other 
 occasions, on the habit of your own minds. If you are restless hunters 
 after curiosities, or vain and self-conscious, anxious in every case at all 
 obscure to signalize yourselves by the display of your wonderful in- 
 genuity, you will be very likely to make mistakes. Let me advise 
 you, if you would escape from error, always to credit the practitioner 
 in whose care the patient has previously been, and with whom you 
 may be called to consult, with the possession of common sense and 
 common powers of observation. Do not listen to his statements as if 
 you were the opposing counsel, and as if it were your business to find 
 every argument that can be adduced against his opinion. Remember, 
 
598 INFANTILE SYPHILIS. 
 
 too, that as a mere question of chances, the more frequent the disease, 
 the more likely is it that on any occasion you will meet with it ; that 
 you are bound therefore first to disprove the common, before you are 
 justified in looking out for the rare. Forgive my saying this. I am 
 but using one of the privileges of age. Every day I am struck, more 
 and more, with the degree to which simplicity of mind helps in arriv- 
 ing at a correct diagnosis, as well as in leading to the adoption of right 
 treatment, and I have, therefore, ventured to warn you against a fault 
 which is especially that of the young, the ingenious, and the accom- 
 plished. 
 
 But to return. These abscesses are characterized by the smoothness 
 of their surface and the regularity of their contour ; by their situation 
 rarely tallying exactly with that which would be occupied by any in- 
 ternal growth ; by the deficient mobility of the abdominal integuments 
 over them, and by their margin not being anywhere as defined as in 
 some part at least of its outline the edge of an internal tumor would be 
 sure to be. The absence of the general constitutional symptoms and 
 of the cachexia which attend upon internal tumors, would further help 
 you, while though if matter were formed in large quantity the general 
 health might be much impaired, still you ought not to allow yourselves 
 to be misled by a mere superficial resemblance to some malignant dis- 
 ease, against which in such conditions the obvious fluctuation in the 
 swelling would guard you. Lastly, in doubtful cases, when, as often 
 happens if the abscess is small and somewhat deepseated, there is no 
 distinct evidence of fluid, and merely a certain vague sense of elastic- 
 ity, the aspirator will enable you with perfect safety to apply a crucial 
 test, and to settle all doubt by the very means which serve at the same 
 time in many instances to get rid of the disease. 
 
 LECTURE XLI. 
 
 The Cachexia of Early Life. — Syphilis, Scrofula, and Kickets. 
 
 Infantile Syphilis. — Its symptoms — Character of the syphilitic cachexia — Morbid 
 appearances supposed to he due to it — Tendency of the symptoms to return after 
 apparent cure — Treatment. 
 
 Scrofula. — Not identical with tuberculosis — Its characteristics — notice of a few of 
 its symptoms — Scrofulous abscesses — Swelling of glands, otorrhoea, and oza3na — 
 Leucorrbceal discharges. 
 
 Rickets. — Due almost entirely to injurious hygienic influences — Alleged occasional 
 occurrence as a congenital condition — Its general characteristics seen in the 
 skeleton — age at which it commences — General symptoms — Influence on the 
 skull, chest, and skeleton generally — Mode of production of deformities inves- 
 tigated — Diseases complicating rickets — Albuminoid disease of different organs 
 — -Spasm of glottis — Hydrocephalus — Bronchitis — Principles of treatment of 
 rickets. 
 
 We pass next by no inapt transition from the study of a set of affec- 
 tions connected for the most part, more or less, with some radical defect 
 
ITS SYMPTOMS. 599 
 
 in the circulating fluid, to the consideration of what may be regarded 
 as the special cachectic diseases of early life. 
 
 These are three in number : Syphilis, Scrofula, and Rickets ; and 
 each of these would well justify a far longer notice than we have leisure 
 to bestow. 
 
 Syphilis, as it occurs in the infant, presents many important differ- 
 ences from the characters which it assumes in the adult ; nor is there in 
 this anything to excite our surprise, if we bear in mind the very differ- 
 ent circumstances in which in the two cases the poison affects the organ- 
 ism. In the adult, the symptoms are almost always the result of the 
 direct inoculation of the system with the venereal virus. In the child, 
 infection by that mode seldom occurs ; and the communication of the 
 disease from the mother to the child during its birth, which was once 
 supposed to be the ordinary mode of origin of infantile syphilis, is now 
 justly regarded as of great rarity. The infection of a child by sucking 
 the milk of a syphilitic nurse is, to say the least, a very unusual occur- 
 rence ; and the weight of evidence is decidedly against it ever taking 
 place. Cases, indeed, are by no means rare, in which the nipple of a 
 previously healthy nurse having been excoriated by the mouth of a 
 syphilitic nursling, the disease is communicated to her own child, who 
 shares the breast with its foster-brother ; but between this accident and 
 the direct transmission of syphilis by the milk, there is obviously no 
 analogy. In by far the greater number of cases, the infant has, with- 
 out doubt, contracted the disease in the womb, although its indications 
 comparatively seldom show themselves until at least fourteen days after 
 birth. In many of these cases the mother has, during her pregnancy, 
 been the subject of primary syphilis, or if not, has presented well-marked 
 secondary symptoms; and under either of these conditions we can under- 
 stand that her infected blood may deteriorate that of her infant, and 
 give rise to consequences more or less analogous to those from which 
 she has recently suffered herself. Cases, however, are now and then 
 met with, in which the venereal taint appears to have been derived en- 
 tirely 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. 1 
 
 Through whatever medium the infant becomes infected with syphilis, 
 symptoms of the same kind appear, though there is no invariable order 
 in which they show themselves ; and coryza is its earliest indication in 
 one case, a cutaneous eruption in a second, ulceration about the corners 
 of the mouth in a third. When we consider the frequency with which 
 abortion or premature labor appears to be due to the influence of the 
 syphilitic poison, it might naturally be expected that cases would be 
 by no means unusual in which infants at the moment of their birth 
 have presented evidences of the venereal taint. This, however, is very 
 seldom the case — so seldom, indeed, that I do not remember to have 
 met with an instance of it, and M. Trousseau, of Paris, 2 whose appoint- 
 
 1 Ample evidence of this is collected by M. Diday, at p. 22 of his Traite de la 
 Syphilis des Enfans Nouveau-Nes, 8vo., Paris, 1854. 
 
 2 See Trousseau's valuable memoir on " Infantile Syphilis," in the Archives Gen. 
 
600 SYMPTOMS OF INFANTILE SYPHILIS. 
 
 ment at the Hopital JSTecker in that city gave him most ample oppor- 
 tunities for observing the diseases of early infancy, bears testimony 
 to its extreme rarity. Children, although infected with syphilis, and 
 in whom the signs of the disease speedily show themselves, are yet 
 generally well nourished, and apparently in good health, at the time of 
 birth. This, too, is observed to be the case even when the mother has 
 suffered severely from secondary symptoms, has already aborted fre- 
 quently, or has given birth prematurely to dead children whose cuticle 
 was peeling off — a condition generally regarded, though far from being 
 satisfactorily proved, to be an effect of the venereal poison. When she 
 at length produces a living child, there is nothing for the first two or 
 three weeks after its birth to distinguish it from the offspring of the 
 most healthy parents. After the lapse of that time the first symptom 
 of disease shows itself; and most commonly this is nothing more than 
 the occurrence of a degree of snuffling with the child's breathing, and 
 slight difficulty in sucking — the signs in short of ordinary coryza. 1 
 Now- and then, as I have already stated, 2 no other indication of syphilis 
 appears ; but nevertheless 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 young infants are some- 
 times produced by that cause. In the majority of instances, however, 
 the coryza does not continue long without characteristic signs of dis- 
 ease appearing about the nostrils themselves, and without syphilitic 
 eruptions breaking out upon the surface of the body. The mucous 
 membrane of the nostrils secretes a yellow ichorous matter, sometimes 
 slightly streaked with blood, which, drying, obstructs the opening of 
 the nostrils, and renders breathing and sucking very distressing to the 
 child. The voice, too, before long becomes affected and assumes a 
 peculiar hoarse tone, which. has been not inaptly compared to the sound 
 of a child's penny trumpet, and which, when you once have heard, you 
 will at once recognize as almost pathognomonic of syphilis. This change 
 of voice depends no doubt on the affection of the throat, which you will 
 often see, in common with the interior of the mouth, to be red and 
 shining, and to present many superficial ulcerations. The skin of the 
 upper lip, over which the discharge from the nostrils runs, often becomes 
 excoriated, or if not, it assumes a peculiar yellowish-brown color, like 
 the hue of a faded leaf. Should the disease be unchecked, large patches 
 of the skin upon the face and forehead put on this appearance, which 
 
 de Medecinefor October, 1847; and his lecture on the subject at p. 291 of vol. iii, of 
 his Clinique de l'Hotel Dieu, 2d ed., Paris, 1865. Two important contributions to 
 our knowledge of this subject must further be noticed : first, M. Kogers's papers in 
 the Union Medicale, Jan. 1865, No. 10-17, and J. f. Kinderkr., vol. xliv, p. 392; 
 and Mr. Hutchinson's researches on vaccino- syphilis in Medico-Chirurgical Trans- 
 actions, vol. liv, p. 317, and Proceedings of Medico-Chirurgical Society, vol. vii, 
 No. 3, of which more hereafter. 
 
 1 Diday has collected the particulars of 158 cases, in which the date of the appear- 
 ance of the first symptom of syphilis was accurately noted. It showed itself in 86 
 within the first month, and in 110 within six weeks, while there were but twelve 
 instances in which it was deferred beyond the third month. Op. cit., p. 164. 
 
 2 In Lecture XIX, p. 261. 
 
CHARACTERS OF THE SYPHILITIC CACHEXIA. 601 
 
 seems due to a kind of staining of the part, and is unaccompanied with 
 any alteration of its texture. Both lips before long become affected ; a 
 number of minute perpendicular fissures take place in them, which 
 bleed whenever the infant sucks; and small ulcerations appear at either 
 angle of the mouth. It generally happens, however, before these effects 
 of the disease have become very obvious about the mouth, that the skin 
 in various parts presents appearances equally characteristic. Though 
 not limited to any situation, the eruption of syphilis usually makes its 
 appearance about the buttocks and nates, in the form of small circular 
 spots of a coppery red color, having a slightly shining surface and dis- 
 posed to become somewhat rough at their centre from the desquamation 
 of the epidermis in that situation. The spots in the neighborhood of 
 the anus often degenerate into small, soft, spongy ulcerations, with a 
 slightly elevated base ; the margins of the anus become fissured ; and 
 the skin about the scrotum and along the inside of the thighs grows 
 red, sore, cracked, shining, and denuded of its epidermis. The eyes 
 become weak, the margins of the eyelids sore, and a scanty, adhesive, 
 puriform secretion is poured out from the Meibomian glands, attended 
 with but little redness of the conjunctiva. Sometimes, too, the hair of 
 the head drops off, as small, red, sometimes slightly elevated spots, ex- 
 tend over the scalp. 
 
 The child is generally by this time reduced to the last stage of weak- 
 ness and attenuation ; but even when the disease proves fatal, it does 
 not, as in the adult, affect the bones. I have chanced, indeed, to see 
 one instance of destruction of the bony palate from this cause in an 
 infant of a few months old ; but so rare is the occurrence, that the late 
 Mr. Colles, of Dublin, 1 notwithstanding his immense experience, states 
 that he had never observed it. Should life be prolonged after the 
 disease has reached an advanced stage, its further manifestations con- 
 sist in the formation of small pustules about the mouth, especially 
 upon the lower lip and chin, which destroy the cutis, and leave the 
 surface after they have healed much scarred by their cicatrices. The 
 epidermis, too, in some bad cases peels off the hands and feet ; it gener- 
 ally becomes thickened to a kind of crust, like that w T hich forms on 
 the hands in psoriasis palmaria, and then cracking, falls off in patches, 
 leaving the skin fissured, and sometimes deeply ulcerated at the bend 
 of the wrist, or at the flexures 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. 
 
 Although such are the effects that may flow from infantile syphilis 
 when it runs its course unchecked, it yet happens but rarely that we 
 ^meet in any case with all the symptoms that have just been described. 
 Most serious constitutional disturbance is associated with the local mis- 
 chief, and the child often falls a victim to the former, when the out- 
 
 1 Practical Observations on the Venereal Disease, 8vo., p. 271. London, 1837. 
 
602 KESULTS OP INFANTILE SYPHILIS. 
 
 ward signs of syphilitic disease are yet comparatively slight. It wastes 
 rapidly, it suffers from sickness, or its bowels become much purged ; it 
 is constantly fretful and uneasy ; the advance of ossification is arrested ; 
 the head feels soft, and the anterior fontanelle is large; conditions 
 which sometimes lead to the suspicion that chronic hydrocephalus has 
 come on, though, if the poison of syphilis should be eradicated from 
 the system, the completeness of the patient's recovery shows that no 
 serious cerebral disease had existed. In children affected by this syph- 
 ilitic cachexia, not only are the loss of flesh, and that withered aspect 
 which gives to infancy the appearance of old age, very remarkable, but 
 also the bloodless state of the conjunctiva, and the yellow, waxen hue 
 of the skin, like that of a person who has been reduced to the most 
 extreme degree of anaemia. Even in children who have survived their 
 earliest infancy, and in whom the disease though not completely eradi- 
 cated has yet been kept in check, this color of the skin continues, and 
 seems indeed to be an almost pathognomonic sign of the affection from 
 which they are suffering. 
 
 When imperfectly cured, other indications of the disease remain 
 besides the impairment of the general health, the loss of flesh, and the 
 peculiar color of the skin ; or at least, if not constantly present, they 
 show themselves from time to time, reappearing at uncertain intervals, 
 without there being any fresh cause for their manifestation. Such 
 symptoms are the return of the small copper-colored spots, which, 
 however, seldom reappear in considerable numbers ; the general loss of 
 hair ; the existence of a slight degree of coryza ; the appearance of one 
 or two soft tubercular elevations, with ulcerated summits, about the 
 organs of generation, or the outbreak of a very severe and unmanage- 
 able intertrigo. In other instances, there are few local signs of the 
 disease beyond the occurrence of small ulcerations at each angle of the 
 mouth, or the development of large soft condylomata at the verge of 
 the anus, or in a few instances the formation of exceedingly trouble- 
 some ulcerations, having a slightly elevated base, between the fingers 
 and toes, which last appearances seem to belong to the tertiary rather 
 than to the secondary consequences of syphilitic disease. 
 
 The duration of the disease, and the mode in which it proves fatal, 
 vary in different cases ; for while death sometimes takes place speedily 
 under the first outbreak of its symptoms, life is in other instances pro- 
 longed for several months. In cases of this kind the more marked 
 signs of the disease recede for a time, either spontaneously or under 
 medical treatment, but the evidences of the syphilitic cachexia con- 
 tinue ; the child never regains its health, glandular enlargement takes 
 place, and it either dies phthisical, or else drags out a miserable exist- 
 ence until some intercurrent disease, as pneumonia or diarrhoea, super- 
 venes and destroys it. 
 
 Within the last few years anatomical research has discovered cer- 
 tain organic affections of the viscera connected with the syphilitic ca-. 
 chexia, to which the fatal termination of the disease is, at any rate in 
 some measure, to be attributed. Suppuration of the thymus gland, 
 the formation of small indurated nodules throughout the lungs passing 
 rapidly into a state of suppuration, and the occurrence of that albu- 
 minoid degeneration and enlargement of the liver of which I spoke at 
 
TREATMENT OF INFANTILE SYPHILIS. 603 
 
 the commencement of this lecture, are the more important changes 
 with which the researches of MM. Dubois/ Depaul, 2 and Gubler 3 have 
 made us acquainted. With reference to the alterations in the lungs, 
 their relation to genuine lobular pneumonia seems to be uncertain, 
 and it also appears to be somewhat doubtful whether their connection 
 with infantile syphilis is anything more than the result of mere acci- 
 dental complication ; but the evidence of the dependence ftf the affec- 
 tion of the thymus and of the liver on the syphilitic poison must be 
 regarded as conclusive. 
 
 Though the consequences of infantile syphilis are so serious, if it is 
 either let alone or inefficiently treated, a fatal result seldom takes place 
 if remedies are employed before the syphilitic cachexia has become 
 fully established, and if treatment, when once begun, is perseveringly 
 continued for some time after the complete disappearance of every symp- 
 tom. This, indeed, sometimes implies the continuance of treatment for 
 two or even three months ; for so long as any symptom remains, be it 
 only a slight spot of eruption, or a small condyloma about the anus, the 
 suspension of remedies will be certainly followed by the reappearance 
 of the whole train of symptoms. Even after the apparent cure of the 
 affection, it is not wise hastily to omit all medicines, since, just as in 
 the adult, the symptoms have a great tendency to recur. 
 
 Mercury in some form or other appears to be indispensable to the 
 cure of this affection. It has been recommended by some writers not to 
 administer it directly to the child, but to content ourselves with bringing 
 the mother's system gently under the mercurial influence, and to cure 
 the infant through her medium. In some slight cases this may suffice, 
 and in almost all, the cure of the infant is materially expedited by the 
 administration of the remedy to its mother; but I think that, as a gen- 
 eral rule, it is expedient to give mercury likewise to the child. For 
 internal administration I prefer the Hydrargyrum cum Creta to any 
 other form of the remedy, and give it in doses of a grain twice a day to 
 a child of six weeks old, combining it with two or three grains of chalk 
 if the bowels are disturbed at the time of commencing the treatment, or 
 if they become so during its continuance. I have never found it seri- 
 ously disagree, though sometimes it causes sickness, in which case small 
 doses of calomel, or of the solution of corrosive sublimate, may be sub- 
 stituted for it. In some cases, whatever be the form of mercurial em- 
 ployed, its protracted use occasions such great irritability of the stomach, 
 that we are compelled to discontinue the remedy. Usually, the child 
 becomes able to take it again, after a pause of two or three days ; but 
 if this should not be the case, we must leave it off, and content ourselves 
 with ordering a scruple of mercurial ointment to be rubbed into the 
 thighs or the axillae twice a day; or with letting the child wear the 
 mercurial belt. This simple contrivance, which consists in nothing 
 else than swathing a piece of flannel, the inner surface of which is 
 smeared daily with the Unguentum Hydrargyri, around the abdomen of 
 
 1 Gaz. Med. de Paris, 1850, p. 392. 
 
 2 Ibid., 1851, p. 288. 
 
 3 Memoires de la Societe de Bioloe;ie, 1853, p. 25. See also, with reference to 
 these subjects, the recent work of M. Diday, already referred to. 
 
604 TREATMENT OF INFANTILE SYPHILIS. 
 
 the infant, is spoken of by those who have employed it most as being 
 an exceedingly efficacious method of bringing the system under the in- 
 fluence of mercury, and as free from all the risks of disordering the 
 child's health which attend upon the internal administration of that 
 remedy. In hospital practice I confess that I have scarcely tried its 
 merits ; for I found that while I could give powders without suspicion, 
 the mercurial ointment was known ; and inconvenience arose from the 
 remedy betraying the nature of the disease. This objection might 
 probably have been got rid of by coloring the ointment with cinnabar; 
 but my experience of the gray powder was on the whole so satisfactory, 
 that I felt the less anxious to try a new plan of treatment. 
 
 As a local application to the sores, the black wash usually agrees 
 better than anything else ; but the large soft condylomata, which form 
 about the anus, often require to be touched with the solid nitrate of 
 silver. It very often happens that as the syphilitic symptoms disap- 
 pear, the health of the child becomes perfectly restored under the use 
 of no other remedy than mercury. If this is not the case, however, 
 some tonic medicine or other must be given. If the bowels are disor- 
 dered, the liquor cinchona?, or the extract of sarsaparilla, will be found 
 very useful. If there is no gastric or intestinal irritation, minute doses 
 of iodide of potassium may be given in combination with the extract of 
 sarsaparilla ; but if the syphilitic cachexia is well marked, and the child 
 has suffered long from the disease, or has had frequent returns of its 
 symptoms, no remedy has appeared to be so serviceable as the iodide 
 of iron, which may be given in the form of syrup, and is in most cases 
 taken by the child very readily, while it is seldom found to disagree. 
 
 Concerning Scrofula I have but little to say, for its more important 
 manifestations are of a kind which custom and convenience have as- 
 signed to the care of the surgeon rather than to that of the physician. 
 Closely allied in its essential nature to tuberculosis ; like it, hereditary, 
 like it induced by scanty food, defective ventilation, and an unhealthy 
 dwelling, and proving fatal in many cases by becoming associated with 
 phthisis, or with tubercular meningitis, there yet are differences be- 
 tween tuberculosis and scrofula at least as marked as those which sepa- 
 rate diphtheria from scarlatina, and the tendency of pathological re- 
 search appears to be to render these differences more and more obvious. 
 Scrofula is much more limited than tuberculosis to early life; it affects 
 the bony structures, the skin and the mucous membranes continuous 
 with it, and the absorbent glands, in preference to the lungs, the brain, 
 or the serous membranes. Fatty degeneration of the liver accompanies 
 tuberculosis ; the albuminoid or amyloid affection of that organ is a not 
 infrequent attendant on scrofula. 
 
 Scrofula and tuberculosis do not mutually pass into each other. It 
 is true that the manifestations of the latter often supervene in the course 
 of the former, but the converse of this does not hold good, and we do 
 not usually find children suffering from tuberculosis in whom the signs 
 of scrofula become superadded, while not infrequently whole families 
 display one or the other diathesis in its most aggravated forms perfectly 
 uncomplicated. 
 
 Having thus expressed my opinion with reference to the relation 
 
scrofula: its different MANIFESTATIONS — ABSCESSES. 605 
 
 which subsists between scrofula and tuberculosis, it remains for me to 
 say a few words concerning some of those most frequent manifestations 
 of the scrofulous cachexia with which I have become practically ac- 
 quainted. 
 
 Apart from the impetiginous and eczematous eruptions on the face 
 and scalp which not infrequently make their appearance in strumous 
 children even before dentition has commenced, one of the earliest signs 
 of the scrofulous habit consists in the occurrence of small abscesses in 
 the subcutaneous cellular tissue. These abscesses form usually on the 
 extremities, though not in general in the neighborhood of the joints. 
 They are extremely indolent in their character — at first they are felt 
 beneath the skin as small round indurations of the size of a bean or of 
 a small marble, and slightly movable. They are not at all tender to 
 the touch; they increase in size very slowly; sometimes indeed they 
 disappear spontaneously, but in the majority of instances they approach 
 by slow degrees to the surface, and then project above it. After they 
 have done so, however, the skin sometimes continues unchanged for a 
 week or two ; and even after it has become red, and the abscesses have 
 seemed about to burst, they may still remain so for many days, before 
 a small opening forms through which their contents escape. They then 
 collapse, and finally disappear ; a slight depression of the skin, and a 
 degree of lividity of the surface, marking for a considerable time the 
 situation which they had occupied. Occasionally such collections of 
 matter form under the scalp, and this even independently of any pre- 
 vious cutaneous affection ; but their usual seat is that which I have 
 indicated. Sometimes they may be observed near the elbow-joint, and 
 then they raise the apprehension, which is often groundless, of their 
 being related to some grave mischief going on in the immediate vicinity 
 of the joint. Their import is much more serious when they occupy a 
 seat about the palm of the hand, or on one of the phalanges of the 
 fingers, since in those situations they are almost always associated with 
 thickening of the periosteum, and their tendency unquestionably is in 
 the majority of cases ultimately to involve the bone itself. 
 
 I believe that in whatever situation these abscesses are met with, they 
 ought to be let alone, and all treatment should be essentially constitu- 
 tional. When they form in the hand, or on the phalanges of the fingers, 
 the affected parts should be kept as quiet as possible by means of a splint 
 of gutta-percha ; but while mere periosteal thickening sometimes dis- 
 appears more quickly if the surface is painted from time to time with 
 tincture of iodine, I have not found any benefit from its application in 
 the vicinity of the abscesses, wherever they may have been seated. 
 
 Swelling of the superficial absorbent glands, especially of those situ- 
 ated near the angle of the jaw and down the side of the neck, is another 
 very characteristic sign of the scrofulous habit. The irritation attendant 
 on the latter stages of the first dentition often seems to give the first 
 occasion to some slight enlargement of these glands, though it is not in 
 general before the fifth or sixth year, often not till a considerably later 
 period, that the increase becomes so remarkable as to attract notice. 
 In consequence, however, of some accidental exposure to cold, after an 
 attack of measles, or of some debilitating disorder, or sometimes alto- 
 
606 SCROFULOUS SWELLING OF GLANDS. 
 
 getlier independently of any obvious exeiting cause, one or other of 
 these glands will somewhat rapidly increase in size. It may so con- 
 tinue enlarged but not otherwise altered, but usually it becomes pain- 
 ful, tender to the touch, adherent to the skin which before moved freely 
 over it ; and then, inflammation going on both in it and the adjacent 
 cellular tissue, an abscess forms which eventually discharges its contents 
 by an irregular opening, that leaves on healing a depressed and puck- 
 ered scar. The inflammation is often slowly propagated to adjacent 
 glands, and several abscesses may then form in succession, each of 
 which leaves a similar scar and thus increases the deformity. Xor is 
 this all : but the abscesses often continue to discharge for some time, 
 and sinuses not infrequently lead from one to another ; while the un- 
 healthy state of the edges of the wound interferes with its healing, and 
 thus increases the size of the scar, and tends to produce those uneven 
 cicatrices which seam the neck of many scrofulous patients. 
 
 There are besides some instances of much rarer occurrence in which 
 the glands increase to the size of a hen's egg or even to larger dimen- 
 sions, but show no disposition to suppurate, although they may affect 
 both sides of the neck and produce a deformity similar to that which 
 is occasioned by goitre. The glands, I believe, in these cases have 
 undergone the albuminoid or amyloid transformation, rather than that 
 infiltration with scrofulous or tuberculous material which is their most 
 common change. 
 
 I have no faith, in cases of scrofulous enlargement of the cervical 
 glands, in the influence of applications of iodine or of any other 
 supposed discutient as a means of producing their absorption. In 
 some cases indeed I admit that, in combination with tonic remedies, 
 and a protracted stay at the seaside, these local means have appeared 
 to conduce, perhaps have really contributed, to this end; but on the 
 other hand I have seen not a few instances in which inflammation has 
 appeared to be excited by them, and in which the occurrence of sup- 
 puration has seemed to me entirely due to local applications intended 
 to promote the absorption of the swellings. I confine myself therefore 
 to the mere application of dry cotton-wool covered with oiled silk, 
 which I direct to be worn constantly even for months together, so as 
 to preserve the uniformity of temperature around the part. If, in spite 
 of this precaution, and of all means calculated to promote the general 
 health, suppuration should take place, the abscess must not be allowed 
 to burst spontaneously, but when thinning of the skin has already 
 begun to be apparent, a very small puncture must be made by a 
 narrow-bladed lancet, and the opening allowed to close as speedily as 
 possible ; no other application being made than simple water-dressing 
 for the first few hours, and afterwards a piece of dry lint covered with 
 oiled silk. 
 
 Obstinate otorrhcea is another of the most troublesome manifestations 
 of the strumous constitution ; but at the same time I believe that, when 
 independent of disease of the internal ear, its persistence is to a great 
 extent due to w^ant of perseverance in the employment of very simple 
 means. The daily syringing of the ear w r ith tepid water, or with a 
 solution of sulphate of zinc, in the proportion of one grain to an ounce 
 
SCROFULOUS OZ.ENA — LEUCORRHC3A. 607 
 
 of water, and the employment of mild counter-irritation by painting 
 the tincture of iodine behind the ear, almost invariably arrests the 
 discharge. It is apt indeed to return again and again, but the same 
 means almost always relieve it, and if resorted to immediately on each 
 occasion of its reappearance, the discharge finally ceases as the general 
 health becomes more robust. Now and then indeed chronic discharges 
 from the ears assume a graver character, and may even, as I have 
 alreadv said, 1 become the point of departure, whence disease of the 
 bones and eventually of the brain itself may originate. 
 
 Strumous ozsena is another peculiarly distressing ailment, and all 
 the more so perhaps because it occurs with greater frequency in girls 
 than in boys, and sometimes befalls those whose appearance of health 
 and good looks may render them otherwise objects of general attraction. 
 Though often associated with a rather abundant thin seropurulent 
 defluxion from the nostrils, this is by no means of constant occurrence. 
 Xeither, I may add, does it, as a rule, depend on disease of the tur- 
 binated bones, though unquestionably that is present in some instances. 
 Either with or without discharge from the nares the offensive odor 
 will sometimes continue even for years together, rendering the patient's 
 bedroom almost intolerable after the night has been passed there, and 
 any near approach to the person, even by day, extremely repulsive. 
 
 Much may be done, however, by the employment of a weak solution 
 of the permanganate of potass in the proportion of a drachm of Condy's 
 fluid to a pint of water, some of which should be sniffed up the nostrils 
 two or three times a day, to diminish the offensive odor. When this 
 ceases to produce any effect, the chloride of soda or chloride of zinc, in 
 very weak solutions, may be substituted for it with advantage, while 
 the internal use of the chlorate of potass in rather large doses, as a 
 drachin in the course of the day for a child ten years old, has seemed 
 in some cases to have something of an almost specific influence over 
 the condition. I need not say that during the whole time, fresh air, 
 sea-breezes, good food, and tonics have the same kind of influence as 
 they exert in the whole class of strumous affections. 2 
 
 The only other scrofulous ailment which I would wish to bring 
 before your notice is the occurrence of purulent or mucopurulent dis- 
 charges from the vagina or vulva in young girls. Such discharges 
 were once erroneously supposed to be due to some impure cause ; an 
 opinion which, though now justly abandoned by the profession, still 
 retains its hold among the vulgar. They take place occasionally in 
 female children of all ages, from the time when dentition commences 
 down to the period of puberty, but are most frequent between the ages 
 of two and seven years. They are almost always essentially chronic 
 in their character, being associated in general with very little swelling 
 of the sexual organs, and with little or no pain ; but proving extremely 
 annoying from their disposition to continue for a long time, from their 
 obstinate resistance to remedies, and their great tendency to recur 
 
 1 See Lecture VIII, p. 104. 
 
 2 There is scarcely a subject noticed in these lectures which does not suggest a 
 reference to the name of M. Trousseau. See his remarks on Ozsena at p. 509 of 
 vol. i of the 2d edition of his Clinique, &c. 
 
608 SCROFULOUS LEUC0RRH03A. 
 
 under very slight exciting causes. Even when the discharge is very 
 profuse, there is no great redness of the parts from which it is poured 
 out ; while it will be seen to be furnished almost entirely by the inner 
 surface of the labia, by the nymphse and the vulva generally, but to 
 come scarcely at all from the canal of the vagina. The slight degree 
 of swelling of the parts ; the source of the discharge almost exclusively 
 from the parts anterior to the hymen ; and the absence of dysuria, or 
 the very slight degree in which it has attended the onset of the affec- 
 tion, coupled with the integrity of the hymen, and the absence of all 
 appearances of injury, are sufficient to distinguish this affection from 
 gonorrhoea. Sometimes, indeed, when this discharge has come on 
 during teething, it has been preceded by considerable dysuria ; but 
 older children rarely suffer more than a degree of itching and smarting 
 of the parts, which is troublesome from its persistence rather than from 
 its severity. When it occurs during dentition, the discharge is not in 
 general abundant, and ceases so soon as the tooth has cut through the 
 gum, though probably returning with a renewal of the irritation. 
 Sometimes it occurs in children who are much troubled by ascarides, 
 when it is kept up in many instances not merely by the irritation 
 excited by their presence in the rectum, but in a measure also by their 
 creeping about the vulva. In some instances it takes place as a sequela 
 of the eruptive fevers, especially of scarlatina ; and though I have 
 never met with it in these circumstances, except as a, chronic ailment, 
 accompanied by great general debility, cases have been related 1 in 
 which it came on with acute symptoms on the decline of the eruption. 
 Generally, however, it neither succeeds to any previous fever, nor is 
 dependent on any local cause, but occurs in strumous children in con- 
 nection with general impairment of health, or following some consid- 
 erable fatigue. Where no special cause can be assigned for its occur- 
 rence, its appearance is yet, in general, preceded for a day or two by 
 some slight increase of indisposition ; such as an attack of feverish- 
 ness, or catarrh, or diarrhoea. 
 
 Be the cause what it may, our great difficulty in almost every in- 
 stance is to effect a permanent cure, so that the suspension of remedies 
 may not be followed by a return of the discharge. When it is con- 
 nected with teething, or with the presence of worms, the indications 
 are plain enough, and cure is in general comparatively easy. Simple 
 but abundant ablution with tepid water, repeated every hour or two on 
 the first appearance of the discharge, will, in conjunction with appro- 
 priate general treatment, not infrequently suffice for its complete arrest. 
 If the discharge, however, continues for more than one or two days, 
 astringents must be had recourse to, such as the Liquor Plurabi Dilutus, 
 or lotions of sulphate of zinc, or of alum, each of which may be em- 
 ployed for a few days, and then changed for another. At the same 
 time frequent cold sponging of the nates and vulva should be employed; 
 and it must be impressed on the child's attendants that no lotion what- 
 ever can supply the place of frequent ablution. Now and then, when 
 at the onset of the discharge there has been more dysuria than com- 
 
 1 By Dr. Cormack, in the London Journal of Medicine, Sept. 1850. 
 
ITS GENERAL CHARACTERS. 609 
 
 mon, I have given small doses of copaiba and liquor potassse ; and 
 have obtained from their administration just the same kind of relief as 
 those remedies afford in acute vaginitis in the adult. Such cases, how- 
 ever, are quite exceptional ; and usually tonics and especially prepara- 
 tions of iron are the only internal remedies which are required, while 
 it is in general necessary to begin their administration early. These 
 medicines, especially if associated with change to the seaside, and sea- 
 bathing, usually suffice, even in the most obstinate cases, to effect a 
 cure. It is however in general a wise precaution to continue the em- 
 ployment of frequent ablution, and in addition to sponge the parte 
 twice a day with alum lotion, even for weeks after the discharge has 
 completely ceased; while once I found the employment of a lotion of a 
 scruple of nitrate of silver to an ounce of water necessary to arrest a 
 discharge which had bid defiance to all other remedies. 
 
 Between the various manifestations of scrofula and rickets there seems 
 to be no other relation than that which subsists between two conditions, 
 each of which is dependent in great measure on unfavorable hygienic 
 conditions. Between those conditions too which beget scrofula and 
 those which promote the occurrence of rickets there are many differ- 
 ences ; insufficient food appears to be the great occasion of the former, 
 insufficient air of the latter ; while the absence in the case of rickets 
 of any marked tendency to the perpetuation of the disease from pa- 
 rent to child forms a distinct peculiarity which separates it 1 from 
 syphilis, tubercle, and, though possibly in a less marked degree, also 
 from scrofula. 
 
 Rickets, though known on the Continent, and especially in Germany, 
 by the name of the English Disease, is by no means limited to this 
 country, but is, I believe, quite as prevalent in many parts of Germany 1 
 as in England, though by no means so frequent in its occurrence nor 
 met with commonly in such serious forms, in France. The rooms 
 overheated in winter by the close stove, the complete want of ventila- 
 tion, and the absence of attention to personal cleanliness, are conditions 
 favorable to the occurrence of rickets, which exist throughout the whole 
 of Northern and Central Germany, and to which a greater analogy is 
 found in the habits of the English than of the French poor. The com- 
 parative rarity of rickets in the purely agricultural population of Eng- 
 land furnishes a further proof of the paramount influence of bad air 
 and insufficient ventilation in the production of the disease. 
 
 At the same time, however, this disease occurs sometimes in cases 
 where no injurious influences have been previously at work, and cases 
 have even been published of the child presenting at birth all the de- 
 formities of the skeleton which are characteristic of rickets. 2 Of such 
 
 1 A recent writer on this subject, Bitter von Rittershain, estimates the number of 
 rickety children at 31 per cent, of the total number who came under his notice as 
 outpatient? at Prague, and Professor Henoch of Berlin, at p. 518 of his translation 
 of my Lectures, confirms this estimate from his own experience in that city. 
 
 2 See various references in Graetzor, Krankheiten des Fotus, 8vo.. Breslau, 1837, 
 p. 170. Of the more recent cases, one of the most remarkable is described and de- 
 lineated by Schuetze, in his dissertation Symbols ad Ossium recens natorum Morbos, 
 4to., Berolini, 1842. 
 
 39 
 
610 GENERAL SYMPTOMS OF RICKETS. 
 
 cases I can offer no explanation, though their occasional occurrence is 
 unquestionable, and I am also unable to say whether in any examina- 
 tion that was made there was any such careful investigation of the 
 state of the internal organs as would have been necessary to ascertain 
 whether, and in what degree, they presented the changes commonly found 
 in those who after birth have suffered severely from rickets. 
 
 The general characters of a rickety child retained through life by 
 those who have suffered severely from it in their early years are famil- 
 iar to us all. The stunted stature, the large head, small limbs, mis- 
 shapen chest, twisted long bones, and enlarged wrists and ankles impart 
 a physiognomy so peculiar that the effects of rickets cannot be con- 
 founded for a moment with those produced by any other disease. Ob- 
 servers looking at these changes in the skeleton have sometimes spoken 
 of rickets as though it were a disease exclusively of the bones, and 
 that the absence from them of the due amount of earthy matter were 
 its sole and essential characteristic. 
 
 But this is by no means the case. The deformity of the skeleton is 
 but one, although the most remarkable, of the effects of rickets ; and 
 there are minor degrees of the affection well worth attentive study in 
 which, though ossification may be tardy, and the development of the 
 skeleton somewhat arrested, no actual deformity is produced. 
 
 Rickets is essentially a disease of childhood, and of early childhood, 
 commonly attracting attention towards the end of the first dentition, 
 though often, I believe, beginning anterior even to the commencement 
 of that process ; while, though I have known its symptoms become more 
 and more grave up to the end of the fifth year, I have never seen it 
 begin later than the age of three. 
 
 I have never seen an infant, while efficiently suckled by a healthy 
 nurse or mother, present any of the symptoms of rickets, even though 
 the hygienic influences by which it was surrounded were in other 
 respects unfavorable. It is commonly at the period of weaning, or 
 when, with the diminution of the supply of the mother's milk, artificial 
 food is first had recourse to, that the premonitory symptoms of rickets 
 appear. The ordinary coincidence of that change in diet, with the 
 demand on the constitution made at the time of the commencement of 
 teething, often renders the advance of the disease very rapid, while the 
 efforts that a child commonly makes to stand or walk between the 
 ages of nine and fifteen months occasion that bowing of the legs which 
 more than, anything else attracts the attention of the friends. Not in- 
 frequently, however, and this especially in children who are brought 
 up wholly or in part by hand, the symptoms of rickets present them- 
 selves at a far earlier period. Dr. Stiebel of Frankfort 1 says that he 
 has observed them as early as the fourth 'or fifth week. 
 
 The infant loses, or never attains, that brightness which is character- 
 istic of the healthy babe. It is dull, dislikes being disturbed, or cries 
 peevishly at the gentlest handling, or at any change of posture, as if it 
 were sore and actually pained by touching ; but though it keeps the 
 
 1 In the article " Kachitis," in vol. i of Virchow's Specielle Pathologie und 
 Therapie. 
 
INFLUENCE OF RICKETS ON THE SKULL. 611 
 
 body as quiet as possible, it rolls the head fretfully from side to side, 
 so as to wear the hair completely off the occiput. It has irregular 
 feverish attacks, not limited to any particular time of day or night, nor 
 of anv fixed duration, attended with increased fretfulness and restless- 
 ness passing off in sleep, during which there is a great disposition to 
 sweat about the head and upper part of the trunk; and with the ad- 
 vance of the disease these sweats become more and more abundant, 
 standing in large drops upon the forehead, and running down so as 
 completely to soak the pillow. The skin at the same time loses its 
 transparency, and becomes dull and dirty-looking ; digestion is ill per- 
 formed, but the disposition is rather to constipation than to diarrhoea; 
 while, though the infant loses flesh, there is very rarely either the ex- 
 treme emaciation of the tuberculous child or the glandular enlargement 
 attendant on scrofula. 
 
 AYith these symptoms of general disturbance there will be found 
 associated the three never-failing evidences of rickety disease — retarded 
 ossification of the skull, enlargement of the wrists, and thickening of the 
 ends of the ribs, coupled with the commencement of the pigeon-breast 
 deformity of the chest. 
 
 I have already noticed the peculiarities of the rickety cranium when 
 speaking of some of the convulsive affections of early infancy, 1 and 
 have told you how we are indebted to Dr. Elsasser for calling our 
 attention to this condition, which from its most striking characteristics 
 he termed " craniotabes," and the " soft occiput/' The fontanelles and 
 sutures not only remain unossified long beyond the usual time, but 
 bone-matter already deposited is removed, so that the occipital and 
 parietal bones become yielding just like tinsel. Coupled with this 
 change in the bones themselves, there is almost always an undue de- 
 velopment of the head ; due not to the occurrence of serous effusion 
 into the ventricles, as in chronic hydrocephalus, but to the overgrowth 
 of the brain itself. The forehead becomes projecting, but this projec- 
 tion is not accompanied with that downward direction of the eyes which 
 occurs in chronic hydrocephalus, and which is due to the pressure of 
 the fluid on the roof of the orbits. The head becomes elongated, and 
 square in form, and though the occiput projects, we do not find the oc- 
 cipital bone depressed from its proper position at the hind head, quite 
 to the base of the' skull, as in cases of chronic water on the brain. The 
 undue size of the head is further exaggerated in appearance by the same 
 arrested development of the bones of the face as takes place in chronic 
 hydrocephalus, while it must not be forgotten that the two conditions 
 are not infrequently associated, and that chronic water on the brain is 
 a by no means rare complication of rickets. 2 The interrupted bone 
 formation is displayed in an equally characteristic manner in the re- 
 tarded dentition. The teeth appear late and irregularly, while the un- 
 developed jaws do not allow them adequate space, and they are crowded 
 together, some behind the others, and some growing edgewise from want 
 
 1 See Lecture XIII, p. 165. 
 
 2 See, for a contrast between the hydrocephalic and the rickety form of head, 
 plates 6 and 7 in Bey lard's essay Du Rachitis, &c, 4to., Paris, 1852. 
 
612 INFLUENCE OF KICKETS ON THE CHEST. 
 
 of space to admit of their being ranged properly. In some instances, 
 too, the bony sockets which should surround the teeth are scarcely 
 formed, so that the teeth are held in their places by the gums alone. 
 
 It is in the skull that rickets first shows itself in a large proportion 
 of cases. The earlier the age at which the disease commences, the more 
 marked will be the affection of the cranium, while in those instances 
 in which the disease does not appear till the age of fifteen or eighteen 
 months, the bones of the head often escape it altogether. 
 
 At how early an age soever rickets begins, the affection of the bones 
 of the skull is invariably associated with some enlargement of the ends 
 of the long bones. This enlargement, which is most apparent at the 
 wrists, is not, as has been suggested, a merely apparent enlargement 
 brought out by contrast with the generally attenuated limbs, but is due 
 to a real heaping up of bone-matter in excess ; in other words, as Sir 
 W. Jenner says in his valuable " Lectures on Rickets," " there is ex- 
 cessive preparation for the process of ossification, and arrest of the com- 
 pletion of the process." 
 
 It is to the same excessive preparation for bone formation that is due 
 the thickening of the end of each rib, which gives to the walls of the 
 chest that peculiar beaded appearance on either side familiarily known 
 on the Continent as the rickety rosary. This peculiar condition, too, 
 is often brought into striking prominence by being associated with an 
 extreme degree of the pigeon-breast deformity of the thorax. The sides 
 of the chest are flattened, the sternum is carried forwards, while the 
 ribs are bent inwards at an acute angle at the point where the bone 
 and cartilage unite, rendering all beyond this spot a sort of narrow 
 appendage to the chest, while its boundary is defined by the deep per- 
 pendicular groove marked out by the beading of the ribs. Below the 
 nipple the chest widens out again, owing to the resistance of the liver, 
 stomach, and spleen, which prevents its walls from collapsing as they 
 do higher up under the pressure of the external air. The yielding 
 walls of the chest, the feeble inspiratory power, and the pressure of the 
 external air contract the chest, give to it its great depth and its small 
 capacity from side to side, and produce the perpendicular groove which 
 follows the situation of the ends of the ribs. The presence of the ab- 
 dominal viscera, the stomach, liver, and spleen, prevents this narrowing 
 from extending through the whole depth of the chest; and the circular 
 constriction which divides the chest into an upper and a lower half 
 represents, as Sir W. Jenner was the first to point out, the upper surface 
 of these viscera, and not the points of insertion of the diaphragm. 
 
 Associated with this contracted chest we find a prominent abdomen. 
 Many causes contribute to produce it. First, the abdominal viscera 
 are carried below their natural situation by the contracted state of the 
 chest, and the small amount of lateral expansion of which it is suscep- 
 tible in inspiration. In the next place, some degree of enlargement 
 both of the liver and spleen from albuminoid infiltration into their 
 substance, is a frequent attendant on rickets. Thirdly, the small 
 pelvis which characterizes infancy often continues still more stunted 
 in its development, and hence presents a greater contrast than usual 
 to the size of the abdomen ; and, lastly, the general .want of muscular 
 
INFLUENCE OF RICKETS ON THE SPINE AND LEGS. G13 
 
 power affects the involuntary as well as the voluntary muscles, so that 
 the intestines are constantly more distended with air than in the healthy 
 child. 
 
 The most striking characteristic of rickets, however, is found in that 
 softening and bending of the long bones which become most marked 
 when the child has begun to walk about, and this deformity increasing 
 daily in proportion as the weight of the child increases, has led to the 
 statement, now abundantly disproved, that the disease begins at the 
 lower extremities, and thence travels upwards. 
 
 It would not be easy, and I do not know that it would answer any 
 important end, to deseribe the exact form in which each limb is pecu- 
 liarly contorted. Even while the child still lies in bed the deformities 
 are very striking. The softened clavicles become greatly curved, and 
 this gives to the upper part of the chest the appearance of a greater 
 degree of contraction than really exists, since the head of the humerus 
 is thereby thrown forwards to the front of the chest, instead of retain- 
 ing its natural position at the side. This bending, too, is not infre- 
 quently increased by actual fracture of the bones (usually the so-called 
 green-stick fracture which takes place in early childhood) ; and this 
 fracture is rendered all the more noticeable by the heaping up of bone- 
 material just at the point where it has taken place. The arm and 
 forearm become much curved, and this curving is usually most re- 
 markable in the latter, w T here the bend sometimes almost amounts to 
 a fracture. All the joints are loose, owing to the yielding of the liga- 
 ments, and this is especially observable in the joints of the wrists. 
 Muscular action has been invoked to explain the deformities of the 
 upper part of the trunk ; but I think with Sir W. Jenner, and to a 
 great degree also with Professor Trousseau, 1 that simple pressure on 
 the softened bones will explain them all. The child who cannot walk 
 endeavors to raise and support itself by its arms, which bend under 
 the weight of the body, while the same pressure communicated by the 
 head of the humerus to the clavicle produces its exaggerated curve, and 
 even occasions its fracture. It is remarkable too to how great an extent 
 this deformity of the upper limbs rectifies itself in after life, while the 
 legs, which now bear the weight of the body, not only become more 
 and more deformed, but retain this deformity permanently. 2 I need 
 not observe that, w r ere muscular action the cause of the deformity, the 
 legs indeed might grow worse, but the upper extremities would show 
 no tendency to grow better. 
 
 It is in the legs that the greatest rickety deformities present them- 
 selves. At first there is some curving outwards and forwards of the 
 thighs, owing, as Sir W. Jenner has observed, to the mere weight of 
 the legs and feet, which even as the child lies in bed is not without its 
 influence in bending the bones, though this becomes much more 
 marked so soon as the child is able to sit up in a chair or in its 
 mother's lap. From this early period, too, dates that bowing out- 
 
 1 Clinique, &c , vol. iii, p. 465. 
 
 2 In illustration, see in plate iii of Bej'lard's essay the contrast between the upper 
 and lower limbs of a man the subject of an extreme degree of rickets. 
 
614 CURATIVE CHANGES IN THE BONES. 
 
 wards of the spine in the dorsal region which sometimes excites the 
 apprehension of friends lest it should imply the existence of actual 
 disease of the bones. It takes place just at that part of the spine 
 which, when the infant is carried in its mother's arms, is left unsup- 
 ported ; it is due to no disease of the bones, but to the yielding of the 
 ligaments, and disappears at once if the child is held up by the arms, 
 or even if it is turned over on its abdomen. Later in life the spine 
 becomes deformed from other causes. It yields to the superincum- 
 bent weight of the head, and bends inwards somewhat in the cervical 
 and upper dorsal region; the weakened ligaments give way, and lateral 
 curvature takes place just as it does in many cases of mere general 
 debility of the system. The weight of the body is borne by the sa- 
 crum, but the weakened pelvic ligaments do not hold it — the keystone 
 as it were of the arch — firmly in its position. Its promontory is 
 driven downwards and forwards, contracting the pelvis, as obstetri- 
 cians know, and at the same time producing the sinking in of the loins 
 which gives to the adult who in early life has suffered from rickets 
 that peculiar gait so characteristic of the affection. 
 
 The pelvic deformity, as you know, is not limited to the altered posi- 
 tion of the sacrum, but the counter pressure of the thighs drives the 
 anterior pelvic wall much above its natural level. At the same time 
 too the pubic arch becomes widened and flattened, and the acetabula 
 assume a position in front of the pelvis instead of at its sides ; a con- 
 dition which still further increases the waddling gait of the rickety 
 patient, and compels the very upright attitude by which alone the 
 tendency to fall forwards in walking is counteracted. Extreme rickety 
 softening of the bones, and its persistence to a later period than usual, 
 sometimes obliterates these characteristics, and gives to the pelvis the 
 triangular form which is usually seen in mollities ossium. With these 
 exceptional cases, however, we have nothing to do. 
 
 With the erect posture of the child, and its gradually increasing 
 weight, there come too the striking deformities in the legs which stamp 
 on the rickety frame its most indelible marks. The curvature of the 
 thighs increases greatly, the tibiae and fibulae bend forward to an arch, 
 and the convexity of their anterior surface looks inwards instead of 
 forwards, and sometimes, in addition to the bowing at their centre, 
 there is a second deep notch in the bones, or second abrupt curve with 
 its convexity turned backwards a few inches ab.ove the malleoli, as if 
 the bones were there doubled on themselves. The ligaments are 
 weakened as at the wrist, so that the child walks in many cases almost 
 on the inner ankle, while if the relaxation is less, and the child still 
 walks on the soles of the feet, the arch of the foot is entirely destroyed, 
 and the child becomes completely flat-footed. 
 
 If to this be added the general influence of rickets in arresting growth, 
 so that the patient is dwarfed not by deformity only, but by the actual 
 shortness of the different long bones, we have, I think, a tolerably com- 
 plete summary of the different modes in which rickets manifests itself 
 in the skeleton. 
 
 With improved health many of the minor consequences of rickets 
 disappear ; much of the superfluous bone-material is absorbed, the en- 
 
CAUSES OF DEATH IN RICKETS. 615 
 
 larged wrists and ankles diminish in size, and the bones of the upper 
 extremities on which there is no permanent pressure regain much of 
 their straightness, though the dwarfed growth is never altogether made 
 up for. In cases where the disease has been severe, however, and 
 almost always to a considerable degree in the lower extremities, the 
 evidences of bygone rickets are more abiding. The bones do not 
 straighten, nor is the superfluous bone-matter which was deposited 
 along their concavity and at their ends absorbed. It undergoes a pro- 
 cess of hardening, concerning the nature of which opinion has differed, 
 some persons regarding it as identical with ordinary ossification, while 
 the majority see in it a process of calcification similar to that which 
 occurs in enchono'romata — a pathological, not a physiological occur- 
 rence. 1 The tissue thus changed presents an ivory-like density and 
 hardness, so as to become susceptible of a high polish. It is in the 
 long bones, and especially in the seat of an old fracture, or at the con- 
 cavity of the arch into which they have bent when softened, that the 
 petrifaction of the bone-matter is most remarkable ; though it is by no 
 means confined to those situations, but is observable, though in a less 
 degree, in the flat bones, and is sometimes strikingly marked in those 
 of the skull. 
 
 I have already described the evidences of general ill health and of 
 imperfect nutrition which are characteristic of rickets, and it sometimes 
 happens that the child dies with no definite disease, but apparently as 
 the result of the aggravation of all these symptoms. In such cases 
 there is usually a considerable degree of albuminoid infiltration of the 
 liver, spleen, and lymphatic glands, and the degree to which the latter 
 are sometimes distinctly enlarged gave rise to the opinion which once 
 prevailed as to the essential identity of scrofula and rickets. The con- 
 dition of the glands in the two cases is, however, entirely different ; and 
 instead of there being any real connection, there is rather a condition of 
 antagonism between tubercle and scrofula on the one hand, and rickets 
 on the other. 
 
 In the majority of instances, death is not due to the mere intensity 
 of the rickety cachexia, but to the supervention of some intercurrent 
 disease. I have already alluded to the connection between spasm of 
 the glottis and that imperfect ossification of the skull which is one of 
 the early indications of rickets ; and rickety children are not seldom 
 carried off either by distinct laryngeal spasm, or by some other form of 
 those convulsions, which, where teething is tardily and ill accomplished, 
 often attend upon it. When the disease comes on in very early infancy, 
 too, it is by no means unusual to find it associated with a slow form of 
 chronic hydrocephalus, which develops itself during the general febrile 
 disturbance of the system. The effusion of fluid in these cases is never 
 very considerable, but the head assumes the regular hydrocephalic form, 
 while the general deformity of the skeleton is often so trivial that, un- 
 less the patient's history is carefully inquired into, the relation of the 
 
 1 Professor Kolliker took the former view, while Trousseau, op. cit., vol. iii, p. 
 472, and Sir W. Jenner more authoritatively, because based on indeppndent micro- 
 scopical examination, take the latter; see Jenner's Lecture in Med. Times, March 
 17, 1860, p. 261. 
 
616 TREATMENT OF RICKETS. 
 
 hydrocephalus to rickets may be altogether overlooked. It will be 
 learned, however, that the symptoms had no acute onset, but supervened 
 very gradually, that they did not come on until the fifth or sixth month 
 at the earliest, and that the enlargement of the skull was preceded by pro- 
 fuse sweats about the head. Children in whom this condition exists 
 appear to suffer much ; their emaciation is usually very great, and their 
 digestive functions are very ill performed. For the most part they sink 
 under some attack of intercurrent diarrhoea, or are carried off at last by 
 convulsions at an early stage of the process of dentition. Bronchitis, how- 
 ever, is the great enemy of the rickety child. The malformed chest is, 
 as you know, the evidence, and the cause as well as the consequence of 
 the imperfect performance of respiration, while an emphysematous state 
 of the lungs due to the same cause is habitual in every instance of con- 
 siderable thoracic deformity. It suffices for a comparatively slight at- 
 tack of bronchitis to interfere with the entrance of air into the tubes, 
 for large portions of lung at once to become collapsed, and for death to 
 follow suddenly and unexpectedly on what in any other child would 
 have been a comparatively slight attack of catarrh or influenza. 
 
 The treatment of rickets need not detain us long, for, notwithstand- 
 ing the importance of the disease, the principles to be borne in mind 
 alike for its prevention and its cure are abundantly simple. Bad air 
 and defective ventilation are its two great causes ; and causes which 
 among the poor it is often difficult, sometimes impossible, to remove. 
 Even among the comparatively wealthy these causes of rickets are not 
 infrequently met with. The nurseries are overcrowded ; the infant is 
 laid in a deep cot, wrapped up overwarmly in blankets, and left to 
 breathe for hours the atmosphere which is inclosed within the curtains 
 or the sides of the cot; and which, moreover, is not seldom rendered 
 still more impure by a want of the most sedulous attention to cleanli- 
 ness on the part of the nurse. If to this be added the attempt to bring 
 up the child entirely, or in great measure, on artificial food, we have at 
 once the two conditions combined which are most certain to generate 
 rickets. 
 
 Remove them ; nourish the infant at the breast of a healthy nurse ; 
 place it in a large room, and in a cot which admits the air to pass 
 freely over the child ; let there be most careful attention to cleanliness ; 
 and improvement will become almost immediately apparent. If the 
 disease is advanced, combine with all these precautions country or, still 
 better, sea air, and even w T here marked deformity has already taken 
 place, amendment will be sure to follow. 
 
 As the child grows older, and other food than the mother's or nurse's 
 milk becomes necessary, let too exclusively farinaceous food be avoided. 
 Beef tea at the age of eight or nine months, and a little underdone meat 
 at fifteen or twenty months, are always desirable, w T hile milk should 
 alw T ays form an important part of the diet. 
 
 There is no specific for rickets — nothing wdiich furnishes ready to 
 hand, in a way in which it can be appropriated, the earthy matters in 
 which the bones are deficient, and the notion that phosphate of lime 
 supplied in large quantities to the child wT>uld directly promote its 
 cure is but an unphysiological fallacy. Iron and cod-liver oil are the 
 
FEVERS — EXANTHEMATA. 617 
 
 two great remedies on which, in this as well as in other cachectic dis- 
 eases, we mainly rely. Their continuous employment, however, re- 
 quires that attention be specially paid to the state of the digestive 
 organs ; but the simpler aperients, as rhubarb and magnesia, or castor 
 oil, or syrup of senna, are to be preferred to the mercurial preparations 
 which are so often employed without due occasion. 
 
 It would be needlessly to occupy your time were I to speak of the 
 management of all those complications to which, as I have already said, 
 the main danger of rickets is due. The diarrhoea, the laryngismus, and 
 the bronchitis are to be treated in accordance with the principles which 
 I have already laid down. One point, however, is always to be borne 
 in mind, that whereas rickets is a disease of debility, a cachexia, all its 
 complications must be treated with a full recognition of this fact. De- 
 pletion and antiphlogistics are out of place ; a tonic plan of treatment 
 should in all cases be adopted. N 
 
 LECTURE XLII. 
 
 Feveks. — Chiefly belong to the class of Exanthemata — Mistakes with reference to 
 simple fever in childhood — Its identity with fever in the adult. 
 
 Ikeantile Remittent Fever, identical with Typhoid Fever, which is a fitter 
 name, occurs in two degrees. — Symptoms of its milder form — Of its severer 
 form — Signs of convalescence — Modes of death — Diagnosis — Treatment 
 
 Intermittent Fever or Ague. — Peculiarities characterizing it in childhood. 
 
 We come now to the last part of this course of lectures ; namely, to 
 the study of the febrile diseases incidental to infancy and childhood. 
 They belong, for the most part, to the class of the Exanthemata — dis- 
 eases characterized, as you know, by very well-marked symptoms, by 
 a very definite course, and by usually occurring only once in a person's 
 life. These peculiarities have always obtained for them the notice of 
 practitioners of medicine, and few of the affections of early life have 
 been watched so closely, or described with so much accuracy, as small- 
 pox, measles, and scarlatina. Hence it will be unnecessary to occupy 
 so much of your time with their investigation as we have devoted to 
 the study of other diseases, which, though not so important, have yet 
 been less carefully or less completely described. 
 
 While the well-marked and unvarying features of the eruptive fevers, 
 however, have forced those diseases on the attention of all observers, 
 the more fluctuating characters of continued fever have been so masked 
 by the differences between youth and age, that the affection as it occurs 
 in early life was long almost entirely overlooked, and its nature was, 
 
618 INFANTILE REMITTENT — IDENTICAL WITH TYPHOID FEVER. 
 
 in many respects, still longer misapprehended. Many, indeed, even 
 of the older writers on medicine, have spoken of fevers as occurring 
 among children at all ages; but under this name they confounded 
 together several diseases in which febrile disturbance was merely the 
 effect of the constitution sympathizing with some local disorder. This 
 mistake was committed with especial frequency in the case of various 
 affections of the abdominal viscera ; many of which are attended by a 
 considerable degree of sympathetic fever, while their symptoms, in other 
 respects, are often so obscure that the imperfect diagnosis of former 
 days failed to discover their exact nature. As medical knowledge in- 
 creased, many of these disorders were referred to their proper place ; 
 but, nevertheless, the descriptions given of the so-called remittent fever, 
 worm fever, and hectic fever of children, present little of a definite 
 character, and are evidently the result of a blending together of the 
 symptoms of various affections. The disease described under these 
 different names Avas supposed to be a symptomatic fever, excited by 
 gastric or intestinal disorder, and limited in the period of its occurrence 
 to early life; while the absence of the well-marked shivering which 
 usually attends the onset of fever in the adult, the rarity of any efflor- 
 escence on the surface of the body, and the comparatively low rate of 
 mortality which it occasions, led persons altogether to overlook the 
 close connection between it and the continued fever of the adult. 
 
 It was not to be wondered at that the identity of continued fever at 
 different periods of life should escape observation, so long as the various 
 types of the disease in the adult, though separated by essential differ- 
 ences, were yet confounded together. The recognition of the distinctive 
 character of typhus and typhoid fevers, which we owe to Sir W. Jenner, 
 was a necessary step towards this object ; and this once taken, the an- 
 alogy between the latter affection in the adiflt, and remittent fever in 
 the child, could not Ions: remain unnoticed. To M. Rilliet 1 we are 
 indebted for a most elaborate inquiry into this subject, which showed 
 so close a resemblance to subsist between the two diseases, as effectually 
 removed all doubt with reference to their identity. They are both in- 
 duced by the same unfavorable hygienic influences, they both run a 
 similar definite course, and have the same duration, while both, though 
 generally affecting isolated individuals, have also their seasons of epi- 
 demic prevalence. Though varying in severity, so that in some cases 
 confinement to bed for a few days is scarcely necessary, while in other 
 cases the patient hardly escapes with his life, yet medicine has not been 
 able to cut short the course even of their mildest forms. And, lastly, 
 though the local affections associated with both vary much in different 
 cases, yet in every instance we meet with that assemblage of symptoms 
 which makes up our idea of fever. Or if, from the examination of the 
 symptoms during life, we pass to the inquiry into the traces left by the 
 disease on the bodies of those to whom it proves fatal, we shall find still 
 further evidence of the close relation that subsists between the fever of 
 the child and that of the adult. Enlargement, tumefaction, and ulcer- 
 
 1 De la Fievre Typhoi'de chez les Enfans : These de la Faculte, 1840; and Traite 
 des Maladies des Enfans, vol. ii, p. 663. 
 
TYPHOID FEVER — SYMPTOMS OP ITS MILDER FORM. 619 
 
 ation of Peyer's glands, constitute one of the most frequent morbid 
 appearances in both diseases, and in both, the changes that these glands 
 are found to have undergone, are more advanced and more extensive 
 in proportion to their nearness to the ileocecal valve. In both, too, 
 the mesenteric glands are enlarged, swollen, of a more or less deep-red 
 color, and manifestly increased in vascularity ; while the softened state 
 of the spleen, the gorged condition of the lungs, and the congestion of. 
 the membranes of the brain, are appearances common to both diseases. 
 There is, however, no more relation between the severity of the intes- 
 tinal lesion, and the intensity of the symptoms in the fever of the child, 
 than in that of the adult ; and there is no ground for regarding the 
 disease as the mere effect of the constitution sympathizing with a certain 
 local mischief in the former case, which may not be equally alleged 
 with reference to the latter. The symptoms in both " are the expres- 
 sion of the influence of the disease on the whole economy, of the disorder 
 which it occasions in the principal functions of the body, and are an 
 essential part of the disease itself, rather than the secondary effects of 
 certain lesions of the bowels." 1 
 
 If, however, this be so, it will tend greatly to the avoidance of errors 
 which time has rendered popular, if for the future we altogether dis- 
 card the term infantile remittent fever from our scientific nomencla- 
 ture, and speak, as many French writers do, only of Typhoid Fever in 
 children. 2 
 
 The different degrees of severity which a disease may present in dif- 
 ferent cases do not in general form a good basis on which to found any 
 classification of its varieties ; but in the case of typhoid fever the dif- 
 ferences are so great between its milder and its severer form as to war- 
 rant our adopting them as a ground for its subdivision into two classes. 
 In cases of the first or milder kind, the disease usually comes on very 
 gradually, often so much so that the parents of a child who is attacked 
 by it are unable to name any fixed time as that at which the illness 
 began. The child loses its cheerfulness, the appearance of health leaves 
 it, the appetite fails, and the thirst becomes troublesome ; by daytime 
 it is listless and fretful, and drowsy towards evening ; but the nights 
 are often restless, or the slumber broken and unrefreshing ; while all 
 these symptoms come on without any evident cause, and are not accom- 
 panied by any definite illness. When once the attention of the parents 
 has been excited to the condition of the child, it is soon ascertained 
 that the skin is often hotter, and almost always drier than natural, 
 though now and then rather profuse sweats break out causelessly on 
 the surface, and continuing for an hour or two, leave the patient in no 
 
 1 Chomel, Lecons de Clinique Medicale : Fievre Typhoi'de, p. 231, 8vo. Paris, 
 1834. 
 
 2 Dr. Murchison, whose Treatise on Continued Fevers, 8vo., London, 1862, has 
 appeared since the fourth edition of these Lectures, suggests as most appropriate the 
 name Pythogenic Fever, from its connection with imperfect drainage, and similar 
 causes. No one can consult this work and fail to do homage to the merits of one of 
 the most remarkable monuments of patient investigation, original thinking, and 
 lucid statement with which our medical literature has been enriched in the present 
 generation, by the worthy successor of Sir W. Jenner at the Fever Hospital. 
 
620 TYPHOID FEVER — SYMPTOMS OF ITS MILDER FORM. 
 
 respect relieved by their occurrence. The bowels are sometimes loose 
 even at the onset of the disease, or if not they are in general readily dis- 
 turbed by medicine ; a very mild aperient being not infrequently fol- 
 lowed by three or four actions of the bowels daily for the next two or 
 three days. In a few instances there is a condition of rather obstinate 
 constipation at the onset of the disease, requiring active measures to 
 overcome it ; but this is not often the case, and when it does occur, it 
 is, I think, more frequently in the severer than in the milder form of 
 the disease. The appearance of the evacuations is almost always un- 
 healthy, and they are usually relaxed, very offensive, of a peculiar yel- 
 low-ochrey color, and separate on standing into a supernatant fluid and 
 a flaky sediment; appearances which become more marked in the second 
 week of the disease. The tongue is generally rather deficient in mois- 
 ture, red at the tip and edges, thinly coated on the dorsum with white 
 mucus, through which the papillae appear of a deep-red color. The 
 abdomen is soft, though there is some flatus in the intestines, and pres- 
 sure is usually borne without pain. These characters often continue 
 through the whole course of the affection, though sometimes after the 
 middle of the second week, pressure in either iliac region, especially 
 the right, appears to cause suffering. The pulse is generally accelerated 
 from the very commencement of the illness ; sometimes it is very much 
 so, but there is by no means a constant relation between the heat of 
 skin and the rapidity of the pulse. Occasionally there is slight cough, 
 but this symptom is very frequently absent in the milder cases of the 
 disease. As the symptoms which constitute this affection come on very 
 gradually, so they often continue for several days with little if any 
 change from day to day, though the patient is far from seeming equally 
 ill at all times of the day; and this periodical exacerbation and remission 
 of the symptoms obtained for the disorder the name of remittent fever. 
 In some instances two distinct exacerbations and remissions maybe 
 observed in the course of every twenty-four hours, but in the majority of 
 cases only one is well marked. The child, who during the day has 
 been listless and poorly, but yet not incapable of being amused, and 
 has had the appearance of a patient convalescent from illness, rather 
 than of one still suffering from disease, becomes flushed and uneasy 
 and feverish as evening approaches; and sometimes slight horripilation 
 ushers in the evening exacerbation of fever. He seems drowsy, and 
 begs to be put to bed, where sometimes he sleeps, though seldom tran- 
 quilly, till morning. In the second week, the nights generally become 
 worse than they were at an earlier stage of the disease; the child's skin 
 is very dry and hot, he sleeps with his eyes half open, talks in his sleep, 
 wakes often to ask for drink, and occasionally has slight delirium. 
 Early in the morning he wakes pale and unrefreshed, but about 9 or 10 
 o'clock seems to have recovered something of his cheerfulness, and for 
 the succeeding three or four hours appears tolerably well ; but as even- 
 ing approaches he seems weary and drowsy, again the febrile paroxysm 
 occurs, and the succeeding night closely resembles the night before. 
 Sometimes, in addition to the evening exacerbation, there is a second 
 one though less severe at about 11 o'clock in the morning; from which 
 the child has hardly recovered before the severe evening attack comes 
 
TYPHOID FEVER — SYMPTOMS OF ITS SEVERER FORM. 621 
 
 on. As the case advances towards recovery, the morning attack disap- 
 pears long before the evening paroxysm ceases to recnr ; and it happens 
 not infrequently that a slight threatening of the evening exacerbation 
 continues to return for some time after the child has seemed in other 
 respects quite well. It is during the second week of the disease that 
 the rose spots characteristic of typhoid fever generally make their ap- 
 pearance if they appear at all ; but they are often very few in number, 
 and not infrequently are altogether absent. Towards the end of the 
 second, or the beginning of the third week, the symptoms begin to abate, 
 the bowels act more regularly, the appearance of the evacuations becomes 
 more natural, the tongue grows cleaner and uniformly moist, the thirst 
 diminishes, and the evening exacerbations of fever become shorter and 
 less severe; while the child's cheerfulness by day gradually returns, 
 and his face resumes the aspect of health. Convalescence, however, 
 after even a mild attack of the disease, is rarely established before the 
 end of the third week, while the child is in general left extremely weak, 
 and greatly emaciated; the loss of flesh and strength being quite out 
 of proportion to the severity of the illness, and the progress to complete 
 recovery being usually very slow. 
 
 It sometimes happens that, having set in with comparatively mild 
 symptoms, the typhoid fever assumes a serious character in the course 
 of the second week. In the majority of instances, however, the 
 severer form of the disease gives some earnest of its severity at a very 
 early period. It commonly sets in with vomiting, accompanied in 
 many cases by headache, or by a remarkable degree of drowsiness and 
 heaviness of the head. Coupled with these symptoms, there are those 
 indications of fever which attend the milder forms of the disease, 
 though in this case with a proportionate increase in their severity ; and 
 sometimes distinct rigors may be observed alternating with the heat of 
 the surface, or preceding the evening exacerbations of the fever. In 
 the greater number of instances, the vomiting with which the fever 
 sets in does not return after the second or third day of the patient's 
 illness ; but to this there are occasional exceptions ; and as the sickness 
 is usually more severe in cases in which constipation is present, there 
 is some risk of mistaking the real nature of the affection, and of re- 
 garding the irritability of the stomach as a sign of approaching cere- 
 bral disease. Now and then too, the drowsiness at the onset of the 
 disease is so overwhelming that I have known a child fall asleep 
 two or three times during breakfast, while his dizziness and inability 
 to walk steadily still further strengthened the impression that he was 
 suffering from some affection of the brain. Either of these occurrences, 
 however, is unusual ; and, though listless and drowsy, the child is in 
 general unwilling to keep his bed, while by night he is commonly 
 very restless, waking often in a state of alarm, or talking much in his 
 sleep. The countenance before long begins to wear the peculiar heavy 
 appearance of a fever patient, and by the end of the first or the begin- 
 ning of the second w 7 eek the child is usually found to have sunk into 
 a state of stupor, from which he seems unwilling to be roused. The 
 skin of the trunk is now almost constantly hot as well as dry ; the tem- 
 perature being often higher than in any other disease, with the excep- 
 
622 SEVERE TYPHOID FEVER. 
 
 tion of scarlatina, and in a few instances ranging as high as 105° Fahr. 
 My own observations with reference to the date of appearance of the 
 eruption on the surface are neither sufficiently numerous nor sufficiently 
 accurate for me to rely on their authority. MM. Rilliet and Barthez 
 observe that it very seldom appears so early as the fourth day, from the 
 sixth to the tenth being the most common date of its appearance ; while 
 both the period during which it remains visible and the number of spots 
 are liable to great variation. In by far the greater number of cases 
 the eruption at any one time is extremely scanty ; not infrequently, in 
 spite of careful daily examination of my patients in the Children's 
 Hospital, two or three spots only have been discovered ; and even 
 these have remained visible for only two or three days; though fresh 
 spots not infrequently appear as the others fade, for several successive 
 days. Now and then I have observed an abundant eruption, thirty 
 or forty spots being scattered at one time over the whole abdomen, but 
 this is altogether an exceptional occurrence. I have observed this 
 abundant eruption only in severe cases of the fever, but there is no 
 constant relation between the amount of eruption and the severity of 
 the fever ; and in some of the severest cases, the most careful examina- 
 tion has failed to discover the characteristic spots at any stage of the 
 disease. In a few cases profuse sweats take place, but they do not 
 seem to have anything of a critical character. The pulse is very fre- 
 quent, and I have known it to continue at nearly 140 in the minute, 
 for several days together, during the increase of the fever in a child 
 eight years old. A frequent short hacking cough often occurs during 
 the first week ; and rhonchus sibilus, and occasional large crepitation, 
 are heard, in many cases in both lungs. Now and then, too, the respi- 
 ration continues much accelerated for several days, without any other 
 sign of serious pulmonary disease being present, and gradually regains 
 its proper frequency as the febrile symptoms subside. Tenderness of 
 the abdomen is generally very evident before the first week is passed, 
 but frequently there is no complaint of pain, even in severe cases, 
 except on pressure ; though that seldom or never fails to elicit evi- 
 dences of uneasiness, often to excite distinct complaints. During the 
 first week, the condition of the abdomen is usually natural and soft, 
 even though slightly tender; it afterwards becomes somewhat dis- 
 tended with flatus, and a sense of gurgling is often perceptible on 
 pressure in one or other iliac region ; but it rarely becomes greatly 
 tympanitic. Diarrhoea is usually present, though it is not in general 
 severe, the bowels not acting above four or five times in the twenty- 
 four hours. The tongue is usually more thickly coated at the com- 
 mencement than in the milder forms of the disease ; a dry streak soon 
 appears down the centre, and by degrees the tongue becomes uniformly 
 dry, red, and glazed ; or less often it is partially covered with sordes. 
 In the course of the second week the patient generally sinks into a 
 more profound stupor — a condition which alternates in many cases 
 with delirium. Sometimes the mind wanders occasionally almost from 
 the commencement of the disease, in other cases delirium is a very 
 temporary symptom, occurring only at night, or when the child during 
 the daytime wakes from sleep. Now and then, though not generally, 
 
SEVERE TYPHOID FEVER. 623 
 
 the delirium is of a noisy kind, but the child not infrequently tries to 
 get out of bed ; and both the restlessness and delirium, though gener- 
 ally present in bad cases during the daytime, are aggravated in a 
 marked degree at night. Once or twice I have known violent de- 
 lirium come on towards evening, the child crying and shouting 
 aloud during nearly the whole night, and sinking into a state of 
 stupor by day. The child now seems nearly or quite unconscious of 
 all that goes on around it ; its evacuations are passed unconsciously, 
 and it often seems dead to the sensation of thirst, by which, in the 
 earlier stages of the disease, it was so much distressed ; but this stupor 
 of fever is so different from the coma which supervenes in affections of 
 the brain, and the insensibility which characterizes it is so much less 
 profound, that one can hardly be mistaken for the other. Once only 
 I have seen convulsions occur in a child between two and three years 
 old, who together with his two brothers suffered from very severe 
 typhoid fever. The convulsions, which recurred on two successive 
 days at the middle of the third week of the fever, were succeeded by 
 paralysis of one side, which continued, though gradually diminishing, 
 for four days. The child was unconscious even before their occurrence, 
 and continued so for several days, though he eventually recovered. 
 Even when the disease is most severe, neither subsultus nor floccita- 
 tion is frequent, though it often happens that during the tedious and 
 fluctuating convalescence, the child picks its nose till it bleeds, or 
 makes the tips of its fingers, or different parts of its body sore by pick- 
 ing them. The patient is by the end of the second week, sometimes 
 earlier, reduced by the continuance of these symptoms to the most 
 extreme degree of emaciation, and to a condition apparently hopeless ; 
 but there is no other disease incidental to childhood from which recovery 
 so often takes place, in spite of even the most unfavorable symptoms. 
 The signs of recovery are, in the main, the same as betoken the recovery 
 of an adult suffering from fever ; but the amendment has seemed to me 
 always to be gradual, and in no case the result of any critical occur- 
 rence. Moisture begins to reappear upon the edges of the tongue, the 
 pulse loses its frequency, the delirium ceases by degrees, more quiet 
 rest is enjoyed at night. Such signs of improvement may in general 
 be looked for about or before the middle of the third week, but for 
 days after their appearance the child's unconsciousness in many in- 
 stances continues. He does not speak ; he neither knows nor notices 
 any one ; and the mother, longing once more for her little one's fond 
 look of recognition, and each day being disappointed of it, mistrusts 
 the assurances that we may have given her, and loses heart and hope 
 at a time when danger is really almost passed. At length it comes — 
 a look, a smile, a gesture — but still no word ; and slowly, very slowly, 
 do the intellectual powers return, or does speech come back again. 
 The first signs of amendment, however, may be taken as giving almost 
 certain promise of complete recovery ; but it is well to bear in mind 
 that there is no disease of early life in which the mental faculties, 
 though time brings them back at length uninjured, yet remain so long 
 in a state of feebleness and torpor as in typhoid fever. Though the 
 first signs of improvement, too, are very seldom deceptive, yet the 
 
624 DIAGNOSIS OF TYPHOID FEVER. 
 
 fever in these severer cases can scarcely be considered as passed before 
 the thirtieth day ; sometimes not till even a week later ; while the 
 patient's convalescence is almost always very slow, and interrupted by 
 many fluctuations. 
 
 In the few cases, and according to my experience they are compara- 
 tively few, in which typhoid fever in children terminates fatally/ 
 death is seldom the result of complications such as not infrequently 
 supervene in the course of fever in the adult, but the vital powers give 
 way under the severity of the constitutional affection, the symptoms of 
 which assume more and more of a typhoid character. It is towards 
 the end of the second, or at the beginning of the third week, that 
 death in these circumstances is most likely to occur ; I have seen it 
 take place as late as the twenty-ninth day in one instance, and at the 
 end of the fifth week in another ; but in both of these instances gangrene 
 of the mouth came on after the more alarming general symptoms had 
 begun to subside ; and to this the death of the child was chiefly due ; 
 while on another occasion perforation of the intestine destroyed a child 
 on the thirty- sixth day after the attack, when apparently advancing 
 favorably towards recovery. Now and then a fatal termination takes 
 place after the lapse of little more than a week from the commencement 
 of the illness, under signs of cerebral disturbance which throw the 
 general febrile symptoms into the shade ; great restlessness and agita- 
 tion, with loud cries, being succeeded by convulsions, and they in 
 their turn, being followed by coma, in which the child dies ; while an 
 examination after death discovers nothing more serious than a some- 
 what greater vascularity than natural of the brain and its membranes. 
 
 The diagnosis of the disease has been rendered needlessly difficult 
 by the loose manner in which the name remittent fever has been ap- 
 plied to a variety of affections : still it must be confessed that there are 
 several maladies between which and typhoid fever points of similarity 
 exist in some parts of their course that may easily deceive the unwary. 
 The resemblance is often very close between the milder varieties of the 
 fever and some of those cases of gastro-intestinal disorder, by no means 
 unusual in young children, which are excited by errors of diet, and are 
 either associated with diarrhoea or preceded by it. Something may be 
 done, however, towards guarding against error in all doubtful cases, 
 by bearing in mind that typhoid fever occurs more than twice as often 
 in boys as in girls ; that it is rare before five years of age, exceedingly 
 uncommon before the age of two ; and when it does happen in such 
 young subjects, can almost always be traced to contagion. The various 
 forms of gastric disorder attending or following dentition may with al- 
 most absolute certainty be determined to be local ailments, producing 
 more or less constitutional disturbance : and thus essentially different 
 from typhoid fever. But even in cases where the patient's age is not 
 
 1 Of 84 cases of typhoid fever under my care in the Children's Hospital, 11 ter- 
 minated fatally. I believe this to be a far higher death rate than the results of 
 private practice would in general yield, though MM. Rilliet and Barthez sUite the 
 mortality in their private practice to have been one in ten. The mortality of one 
 in four in the Hopital des Enfans, at Paris, is obviously due rather to intercurrent 
 diseases contracted in the hospital than to the fever itself. 
 
DIAGNOSIS OF TYPHOID FEVER. 625 
 
 such as to raise a presumption one way or the other, the degree of loss 
 of strength, and the rapidity with which it becomes apparent, the dry 
 heat of the skin, and its intensity at the time of the exacerbations of 
 the fever, the marked disturbance of the sensorium, and the delirium 
 at night, are characters by which typhoid fever may be known, and 
 whose absence would suffice to disprove the existence of that disorder. 
 General tubercular disease, running an acute course, may indeed be 
 taken for typhoid fever ; and the distinction between the two affections 
 is sometimes attended by very considerable difficulty; 1 especially if the 
 case is not seen until the symptoms have become severe. Even then, 
 however, something may be gathered for our guidance from the absence 
 of rose spots, from the abdomen being generally flat, often shrunken, 
 and from diarrhoea being absent, or at any rate not having occurred in 
 acute tuberculosis until all the symptoms have assumed an extreme 
 degree of severity. Auscultation, too, will often show good reason for 
 suspecting the real nature of the case, or the previous history of the 
 child will afford some clue with reference to it, though I believe that, 
 with every care, instances will sometimes occur in which doubt will re- 
 main until removed by examination of the body after death. There 
 are two other affections, between which and typhoid fever, though their 
 resemblance is far less deceptive than that of acute tuberculosis, it is 
 often far from easy to distinguish, while, unfortunately, the practi- 
 cal evils which follow from a wrong diagnosis are of a very serious 
 nature. When speaking, however, of tubercular meningitis 2 and of 
 pneumonia, 3 I dwelt so fully on the circumstances that might lead you 
 to mistake either of those diseases for typhoid fever, and of the charac- 
 teristics which belong to the last-named affection, that it can scarcely 
 be necessary to do more than refer you to the observations made on 
 those occasions. I have already said so much of the value of the in- 
 dications furnished by the thermometer in guarding us from error in 
 diagnosis, that I need now scarcely do more than remind you that the 
 one great unfailing evidence of the existence of typhoid fever, is the 
 invariable increase of temperature ; an increase quite out of proportion 
 to the acceleration of breathing, or the increased rapidity of pulse ; 
 and further, the law, to which there is no exception, of marked evening 
 increase, and morning diminution of that heightened temperature, 
 which yet continues above the natural degree throughout and is higher 
 in proportion to the danger of the case. 
 
 I am anxious, before we pass to the treatment of the disease, to 
 guard against an error which may possibly arise from my having 
 pointed out certain well-marked distinctions between the cerebral 
 symptoms of tubercular meningitis, and those which accompany ty- 
 phoid fever. Now, although it is perfectly true that the disturbance 
 of the brain in the latter case is the result of mere functional disorder, 
 which, with the abatement of the fever, will, in general, by degrees 
 pass away, still it is not to be forgotten that serious and even fatal 
 
 1 See remarks on this subject in Lecture XXIX, p. 420. 
 
 2 See Lecture VII, p. 85, and especially the remarks at p. 86 on the temperature 
 in typhoid fever. 
 
 3 Lecture XXI, p. 292. 
 
 40 
 
626 COMPLICATIONS OF TYPHOID FEVER. 
 
 cerebral affection occasionally attends it. It is not, indeed, commonly 
 at an early stage of the fever that we need be anxious on this account, 
 for dangerous cerebral complications seldom occur before the middle of 
 the second week, sometimes even later ; while now and then they suc- 
 ceed to a sort of imperfect convalescence, from the signs of which we 
 had already begun to hope that the most anxious period was passed. 
 The indications of their supervention are various, and often of such a 
 kind as, considering the character of the child's previous illness, may 
 fail to excite that attention which otherwise they would attract. The 
 more than ordinary excitability of the patient, the peculiar noisiness of 
 his delirium, and the ungovernableness of his temper, should arouse 
 our suspicions even in the case of an ill-managed and wayward child, 
 in whom these symptoms may in part be due to mere petulance. 
 Sometimes, however, the mode of approach of serious head mischief is 
 even more treacherous. The fever has already abated, the tongue has 
 grown somewhat moister, the delirium is less constant, the restlessness 
 less distressing, and the child even has some quiet sleep ; but he lies 
 often grinding his teeth, or there is frequent machonnement, or slight 
 twitchings of the facial muscles occur occasionally. The eyes grow less 
 intolerant of light, and as the child opens them once more, the parents 
 please themselves with its fancied improvement, fondly imagining that it 
 looks around and notices again. The pupils, however, are more dilated 
 than natural, and act more sluggishly; the pulse presents a slight 
 irregularity or intermission ; sensibility to external objects lessens ; and 
 coma steals on almost imperceptibly, while in other cases all the symp- 
 toms of tubercular meningitis by degrees develop themselves. 
 
 The unobserved supervention of pneumonia is guarded against by 
 daily careful auscultation ; the existence of diarrhoea tells too plainly of 
 the abdominal complication for that to be overlooked ; but when so 
 much disturbance of the nervous system is part and parcel of the affec- 
 tion, some excess of it may readily pass without due importance being 
 attached to it. When, then, you may ask, are we to become anxious 
 about the head? I should say, whenever delirium is present, not 
 merely during the night, or on waking from slumber in the daytime, 
 but whenever it also continues during the day, or when there is during 
 the day an extremely excitable and unmanageable condition, though 
 not amounting to actual delirium. Or, secondly, whenever, with the 
 abatement of the fever, the cerebral symptoms do not diminish in pro- 
 portion ; or some new, even though very slight, indication of disorder 
 of the nervous system appears, although the excitement manifest in 
 the earlier stages of the affection may have almost or altogether passed 
 away. These symptoms may, indeed, speedily subside, or they may 
 yield, and probably will, to judicious treatment, but they indicate a 
 source of danger against which you cannot be too carefully or too un- 
 ceasingly on the watch. 
 
 Thus much concerning the disease; now, in conclusion, as to its 
 treatment. In the management of typhoid fever in the child, just as 
 of fever in the adult, the grand object to which our attention ought to 
 be turned, is to carry the patient through an affection which we cannot 
 cut short, with as small an amount of suffering and danger as possible. 
 
TREATMENT OF TYPHOID FEVER. 627 
 
 "Medicus curat, nature sanat morbum" says an old Latin adage; and 
 in no disease is it of so much importance as in fever, that we should 
 assign to our art its proper position as the handmaid of nature. The 
 gradual approach of the disorder, in the great majority of instances, of 
 itself points out the propriety of that expectant mode of treatment 
 which is generally the most appropriate during the first week of the 
 child's illness. The languid and listless state of the little patient, his 
 headache and drowsiness, often lead him to wish to remain in bed all 
 day long ; but there is no reason for confining him to bed, if during 
 the period of remission of the fever he should prefer to sit up. The 
 impaired appetite often renders any other directions about the diet un- 
 necessary, than a caution to the parents or nurse not to coax or tempt 
 the child to take food, which it is and will probably for some days 
 continue to be entirely unable to digest. The heat of skin and the 
 craving thirst are the two most urgent symptoms in the early stages of 
 the affection. The first of these is generally relieved by sponging the 
 surface of the body several times a day with lukewarm water. The 
 desire for cold drinks is often very urgent, and no beverage is half so 
 grateful as cold water to the child. Of this it would, if permitted, 
 take abundant draughts ; but it should be explained to the attendants 
 that the thirst is not more effectually relieved by them than by small 
 quantities of fluid, while pain in the abdomen is very likely to be 
 caused by the overdistension of the stomach. The cup given to the 
 child should therefore only have a dessert or tablespoonful of water in 
 it, for it irritates the little patient to remove the vessel from its lips 
 unemptied. In the milder forms of the disease, and during the first 
 week, medicine is little needed : but a simple saline may be given, 
 such as the citrate of potass, in a mixture to which small doses of 
 vinum ipecacuanha? may be added, if as sometimes happens the cough 
 is troublesome. If the bowels act with due frecjueney, and the appear- 
 ance of the evacuations is not extremely unhealthy, it is well to abstain 
 from the employment of any remedy that might act upon them, for 
 fear of occasioning diarrhoea, which is so apt to supervene in the course 
 of this affection. For the same reason, if an aperient is indicated, 
 drastic purgatives are not to be given, but a moderate dose of castor 
 oil should be administered. Xow and then, however, cases are met 
 with in which the bowels remain confined during a great part of the 
 affection, and in which such purgatives as senna are not only borne, 
 but are absolutely necessary. They, however, are purely exceptional 
 cases ; and it will generally suffice if there exists any tendency to con- 
 stipation, to give a small dose of the mercury and chalk night and 
 morning, and during the daytime a small quantity of the tartrate of 
 soda or sulphate of magnesia, dissolved in some simple saline mixture, 
 every six or eight hours. 
 
 The unhealthy state of the evacuations that exists in a large number 
 of cases is generally associated with a disposition to diarrhoea, which 
 becomes a more prominent symptom in the second than it was in the 
 first week of the disorder. Equal parts of the Hydrargyrum cum Creta 
 and Dover's powder are the best means of relieving both these morbid 
 conditions ; the remedy being given either once or twice a day, or more 
 
628 HEAD-SYMPTOMS, TREATED BY ANTIMONY AND OPIUM. 
 
 frequently, according to the urgency of the symptoms. The amount 
 of abdominal pain and tenderness must be ascertained every day ; and 
 a few leeches must be applied to either iliac region if the tenderness 
 seems considerable, or if the child appears to suffer much from pain in 
 the abdomen, or if the diarrhoea is severe. If depletion is needed, the 
 application of but a small number of leeches will generally meet the 
 requirements of the case, while copious bleeding is neither useful nor 
 well borne. Even in children of ten years old I never apply above 
 four or six leeches, and it is very seldom that any occasion arises for a 
 repetition of the bleeding. The application of poultices of linseed meal 
 or scalded bran to the abdomen, and their frequent repetition, is a very 
 valuable means of relieving the griping pain which often distresses 
 children ; and in most cases it is desirable to make trial of them before 
 having recourse to depletion. 
 
 There is but one other class of symptoms likely to occur during the 
 first week of the fever, to the management of which I have not yet 
 referred ; namely, those signs of cerebral disturbance which are some- 
 times so serious as to call for treatment. The early occurrence of 
 delirium, though it generally implies that the disease will assume a 
 rather serious character, yet does not of itself indicate the necessity for 
 taking blood from the head ; but if the child is quiet and generally 
 rational during the daytime, and though dull yet not in a state of 
 stupor, while the delirium at night is of a tranquil kind, and inter- 
 rupted by frequent and tolerably quiet slumber, it will suffice to cut 
 the hair quite short, apply cold to the head by means of pounded ice 
 in a bladder or india-rubber bag, as I have already explained when 
 speaking of the management of acute cerebral disease, and to keep the 
 apartment cool and absolutely quiet. The irritability, excitability, 
 and restlessness at night, accompanied by loud and noisy delirium, 
 from which the child gets scarcely any respite all night long, are fre- 
 quently arrested at once by an opiate. Unless some abdominal com- 
 plication should forbid its employment, the tartar emetic is in these 
 cases a most valuable adjunct to the opium. 1 A draught containing 
 five minims of laudanum, and a quarter of a grain of tartar emetic, 
 will be a suitable anodyne for a child of five years old, and may be 
 repeated night after night with almost magical effect. On the whole, 
 too, I think the action of opium is more satisfactory than that of chloral 
 in the restlessness of fever. When the delirium at night is succeeded 
 during the daytime by an almost equally distressing condition of ex- 
 citement, accompanied with a burning skin, and a very frequent 
 though feeble pulse, the continuing the tartar emetic in slightly nau- 
 seating doses, combined with smaller quantities of laudanum every four 
 hours, will often be of essential service. If, however, there is any 
 injection of the conjunctivae, or if the head is in a marked degree hotter 
 than the surface generally, or if any other indication of disorder of the 
 brain is present besides the delirium and excitement, leeches should be 
 
 1 The remarks of Dr. Graves, in his Lectures on Clinical Medicine, vol. i, p. 207, 
 on the use of Tartar Emetic and Opium in Fever, are little less applicable to its 
 management in the child than in the adult. 
 
TREATMENT OF TYPHOID FEVER. 629 
 
 applied to the head — though depletion should in these cases be used 
 sparingly ; and after the abstraction of blood by the application of half 
 a dozen leeches, we should return to the tartar emetic and opium, 
 remembering that we have no active inflammation to combat, nor even 
 that intense cerebral congestion which we occasionally meet with in 
 other circumstances, and safety from which is found only in very 
 active depletory measures. 
 
 Depletion is also called for in cases, not very commonly met with, 
 in which even at an early period of the disease there is a great degree 
 of stupor and apathy, with a dilated and sluggish pupil, but little com- 
 plaint of thirst, and none of headache or local suifering. By the cau- 
 tious abstraction of blood we may here sometimes anticipate the devel- 
 opment of the more alarming head-symptoms, which, if we leave the 
 patient alone, lulled into a false security by the absence of any signs of 
 active mischief, will not fail before long to manifest themselves. As a 
 general rule, indeed, it must be our object in the management of this 
 fever to anticipate the head-symptoms as far as possible, to keep down 
 the excitement and quiet the delirium by tartar emetic and opium, or 
 by the local abstraction of blood ; a purely expectant course of practice, 
 when the cerebral disturbance is considerable, is neither wise nor safe. 
 The head-symptoms, which come on slowly and almost imperceptibly 
 at a more advanced stage of the disease, are sometimes very unmanage- 
 able. Depletion is no longer of service, but blisters may be applied to 
 the occiput and nape of the neck with advantage ; they should, how- 
 ever, not be kept ou so long as to produce complete vesication ; but 
 only for a time sufficient to obtain their counter-irritant effect, and to 
 allow of their reapplication in the same neighborhood, if not upon ex- 
 actly the same spot, on the next day. The unfavorable termination of 
 the disease in this stage is, I apprehend, due, in the great majority of 
 cases, to the development of some previously latent tendency to tuber- 
 cular meningitis ; while the more active head-symptoms, which are met 
 with at an earlier period, are often merely the result of functional dis- 
 turbance, and therefore generally yield to well-considered treatment. 
 
 In mild cases of the disease, the expectant treatment usually appro- 
 priate during its earlier stages, may be continued throughout its course; 
 great caution being exercised as the child begins to improve, to prevent 
 its committing any error in diet. When severe, however, the second 
 week often brings with it a train of symptoms that require many modi- 
 fications in the plan of treatment. The vital powers need to be sup- 
 ported, and the nervous system requires to be tranquillized ; and this 
 is to be attempted by means similar to those which we should employ 
 in the management of fever in the adult. The mere diluents which 
 were given during the previous course of the disease must now be ex- 
 changed for beef or veal tea or chicken broth, unless the existence of 
 severe diarrhoea contraindicate their administration ; in which case we 
 must substitute arrowroot, milk, and isinglass, for animal broths. In 
 a large proportion of cases nutritious food is all that will be required ; 
 but wine is sometimes as essential as in the fevers of the adult ; and 
 the indications for giving it are much the same at all ages, while its 
 influence on the patient must be the only measure of the quantity to 
 
630 TREATMENT OF TYPHOID FEVER. 
 
 be administered ; and I have on some occasions given as much as twelve 
 ounces of wine and four ounces of brandy daily, to children not above 
 ten years old, and believe that this copious use of stimulants alone pre- 
 served their life. Even though wine be not necessary, I generally give 
 some form of stimulant during the second and third weeks of the affec- 
 tion. The prescription 1 that I usually follow is one much praised in 
 such circumstances by Dr. Stieglitz, of St. Petersburg, the chief ingre- 
 dients of which are ether and hydrochloric acid, and to this I very 
 frequently add either the tincture or Battley's concentrated infusion of 
 bark, or else quinine in moderate doses. I have no experience of the 
 employment of large doses of quinine as recommended by some French 
 physicians, either given by the mouth or in enema. It seldom disorders 
 the bowels if they are not much disturbed at the time of commencing 
 its administration, while if this is the case, a small dose of Dover's 
 powder, as a grain or a grain and a half at bedtime, will be doubly 
 useful, both in checking the tendency to diarrhoea, and in procuring 
 sleep for the child, who, without it, would probably be watchful and 
 delirious all night long. If diarrhoea is present, I either abstain from 
 the use of the acid mixture, or acid a drop or two of laudanum to each 
 dose. If purging becomes really severe, aromatics and astringents must 
 be employed, and small doses of mercury and chalk with Dover's powder 
 and bismuth may be given with much advantage for two or three days 
 at intervals of four or six hours. An opiate enema, as small in bulk 
 as possible, will more effectually quiet the intestines than much larger 
 doses given by the mouth. 
 
 The only other complication that is apt to be troublesome is bron- 
 chitis. Usually, however, the cough to which this gives rise, is an 
 annoying rather than a dangerous symptom ; and it is in general more 
 harassing at the commencement of the affection, and again when con- 
 valescence is beginning, than during the time when the graver symp- 
 toms are present. A little ipecacuanha wine, nitrous ether, and com- 
 pound tincture of camphor, will usually relieve it, to which it may 
 occasionally be expedient to add the application of a mustard poultice 
 to the chest. 
 
 The convalescence is often extremely tedious ; the child is left by 
 the disease not only extremely weak and emaciated, but with its diges- 
 tive powers greatly impaired. It is often many days before the 
 stomach is able to digest any solid food ; even a piece of bread will 
 sometimes irritate the intestines, and bring on a return of diarrhoea. 
 The appetite seems sometimes quite lost-; tonics either do no good or 
 are actually injurious by rekindling the fever ; or symptoms supervene 
 which seem to threaten the development of tubercular disease, a conse- 
 quence that not very seldom follows severe attacks of remittent fever. 
 
 1 (No. 39.) 
 R. Acid. Hydrochlor. dil., ti^xxxij. 
 Spt. ^Eth. CO., £} TTJ7XX. 
 Syr. Khaeados, sji.v. 
 Mist. Camph., ^iijss. M. 
 A tablespoonful every six hours. For a child five years old. 
 
TREATMENT OF INTERMITTENT FEVER. 631 
 
 In such circumstances, change of air and the removal, if possible, to 
 the seaside, are often the only means of restoring the child to health; 
 a means which you may recommend with the more confidence, since it 
 ljardly ever fails to be successful. 1 
 
 I know of no better place than the present for making a few remarks 
 to you concerning intermittent fever or ague as it occurs in early life. 
 In some countries, as you know, this disorder affects persons at all ages, 
 but in healthier regions it is found commonly to spare the two extremes 
 of life, and to attack but seldom either the aged or the very young. 
 Accordingly, in this country, ague is seldom observed in infancy and 
 childhood, and is so uncommon in this metropolis, that in almost all of 
 the instances of it which have come under my observation in early life 
 the disorder was not contracted in London. 
 
 Considering its rarity, therefore, I should not occupy your time by 
 speaking of ague, if it were not that it presents certain peculiarities in 
 early life, and those of a kind to render its nature obscure, and to lead 
 you altogether to overlook its existence, or to mistake it for some other 
 disease. These peculiarities consist in the ill-marked character, or 
 even the complete absence of shivering, the place of which is taken by 
 a condition of extreme nervous depression, or sometimes even by a 
 disturbance of the nervous system issuing in convulsions — in the severity 
 and long continuance of the hot stage, and in the absence of any dis- 
 tinct sweating stage, the child recovering by degrees, but without the 
 well-marked crisis which marks the cessation of each fit of ague in the 
 grown person. AVhen to this is added that the child always appears 
 more ailing between the fits than is usual with the adult, that dulness, 
 heaviness, and fretfulness, with some degree of febrile disturbance, con- 
 tinue in the intervals, and that the periodicity of the attacks is not so 
 regular as in the adult, you will at once see that an erroneous diagnosis 
 is very possible, I might almost say very pardonable. 
 
 The youngest child whom I have seen suffering from ague was not 
 quite two years old, and in his case the rigors were so slight that they 
 did not attract the mother's notice until her attention was especially 
 called to their occurrence. In proportion to the tender age of the child 
 are the above-named peculiarities distinctly marked, while after the 
 age of five years the few cases of ague which I have seen scarcely dif- 
 fered from the same disease in the adult. 
 
 The treatment of the affection is the same in the child or infant as in 
 the grown person, and quinine is no less a specific for it in the one case 
 than in the other. The tendency to relapse, however, I believe to be 
 very great in early life, and I have known ague return after several 
 months, on removal to a district which though healthy, and free from 
 ague, was yet somewhat lower and less dry than the child's previous 
 residence. On this account much care is needed, and that continued 
 for a considerable period, in the selection of the dwelling of a child 
 who has to all appearance perfectly recovered from an attack of inter- 
 mittent fever. 
 
 1 I have said nothing, because I know nothing practicall\ r , of the hydropathic 
 treatment of typhoid fever. I feel, however, that far too high authorities have 
 "been adduced in its favor to warrant its being passed over without mention. 
 
632 SMALL-POX. 
 
 LECTURE XLIIL 
 
 Small Pox. — Cheeked but not extirpated by vaccination — Its chief mortality 
 among children — Rate of mortality in cases of the disease undiminished during 
 the last fifty years — Its symptoms — Their early differences from those of the 
 other exanthemata — Characters and progress of the eruption — Peculiarities of 
 confluent small-pox — Dangers attending the maturation of the pustules, and the 
 secondary fever — Treatment. 
 
 Modified Small-Pox — Its low rate of mortality — Protective and mitigating power 
 of vaccination— Objections to vaccination — Communication of syphilis by vac- 
 cination. Peculiarities of modified small-pox. 
 
 Chicken-Pox. — Its symptoms, and differences from small-pox 
 
 Until the commencement of this century, the disease to which I 
 wish to-day briefly to call your attention, possessed a degree of impor- 
 tance far greater than that which attaches to it at present. Before the 
 introduction of vaccination, the small-pox was a disease of almost univer- 
 sal prevalence, causing at the least eight per cent, of the total mortality 
 of this metropolis, and disfiguring for life thousands whom it did not 
 destroy. Its loathsome character, and its formidable symptoms, when 
 it attacked the constitution at unawares, led to the adoption of vario- 
 lous inoculation, by which the disease was communicated in a mild 
 form, and under favorable conditions ; and persons having undergone 
 comparatively little suffering, and having been exposed to still less 
 danger, enjoyed by this means almost complete immunity from subse- 
 quent attacks of small-pox. But great as its benefits were, variolous 
 inoculation perpetuated at all times, and in all places, a disease which 
 would otherwise have obeyed the general law of epidemics, and would 
 have had its periods of rare occurrence as well as those of widespread 
 prevalence. Thus, as has been well observed, while the advantages of 
 the practice were great and obvious to the individual, to the community 
 at large they were very doubtful. 
 
 No such drawback exists to detract from the benefits of vaccination, 
 though unfortunately our present experience does not altogether justify 
 the sanguine expectations entertained concerning it by its first promo- 
 ters. Peculiarities of climate oppose a serious barrier to its successful 
 introduction into some countries, 1 and even in our own land individuals 
 are occasionally met with in whom vaccination altogether fails, or over 
 whom it seems to extend but a partial or temporary protective power. 
 
 But I will not enter on the question of the merits of vaccination, 
 nor of the circumstances that impair its preservative power, or call for 
 its repetition ; for though the subject is one important alike to the phy- 
 
 1 Dr. Duncan Stewart's valuable Eeport on Small-pox in Calcutta, and Vaccina- 
 tion in Bengal, 8vo., Calcutta, 1844, shows conclusively that the peculiarities of the 
 Indian climate present obstacles to vaccination such as greatly to detract from its 
 value ; while it is to be feared that they are of a nature which the greatest care will 
 never wholly overcome. 
 
SYMPTOMS OF SMALL-POX. 633 
 
 sician and the philanthropist, I have had no opportunities of forming 
 a judgment concerning it which are not alike open to you all. Prob- 
 ably indeed, I have seen much less of it than many others. Properly 
 enough, small-pox cases are not received into the Children's Hospital ; 
 and I do not think that within the past twenty years as many as five 
 cases of the disease have come under my care. In the writings of the 
 late Dr. Gregory, physician to the Small-Pox Hospital, in the treatise 
 on vaccination by Dr. Steinbrenner, to which the Institute of France 
 adjudged a prize in 1835, and in the still more recent Report to the 
 Board of Health, drawn up by Mr. Simon, in 1857, 1 you will find 
 everything that either large experience or unwearied research can bring 
 to its elucidation. 
 
 One fact which it behooves us always to bear in mind, is that albeit 
 the prevalence of the disease has been greatly checked by vaccina- 
 tion, small-pox is still one of the most fatal maladies of this country ; 
 and further, that it selects its victims, as heretofore, chiefly from among 
 children and young persons — nearly three-fourths of the fatal cases of 
 this affection occurring before the age of five, and more than nine-tenths 
 before the age of fifteen years. 
 
 In spite, too, of the increase of medical knowledge during the past 
 fifty years, the proportion of small-pox cases that terminate fatally has 
 been estimated by the best authorities to be as great now as it was half 
 a century ago. To some extent, perhaps, the very diminution in the 
 frequency of the disease may have had an unfavorable influence on its 
 issue in individual cases ; for practitioners, meeting with it now less 
 often than medical men in former days were wont to do, are not so 
 familiar with the meaning of those minuter variations in its symptoms, 
 from which important practical conclusions might be drawn by those 
 who knew how to interpret them aright. 
 
 Let me therefore urge you to watch every case of this formidable 
 disease that may come under your observation with most minute care, 
 lest you misinterpret the symptoms, or mistake the treatment of some 
 patient affected with it, whose well-being may be dependent on your 
 skill. For my own part, I cannot pretend to give you more than an 
 outline sketch of its characters, and must refer you to the writings of 
 others who have had greater opportunities of watching it than have 
 fallen to my share, to fill up the portrait. 
 
 The early symptoms of small-pox are those of approaching fever, and 
 if any other febrile disorder be prevalent at the time of their occurrence, 
 they may possibly be taken for the indications of an approaching 
 attack of the prevailing epidemic. There are, however, some peculi- 
 arities in the mode of onset of small-pox which are sufficiently charac- 
 
 1 Nothing can more conclusively establish the immensity of the boon which 
 vaccination has conferred on society, than the contrast which Mr. Simon's report 
 exhibits between the mortality from small-pox before and after its introduction. 
 " The fatality of small-pox in Copenhagen is but an eleventh of what it was; in 
 Sweden a little over a thirteenth; in Berlin and in large parts of Austria but a 
 twentieth ; in Westphalia but a twenty-fifth. In the last-named instance, there 
 now die of small-pox but five persons, where formerly there died a hundred." See 
 p. xxiii of the Keport. 
 
634 PROGRESS OF THE ERUPTION. 
 
 teristic of it even in the child, and which generally distinguish it from 
 any of the other eruptive fevers. The sickness with which it sets in is 
 in general severe, and the disorder of the stomach often continues for 
 forty-eight hours, during which time vomiting recurs frequently. In 
 measles there is comparatively little gastric disorder ; and the vomiting 
 that often ushers in scarlatina, though frequently severe, is not of such 
 long continuance. In young children we lose those complaints of in- 
 tense pain in the back which in the case of older patients often awaken 
 our suspicion ; but on the other hand, the severity of the cerebral dis- 
 turbance is an important feature in the early stage of the disease. At 
 the commencement of measles, the brain is in general but little dis- 
 turbed ; in scarlatina, delirium often occurs very early ; but in small- 
 pox the condition is one rather of stupor than of delirium, while con- 
 vulsions sometimes take place, and continue alternating with coma for 
 as long a period as twenty-four or thirty-six hours. Lastly, though 
 the skin in small-pox is hot, it is neither so hot nor so dry as in scarlet 
 fever ; the tongue does not present the peculiar redness, nor the promi- 
 nence of its papilla?, which are observable in scarlatina ; neither is there 
 any of the sore throat which forms so characteristic a symptom of that 
 disease. The early stages of small-pox are not attended with the 
 catarrhal symptoms which accompany measles; the eruption of measles 
 usually appears later, that of scarlet fever always sooner, than the erup- 
 tion of small-pox ; while its papular character is in general sufficiently 
 well marked to distinguish it from the rash of either of those diseases. 
 It never appears in less than forty-eight hours from the first sign of 
 indisposition, often not till after a somewhat longer time. It shows 
 itself in the form of small papulse, which are first discernible on the 
 face, forehead, and wrists, whence they extend to the trunk and arms, 
 and lastly to the lower extremities. These papulse are at first slightly 
 red, somewhat acuminated elevations, so minute that they may be 
 easily overlooked on a hasty examination, but yet conveying a distinct 
 sense of irregularity to the finger when passed over the surface. They 
 increase in size, and in the course of forty-eight hours assume a vesicu- 
 lar character, and contain a whey -like fluid ; while, instead of a conical 
 form, they now present a central depression. During another period 
 of forty-eight hours or thereabouts, these vesicles go on enlarging, their 
 central depression grows more and more apparent, and their contents 
 become white and opaque ; they are no longer vesicles, but have become 
 converted into pustules, each of which, if they are distinct, has an 
 areola of a red hue round its base. As the pustules enlarge, the face, 
 hands, and feet become swollen, and a general redness of the surface 
 succeeds to the more circumscribed areola which had previously sur- 
 rounded each separate pustule. As the size of the pustules increases, 
 they lose that central depression which they had presented while vesi- 
 cles ; they assume a spheroidal form, or even become slightly conical. 
 The next change observable in them is an alteration of their color from 
 a white to a dirty yellow tint, which they continue to retain until the 
 desiccation of the eruption commences. This token of the decline of 
 the disease is first apparent on the face, where, as you will remember, 
 the eruption is earliest observable ; while on the hands and feet, prob- 
 
PROGRESS OF THE ERUPTION. 635 
 
 ably owing to the thickness of the epidermis in those situations, this 
 change is longest delayed, and the pustules there attain a greater size 
 than in any other situation. The maturation of the pustules usually 
 occupies from the commencement of the fifth to the commencement of 
 the eighth day of the eruption, or from the eighth to the eleventh day 
 of the disease, when the process of desiccation begins. A few of the 
 smaller pustules dry up and become converted into crusts, which after- 
 wards drop oif ; but the greater number of them burst, and the pus 
 that they discharge, together, with a very adhesive matter which they 
 continue to secrete for two or three days, contribute to form the scab, 
 which incrusts more or less extensively the surface of a small-pox 
 patient during the decline of the disease. When the scab falls off, 
 which it does in from three to five or six days, the skin appears stained 
 of a reddish-brown color, which often does not disappear for several 
 weeks ; but it is only in cases where the pustule has gone so deep as to 
 destroy a portion of the true skin, that permanent disfigurement, the 
 so-called pitting of the small-pox, is produced. 
 
 It is only in cases of discrete small-pox, in which the eruption is but 
 moderately abundant, and the pustules consequently run their course 
 without coalescing with each other, that the above-mentioned changes 
 can be distinctly traced. In the confluent variety of the disease, in 
 which the pustules are so numerous that they run together as they 
 increase in size, the characteristic alterations in the individual pustules 
 cannot be followed. In those situations where the eruption is con- 
 fluent, the pustules never attain the size which separate pustules often 
 reach ; they do not become so prominent, nor do their contents in gene- 
 ral assume the same yellowish color, but several of them coalesce to 
 form a slightly irregular surface of a whitish hue ; while, when the stage 
 of desiccation comes on, each of these patches becomes converted into 
 a moist brown scab, which is many days before it is detached. Nor is 
 it merely at those parts, such as the face, where the eruption is actually 
 confluent, that its character is modified, but even where the pustules 
 are distinct, their advance goes on more slowly, and the maturative 
 stage is longer in being completed, than in less severe cases of the dis- 
 ease. It is, moreover, in cases of confluent small-pox that the ulcer- 
 ation of the pustules most commonly invades the true skin, and that 
 serious disfigurement is most likely to take place ; while, further, the 
 degree of danger to life is in almost direct proportion, in every case of 
 small-pox, to the amount of confluence of the eruption. 
 
 The appearance of the eruption of small-pox is attended with a 
 great abatement, sometimes with the almost complete disappearance, 
 of those signs of constitutional disturbance with which the disease sets 
 in ; and in mild cases the child shows few other indications of illness 
 than are furnished by the eruption on the skin. But with the matu- 
 ration of the pustules, the secondary fever, as it is called, is excited, 
 and the period of the greatest danger to the patient now comes on. 
 The skin once more grows hot ; the pulse rises in frequency ; restless- 
 ness, thirst, and all the phenomena of inflammatory fever, develop 
 themselves, and continue with more or less intensity for about three 
 days. These symptoms afterwards diminish, and finally disappear as 
 
636 DANGERS ATTENDING THE MATURATIVE STAGE. 
 
 the pustules burst, and the stage of desiccation is accomplished. It is, 
 however, only in cases of a favorable kind that the secondary fever- 
 runs so mild a course. In confluent small-pox the secondary fever is 
 always more severe than in the discrete form of the disease, though it 
 comes on later, in consequence of the more tardy maturation of the 
 pustules. Often, indeed, 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 maturation 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 circum- 
 stance, 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, 
 collapse ; the extremities grow cold, and in a few hours the patient 
 dies. This fatal change is sometimes ushered in by a fit of convul- 
 sions ; at other times it is preceded by a condition of extreme rest- 
 lessness, which contrasts remarkably with the quietude of the child's 
 manner for the two or three previous days ; and it is well to bear in 
 mind that the supervention of either of these two symptoms during the 
 maturative stage of small-pox is the almost certain herald of speedily 
 approaching death. One other not infrequent source of danger during 
 this period arises from the pustules which have formed on the mucous 
 membrane of the mouth, fauces, and air-passages. In almost every 
 case of small-pox, a few spots of the eruption may be seen upon the 
 tongue and on the interior of the mouth ; while an inspection of the 
 bodies of patients to whom it has proved fatal has shown that the 
 pustules form likewise on the interior of the larynx and trachea — 
 sometimes in considerable numbers. It is to the presence of pustules 
 in these situations that the hoarse or altered voice, and the difficulty 
 of deglutition, which are observed in most cases of severe small-pox, 
 are due ; as well as that short hacking cough which sometimes proves 
 a very troublesome symptom. The ptyalism, too, which occurs in 
 many instances, is apparently owing to the salivary glands sympathiz- 
 ing with the irritated and inflamed state of the mucous membrane of 
 the mouth. In cases which run a fortunate course, those symptoms 
 have come on about the third or fourth day of the eruption, and hav- 
 ing increased in severity until the eighth or ninth, then progressively 
 decline. In less favorable circumstances, however, they continue to 
 grow worse ; the voice becomes perfectly extinct, and deglutition almost 
 impossible, and the patient dies from the obstacle which the inflam- 
 mation and swelling of the lining membrane of the larynx present to 
 the free access of air to the lungs ; though the symptoms are seldom or 
 never those of active inflammatory croup. 
 
 You will find in the writings of those whose opportunities of observ- 
 ing small-pox have been considerable, the description of many other 
 modes in which it occasionally proves fatal. Thus, it is sometimes 
 associated with a great tendency to hemorrhage ; petechia? appearing 
 on the surface of the body, and the pustules assuming a black color, 
 from the extravasation of blood into them. In other instances, gan- 
 
TREATMENT OF SMALL-POX. 637 
 
 grene attacks the feet or some other part of the body. But these are 
 occurrences which it has not been my lot to witness, and I will not 
 therefore take up your time by detailing them at second hand. 
 
 Let us now glance for a few minutes at the treatment to be pursued 
 in this disease. You know that before the time of Sydenham, phy- 
 sicians adopted a heating regimen in cases of small-pox ; excluding 
 fresh air from the chamber, covering the patient with blankets, and 
 administering stimulating medicines and cordial drinks. To this prac- 
 tice the then prevalent theory of fermentation, and of nature's efforts 
 in disease being directed to eliminate the peccant matter from the 
 blood, had given occasion. In accordance with these notions, it was 
 assumed that the more abundant the eruption, the more complete 
 would be the separation of these noxious matters, and consequently 
 the better the chance of the patient's well-doing. The observa- 
 tion of nature, however, taught Sydenham that the very reverse was 
 the case ; that the more abundant the eruption, the greater the danger — 
 the fewer the pustules, the more favorable the prospect of the patient's 
 recovery. A cooling regimen, therefore, is now universally adopted 
 in the early stage of the disease, and fresh air is freely admitted into the 
 chamber, in order to prevent, if possible, a copious eruption, while the 
 same end is sought to be still further promoted by keeping the bowels 
 gently open, by a spare diet, and by mild antiphlogistic medicines. 
 Depletion, which even in the adult is not to be practiced merely with 
 the hope of thereby diminishing the quantity of the eruption, is still 
 less to be resorted to in the child, unless evidently called for by symp- 
 toms of severe cerebral disturbance; such as convulsions frequently 
 recurring, or ending in coma. Such occurrences as those, however, 
 demand not merely the abstraction of blood, but its removal with an 
 unsparing hand; for as I told you at the commencement of these lec- 
 tures, the cerebral congestion which attends the onset of the eruptive 
 fevers, if not speedily relieved, may prove very quickly fatal. Cases 
 of an opposite kind are sometimes met with in which the patient, 
 before the appearance of the eruption, is in a state of depression so 
 great as to call for warmth to the surface, or for the hot bath, for dia- 
 phoretic medicines, and sometimes even for stimulants. In this, how- 
 ever, there is nothing more than we may occasionally witness in a 
 patient completely prostrated during the first stage of typhus fever, and 
 needing perhaps the free administration of wine and ammonia to pre- 
 serve him from death. 
 
 With the outbreak of the eruption there ensues a lull in the symp- 
 toms, and a period now succeeds during which we have nothing else to 
 do than to leave nature to her workings undisturbed. Even in cases 
 of confluent small-pox, there is in many instances not a single symp- 
 tom just at this time which could either excite solicitude or call for 
 treatment, and you must therefore take care not to allow yourself at 
 this moment to be betrayed into the hasty expression of a very favora- 
 ble prognosis, which the supervention of the secondary fever may per- 
 haps in a day or two most grievously belie. If, however, the number 
 of pustules should be but small, the secondary fever will be slight : our 
 favorable opinion may, in these circumstances, be expressed with some 
 
638 TREATMENT OF SMALL-POX. 
 
 confidence, and most probably no deviation from our previous expec- 
 tant plan of treatment will be required during the subsequent progress 
 of the disease. If the eruption is more abundant, and the accompany- 
 ing secondary fever consequently severe, an antiphlogistic plan of treat- 
 ment must be carried out more strictly, while in all cases the restless- 
 ness which is so common a symptom during the maturative stage of 
 small-pox must be controlled by the administration of Dover's powder, 
 or of some other form of opiate, once or twice a day. In cases of con- 
 fluent small-pox, the patient needs to be very closely watched during 
 the maturation of the pustules, for on the secoud or third day of this 
 process the vital powers sometimes suddenly fail. The first indications 
 of any such occurrence, which would be furnished by a great aggrava- 
 tion of the previous restlessness, by the subsidence of the swelling of 
 the face and hands, the paleness of the skin in the interval between 
 the pustules, and the collapse of the pustules themselves, attended with 
 a sinking in the temperature of the surface, and a great diminution in 
 the power of the pulse, call at once for the energetic employment of 
 stimulants, for the administration of wine, and the substitution of 
 nutritious food for the previous meagre diet. A similar course must 
 also be pursued whenever the secondary fever shows any disposition to 
 assume a typhoid character, while, irrespective of any unfavorable 
 symptoms, it is not infrequently expedient, if the eruption is abundant, 
 to give beef tea, and to adopt other means for supporting the strength 
 from the fifth or sixth day of the eruption, — a period corresponding, as 
 I hardly need remind you, with the eighth or ninth day of the disease. 
 
 Various local means have been recommended to be adopted at an 
 early stage of the disease, with the view of preventing the full develop- 
 ment of the pustules, and consequently of preserving the patient from 
 the disfigurement produced by the pitting of the eruption. The cau- 
 terization of each individual pock with the nitrate of silver is a process 
 impracticable from its tediousness, while there is some discrepancy in 
 the results w x hich different persons allege that they have obtained by 
 applying mercurial ointment or plaster, or by washing the surface which 
 it is wished to defend with a solution of corrosive sublimate. The 
 weight of evidence appears to me, however, to be in favor of some pro- 
 ceeding of this kind ; and that which seems to have been the most suc- 
 cessful, is the application of the mercurial plaster at a period not later 
 than the third day from the outbreak of the eruption, or the painting 
 the surface with the elastic collodion. 
 
 Attention must be paid to the state of the eyes, which often suffer 
 much during attacks of the small-pox, though Dr. Gregory states that 
 the conjunctiva never becomes the seat of the pustules. From the time 
 when the swelling of the face begins during the maturation of the 
 eruption, the eyelids are often so much swollen as completely to close 
 the eyes, while their edges are glued together by a tenacious secretion 
 from the Meibomian glands. The patient will be much relieved by 
 bathing the eyes frequently with warm water, and any pustules that 
 occupy the margins of the palpebral should be carefully cauterized with 
 the nitrate of silver. 
 
 The condition of the mouth and throat must not be neglected. If 
 
SMALL-POX AFTER VACCINATION. 639 
 
 old enough, the child may be made to gargle with the infusion of roses, 
 while, should it be too young to do this, the endeavor must be made to 
 keep the mouth and throat free from the secretions which collect there, 
 by washing or syringing them frequently with warm water, and by 
 applying a weak solution of chloride of lime to the fauces. If difficult 
 respiration should come on, in consequence of the affection seriously 
 involving the larynx and trachea, the patient's condition, according to 
 the testimony of almost all writers, is rendered nearly hopeless. 
 
 The intense itching of the eruption during the latter part of the 
 period of maturation, and the stage of desiccation, not only distresses the 
 patient exceedingly, but is often the occasion of subsequent disfigure- 
 ment, in consequence of the desire to scratch being irresistible, and the 
 pustules being converted by abrasion of their heads into troublesome 
 ulcerations. 
 
 The application of sweet oil, cold cream, or spermaceti ointment, 
 will do something towards allaying the irritation ; but you will often 
 find it necessary to muffle the hands of children, in order to prevent 
 their producing troublesome sores by scratching themselves. 
 
 The convalescence from small-pox is often very tedious ; the patient's 
 recovery is frequently interrupted by various intercurrent affections, 
 and the latent seeds of scrofulous disorder are in many instances called 
 into activity by its attack. These, however, are occurrences which 
 present nothing of a special character, and it is therefore unnecessary 
 to make any observation with reference to their treatment. 
 
 Although previous vaccination usually confers upon the system a 
 complete immunity from subsequent attacks of small-pox, yet to this 
 rule there are occasional exceptions. In many instances, indeed, the 
 occurrence of small-pox after alleged successful vaccination may be ac- 
 counted for by the careless performance of that operation, by the use of 
 lymph taken from the arm at too late a period, or by the production in 
 some way of a spurious instead of a genuine vaccine vesicle. It must 
 be confessed, however, that when every allowance has been made for 
 these casualties, the number of cases of small-pox occurring after suc- 
 cessful vaccination is proportionably much greater than the number in 
 which a second attack of small-pox is experienced by those who have 
 either had that disease casually, or in whom it has been produced by 
 variolous inoculation. It would occupy far more time than we have 
 at our command, if we were to attempt to enter upon the inquiry as to 
 the causes of the failure in the protective power of vaccination. Dif- 
 ferent views have been taken by very high authorities upon this sub- 
 ject ; but there is one important fact concerning which nearly all are 
 agreed, namely, that the liability to a subsequent attack of small-pox 
 is almost incalculably diminished by revaccination. Considering, then, 
 how- simple the operation is/ and how nearly painless its perform- 
 ance, while the benefit to be obtained by it is so inestimable, I would 
 strongly urge you to revaccinate all persons turned twelve years old, 
 even though they had been vaccinated with the most complete success 
 in their infancy. 1 
 
 1 For facts showing the preservative influence of revaceination, see Steinbren- 
 ner, Traite sur la Vaccine, 8vo., pp. 683-734. Paris, 1846. The report of Mr. Simon, 
 
640 SMALL-POX AFTER VACCINATION. 
 
 But although we should take a comparatively low estimate of the 
 value of vaccination, and confess to the fullest extent the failure in its 
 complete preservative virtue, we shall yet find, in the modifying and 
 mitigating influence which it exerts over small-pox, more than enough 
 to make us value it as a priceless boon. Thirty years ago, small-pox 
 raged epidemically at Marseilles, where it attacked almost exclusively 
 persons under 30 years of age. M. Favart, 1 who sent an account of 
 this epidemic to the Academy of Medicine at Marseilles, estimated the 
 number of the inhabitants of that city under 30 years of age at 40,000. 
 •Of those, about 30,000 had been vaccinated, 2000 had had small-pox 
 casually or by inoculation, and 8000 had had neither variola nor cow- 
 pox. Of this last class 4000, or 1 in 2, were attacked by small-pox, 
 and 1000 of them, or 1 in 4, died. Of those who had had small-pox 
 previously, only 20, or 6 in 1000, were again affected ; but 4 of these, or 
 1 in 5, died; while of the vaccinated, although 2000, or 1 in 15, had 
 it, yet it proved fatal only to 20, or 1 per cent. If we come down to 
 the present day, and to our country, the results at which we arrive are 
 but little less striking. During the recent epidemic prevalence of 
 small-pox in London and its vicinity in the years 1870-1872, the total 
 mortality among 3634 unvaccinated patients, at all ages, was at the 
 rate of 44.80 per cent., and among 11,174 vaccinated patients at the 
 rate of 10.15 per cent. Further, if the patients alleged to have been 
 vaccinated are divided into classes according as the evidence of efficient 
 vaccination is more or less conclusive, we find that the number of those 
 attacked diminishes in proportion to the number of vaccination -marks, 
 and also that the mortality lessens in the same proportion, until, in the 
 case of those in whom there are five marks or more as proofs of suc- 
 cessful vaccination, it amounts to only 5.5 per cent., or little more than 
 one-tenth of the mortality among the non- vaccinated. 2 
 
 It may indeed be said that vaccination has recently been put anew 
 upon its trial ; and the report to the House of Commons in 1871 of the 
 committee appointed to inquire into the operation of the Vaccination 
 Act of 1867, contains all that can be reasonably alleged, or I think I 
 may say fondly imagined, to the discredit of vaccination. The one 
 only fact of' importance put on record by the committee is that of the 
 occasional communication of syphilis by vaccination, to which Mr. 
 Hutchinson, of the London Hospital, had already drawn the attention 
 of the profession at a meeting of the Medico-Chirurgical Society, 3 as an 
 accident which, though very rare, was yet not of that extreme infre- 
 
 to which reference has already been made, contains a mass of most conclusive evi- 
 dence illustrative both of the value of vaccination, of the share which imperfect vac- 
 cination has in the production of its apparent failures, and lastly, of the extreme 
 importance of revaccination as a means by which, if it were but systematically 
 practiced, small-pox would be almost or altogether exterminated. The papers of 
 Mr. Marson and Dr. Balfour, originally published in the Medico-Chirurgical Trans- 
 actions, but reprinted in the Appendix to the Report, have afforded specially valu- 
 able elucidation of these last two points. 
 
 1 As reported by Steinbrenner, op. cit., p. 166. 
 
 2 See Tables in the Report of a Committee of the Managers of the Metropolitan 
 Asylum District, July 13, 1872. Folio. 
 
 3 Transactions of Medico-Chirurgical Society, vol. liv, 1872, and Proceedings, 
 1873, vol. vii, No. Ill, p. 109. 
 
VARICELLA, OR CHICKEN-POX. 64:1 
 
 quency which had been supposed, and not due in all instances, as it 
 appeared to have been in the cases previously related by Continental 
 observers, to grave carelessness on the part of the vaccinator. It is, 
 however, more satisfactory to know that no one could speak more 
 strongly than Mr. Hutchinson did, in spite of these facts, of the impor- 
 tance of vaccination, and next, that the precautions which he suggests 
 for the prevention of the evil are so simple, that nothing can be easier 
 than their observance. He advises first, that the possibility of this 
 disaster be always borne in mind by the vaccinator, next that he never 
 vaccinate from a child whose parents are unknown to him, and as far 
 as possible also not from first-born children, and lastly, that he invari- 
 ably take care to use only the perfectly transparent lymph, and to avoid 
 bloodstained lymph or any recent exudation from the walls of the 
 vesicle. 
 
 The influence of vaccination in rendering attacks of small-pox which 
 may succeed to it so much less severe and so much less dangerous than 
 the unmodified disease, does not in many instances manifest itself in 
 any diminution of the intensity of the primary fever. The symptoms 
 with which modified small-pox sets in are often as severe as those of 
 the unmodified disease, and are also in general of the same duration. 
 So soon as the eruption begins to make its appearance, however, the 
 difference between the two diseases usually becomes apparent. In 
 many instances, notwithstanding the sharp onset of the patient's illness, 
 the eruption is exceedingly scanty, not more than from twenty to a 
 hundred pustules appearing over the whole body. In other instances, 
 the eruption is much more abundant, and in a few exceptional cases 
 the pustules are actually confluent. But even when they are most 
 numerous, the pustules seldom fail to follow a different course from 
 that which they pursue in ordinary variola, and run through their 
 different stages within little more than half the period required by the 
 eruption of unmodified small-pox. The small size of the pocks, the 
 frequent absence of the central depression, their imperfect suppuration, 
 and their speedy desiccation, are the chief local characters of this affec- 
 tion ; while the almost complete absence of the secondary fever, is both 
 its grand constitutional peculiarity and the main source of the patient's 
 safety. 
 
 Besides the modified small-pox to which reference has just been made, 
 there is another and still milder affection often observed in children, to 
 which, from the extreme lightness of the symptoms that usually attend 
 it, the diminutive appellation of varicella or chicken-pox has been given. 
 Much difference of opinion has existed with reference to the relations 
 borne by this disease to small-pox ; and even at the present day writers 
 are not quite agreed whether to regard it as an extremely mild form of 
 variola, or as an affection altogether distinct from it. The weight of 
 evidence, however, is decidedly in favor of the opinion that varicella is 
 an affection distinct from, and wholly independent of, small-pox, not 
 being produced by any modification of the poison of that disorder, nor 
 affording any kind of protection from its attacks. 
 
 Varicella is almost exclusively a disease of childhood, and in the 
 great majority of cases it occurs prior to the completion of the first 
 
 41 
 
642 
 
 dentition. Its initiatory fever, which is scarcely ever severe, is some- 
 times altogether wanting, so that the appearance of the eruption on the 
 surface is the first occurrence that calls attention to the child's condi- 
 tion. Now and then, however, exceptions occur to this mildness in the 
 onset of the disease ; and I have occasionally seen children (chiefly those 
 in whom the process of dentition was going on with activity at the time 
 of the attack) suffer for twenty-four or thirty-six hours from febrile 
 symptoms quite as severe as those which precede the outbreak of mea- 
 sles, or as accompany a sharp attack of influenza. The duration of this 
 premonitory stage of chicken-pox is somewhat uncertain ; the vesicles 
 which characterize it making their appearance after twenty-four hours 
 in some cases, not for thirty-six or forty-eight hours in others ; while, 
 as already mentioned, the eruption is occasionally the first symptom of 
 the existence of the disease. 
 
 The eruption usually consists of more or less numerous minute, cir- 
 cular vesicles, containing a transparent serum, irregularly distributed 
 over the face, head, shoulders, and trunk, but rarely appearing on the 
 lower extremities; and, even when present in considerable abundance, 
 being very seldom confluent at any part. These vesicles differ essen- 
 tially from those of small-pox in the absence of the central depression and 
 of the multilocular structure which characterize the varioloid pustules. 
 The former, composed of a single cell, collapse at once if punctured, 
 but no such effect follows puncture of the small-pox pustule. For two 
 or three days the vesicles of chicken-pox increase somewhat in size, but 
 their contents then become turbid and milky ; about the fourth or fifth 
 day they shrivel, and then dry up into a light pulverulent scab, which 
 falls off on the eighth or ninth day of the disease. It very seldom hap- 
 pens that any cicatrix is left after the detachment of the scab of vari- 
 cella, unless the skin has been irritated by the patient scratching it in 
 order to relieve the itching, which is sometimes very troublesome. Be- 
 sides these differences between the eruption of chicken-pox and that of 
 variola, another, and still more striking peculiarity of the former dis- 
 ease consists in the appearance of two or three successive crops of vesi- 
 cles, so that after-the third day of the affection vesicles may be observed 
 close to each other in all stages of their progress. 
 
 The disease is one so void of danger, that it requires hardly any 
 treatment beyond the adoption of a mild antiphlogistic regimen ; and 
 no complications occur during its course, nor sequelae remain after its 
 disappearance, concerning which anything more need be added. 
 
MEASLES AND SCARLET FEVER. 643 
 
 LECTUEE XLIV. 
 
 Measles once confounded with scarlatina, though essentially different diseases. — 
 Share of contagion in producing it — Symptoms of measles — Its dangers depend 
 chiefly on its complications — With convulsions, with inflammation of the lungs, 
 which occurs at different stages of the disease — Sequelae of measles — Treatment. 
 
 Scarlatina. — Great differences in its severity in different cases — Its three varie- 
 ties — Scarlatina simplex — Scarlatina anginosa — Sources of danger in it — Its 
 disposition to assume characters of scarlatina maligna — Occasional rapid course 
 of that variety — Modes in which it proves fatal — Complications and sequelae of 
 the disease — Diagnosis — Treatment, use of inunction — Treatment of compli- 
 cations. — Prophylaxis, use of belladonna. 
 
 When the short-lived prejudices which at first were entertained 
 against vaccination had been removed, men passed, as they not seldom 
 do, to the opposite extreme, and overestimated the worth of that dis- 
 covery which they had before undervalued. Physicians rejoiced in it, 
 as a means of getting rid forever of a disease which might well be 
 counted among the opprobria of their art — philanthropists exulted in 
 the probable extermination of one of the most terrible scourges of the 
 human race, and statisticians counted the increase brought to the popu- 
 lation, and drew up elaborate tables to illustrate their bright anticipa- 
 tions of the future. 1 In these oversanguine calculations, however, they 
 almost entirely lost sight of the fact, that not all who were preserved 
 from small-pox would be added to the useful population of the country, 
 but that the life of many would be prolonged only for a short season, 
 to be cut off soon by some other disease, against which neither science 
 nor fortunate accident has hitherto discovered a talisman. Experience 
 has proved the truth of what calm reflection might have suggested, and 
 with the diminution in the frequency of small-pox there has been an 
 increase, though not to an equal extent, in the prevalence of measles and 
 scarlatina. 
 
 It is not easy to state with exactness the amount of mortality which 
 these two diseases occasion, for though they are never altogether absent 
 from a large city like London, yet their frequency and their fatality 
 vary much in different years. At one time they occur sporadically, 
 and are then in most instances mild in their character and readily 
 amenable to treatment ; while at another time they prevail as epidemics, 
 and are attended with alarming symptoms which it is often not in the 
 power of medicine to control. Dr. Gregory, who, in his work on the 
 Eruptive Fevers has collected together with much labor the statistics 
 of these diseases, presents us with a table, from which it appears that, 
 on an average of five years, very nearly six per cent, of the mortality of 
 London is due to measles and scarlatina. This number, indeed, is not 
 
 1 As an instance of which may be mentioned the work of Duvillard, De l'lnflu- 
 ence de la Petite- Verole sur la Mortalite, 4to., Paris, 1806. 
 
644 CONTAGION OF MEASLES: 
 
 so great as at once to impress us with the formidable nature of these 
 two affections ; but it should not be forgotten, that (according to the 
 Fifth Report of the Registrar-General) 81 per cent, of this mortality 
 occurs in children under five ; and 97 per cent, in children under ten 
 years old ; while no figures can accurately represent the instances in 
 which death is occasioned by their complications or their sequelae. 
 
 These two diseases present many points of resemblance, — so many, 
 indeed, that they were long supposed to be but varieties of the same 
 malady ; and the essential differences between them were not recognized 
 till within the last eighty years. It is, however, on many accounts 
 important to distinguish between them, — for not only are they not 
 attended by the same degree of danger, but this danger arising from 
 dissimilar causes, the treatment which they require is in many respects 
 different. We shall presently examine into some of those peculiarities 
 in their symptoms on which we chiefly rely in forming our diagnosis 
 between the two affections ; but I may even now state some of the 
 broad distinctions between them. 
 
 Measles is still more eminently than scarlet fever a disease of early 
 childhood, — for of 1293 deaths which it occasioned in London in 1842, 
 93.8 per cent, occurred in children under five years old, and 99 per 
 cent, in those under the age of ten ; while of 1224 deaths from scarla- 
 tina, 31 per cent, occurred after five, and 10 per cent, after ten years 
 of age. Though there are great fluctuation both in its prevalence and 
 in the mortality which it occasions, yet its variations in these respects 
 are less considerable than those of scarlet fever; while the number of 
 persons who pass through life without having experienced its attacks 
 is smaller than of those who die without ever having been affected 
 with scarlatina. But though this is the case, and though we observe 
 the disease to occur in many instances where we are unable to trace 
 the influence of contagion, there yet seems good reason for the belief 
 that in every case it has been communicated through some medium or 
 other. Facts such as the absence of the disease for the period of thirty 
 years from the Cape of Good Hope, 1 and its development after the 
 arrival there of a vessel from Europe, in which several cases had oc- 
 curred during the voyage, substantiate the correctness of this opinion. 
 The strongest proof of it, however, is afforded by the circumstances in 
 which measles prevailed in the Feroe Islands in 1846, 2 after an inter- 
 val of sixty-five years. They were then introduced into one of these 
 islands by a workman, who leaving Copenhagen on March 20th, 
 reached the Feroe Islands on the 28th, apparently in good health, 
 but fell ill with measles on April 1st. His two most intimate friends 
 were next attacked; and from that time the disease could be traced from 
 hamlet to hamlet, and from island to island, until 6000 out of a total 
 population of 7782 had been attacked by it; age bringing with it no 
 immunity from the contagion, though the disease was found to spare 
 all who in their childhood had suffered from it at the time of the pre- 
 
 1 Mentioned by Dr. Copland, in his Dictionary, art. " Measles," vol. ii, p. 822. 
 
 2 Of which an account, by the commissioner from the Danish Government, Dr. 
 Pannum, is given in the Archives Gen. de Med., April, 1851. 
 
ITS SYMPTOMS. 645 
 
 vious epidemic. It is probable, then, that the extreme contagiousness 
 of measles is the reason of its greater prevalence, and that it is so 
 peculiarly a disease of early life not so much on account of any special 
 susceptibility to it then, as because the subtle materies morbi is so widely 
 diffused as to leave little chance of any escaping it. 
 
 Though a more universally prevalent disease, however, than scarla- 
 tina, it is fortunately less dangerous, its mortality not exceeding 3 per 
 cent, of the patients attacked by it, while the average rate of mortality 
 from scarlet fever is estimated as at least double that amount. When 
 measles proves fatal, too, it is very seldom the fever itself which occa- 
 sions the patient's death, but generally its complication with inflam- 
 matory disease of the respiratory organs. Scarlet fever, on the con- 
 trary, destroys its victims in all stages of the disease; and in many of 
 the worst cases, in which death takes place early, no organic change is 
 left behind which the scrutiny of the anatomist can discover. 
 
 Within a period of thirteen or fourteen days (according to the ob- 
 servations made on this subject in the Feroe Islands) from the recep- 
 tion of the contagion, the eruption of measles makes its appearance. 
 But though this period is tolerably constant, the duration of the pre- 
 monitory symptoms is very variable; the fourth day being that on 
 which the rash most frequently appears, but the extremes varying as 
 widely as twenty-four hours, and thirteen days, according to the care- 
 ful observations of M. Rilliet. In the premonitory symptoms them- 
 selves, there is little besides their greater severity to distinguish them 
 from ordinary catarrh. A child, previously in perfect health, becomes 
 suddenly restless, thirsty and feverish, and, if able to talk, generally 
 complains of headache. The eyes grow red, weak, and watery, and 
 are unable to bear the light ; the child sneezes very frequently, some- 
 times almost every five minutes, and is troubled by a constant short 
 dry cough. Usually, on or about the fourth day from the commence- 
 ment of these symptoms, a rash makes its appearance on the face, 
 whence it extends in the course of about forty-eight hours to the rest 
 of the body and the extremities, travelling in a direction from above 
 downwards. The rash is made up of a number of minute deep-red, 
 circular stigmata not unlike flea-bites, slightly elevated, especially on 
 the face, and though close together, yet usually distinct from each 
 other, the skin in the interspaces between them retaining its natural 
 color. On the cheeks, the spots sometimes become confluent, and then 
 form irregular blotches about a third of an inch long by half that 
 breadth, while the spots elsewhere often present an indistinctly cres- 
 centic arrangement. The eruption fades in the same order as that in 
 which it appeared, and after the lapse of forty-eight hours from its 
 appearance, at which time it is at its height on the trunk, it is begin- 
 ning to disappear from the face. On the seventh day of the disease 
 the rash grows faint on the body generally, and on the eighth, or at 
 latest the ninth day, it has entirely vanished, leaving behind either a 
 little general redness of the surface, or a few yellowish-red spots, cor- 
 responding to some of the situations which the eruption itself had 
 occupied. In some cases a partial desquamation of the cuticle takes 
 
64:6 COMPLICATIONS OF MEASLES: 
 
 place after the rash has disappeared ; but this is by no means constant, 
 while, when it occurs, the epidermis separates in minute branny scales, 
 never in large portions, as it often does after scarlatina.^ 
 
 Unlike small-pox, in which the appearance of the eruption is imme- 
 diately followed by the subsidence of all the previous symptoms, the 
 constitutional disturbance of measles is often not at all alleviated on 
 the outbreak of the rash. The reverse, indeed, is frequently the case ; 
 and in many instances, for twenty-four or forty-eight hours afterwards, 
 the fever is aggravated, and the cough more troublesome than before, 
 while the voice often becomes hoarser, and the throat is somewhat sore 
 in consequence of the inflammation of the palate and fauces, which 
 may be seen to be the seat of a punctated redness, resembling that pro- 
 duced by the eruption on the skin. 
 
 The aggravation of the symptoms, however, when it does occur, is 
 only temporary ; and on the sixth day of the disease, if not sooner, an 
 amelioration in the patient's condition becomes apparent ; the fever 
 diminishing, the cough growing looser and less frequent, and moist 
 sounds becoming audible in the lungs, where previously nothing was 
 heard but rhonchus or sibilus. This amelioration goes on slowly from 
 day to day, and in ten days or a fortnight from the first symptom of 
 illness, convalescence is, in favorable cases, fully established. 
 
 Such as I have described, and sometimes even less severe, are the 
 symptoms of uncomplicated measles; a disease attended by discomfort 
 rather than danger, and requiring judicious nursing more than actual 
 medical interference. But to this favorable course of the disease there 
 are numerous exceptions, and these are more frequent in some epi- 
 demics than in others. Occasionally, though very rarely, the out- 
 break of the eruption is preceded by convulsions, which subside even 
 before the rash becomes visible, and are not succeeded by any more abid- 
 ing symptom of cerebral disorder. Only one instance of this, however, 
 has come under my notice ; and that was in a child aged two years and 
 ten months, in whom also an attack of chicken-pox a year before had 
 been ushered in by convulsions. The fits in this case ceased of their 
 own accord, though the rash of measles did not come out till twenty- 
 four hours afterwards. There are, however, a few instances on record 
 of the supervention of convulsions after the eruption has shown itself, 
 and of their succeeding each other rapidly till the patient's death ; and 
 others in which the sudden disappearance of the rash has been suc- 
 ceeded by violent convulsions. 
 
 Dangerous complications of measles, however, but seldom present 
 themselves-on the side of the nervous system, but generally assume the 
 form of disorders of the respiratory organs. The cough, and hoarse- 
 ness, and suppressed voice which accompany the onset of measles, are 
 sometimes so marked as to raise the apprehension that croup is about 
 to come on ; and now and then this actually occurs, though in the 
 great majority of instances the symptoms apparently so threatening 
 subside readily under small doses of antimonial and anodyne medi- 
 cines. The risk, indeed, either of real cynanche trachealis coming on, 
 or of that form of ulcerative laryngitis to which I referred some days 
 
IMPERFECT APPEARANCE OF THE RASH. 647 
 
 ago 1 attacking the patient, is much greater when the eruption is on the 
 decline, or even at a later period, constituting a sequela of the disease 
 more often than an actual complication. 
 
 The most serious as well as the most frequent complication of measles 
 is that with bronchitis or pneumonia. This is not equally frequent 
 at all periods of the disease, being much commoner about the third or 
 fourth day of the eruption than at an earlier time; while on the decline 
 of the disease it is likewise that sequela against which we have to watch 
 with the most sedulous care. When pulmonary inflammation comes on 
 early in the disease, the retrocession of the eruption from exposure to 
 cold is its most frequent cause, though sometimes it seems to occur 
 causelessly, its symptoms developing themselves simultaneously with 
 the outbreak of the rash. In that case, however, the rash almost in- 
 variably fades earlier than it should do, and disappears in thirty-six or 
 forty-eight hours ; no desquamation succeeding to it, nor any roughness 
 of the skin remaining behind ; while the pulmonary affection runs its 
 course rapidly to a fatal issue. 
 
 In other instances the rash comes out imperfectly, and presents from 
 the first a dark, livid hue, almost like that of the rash in some cases of 
 malignant scarlet fever ; while coupled with this there are great oppres- 
 sion and extreme dyspnoea ; and subcrepitant rale, more or less abun- 
 dant, is perceptible in the chest. Cases of this congestive form of 
 measles are, I believe, less common now than they were some forty years 
 ago, when the fevers which our fathers treated seemed to require free 
 venesection, and actually benefited by its employment. I will there- 
 fore relate to you a well-marked instance of it, both to point out its 
 general characters, and also to impress upon you the necessity for 
 occasionally adopting a much more active mode of treatment than is 
 applicable to the great majority of the cases of measles which at present 
 come under our notice. 
 
 A little girl, ten years of age, had had slight catarrhal symptoms for 
 a few days, w r hen she was attacked, on the evening of June 7th, 1843, 
 by shivering, pain in the head, and a feeling of sickness. Her head 
 pained her much, and she was very drowsy on the two following days, 
 and on the 10th she came under my notice, when, though no eruption 
 had appeared on the surface, yet the child's history, coupled with the 
 severity of her catarrhal and febrile symptoms, left little room for 
 doubting that she was about to have an attack of measles. On the 
 evening of the 11th of June the rash appeared, and twenty-four hours 
 afterwards I visited the child at her mother's request, who told me that 
 though the rashw^as fully out, yet the respiration was greatly oppressed. 
 The child was lying in bed, her face puffy, covered by an abundant 
 purple-red rash, of an almost livid hue. The rash was in patches of 
 an irregular form and size, running into each other ; while a few small, 
 slightly elevated, dark-purple stigmata were scattered here and there, 
 and a few also were collected together into a crescentic arrangement. On 
 the arms and legs the rash had not the patchy appearance, but an im- 
 mense number of distinct stigmata, very like petechias, except that they 
 
 366. 
 
648 COMPLICATIONS OF MEASLES. 
 
 were a little larger, and slightly raised, covered the skin. The eyelids 
 were much swollen, and glued together by a thick gummy secretion ; 
 the lips were dry, the teeth covered with sordes, the tongue very red, 
 dry, and glazed in the centre, with a thin coating of yellow fur at the 
 edges; and the nares were perfectly dry. The pulse was 110, hard; 
 respiration sixty in the minute, hurried, loud, and wheezing, interrupted 
 by very frequent hard and short cough. The child was very drowsy, 
 but sensible when roused, and she then complained of pain in the chest, 
 and of great soreness of all her limbs. 
 
 Air did not enter the lungs freely, and on a deep inspiration sub- 
 crepitant rale was heard in both infrascapular regions, especially in 
 the right. The child was at once bled to 5yj, which, however, did not 
 cause faintness, and was ordered J gr. of tartar emetic every four hours. 
 
 The good effect of these measures was not immediately apparent, but 
 in the course of some six hours the child felt relief. Early on the fol- 
 lowing morning I saw her, and found that the rash had completely 
 lost its patchy character, and was now universal over the whole body, 
 while it was of a bright red color, almost as vivid as the rash of scarlet 
 fever. The tongue was no longer glazed and dry, nor were the teeth 
 covered with sordes, while the respiration, though still fifty-six in the 
 minute, was neither so hurried nor so oppressed as on the previous day, 
 and the cough had lost much of its hardness. The auscultatory symp- 
 toms, however, were not much altered. The antimonial plan of treat- 
 ment was continued, but as on the following day the cough was harder, 
 and the subcrepitant rale more abundant, §iv of blood were taken by 
 cupping from between the scapulse, and from this period no unfavora- 
 ble symptom manifested itself. 
 
 This case, however, and cases similar to it, may be regarded as ex- 
 ceptional. In most instances, either the slight cough which accom- 
 panied the early stage of measles increases in severity with the progress 
 of the disease, and the signs of thoracic mischief creep on gradually 
 till they assume an alarming character about the fifth or sixth day ; 
 or in other cases the symptoms of affection of the chest do not mani- 
 fest themselves at all till the eruption is already declining. I believe 
 that the chest complication is generally serious in proportion as it comes 
 on early and sets in severely ; though still more hazardous are the re- 
 lapses which sometimes succeed to improvement, even after it has per- 
 sisted for three or four days, and which are peculiarly unmanageable, 
 and issue with great rapidity in extensive hepatization of the lung. 
 The symptoms to which inflammation of the lungs at the decline of 
 measles gives rise are sometimes very slight, so slight that nothing 
 short of careful daily auscultation will in many instances suffice to de- 
 tect it. Two circumstances which are especially calculated to mislead, 
 are the fact that the pneumonia is often unattended by much cough or 
 dyspnoea, while it is frequently associated with considerable sympathetic 
 disturbance of the stomach and bowels. The course of the affection of 
 the lungs in these cases is usually chronic; the child loses flesh, becomes 
 the subject of an irregular hectic fever, and when at length the thoracic 
 symptoms become more apparent than at first they had been, and when 
 the cough grows more frequent, and is attended by some expectoration, 
 
TREATMENT OF MEASLES. 649 
 
 the case so closely resembles one of acute tubercular phthisis that it is 
 extremely difficult to avoid an erroneous diagnosis. 
 
 That extreme susceptibility of the mucous membranes, to which are 
 due the persistence of the cough, the supervention of bronchitis, or the 
 occurrence of ulcerative inflammation of the fauces and larynx on the 
 decline of the rubeoloid eruption, very frequently extends to the intes- 
 tinal canal and gives rise to diarrhoea. The character of the attack 
 corresponds in general to those which some days ago I described under 
 the name of catarrhal diarrhoea, and in the greater number of instances 
 its symptoms yield readily to treatment. Among the poor, however, 
 who, in accordance with the notions of humoral pathology current 
 among the vulgar, generally regard looseness of the bowels after fever as 
 a salutary provision of nature, I have not infrequently met with cases 
 of neglected diarrhoea, in which the symptoms have put on a dysenteric 
 character, and have either seriously threatened life, or in some instances 
 have actually destroyed it. Sometimes, too, the acute stage of diarrhoea 
 is succeeded by an habitual chronic relaxation of the bowels, not only 
 serious in itself, but still more so from its persistence, not infrequently 
 issuing in the development of phthisical disease. 
 
 This last hazard is one which, though perhaps overrated by the older 
 observers, who had not the means which we now possess of forming a 
 correct diagnosis, is yet a very real one, and one too against which it 
 behooves us to be on our guard, not simply during the decline of the 
 eruption, but also throughout the whole period of convalescence. 
 Phthisis coming on early in the disease often runs an acute course, de- 
 veloping itself apparently out of the fever itself, and being often diffi- 
 cultly distinguished from the inflammatory affection of the lungs, of 
 which I have already spoken. When it comes on later its course is 
 more chronic, its symptoms are more easily recognizable as those of 
 ordinary phthisis, and the child's history is that of an incomplete re- 
 covery from measles having been succeeded by progressive failure in 
 health, and by the gradual appearance of consumption, which proves 
 fatal in some months, or a year, or even not till after a longer period 
 from the occurrence of the fever. 
 
 The danger of measles, you must have already seen, depends almost 
 exclusively on its complications, and as in their absence there is little 
 to excite alarm, so also there is little to call for treatment. In mild 
 cases, indeed, scarcely anything is needed beyond confinement to a warm 
 chamber, a spare diet, and gentle antiphlogistic remedies. The cough, 
 which is the most troublesome symptom — frequently, indeed, the only 
 one that calls for much attention — is often very much relieved by the 
 application for three or four hours of a small blister, no bigger than a 
 shilling, to the trachea, at the point just above the sterum; and this 
 slight counter-irritation, which seldom produces any vesication of the 
 surface, may be repeated during the course of the affection. If more 
 than this is needed, small doses of antimonial and ipecacuanha wine, 
 with laudanum or the compound tincture of camphor, may be given 
 every few hours. The imperfect desquamation that sometimes takes 
 place as the eruption declines, is often attended with very distressing 
 itching of the whole surface; while the cough is sometimes frequent 
 
650 TREATMENT OF COMPLICATIONS OF MEASLES. 
 
 and troublesome at night, and the child is thus prevented from sleep- 
 ing. To relieve these troublesome symptoms, as well as to check that 
 tendency to diarrhoea which often comes on at the decline of measles, 
 it is desirable to follow the plan pursued by Sydenham, and to give an 
 opiate every night, — a small dose of Dover's powder being the best 
 form in which it can be administered, while the warm bath every even- 
 ing both soothes the patient and expedites the completion of the des- 
 quamative process. 
 
 But though these simple measures are amply sufficient in the great 
 majority of cases, we yet must not allow ourselves to be betrayed into 
 inertness when any indications of mischief in the chest make their 
 appearance. Such symptoms sometimes come on early in the disease, 
 and before the eruption has well appeared, the child seeming much op- 
 pressed, and experiencing considerable dyspnoea, although the auscul- 
 tatory evidences of disease in the chest may be but small. This nervous 
 dyspnoea is often relieved by the application of a mustard poultice to 
 the chest, and by placing the child in a hot bath — a proceeding which 
 will very frequently be followed by the appearance of the rash abun- 
 dantly over the whole surface. Should these measures, however, fail 
 to produce relief, or should the symptoms from the first be alarming, 
 the distress and dyspnoea very considerable, and the rash not merely 
 scanty, but of a dark or livid hue wherever it has appeared, as in the 
 case I just now related to you, the abstraction of blood is urgently 
 required ; and general depletion should, in such circumstances, be em- 
 ployed in preference to merely local bleeding. If bronchitis or pneu- 
 monia should come on at a later period of the disease, when the rash 
 has already fully appeared, or is beginning to decline, the question of 
 bleeding, as well as of the mode in which the depletion shall be prac- 
 ticed, must be determined entirely by the severity of the chest symp- 
 toms, and is little if at all modified by any considerations drawn from 
 the circumstance of their supervening during the course of another 
 disease. The unfavorable conditions under which infants are placed 
 in the Hopital des Enfaus at Paris, have induced, on the part of French 
 physicians, a dread of depletion in the course of measles which is cer- 
 tainly not justified by the characters that the disease presents in this 
 country. A repetition of depletion is, however, not generally either 
 necessary or useful, especially if the first abstraction of blood is followed 
 up, as it ought to be, by the free employment of tartar emetic. The 
 dyspnoea, which is frequently exacerbated towards evening in the 
 course of the pneumonia and bronchitis that accompany measles, is 
 generally much relieved by mustard poultices; but the application of 
 blisters in these circumstances is hazardous, siuce the sores which they 
 produce are often very intractable ; and the irritation and suffering they 
 occasion prove, in many instances, seriously prejudical to the children. 
 It is important, too, to bear in mind that little reliance can be placed 
 on mercurial remedies in the treatment of active rubeolous pneumonia, 
 though small doses of the Hydr. c. Creta with Dover's powder, are 
 often exceedingly useful in cases where a hepatized state of the lung is 
 left behind after the subsidence of the fever, and of the more acute in- 
 flammatory symptoms. I spoke so fully some time since concerning 
 
SYMPTOMS OF SCARLATINA SIMPLEX. 651 
 
 croup succeeding to measles, that it cannot be necessary to repeat the 
 remarks which were then made ; neither need I add anything to what 
 I said on a former occasion about canerum oris — which distressing 
 affection occasionally supervenes on its decline, as also does otorrhoea, 
 though with far less frequency than after scarlatina. The period of 
 convalescence, too, and the ailments which I have referred to as some- 
 times coming on at that time, require no special notice now. I have 
 described the dangers ; the general principles of medical treatment must 
 guide your endeavors either to avert or to remove them. 
 
 I will now T , in conclusion, briefly sketch the most striking features 
 of scarlet fever. Like measles, it is a disease chiefly occurring in early 
 childhood, and the highest mortality from it takes place during the 
 third year of life. 1 It differs, however, from measles, as I have already 
 stated, in not being so generally prevalent at all times, but usually as- 
 suming an epidemic form for a season, and then for months disappear- 
 ing altogether. Its characters also are more variable than those of 
 measles, and one epidemic is often marked by certain distinguishing 
 features quite dissimilar from those which characterized a previous, or 
 wdiich may be observed in a succeeding epidemic. Even when it occurs 
 in a sporadic form its characters are very variable. It presents itself 
 in one case as an ailment so trifling as scarcely to interrupt a child's 
 cheerfulness even for a day ; in another it is so deadly that medicine is 
 unable to stay its course even for a moment, and that it destroys life in 
 a few days, sometimes even in a few hours. 
 
 These remarkable variations in the character and severity of the 
 affection, and in the symptoms which attend it, have given rise to its 
 subdivision into the three varieties of scarlatina simplex, scarlatina 
 anginosa, and scarlatina maligna. In the first of these the patient ex- 
 periences an attack of fever, often very mild, always of very short du- 
 ration, and accompanied by the appearance of a bright scarlet rash 
 over the w r hole surface, and generally by a slight degree of sore throat. 
 In the second the fever is more intense and subsides less speedily, while, 
 as its name implies, the attendant sore throat is very severe ; and in the 
 third the fever generally assumes a typhoid character, sloughing of the 
 inflamed tonsils not infrequently occurs, and a variety of complications in 
 many instances supervene, by which the danger is still further aggra- 
 vated. 
 
 The symptoms of scarlatina usually set in within three days after 
 exposure to its contagion : often indeed the incubation period of the 
 disease is much shorter, sometimes even less than twenty-four hours; 
 while, according to Dr. Murchison's experience, the extreme period 
 does not exceed six days. The law, however, which governs the time 
 of its latency is liable to far greater fluctuations than occur in the 
 case of either small-pox or measles. The symptoms with which the 
 mildest form of the disease, or the scarlatina simplex, sets in, vary very 
 much in degree, and sometimes are so slight that the appearance of 
 the rash upon the surface, usually with, but sometimes even without 
 
 1 See Table by Dr. Tripe, in Med.-Chir. Keview, Jan. 1854, p. 238, whose con- 
 clusions are in the main, identical with those to which Dr. Murchison's independent 
 researches have led. him. See his Lectures in the Lancet for June 18, 1864. 
 
652 SYMPTOMS OF SCARLATINA SIMPLEX. 
 
 slight sore throat and feverish ness, may be the first indication of the 
 existence of an affection which sometimes is so deadly. In the ma- 
 jority of cases, however, it is ushered in by vomiting once or oftener, 
 accompanied by headache, heaviness of head, great heat of skin, and 
 some measure of sore throat. The amount of sensorial disturbance at 
 the onset of the attack usually furnishes some measure of the probable 
 subsequent severity of its course, though in children whose brain for the 
 most part is readily disturbed, delirium sometimes occurs within the 
 first twenty-four hours of an attack of scarlatina, but then passes away, 
 and the fever runs its subsequent course quite mildly. On the mor- 
 row, often indeed within twenty-four hours from the commencement 
 of the patient's illness, the rash of scarlatina makes its appearance. It 
 usually shows itself first on the neck, breast, and face, whence it 
 extends, in the course of twenty-four hours, to the trunk and extremi- 
 ties. Its color is a very bright red, due in part to a general flush of 
 the skin, in part to the presence of innumerable red dots or spots, 
 which look like minute red papillae, though often' they communicate 
 no sense of roughness to the hand. To this, however, there are occa- 
 sional exceptions : the rash on the chest and body presenting some- 
 times, when at its height, a slightly papular character ; and now and 
 then minute sudamina are intermingled with the eruption. In some 
 instances the redness of the surface is universal, but in other cases the 
 rash appears in patches of uncertain size and irregular form, which 
 never affect any definite shape, and never present a clearly circum- 
 scribed margin. For three days the rash usually continues to become 
 of a deeper color, and more generally diffused over the whole surface ; 
 it then slowly declines, but does not wholly disappear until the seventh, 
 or sometimes the eighth day of the disease. The appearance of the 
 eruption is not in general succeeded by any immediate diminution in 
 the other symptoms ; but on the contrary, they often increase in se- 
 verity until the eruption has reached its acme, when they slowly 
 decline with the disappearance of the rash. Sometimes, indeed, w T hen 
 the case as very mild, the fever abates so soon as the rash is fully out; 
 and the child regaining its cheerfulness on the third day, shows no 
 further signs of illness, though the rash remains visible for two or three 
 days longer. Now and then, too, as I have mentioned, especially in 
 young infants, the affection throughout consists of little more than an 
 eruption on the skin, the presence of which is almost, occasionally 
 altogether, the only evidence of their having been attacked by the dis- 
 ease. Such, however, are exceptional cases ; and in most instances, 
 even when the disease is mild, a slight degree of soreness of the throat 
 comes on on the second or third day ; the palate and tonsils appear 
 red, the latter are generally somewhat swollen, and deglutition is 
 slightly impeded. The tongue also is preternatural ly red, and its 
 papillae, which are very prominent, project through the white or yel- 
 lowish fur which coats it, and thus form an appearance as character- 
 istic of scarlatina as the rash itself. The redness fades from the fauces 
 and the fur disappears from the tongue, as the eruption declines ; but 
 the prominence of the papillae often continues for some days longer, 
 and the tongue presents a vivid red color, and appears raw, as if from 
 
SYMPTOMS OF SCARLATINA ANGINOSA. 653 
 
 the absence of its ordinary mucous coating. As the rash subsides, 
 desquamation of the epidermis generally commences, the cuticle peel- 
 ing off from the hands and feet in large flakes, though on the face 
 and trunk the desquamation usually takes place in furfuraceous scales. 
 Both its degree and duration vary much in different cases ; sometimes 
 it is over in five or six days, while in other cases the cuticle is repro- 
 duced, and then desquamates several times in succession, and the pro- 
 cess is thus protracted for three or four weeks, or even longer. It is 
 not possible to assign a cause for these differences. Some epidemics of 
 scarlatina are characterized by the abundance of the desquamation, and 
 its almost universal occurrence, while at other times it is scanty, and 
 often wanting. 
 
 The danger of this disease is by no means in proportion to the 
 abundance of the rash, but rather to the degree of the affection of the 
 throat, the severity of which is the distinguishing feature of scarlatina 
 anginosa. In this form of the affection the premonitory symptoms are 
 usually much more severe than in the scarlatina simplex : they are 
 also often of longer duration, the rash not showing itself until the end 
 of the second, and sometimes even not until the third day. It is, 
 moreover, less generally diffused over the surface than in the milder 
 variety of the disease, but appears in the form of large scarlet patches 
 irregularly distributed over different parts of the body, especially on 
 the back. In some cases, too, of this variety of scarlet fever, though I 
 think more commonly in the adult than in the child, the rash is alto- 
 gether wanting, fever and sore throat alone characterizing the disease. 
 In such cases its real nature is sometimes not suspected until other 
 members of the same family are seized with similar symptoms, coupled 
 with a well-marked scarlatinal rash ; or, until perhaps the occurrence 
 of dropsy during convalescence awakens suspicion as to the nature of 
 the previous illness. Almost from the commencement of the attack, 
 soreness of the throat is experienced, attended with difficulty of deglu- 
 tition, and often with considerable stiffness of the neck, and pain and 
 difficulty in moving the lower jaw, due in part to the swelling of the 
 submaxillary glands. On examining the throat, it is seen to be in- 
 tensely red, and the tonsils are both red and swollen. The swelling of 
 the tonsils increases rapidly, until they almost block up the entrance 
 to the pharynx, and thereby render the attempt to swallow so difficult 
 that fluids are often returned by the nose. An adhesive mucus collects 
 about the back of the throat, and often seems to cause great annoyance 
 to the patient, and specks or patches of lymph form upon the tonsils, 
 and look like sloughs covering ulcers, though, on detaching them, it is 
 seldom that any breach of surface appears beneath. In some of the 
 severest cases, a very troublesome coryza comes on, and an adhesive, 
 yellowish matter is secreted in abundance by the mucous membrane of 
 the nares, whence it runs down upon the upper lip, excoriating the 
 skin over which it passes, and causing still more serious suffering by 
 the obstacle that it presents to free respiration. In some epidemics the 
 inflammation extends to the parotid glands, and to the cellular tissue 
 about the neck, the parts thus affected becoming rapidly swollen, and 
 acquiring a great size and a stony hardness. In some cases this affec- 
 
654 SYMPTOMS OF SCARLATINA ANGINOSA. 
 
 tion is confined to one side ; in others, both sides are attacked in suc- 
 cession, while sometimes both are involved simultaneously; the integ- 
 uments under the chin and in front of the neck become likewise in- 
 flamed and tense and swollen ; and the lower jaw is so firmly fixed, 
 that the attempt to swallow is rendered almost impracticable, so that 
 the patient is exposed to a new source of danger, from the difficulty of 
 taking nutriment in quantity sufficient to support the feeble powers of 
 life. Coupled w r ith this severe local affection, there is, as might be 
 expected, a corresponding intensity of the constitutional disturbance. 
 The heat of the skin is very great, the pulse extremely frequent, and, 
 though not small, it is yet from an early period very easily compressed; 
 the sensorial disturbance is considerable, and the restlessness extreme. 
 The tongue does not present that appearance which I mentioned as 
 being characteristic of scarlatina in its milder form, but is coated with 
 brown fur, though red at its tip and edges, and often becomes dry at 
 a very early period of the disease — partly, no doubt, in consequence of 
 the swelling of the tonsils and of the glands compelling the patient to 
 breathe with his mouth open. 
 
 In cases where the throat affection is very severe, the dyspnoea 
 arising from the difficult entrance of air into the lungs seems some- 
 times to be the chief cause of the patient's death ; though it is very 
 rarely, even when the pharyngitis is most intense, that the larynx 
 presents any signs of having been seriously involved in the mischief. 
 In the greater number of instances, however, that terminate fatally, 
 the local symptoms do not seem to be by any means the sole cause of 
 death, but the fever assumes more and more of a typhoid character, 
 and this even though the throat affection should not increase in sever- 
 ity, but should even retrograde. On the other hand, cases of simple 
 scarlatina anginosa generally have a favorable issue : for in spite of 
 the severe sore throat the constitutional disorder retains the characters 
 of active inflammatory fever, and begins to subside in three or four 
 days at the latest ; abating as the local symptoms themselves subside, 
 w r hich they generally do about this time. The sore throat, too, though 
 it comes on early, increases rapidly, and soon attains a great severity, 
 is yet not accompanied in the majority of instances by great swelling 
 of the submaxillary glands, which do not assume that stony hardness, 
 nor do the surrounding integuments acquire that swelling or tension 
 which are observed in less favorable cases. Between the severer forms 
 of scarlatina anginosa, and that still more dangerous variety of the 
 disease to which the name of malignant has been applied, the differ- 
 ences are often rather of degree than of kind. In malignant scarlet 
 fever, however, the sore throat, though a general is by no means a con- 
 stant symptom ; death takes place in some instances before it has man- 
 ifested itself with much severity, whilst in many other cases it is only 
 one of several symptoms which threaten the patient's life. 
 
 Cases of scarlatina anginosa, even when running; the least favorable 
 course, occupy some days before the dangerous character of the disease 
 becomes fully developed. The malignant form, however, sets in with 
 ill-omened symptoms, and these sometimes are so intense as to carry off' 
 the patient in less than forty-eight hours. One such case I remember, 
 
OCCASIONAL RAPIDITY OF ITS COURSE. 655 
 
 in which, after exposure to the contagion of scarlatina, convulsions suc- 
 ceeded by coma destroyed in a single day a previously healthy boy of 
 two years of age. In other instances, the onset of the disease announces 
 itself by sudden and intense collapse, from which the patient rallies, 
 but sinks under it in one or two days. Dr. Henry Kennedy, in his 
 very excellent account of the epidemic of scarlatina which prevailed at 
 Dublin between 1834 and 1842, 1 relates some instances of this occur- 
 rence far more striking in character than any which have come under 
 my own notice. Among others, he narrates the case of a little girl, 
 four years old, who was seized with the usual symptoms of the epi- 
 demic; in about eight hours she lost the power of swallowing, and 
 this was followed by a state of coma, alternating with convulsions of 
 one side of the body. When seen, there was no pulse to be felt at the 
 wrist, the hands and feet were cold and perfectly livid, and the patient's 
 condition was very like that of a person in the last stage of Asiatic 
 cholera, except that her body was covered by a dark-colored eruption. 
 Six hours before death, wdiich took place before the end of the second 
 day, diarrhoea made its appearance, and continued up to the moment 
 of dissolution. 2 
 
 Though no instance comparable with this in the suddenness and com- 
 pleteness of the collapse has presented itself to my observation, I have 
 met with several in which it was apparent, almost from the moment of 
 the seizure, that there was scarcely any chance of the child's recovery. 
 The frequency of such cases varies much in different epidemics, as do 
 also the characters of the symptoms by which the malignancy of the 
 disease announces itself. In some instances, as in that just related, the 
 complete collapse is not succeeded by any attempt at rallying the ener- 
 gies of the system ; in others convulsions destroy the patient; in another 
 class uncontrollable diarrhoea sets in almost at the commencement, and 
 speedily exhausts the patient's powers ; in others petechia? and vibices 
 appear on the surface, or hemorrhage takes place from the bowels, — the 
 tokens and consequences of the changes in the circulating fluid ; while 
 in other instances typhoid symptoms come on on the second or third 
 day; and death takes place long before the termination of the first week, 
 with phenomena such as one would scarcely expect to meet with earlier 
 than the second or third week of severe typhus fever. One or other 
 of these types is that which in each epidemic of severe scarlet fever 
 characterizes the majority of the worst cases, but isolated cases of the 
 disease sometimes occur sporadically, marked by its worst features, or 
 present themselves as exceptions to the generally mild character of some 
 epidemic of the disease. Of this I saw a striking example some years 
 ago in a large public school some miles from London, in which scarlet 
 fever became prevalent. Almost all of the cases, which occurred among 
 lads from fourteen to eighteen years of age, were extremely mild ; but 
 one youth more robust than most of the others, sank from the moment 
 he was taken, and died with typhoid symptoms before the end of the 
 third day. His case stood by itself, unlike any of those which pre- 
 ceded or which followed it. 
 
 1 Dublin, 1813. 12mo. 2 Op. cit., p. 62. 
 
656 DANGEROUS COMPLICATIONS OF MALIGNANT SCARLATINA. 
 
 Sometimes", too, we meet with instances where scarlatina (and I have 
 observed the same fact with diphtheria) appears to exercise a peculiarly 
 fatal influence over the members of one family; as though some pecu- 
 liar idiosyncrasy on their part tended to render the disease deadly. 
 The two children of a person in a good position in life died within 
 forty-eight hours of the appearance of the first symptoms of scarlatina. 
 Five years afterwards two other children were attacked by the disease, 
 the family then residing in a different locality, in a healthy neighbor- 
 hood, and In a perfectly well-ventilated and well-drained house. The 
 boy, aged four years, sickened on the 6th of September, the rash of 
 scarlatina appeared on the 7th ; fatal convulsions occurred on the 8th. 
 His sister, aged five years, vomited on the morning of the 8th, and 
 vomiting continued at frequent intervals with some disposition to diar- 
 rhoea. The skin on the trunk was burning hot, but that of the extrem- 
 ities was cold, the soft palate and tonsils were greatly swollen, but 
 there was no rash on the surface twelve hours after the child had first 
 sickened. In eighteen hours convulsions came on, and the child died 
 within twenty-four hours from the first symptom of illness. The only 
 remaining child, an infant at the breast, escaped the disease. 
 
 Even in the malignant form of scarlatina, however, it is seldom that 
 death takes place with this extreme rapidity ; but the patient more 
 commonly survives to the end of the sixth or seventh day, and in 
 these circumstances the affection of the throat generally goes on in- 
 creasing in severity. The inflammation of the tonsils in these cases 
 terminates in the formation of excavated, ragged, unhealthy ulcera- 
 tions, which I have occasionally found also in the pharynx, and at the 
 upper part of the oesophagus ; or sometimes a more extensive slough- 
 ing involves the parts at the back of the throat. The tongue and soft 
 palate are found denuded of their epithelium ; the papillae of the tongue 
 very prominent, and those at its base, as well as the lingual glands in 
 that situation, extremely enlarged, and covered by a dirty tenacious 
 mucus. The coryza, to which reference was made just now, is gener- 
 ally very severe, while the mischief at the back of the throat some- 
 times extends to the air-passages; and I have found the mucous mem- 
 brane at the under surface of the epiglottis, and about the arytenoid 
 cartilages, much injected and thickened ; a condition which, during life, 
 was sufficient to occasion intense dyspnoea, and to give rise, on each 
 attempt at deglutition, during the last twenty-four hours of the child's 
 life, to a struggle for breath which threatened every moment to be 
 fatal. Now and then, too, diphtheritic deposit takes place at the back 
 of the fauces, and extending into the larynx, destroys the child by 
 producing the ordinary symptoms of croup. The swelling of the 
 parotids in some of these cases increases with very great rapidity, and 
 forms not un frequently, by the implication of the integuments of the 
 neck, a sort of collar of brawny hardness, which interferes alike with 
 deglutition and respiration. These swellings are remarkable for the 
 slight tendency which they show to suppurate ; and even after they 
 have attained a very considerable size, and have been in great meas- 
 ure instrumental in occasioning the child's death, I have found the 
 parotids much enlarged, of a rose-red color, infiltrated with thin 
 
POST-MORTEM APPEARANCES — DEATH IN SCARLATINA. 657 
 
 serum, and a dirty seropurulent fluid also pervading the cervical 
 cellular tissue, but no true pus either in the substance of the gland 
 itself, or in the surrounding cellular tissue. Now and then, however, 
 suppuration takes place, not in the substance of the glands themselves, 
 but in the surrounding cellular tissue ; and the quantity of pus which 
 is formed there is sometimes very considerable. The destruction of 
 tissue, too, is not always the result of mere suppuration, but a process 
 of sloughing sometimes destroys the cellular membrane very exten- 
 sively ; and, by involving the large vessels of the neck, has caused the 
 child's sudden death from hemorrhage — an occurrence, indeed, which 
 I have only twice met w T ith, but which came thrice under the observa- 
 tion of Dr. H. Kennedy, of Dublin, whose excellent account of the 
 epidemic which prevailed in that city will well repay your attentive 
 perusal. 
 
 As in other blood diseases, so in scarlatina, we meet now and then 
 with secondary inflammation of the joints, which may even go on to 
 the formation of pus. It is, however, not a common occurrence ; but 
 I saw the hand thus affected in a child who died on the sixth day of 
 the disease, and in another child w T ho had recovery from scarlatina, in 
 the course of which inflammation attacked the right shoulder-joint, the 
 humerus remained permanently anchylosed. Several other instances 
 have of late years come under my notice. The wrist and the back of the 
 hands are the parts usually aifected. The symptom is always a very ill- 
 omened one, even though it should be but evanescent, and should dis- 
 appear one day from the part aifected the day before, for its reappear- 
 ance at some other joint in general indicates but too plainly that the sys- 
 tem at large is poisoned by the disease. It is not, however, necessarily a 
 fatal sign, and I have met with other cases than the one just mentioned 
 of recovery even after suppuration had occurred in the affected joint. 
 Both the pericardium and endocardium are also sometimes aifected, 
 but in this stage of the disease that special tendency to inflammation 
 of the serous membranes which is afterwards observed does not mani- 
 fest itself. Pneumonia, indeed, is a more frequent affection, running 
 its course without any marked symptom, though a large portion of 
 one or both lungs may be found after death in a state of hepatization. 
 
 The other post-mortem, appearances observed in scarlatina are to a 
 great degree identical with those observed in malignant fevers gener- 
 ally. The blood is usually semi-coagulated, of the appearance and 
 consistence of gooseberry jelly, or even altogether fluid, and the coats 
 of the vessels are often stained by it. The mucous membrane of the 
 bronchi, stomach, oesophagus, and trachea, is often of an intensely red 
 color, though nothing can be more arbitrary than the extent, degree, 
 and situation of this redness. The texture of the kidneys and heart is 
 also often very much softer than natural, so as to tear very readily ; 
 and once I found the heart exceedingly flaccid, its tissue infiltrated 
 with reddish serum; and not merely tearing easily, but even beiug so 
 soft that the finger could be pushed through its walls with the slightest 
 effort. As in the case of other fevers, and as is especially observable 
 in puerperal fevers, the character of the epidemic constitution of the 
 
 42 
 
658 SEQUELS. 
 
 period often governs the symptoms, and modifies the post-mortem 
 appearances. There was an epidemic of puerperal fever some years 
 ago in Paris, in which symptoms of disorder of the intestines predomi- 
 nated, and in which tumefaction of the mesenteric glands, and ulcera- 
 tion of Peyer's patches, were constant morbid appearances. It is just 
 in accordance with the same law that the characters of scarlatina may 
 approach to those of typhoid fever, as in the cases described by Dr. 
 John Harley ;* cases illustrating affinity between the two diseases, but 
 no more; or perhaps rather the influence of a common cause modify- 
 ing the characters of both. 
 
 Such are the chief modes of death from scarlet fever, and such the 
 more important appearances discovered afterwards ; at least as far as 
 my personal observation extends, though I scarcely need remind you 
 that there are but few diseases of which the characters are liable to 
 greater variations ; so that no account, how minute soever, can be taken 
 as a true portraiture of more than just that one form of the fever with 
 which its describer may chance to be most familiar. 
 
 Unhappily the first few days of the disease do not by any means 
 comprise the whole period of danger, but even though the patient 
 should survive the peril of the fever, a long catalogue of sequelae re- 
 mains, some of which may endanger or even destroy life. Sometimes, 
 indeed, the patient passes through the first week of the disease with few 
 or no symptoms to excite anxiety, and then when the rash is on the 
 decline, the parotid glands swell, grow hard and intensely painful, and 
 on one or two occasions I have seen the integuments covering them 
 become gangrenous; or sloughing ulcers form on the tonsils, which 
 had not seemed to be very much inflamed previously ; while an acrid 
 discharge takes place from the nostrils, and death follows in the course 
 of four or five days. In the majority of instances, however, the gland- 
 ular swellings which come on after the lapse of a week from the com- 
 mencement of the disease, though tedious and painful, yet do not en- 
 danger 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, and constituting retropharyngeal abscess; an 
 affection concerning which I spoke to you a few T days ago. 2 
 
 Coupled with the swelling of the parotid glands, or even independ- 
 ently of it, inflammation of the internal ear is often met with as a con- 
 sequence of scarlatina. This otitis terminates in abundant purulent 
 discharge, which sometimes continues for many weeks ; and occasion- 
 ally it completely destroys the organ of hearing, and renders the pa- 
 tient hopelessly deaf for the remainder of his life. 
 
 I have already spoken, in a previous lecture, 3 of that very frequent 
 and very serious occurrence, the dropsy which succeeds to scarlet fever, 
 and need not, therefore, refer to that subject now. But there are other 
 cases in which, without any definite local complication, the convales- 
 
 1 Med.-Chir. Transactions, vol. lv, p. 102. 
 
 2 See Lecture XXXIII, p. 482. s See Lecture XXXIX, p. 562. 
 
DIAGNOSIS AND TREATMENT OF SCARLATINA. 659 
 
 cence from scarlet fever is fluctuating and protracted. In such cases 
 the bowels are irregular in their action, alternately relaxed and consti- 
 pated ; the evacuations unhealthy ; the tongue red and raw ; and aph- 
 thous ulcerations sometimes appear on the inside of the mouth; while 
 an irregularly remittent fever harasses and weakens the child. These 
 symptoms, however, which closely resemble those that sometimes come 
 on during convalescence from measles, are of much less frequent oc- 
 currence as consequences of scarlatina. 
 
 The diagnosis of scarlatina is not in general attended with much dif- 
 ficulty ; and the points of difference between it and measles are so well 
 marked, that it is not easy to understand how the two diseases should 
 so long have been confounded together. Their period of incubation is 
 different ; that of scarlatina not exceeding a week, that of measles ex- 
 tending to two. Their premonitory symptoms are very dissimilar, 
 those of measles closely resembling the signs of a severe catarrh ; while 
 the attack of scarlatina is announced by sickness, succeeded by intense 
 heat of skin, by sore throat, great sensorial disturbance, and extreme 
 rapidity of the pulse. There is no other disease of childhood, indeed, 
 in which the two last-named symptoms supervene so speedily after the 
 commencement of illness ; and their occurrence will often enable you, 
 even before the appearance of the rash or any complaint of sore throat, 
 to form a correct conclusion with reference to the nature of the affec- 
 tion. The premonitory stage of measles usually continues for three 
 or four days ; that of scarlet fever, in its regular form, only for twenty- 
 four hours ; while the other symptoms that appear in cases of scarlet 
 fever, in which the rash is delayed, are such as quite to forbid the sup- 
 position of the patient being affected with measles. The character of 
 the two eruptions is so dissimilar, that I need not here dwell on their 
 peculiarities, nor do more than remind you that while in measles the 
 great danger to life arises from the supervention of bronchitis or pneu- 
 monia, the two great sources of hazard in scarlet fever are the affection 
 of the throat during its progress and the occurrence of dropsy after its 
 decline. 
 
 With a few words on the treatment of scarlatina, I will bring this 
 subject and the present course of lectures to a close. The milder forms 
 of the disease require, as you know, but little interference; and you 
 fulfil every indication by keeping the child in a cool and well-ventilated 
 chamber, placing him on a spare diet, giving some mild antiphlogistic 
 medicine during the progress of the fever, and sponging the surface 
 occasionally with tepid water if the heat of the skin is considerable. 
 
 For the past several years, however, I have been accustomed to sub- 
 stitute for tepid sponging the inunction of suet into the whole surface 
 twice a day ; and my experience leads me very strongly to recommend 
 the adoption of this practice. I was led to try it by the strong enco- 
 miums which the late Professor Mauthner, of Vienna, bestowed upon 
 the use of inunctions in these cases, as originally advocated by Dr. 
 Schneeman, of Hanover. 1 It seems to relieve the sense of burning 
 
 1 In a work published at Hanover, in 1818, and of which an analysis is given in 
 the Journal fiir Kinderkrankheiten, March, 1848, p. 214. With no previous knowl- 
 
660 TREATMENT OF MILD SCARLATINA. 
 
 heat, so distressing to the patient, more effectually than tepid or cold 
 sponging, however often repeated ; while it has the further advantage 
 of not requiring repetition above twice in the twenty-four hours, by 
 which the patient is spared much otherwise unavoidable fatigue. To 
 the hand of a bystander it seems to have the effect of removing the 
 pungent heat so remarkable in most cases of scarlet fever, and of keep- 
 ing the skin supple and comparatively cool, though I am not prepared 
 to say whether it exerts any real influence on the temperature of the 
 surface as estimated by the thermometer. It does not prevent the 
 desquamation of the cuticle after the decline of the eruption, nor does 
 its most diligent employment exclude the occurrence of albuminous 
 urine ; though I think it considerably lessens the amount of the former, 
 and diminishes the risk of the latter assuming a serious character. 
 
 This immunity from bad symptoms, however, is doubtless in great 
 measure due to the circumstance that the cases in which the inunction 
 w r as employed were those which came earliest under treatment, and in 
 which, consequently, opportunity existed for carrying out a judicious 
 management of the disease through all its stages. I believe it promotes 
 the patient's comfort, and lessens the risks of some of the ordinary 
 sequela? of the disease; but the extravagant laudations which this pro- 
 ceeding has received from some medical men, induce me to add that I 
 do not consider it as anything more than a useful adjunct to appropriate 
 treatment, and in no sense a substitute for it. During the period of 
 development of the rash, the inunction should be practiced twice a 
 day : when the eruption is on the decline, its employment once in the 
 twenty -four hours is generally sufficient ; whilst, if the desquamation 
 is at all abundant, the hot-air bath is of the greatest service in facili- 
 tating its completion and maintaining the activity of the skin. How 
 slight soever the attack of scarlet fever may have been, it is prudent to 
 confine the patient to bed for three weeks, since it is not until after the 
 lapse of that time that one can feel absolutely secure from the super- 
 vention of albuminuria; and the urine during the whole of this period 
 ought to be tested for albumen twice a clay, in order that the first 
 threatening of so serious an evil as scarlatinal dropsy may at once be 
 met by appropriate treatment. During the whole of the stage of con- 
 valescence, or so long at least as the skin shows any trace of desqua- 
 mation, even though the child is allowed to leave his bed, the inunc- 
 tion should be continued every morning, while the child should be 
 placed in a warm bath every evening, and well rubbed with a soft 
 towel on being placed in bed again. During the whole of this time 
 the diet must be mild and unstimulating, and due attention must be 
 paid to the state of the bowels. For some time after, much caution 
 must be exercised in not allowing the child to go out when the air is 
 cool, and in avoiding all errors of diet, while it is also expedient that 
 
 edge of the observations of others, Mr. W. Taylor, of London, was accustomed, 
 from the year 1829, as he states in a little work published in 1850, to adopt a very 
 similar course in the treatment of various febrile diseases, for which he regards it 
 as almost a panacea. 
 
OF ITS SEVERER FORMS. 661 
 
 flannel should be worn next to the skin for a considerable period after 
 apparent convalescence from scarlet fever. I know that these precau- 
 tions may appear to you overstrained, — they often do to our patients ; 
 but I can only say that every year of added experience leads me to 
 insist upon them more and more, just as each year shows me more of 
 the dangers of scarlatinal dropsy, and of its intractable character. 
 
 Even in severer cases of the disease, you must not be in too great a 
 hurry to resort to active measures, for you will remember that a some- 
 what stormy onset is characteristic of all but the very mildest forms of 
 scarlatina. That disturbance of the sensorium, for instance, which, when 
 the child is sufficiently old, shows itself by the early occurrence of de- 
 lirium, must not lead you to have recourse hastily to depletion either 
 general or local, in order to quiet the disorder of the brain. The results 
 afforded by depletion in scarlet fever even when the disease occurs in 
 the adult are by no means encouraging ; and in the child the loss of 
 blood in these circumstances is even less well borne; so that, unless the 
 patient is robust and plethoric, and the cerebral disturbance very serious, 
 you should content yourselves with the application of cold to the head, 
 perhaps employing cold affusion, if the symptoms are very urgent. 
 These are the cases, too, in which the results of hydropathic treatment 
 are often most remarkable, and I have seen the gravest symptoms of 
 brain disturbance subside, the temperature fall, and the rash appear 
 upon the skin under the use of the wet sheet. It is indeed many years 
 since I employed depletion in the course of scarlet fever, though, as I 
 have already mentioned, the abstraction of blood is frequently needed 
 in the dropsy which constitutes its most formidable sequela. In the 
 malignant forms of the disease there is often very considerable disturb- 
 ance of the sensorium, great restlessness alternating with a state of 
 stupor ; but the frequent and feeble pulse at once forbids depletion in 
 such cases, and points out the necessity for adopting every means to 
 support the feeble powers of life. It is very likely that the low type 
 which a disease such as scarlatina is almost sure to assume in the crowded 
 dwellings of the poor, has rendered my practice in this respect some- 
 what different from that which might be advantageously pursued in 
 the case of children more favorably situated. To the same circumstance 
 it is also probably due that, in a large proportion of cases, I have found 
 it desirable to give ammonia almost from the outset of the disease ; a 
 practice which has been recommended as universally applicable, and 
 which (though the remedy does not deserve the indiscriminate praises 
 that have been lavished on it) you will do well to follow, whenever 
 the pulse presents the characters of frequency and softness combined. 
 The state of the throat must be carefully watched in every case of 
 scarlet fever; and whenever there is much swelling of the tonsils, if 
 the child is too young to gargle, a slightly acidulated lotion should be 
 injected into the throat by means of a syringe every few hours, in order 
 to free it from the mucus which is so apt to collect there, and to be the 
 source of much discomfort ; or the solution of chlorate of soda or of 
 permanganate of potash largely diluted, may be used for the same pur- 
 pose, or the sulphurous acid in the proportion of one part to eight of 
 
662 TREATMENT OF LOCAL SYMPTOMS OF SCARLATINA. 
 
 water may be frequently employed with the spray-prod acer. If there 
 is much deposit of lymph upon the tonsils, it is generally desirable to 
 apply strong hydrochloric acid, mixed with honey, in the proportion of 
 about one part of the former to six of the latter, by means of a camel's- 
 hair pencil, or a solution of twenty grains of nitrate of silver in an 
 ounce of distilled water, once or twice at intervals of twenty-four hours ; 
 but I do not think that in scarlatinal sore throat, any more than in that 
 of diphtheria, the frequent application of strong caustics either does as 
 much good, or yields as much relief, as the frequent gargling or syring- 
 ing the throat with milder remedies. The coryza, which is so distressing 
 and so ill-omened a symptom in cases of severe scarlatina, is best treated 
 by throwing a small quantity of a solution of gr. j or gr. ij of nitrate of 
 silver in §j of distilled water, up the nostrils every four or every six 
 hours. The glandular swellings are very difficult to relieve, though their 
 development sometimes seems to be retarded by painting the skin over 
 them, two or three times a day, with tincture of iodine. When consid- 
 erable, they do not seem to be benefited by leeches; the employment of 
 which is also contraindicated by the feeble state of the patient's powers; 
 while they show very little disposition to suppurate, and consequently 
 are not relieved by lancing; so that the constant application of a warm 
 poultice is often all that can be done to afford ease to the patient. 
 Children in whom the local affection is severe, or in whom the disease 
 assumes a malignant character, require all those stimulants, and that 
 nutritious diet, which we are accustomed to give to patients in certain 
 stages of typhus fever; though unfortunately, the best devised means 
 will in many such cases prove ineffectual. 
 
 It may be well to add a few words in conclusion with reference to 
 the alleged virtues of belladonna as a prophylactic against scarlatina. 
 Hahnemann, the founder of the homoeopathic system, first introduced it 
 into practice, being induced to try it by certain resemblances which he 
 believed to exist between its effects and the ordinary symptoms of 
 scarlet fever. Other practitioners, without subscribing to homoeopathic 
 opinions, have yet adopted this proceeding, and aver that infinitesimal 
 doses of belladonna do in reality exert the marvellous protective powers 
 which the drug was said to possess. 
 
 The evidence of its virtues, however, is in the last degree unsatisfac- 
 tory. There are many recorded instances of its failure when tried on 
 a large scale, while the strongest advocates of its use have never put 
 its virtues to the obvious and simple test of administering the remedy 
 to half of a given number of persons placed in similar circumstances 
 as to age, health, and exposure to contagion, and comparing the results 
 thus obtained. In the only instance with which I am personally 
 acquainted where this mode of inquiry was adopted, the results, though 
 the experiment was on too small a scale to justify a positive conclusion, 
 seemed to show that the protective power of belladonna was absolutely 
 null. I cannot do better than relate the experiment which was made 
 at the Royal Military Asylum at Chelsea, by Dr. Balfour, in the 
 words in which he was good enough to communicate it to me. Scarlet 
 fever having broken out in the institution, Dr. Balfour determined to 
 
PROPHYLAXIS OF THE DISEASE. 663 
 
 try the virtues of belladonna. " There were," he says, " 151 boys of 
 whom I had tolerably satisfactory evidence that they had not had 
 scarlatina ; I divided them into two sections, taking them alternately 
 from the list, to prevent the imputation of selection. To the first sec- 
 tion (76) I gave belladonna ; to the second (75) I gave none ; the 
 result was that two in each section were attacked by the disease. 
 The numbers are too small to justify deductions as to the prophy- 
 lactic power of belladonna, but the observation is good, because it 
 shows how apt we are' to be misled by imperfect observation. Had I 
 given the remedy to all the boys, I should probably have attributed 
 to it the cessation of the epidemic." 1 
 
 To these remarks I need add nothing. They convey a most im- 
 portant lesson, but one which I fear we are all too apt to forget in the 
 study and in the practice of medicine. 
 
 1 Any one who still feels a lingering faith in the prophylactic powers of bella- 
 donna, will do well to read the very careful and candid inquiry into the evidence 
 on both sides of the question, published by Dr. Warburton Begbie, in the British 
 and Foreign Medico-Chirurgical Eeview for January, 1855. 
 
INDEX. 
 
 Abdomen, examination of, in sick children, 20 
 shrunken, in tubercular meningitis, 80 
 naturally large in childhood, 680 
 causes of excessive size of, 581 
 enlarged, from flatus, 582 
 fluid. 583 
 
 various tumors, 584 
 Abdominal tumors, from general enlargement 
 of abdomen, 582 
 suspected sometimes when not pres- 
 ent, 582 
 from enlarged liver, 583 
 
 hydatids of the liver, 588 
 fungoid disease of the liver, 589 
 
 kidney, 593 
 psoas abscess — caution as to di- 
 agnosis, 595 
 enlargement of the spleen, 591 
 enlarged mesenteric glands, 596 
 malignant tumors of intestines, 
 
 596 
 malignant tumors of ovaries, 596 
 abscess of abdominal walls, 597 
 Abscess, retro-pharyngeal, 482 ( see Retro- 
 pharyngeal Abscess) 
 Aconite, as febrifuge and sedative, 52, 97 
 Acute hydrocephalus, 71 (see Tubercular 
 
 Meningitis) 
 Ague" peculiarities and treatment of, in child- 
 hood, 631 
 enlargement of spleen in connection with, 
 591 
 Air, vitiated, cause of infantile trismus, 160 
 Albuminoid enlargement of liver, 585 
 
 its connection with rickets and scrof- 
 ula, 586, 615 
 Albuminuria, 562 ( see Kidneys, Inflamma- 
 tion of) 
 in diphtheria, 353 
 
 scarlatina, its varying frequency, 563 
 idiopathic, 572 
 Alkalies, their use in infantile dyspepsia, 492 
 Amyloid liver, 585 
 Ansetnia, bruits due to, very rare in child, 
 
 442 
 Angina maligna, 323. 347 (see Diphtheria) 
 Antimony, general rules for employment of, 
 31 
 in treatment of bronchitis, 278 
 pneumonia, 295 
 croup, 334 
 chorea, 198 
 
 dropsy after scarlatina, 570 
 and opium, in head symptoms of typhoid 
 fever, 628 
 
 Anus, prolapsus of, in course of chronic diar- 
 rhoea, treatment of, 539 
 imperforate, 507 (see Rectum, Imper- 
 forate) 
 Aphthae, 457, 458 ; 469 (see Thrush) 
 Apoplexy, symptoms less dangerous in child 
 
 than in adult, 58 
 Arachnoid, peculiar condition of, in tuber- 
 cular meningitis, 71 
 granulations of, in tubercular menin- 
 gitis ; their tubercular nature, 73 
 lining the ventricles, granular state of, 
 
 77, 114 
 hemorrhage into the, 60, 63 
 
 changes of the effused blood, 63 
 obscurity of its symptoms, 64 
 cases of. 65 
 
 chronic hydrocephalus an occasional 
 result of, 64, 117 
 Arsenic in treatment of chorea, 199 
 Asphyxia, of new-born child, sometimes due 
 to cerebral hemorrhage, 59 
 interrupted placental circula- 
 tion, its usual cause, 239 
 its treatment, 59, 240 
 Asthma in children, 2S3 
 
 thymicum, vote, 370 (see Spasm of the 
 Glottis) 
 Astringents, use of, in treatment of diarrhoea, 
 
 535 
 Atelectasis pulmonum, 239 (see Lungs, Imper- 
 fect Expansion of) 
 Atrophic paralysis, vote, 212 
 Atrophy of brain, 127 (see Brain, Atrophy of) 
 
 infantile, 457 (see Infants, Atrophy of) 
 Auscultation, general rules for, 20 
 
 Backwardness, distinguished from idiocy, 
 
 229 
 Barthez, Dr., on expectant treatment of pneu- 
 monia, 294 
 Belladonna, as prophylactic of scarlatina, 662 
 in treatment of epilepsy, 185 
 
 of hooping-cough, 394 
 incontinence of urine, 580 
 Blisters, rules for management of, 33, 34 
 
 in treatment of tubercular meningitis, 98 
 pneumonia, 297 
 croup, 338 
 hooping-cough, 396 
 Brain in infancy, peculiarities of its circula- 
 tion, 39 
 controlling power over spinal 
 cord not manifest, 43, 44 
 
66Q 
 
 INDEX. 
 
 Brain in infancy, disense of, symptoms of, 41 
 importance of vomiting as a sign 
 
 of, 42-49 
 use of ophthalmoscope in, 41 
 paralysis from, diagnosis of, 206 
 disorder of, sympathetic in pneumonia, 
 133, 291 
 in jaundice, symptoms of, 505 
 atrophy of, with premature ossification of 
 skull, 127 
 in course of long illness, 128 
 partial— case of, 129 
 cancer of, 146 
 congestion of, 47 (see Congestion of the 
 
 Brain) 
 dropsy of, 70 (see Hydrocephalus) 
 hemorrhage into substance of — cases of, 
 
 66 (see Cerebral Hemorrhage) 
 hydatids of, 146 
 hypertrophy of, 121 
 
 its symptoms, 123 
 its connection with rickets, cre- 
 tinism, and idiocy, 123, 611 
 state of brain-substance in, 124 
 diagnosis from chronic hydro- 
 cephalus, 124 
 occasional cure of chronic hydro- 
 cephalus by, 116 
 treatment of, 125 
 partial, 126 
 inflammation of, deaths from, at differ- 
 ent ages, 69 
 in infancy, progress of knowledge 
 
 concerning, 70 
 two kinds of, simple and scrof- 
 ulous, 70, 71 
 consequent on disease of bones 
 of skull, 103 (see Encephalitis 
 and Hydrocephalus) 
 sinuses of— case of, 107 
 malformation of, 126 
 
 connection of chronic hydro- 
 cephalus with, 110, 111, 113, 
 117 
 softening of, in tubercular meningitis, 
 
 not due to imbibition, 76 
 tubercle of, its frequency in childhood, 
 136, 138, 139 
 anatomical characters of, 137 
 
 changes it undergoes, 137 
 capillary apoplexy in, 68 
 in cases of tubercular men- 
 ingitis, 78 
 symptoms of, 139 
 
 illustrative tables, note, 140, 
 
 141 
 premonitory symptoms of, 139, 
 
 140 
 peculiar character of convul- 
 sions in, 45. 142, 143 
 varieties in course of the disease, 
 
 143, 144 
 deposit occasionally external to brain 
 
 — case of, 144 
 diagnosis, 145 
 
 treatment of suspected cases of, 145, 
 146 
 ventricles of, changes of their lining in 
 
 tubercular meningitis, 76 
 ventricles of, changes of their lining in 
 chronic hydrocephalus, 114 
 Bromide of potass, as a sedative, 33, 218 
 
 Bromide of potass, in spasm of the glottis, 174 
 
 in epilepsy, 185 
 Bronchial phthisis, anatomical characters of, 
 405 
 process of cure of, 407 
 perforation of bronchi in, 407 
 symptoms of, 410, 416 
 
 auscultatory, peculiarities of, 
 
 414, 416 
 exaggerated by intercurrent 
 bronchitis, 416 
 occasional recovery from, 411 
 modes of death in, 412 
 Bronchitis, points of difference in child and 
 adult, 263 
 morbid appearances of bronchi in, 263 
 dilatation of bronchi in, 265 
 nature of vesicular, 265 
 affection of pulmonary tissue in, 266 
 symptoms of, 273 
 
 similar to those of pneumonia, 267, 
 290 
 sudden supervention of collapse of lungs 
 
 in, 274 
 when chronic, may simulate phthisis, 280 
 intercurrent, exaggerates symptoms of 
 
 phthisis, 419 
 treatment of, 277 
 
 nervous dyspnoea in, 278 
 convalescence from, 279 
 complicating hooping-cough, 379 
 treatment of, 398 
 inflammatory diarrhoea, 527 
 measles, 648, 650 
 capillary, its nature and symptoms, 275 
 results of auscultation in, 276 
 average duration of, 276 
 Bronchio-pneumonia, import of the term, 263, 
 285 
 its symptoms, 290 
 
 Cachexia, the, of early life, 598 
 Calculus, frequency of, in childhood, 572 
 symptoms of, 573 
 treatment of, 575 
 Cancer of brain, 146 
 kidney, 593 
 liver, 589 
 Cancrum oris, 471, 472 (see Stomatitis, Gan- 
 grenous) 
 Case-taking, rules for, 23 
 Castor oil, use of small doses of, in diarrhoea, 
 
 533 
 Catarrh, influence of age and of season of 
 year in its production, 261 
 its special importance in infancy, 273 
 symptoms of, 262 
 treatment of, 262 
 epidemic, or influenza, 280 
 suffocative, 274 (see Bronchitis, Capillary) 
 CephalhEematoma, its characters and changes, 
 60 
 cases illustrating process of cure of, 62 
 diagnosis and treatment of, 62 
 subaponeurotic, 63 
 Cerebral circulation, its peculiarities in in- 
 fancy, 39 
 congestion, 47 (see Congestion of the 
 
 Brain) 
 hemorrhage, 63 
 
 occasional cause of asphyxia, 59 
 
INDEX. 
 
 667 
 
 Cerebral hemorrhage, genernl capillary, 59 
 into substance of brain, 66 
 capillary, in cases of tubercle, 68 
 into sac of arachnoid, 63 
 treatment of, 68 
 
 external to skull, 60 (see Cephal- 
 hematoma) 
 respiration, meaning of the term, 43 
 pneumonia, 291 
 sinuses, thrombosis of, 107 
 Chest, elasticity of walls of, 237 
 
 examination of, in sick children, 21 
 Chicken-pox, essential differences from small- 
 pox, and symptoms, 641 
 relation of to hooping-cough, 385 
 Children, high mortality of, 17 
 
 peculiarities of their diseases, 18 
 rules for conducting examination of, 19 
 use of thermometer in examining, 20 
 feebleness of inspiratory power in, 236 
 imperfect expansion of lungs in new- 
 born. 239 
 rules for treatment of their diseases, 27 
 Chloral, its use as a sedative, 33, 218 
 in disorder of the brain, 97 
 spasm of the glottis, 174 
 Chlorate of potass, in treatment of stomat- 
 itis, 467, 472 
 Chloroform in treatment of convulsions, 174 
 
 hooping-cough, 394 
 Chorea, rare in early childhood. 188 
 
 influence of sex and other causes in pro- 
 ducing it, 188 
 symptoms of, 190 
 
 its connection with rheumatism, 192 
 affection of heart in, 193 
 paralytic form of, 191 
 embolism as a cause of, 194 
 duration of, 195 
 morbid appearances in, 195 
 treatment of, 195 
 use of strychnine in, 200 
 
 rest, and of gymnastics in, 197 
 antimony in, 198 
 zinc in, 199 
 Chronic hydrocephalus, 110 (see Hydroceph- 
 alus) 
 Cod-liver oil, in treatment of phthisis, 426 
 
 in rickets, 616 
 Cold, influence of exposure to, 237 
 mode of applying to head, 51 
 external application of, in tubercular 
 meningitis, 96 
 Congestion of the brain, its frequency, 48 
 
 states erroneously attributed to it, 
 
 49-53 
 its symptoms, 49 
 post-mortem appearances often slight, 
 
 50 
 treatment of, 51 
 symptoms simulating it, 53 
 passive, various causes of, 55 
 
 its symptoms and treatment, 56 
 
 Constipation, from congenital malformation 
 
 of intestines, 507 
 
 strangulated hernia, 513 
 
 intussusception, 513 (see Rectum, 
 
 Imperforate, and Intussusception) 
 
 Constitution, epidemic changes in, 277. 294, 
 
 321 
 Convulsions in child answer to delirium in 
 adult, 43 
 
 Convulsions, deaths from, at different periods 
 of life. not*, 44 
 symptomatic value of. considered, 43 
 due to predominance of spinal system in 
 
 early life, 44 
 description of a fit of, 46 
 importance of ascertaining their cause, 44 
 in tubercular meningitis, 81 
 relation of, to epilepsy, 177 
 independent of disease of brain, 161 
 two forms of, 161 
 
 associated with rickets, 165 
 
 with fatty liver, 166 
 treatment of, 170 
 
 chloroform in, 174 
 bromide of potass, and chloral in, 174 
 complicating hooping-cough, 382 
 from intestinal worms, 558 
 
 malaria, 530 
 in scarlet fever, 655 
 scarlatinal dropsy, 566 
 salaam convulsions, 176 
 Copper, sulphate of, in advanced stages of 
 
 croup, 337 
 Corrigan, Sir D., on nocturnal incontinence 
 
 of urine, 580 
 Coryza, symptoms of, 260 
 malignant, 260 
 
 its connection with syphilis, 261 
 sometimes sole symptom of infantile syph- 
 ilis, 600 
 Cough, peculiar in disease of brain, 43 
 at onset of tubercular meningitis, 83 
 paroxysmal, in course of capillary bron- 
 chitis, 275 
 in bronchial phthisis. 370, 410 
 spasmodic, in bronchial phthisis, intesti- 
 nal irritation, cerebral inflammation, 
 370 
 peculiar in croup, 327 
 night, 282 
 Craniotabes, 166, 611 
 
 Cretinism, connection of, with hypertrophy of 
 brain, 123 
 frequent misuse of term, 219 
 Croup, definition of the disease, 321 
 
 different diseases included under name of, 
 
 322 
 peculiarity of the field in which many of 
 the author's observations were made, 
 note, 321 
 difference between it and diphtheria, 350 
 influenced by changes in epidemic con- 
 stitution, note, 321, 354 
 influence of age, sex, climate. &c, in 
 
 causing it, 324 
 morbid appearances, 325 
 
 peculiarities of croup after mea- 
 sles, 366 
 symptoms of, onset, and first stage, 327 
 second stage, pathognomonic sound 
 
 of voice and cough, 327 
 third stage, delusive appearances of 
 improvement, 329 
 results of auscultation in, 329 
 spasmodic dyspnoea in, 336, 368 
 duration of, and prognosis in, 330 
 danger of relapse in, 331 
 treatment of, premonitory symptoms of, 
 332 
 depletion in, 333 
 employment of antimony in, 334 
 
668 
 
 INDEX. 
 
 Croup, treatment of, calomel in, 334 
 
 danger of overtreatment in, 336 
 convalescence from the disease, 336 
 advanced stages of, 337 
 
 caution with reference to emet- 
 ics in, 338 
 use of blisters in, 338 
 bronchotomy in, 339 
 
 difference of results in England and 
 
 France, 339 
 results modified by rickets, 339 
 reasons for not rejecting it, 340 
 asthenic variety of. 323, 347 (see Diph- 
 theria) 
 ■with predominance of spasmodic symp- 
 toms, 368 
 spasmodic, 163 (see Spasm of the Glot- 
 tis) 
 Cri hydrencephalique, 80 
 Cry in infancy, its two periods, 22 
 
 characteristic, in imperfect expansion of 
 the lungs, 244 
 Cynanche laryngea, cynanche trachealis, 321 
 (see Croup) 
 parotidea. symptoms of, 486 
 
 treatment of, 4S7 
 tonsillaris, 479 
 Cystic disease of kidney, 594 
 
 Dentition, tardy in human subject, 446 
 order of appearance of the teeth, 463 
 pauses in its course, 171. 465 
 development of the digestive system dur 
 
 ing, 519 
 disease frequent during, 18 
 high mortality during, and reasons for it 
 
 462 
 affections of mouth during, 464 
 connection of with diarrhoea, 519 
 congestion of brain frequent during, 49 
 occurrence of paralysis during, 204 
 connection of, with spasm of the glottis, 
 
 164 
 diagnosis of pneumonia supervening dur- j 
 
 ing, 293 
 dysuria during, 573 
 treatment, use of the gum-lancet, 465 
 constitutional, 466 
 affections of mouth during. 467 
 treatment of eruptions of scalp, &c, cau 
 tion concerning, 468 
 of diarrhoea during, 531 
 Depletion, general rules for. 28 
 
 excessive, its peculiar danger in infancy, 
 
 28, 134 
 in congestion of brain, 52 
 in tubercular meningitis, 94 
 in bronchitis, 277 
 in pneumonia, 294 
 in pleurisy, 313 
 in croup, 333 
 
 from head in hooping-cough, 394 
 in spasm of the glottis, 172 
 in inflammatory diarrhoea, 533 
 in peritonitis, 548 
 from head in typhoid fever, 628 
 in course of measles, 650 
 caution concerning, in affection of head 
 
 in scarlet fever, 661 
 in dropsy after scarlet fever, 569 
 Desquamative nephritis, 562 
 
 Diabetes, rarity of, in childhood, 576 
 
 symptoms of, connection with dyspepsia, 
 
 576 
 treatment of, 578 
 Diarrhoea, its frequency and importance, 517 
 table illustrating, 518 
 influence of age on, of dentition, 
 519 
 season on, 519 
 locality on, malaria, 530 
 two forms of, 518 
 
 simple or catarrhal, symptoms of, 520 
 
 during teething. 521 
 
 danger from exhaustion, 521 
 
 of supervention of dysentery, 521 
 inflammatory, or dysentery. 522 
 
 morbid appearances, chiefly in large 
 intestine, 522 
 in other parts. 524 
 symptoms of acute attack of, 524 
 occasional rapidity of course of, 
 
 525 
 chronic course of. 526 
 various causes and modes of death 
 
 from, 527 
 relapses of, 527 
 supervention of cerebral symptoms from 
 
 exhaustion in course of — cases, 132 
 complicating hooping-cough, 384 
 
 measles, 648 
 sometimes associated with congestion of 
 
 the brain, 55 
 possibility of its occurrence in tubercular 
 
 meningitis, 96 
 treatment of simple form, 530 
 during teething. 531 
 in its decline, 532 
 inflammatory form ; depletion, 533 
 vomiting, and of nervous symptoms, 
 
 533 
 use of stimulants in, 534 
 
 aromatics and astringents, 535 
 chronic stage of, 535 
 diet in, 537 
 intertrigo in. 538 
 prolapsus ani in. 539 
 Digestive system, peculiarities of, in early 
 childhood, 445 
 changes, with advancing years, 446, 
 
 519 
 deaths from diseases of, and from 
 
 other causes, compared, note, 235 
 disorder of, associated with diabetes, 
 577 
 Dilatation of heart, importance of, 439, 443 
 Diphtheria, 347 
 
 its relation to true croup, 323, 348 
 
 tabular view of differences from it, 350 
 
 symptoms, 348, 351 
 
 two forms, primary and secondary, 351 
 
 its affinity to blood diseases, 354 
 
 duration, and modes of death, 353, 356 
 
 albuminuria in, 353 
 
 affections of nervous system in, 354, 356 
 
 sequelae, 358 
 
 paralysis after, 357 
 
 relation to scarlatina, 361 
 
 treatment, 362 
 
 secondary to measles, 366 
 
 morbid appearances, 367 
 Disease, peculiarities of, in childhood, 18 
 difficulties of investigating, 18 
 
INDEX. 
 
 669 
 
 
 Disease, hereditary tendency to, important, 23 
 rules for treatment of, 27 
 changes in, 29 
 Dropsy after scarlatina, 562 (see Kidneys, 
 
 Inflammation of) 
 Duchenne's paralysis, note, 212 
 Dura mater, thrombosis of sinuses of, 107 
 Dyspepsia of infants, symptoms of, 489 
 
 treatment, when dependent on de- 
 bility, 491 
 gastric disorder, 492 
 use of alkalies in, 492 
 strumous, as a symptom of phthisis, 409 
 Dyspnoea, nervous, in course of bronchitis, 278 
 hooping-cough, 375, 380 
 treatment of, 396 
 Dysuria of young children, 573 
 treatment of, 574 
 from calculus iu urethra, from long pre- 
 puce, 575 
 
 Ear, inflammation of internal, 103 
 symptoms of, 104 
 diagnosis from inflammation of 
 
 br.-.in, 106 
 extending to brain, 104 
 treatment, 106 
 Eclampsia nutans, 176 
 Electricity in treatment of paralysis, 211 
 Elsasser. Dr., on hypertrophy of the brain, 
 
 126, 166 
 Embolism, as a cause of chorea, 194 
 Emetics, in treatment of croup, 333, 337 
 
 caution with reference to their 
 use, 338 
 Emphysema, its association with pneumonia, 
 271 
 relation of hooping-cough to its produc- 
 tion, 389 
 Empyema, 3 1 1 
 
 puncture of chest in, results of, 316 
 indications for, 316 
 rules for, 3 1 7 
 pleural fi.-tula from, 319 (see Pleurisy) 
 causes of death from, 319 
 Encephalitis, or simple inflammation of the 
 brain, 71, 101 
 its differences from tubercular meningitis, 
 
 101 
 morbid appearances iu. 102 
 its occurrence rare, 102 
 treatment of, 103 
 Endocarditis, 435 
 
 effects of, tendency to increase — cases, 
 436 
 occasional amelioration in — cases, 
 438 (see Heart, Diseases of) 
 Epidemic constitution, changes in, 277, 294 
 
 note, 321 
 Epilepsy, its frequency in childhood, 177 
 causes of, 178 
 affection of mind in. 179 
 general characters in childhood, 180 
 prognosis in, 181 
 checked by intercurrent acute disease, 
 
 183 
 treatment of, 183 
 general management in, 184 
 employment of belladonna and bromide 
 of potass in, 185 
 Exanthemata, general characteristics of, 617 
 
 Facial hemiplegia in new-born infants, 213 
 Feeding, artificial, of infants, high mortality 
 from, 448 
 its injurious effects explained, 
 
 449 
 morbid appearances produced 
 
 by, 450 
 rules for, when necessary, 454 
 quantity of food, 456 
 caution as to occasional un- 
 healthiness of cow's milk, 
 424, 455 
 Fevers in childhood, chiefly exanthemata, 617 
 continued fever, same in child and in 
 
 adult, 618 
 identity of remittent and typhoid fever, 
 619 (see Typhoid Fever) 
 Flatus, as cause of abdominal enlargement, 
 581 
 
 Galvanism, in treatment of paralysis, 212 
 Gangrene of the lung. 301 
 
 mouth, 473 (see Stomatitis, Gangrenous) 
 Gastric disorder, diasnosis of, from pneumo- 
 nia, 292 
 from pleurisy, 309 
 
 typhoid fever, 624 
 Glioma, deposit of in brain, 146 
 Glottis, spasiu of, 163 (see Spasm of Glottis) 
 
 tubage of. note, 341 
 Grav granulations, original form of tubercle, 
 
 408 
 Gums, lancing of. rules for, during teething, 
 465 
 caution needed in cases of spasm 
 of the glottis, 171 
 Gymnastics, use of, in chorea, 196 
 paralysis, 212 
 
 ] Hall, Dr. Marshall, mode of treating infantile 
 
 asphyxia, 241 
 \ Hasuiateuiesis, circumstances in which it oc- 
 curs, 497 
 illustrative cases, 498 
 spurious, 500 
 ' Hsemoptysis rare in phthisis of children, 416 
 cases of fatal, 412 
 Hemorrhage from umbilicus in new-born chil- 
 dren, 504 
 Hemorrhagic diathesis, note, 593 
 Heart, diseases of, 427 
 
 frequency in childhood, underrated, 
 
 428 
 connection with malformations, 430 
 acute rheumatism most frequent 
 
 cause of, 429 
 associated with scarlatina ; with 
 
 pleurisy, 430, 431 
 connection of, with chorea, 193 
 idiopathic, 430 
 
 sometimes independent of inflamma- 
 tion, 436 
 their tendency to increase, 439 
 occasional pauses in advance of, 438 
 importance of dilatation of, 440, 443 
 rarity of aneemic bruits, 442 
 conclusions concerning, 443 
 Hectic, rare in phthisis of children, 410 
 Hemiplegia, facial, in new-born infants, 213 
 Hernia, strangulated, in infants, 513 
 
670 
 
 INDEX. 
 
 Hip-joint disease, diagnosis from partial palsy 
 
 of leg, 205 
 Hooping-cough, essentially a disease of child- 
 hood. 371, 387 
 symptoms of the hoop, 372, 376 
 catarrhal stage, 373 
 varying at onset of, 374 
 nervous dyspnoea in, 376, 379 
 at its acme, 375 
 
 nocturnal exacerbations of, 375 
 indications of amendment and 
 
 deterioration, 376 
 cough often diminished by in- 
 tercurrent febrile affections, 
 378 
 complication of, with bronchitis and 
 pneumonia, 377 
 disorder of nervous system, 380 
 with congestion of brain, 55 
 convulsions, 43, 382 
 tubercular meningitis, case illus- 
 trative of, 382 
 diarrhoea, 384 
 irritable stomach and vomiting, 
 
 381, 385 
 measles and varicella, 385 
 duration of, 386 
 
 its catarrhal stage, 373 
 recurrence of, 387 
 
 causes of; influence of sex and age, 387, 
 vote, 387, 388 
 season and temperature, 388 
 contagion, 388 
 deaths from, at different ages, note, 388 
 
 from different complications, note, 377 
 morbid appearances in, 389 
 
 production of emphysema in, 
 
 389 
 state of the lungs, Alderson's ob- 
 servations, note, 390 
 pnpumogastric nerves, 390 
 treatment of, of first stage, 391 
 
 second stage, use of hydrocyanic acid, 
 39.2 
 sedatives, 394 
 chloroform in, 394 
 cauterization of larynx in, 
 
 395 
 counter-irritation and blis- 
 ters, 395 
 third stage, 399 
 
 the nervous dyspnoea ; danger of over- 
 treatment — cases in illustration, 
 397 
 bronchitis complicating, 396 
 decline of, 399 
 Hydatids of brain, 146 
 
 liver, 588 
 Hydrocephaloid disease, Br. M. Hall's ac- 
 count of, 131 
 supervention of, in course of diar- 
 rhoea, 132 
 pneumonia, and consequent 
 on cerebral congestion, 
 133 
 cautions against mistaking its symp- 
 toms, 134 
 rules for its prevention and treat- 
 ment, 135 
 Hydrocephalus, acute, or scrofulous inflamma- 
 tion of the brain, 70 (see Tubercular Menin- 
 gitis) 
 
 Hydrocephalus, chronic, circumstances in 
 which it occurs, 110 
 occasional result of cerebral con- 
 gestion, 50 
 connection with malformation of the 
 
 brain, 110, 113 
 external and internal, 111 
 internal, symptoms of, HI 
 changes of skull in. 111 
 relation of rickets to it, 117 
 progress and termination of, 113 
 age at which it comes on, 113 
 post-mortem appearances in, 114 
 frequent connection with inflam- 
 mation, 115 
 sometimes arrested, rarely cured, 
 116 
 external, its various causes, 117 
 diagnosis from hypertrophy of brain, 
 
 124 
 treatment of, 118 
 
 Golis's plan and use of com- 
 pression, 118 
 by puncture. 120 
 spurious, 131 (see Hydrocephaloid Dis- 
 ease) 
 Hydrocyanic acid in treatment of hooping- 
 cough, 392 
 Hydropathic treatment of pneumonia, 297 
 
 of typhoid fever, note, 631 
 Hypertrophy of brain, 121 (see Brain, Hyper- 
 trophy of) 
 Hypochondriasis in childhood, 220 
 Hypodermic injection of morphia, 33 
 Hysteria in childhood, 223 
 
 Icterus neonatorum, 501 (see Jaundice) 
 Idiocy, distinguished from backwardness, 229 
 causes of, 230 
 symptoms of. 231 
 mental faculties in, 232 
 education in, 233 
 
 association of, with hypertrophy of brain, 
 124 
 with congenital atrophy of brain, 127 
 Incontinence of urine, sometimes due to phi- 
 mosis, 574 
 treatment of, 580 
 Induration of the cellular tissue, symptoms 
 of, 255 
 appearances after death, 256 
 not entirely explicable by col- 
 lapse of the lung, 257 
 treatment of, 258 
 Infantile asphyxia, 239 
 
 treatment of, 240 
 Infants, artificial feeding of, high mortality 
 from, 447 
 injurious action of explained, 
 
 449 
 farinaceous substances unsuita- 
 ble for, 450 
 atrophy of, causes of, various, 450, 456 
 post-mortem appearances in, 450 
 Inflation of intestine in intussusception, 516 
 Influenza, its peculiarities in childhood, 280 
 
 treatment, 281 
 Inoculation of small-pox, comparative advan- 
 tages and evils of 632 
 Intellect, temporary weakening of, after long 
 illness, 128 
 
INDEX. 
 
 671 
 
 Intermittent fever, peculiarities of, in child- 
 hood, 631 
 Intertrigo in course of chronic diarrhoea, 
 
 treatment of, 538 
 Intestinal worms, 557 (see Worms) 
 Intestines, malignant tumor of, 596 
 
 softening of, 494 
 Intussusception of intestines, symptoms of, 
 513 
 age at which it occurs, note, 514 
 diagnosis of, 515 
 treatment of, 516 
 Inward fits, meaning of the term, 46 
 
 Jaundice, of new-horn infants, 501 
 
 influence of cold and bad air, in 
 
 causing it, 502 
 sometimes depends on obstruc- 
 tion or malformation of bili- 
 ary ducts, 503 
 treatment of, 502 
 of children, sometimes associated with 
 head symptoms, 504 
 treatment of, 505 
 .Tenner, Sir W., on mode of production of 
 pigeon breast, 252, 612 
 
 Kidneys, inflammation of, with albuminuria, 
 562 
 as sequela of scarlatina, 562 
 symptoms of, 563 
 composition of urine in, 565, 567 
 causes of death from, 565 
 post mortem appearances, re- 
 sults of the microscope, 568 
 treatment of, 569 
 chronic form of, 573 
 gravel and calculus in, very frequent in 
 
 children, 574 
 lithic acid in, very frequent in new-born 
 children, 572 
 formed during teething, 573 
 associated with dyspeptic symp- 
 toms, 575 
 fungoid disease of, 593 
 
 Laryngitis stridula, 368 (see Croup) 
 
 ulcerative, 326, 366 (see Croup) 
 Larynx, cauterization of, ia croup, 335 
 
 in hooping-cough, 395 
 Leeches, rules for application of, 28 
 
 applying to the head. 94 
 employment of, in congestion of 
 brain, 52 
 Leucaemia, associated with large spleen, 591 
 disposition to hemorrhage, 592 
 Leucorrhcea of young children, 607 (see Vulva, 
 
 Discharges from) 
 Lithates. formation of, in new-born children, 
 573 
 during dentition, 573 
 connection of, with dyspepsia and rheu- 
 matism, 575 
 treatment of excess of, 576 
 Liver, large in childhood, 581 
 
 enlarged, as cause of abdominal tumor, 
 584 
 from fatty deposit, 584 
 connection of fatty liver with in- 
 fantile convulsions, 166 
 
 Liver, enlarged, from albuminoid deposit. 585 
 from hydatids, 588 
 
 malignant disease, 589 
 Lungs, elasticity of, 238 
 
 imperfect expansion of, 239 
 
 conditions under which it occurs, 
 
 240, 243 
 anatomical characters, and ef- 
 fects of inflation on the lung, 
 242 
 symptoms of, 243 
 cases illustrative of, 244 
 diagnosis of, from congenital 
 
 phthisis, 246 
 treatment of, 246 (see Lungs, 
 Collapse of) 
 carnification of, 249, 301 (see Lungs, 
 
 Collapse of) 
 collapse of, erroneously regarded as pneu- 
 monia, 247 
 anatomical characters and symp- 
 toms of this supposed lobular 
 pneumonia, 248 
 effects of inflation on lung, 250 
 researches of Bailly and Le- 
 gendre, and of Gairdner on it. 
 250 
 cases illustrative of its occur- 
 rence, 251 
 occurs from similar causes in 
 
 adults as in children, 253 
 observations of its occurrence in 
 
 the aged, 25-1 
 its supervention in course of 
 bronchitis, 274 
 in hooping-cough. 390 
 association with it of induration 
 of the cellular tissue, 257 
 congestion and other changes of sub- 
 stance of, in course of bronchitis, 266 
 disease of, from infantile syphilis, 577 
 inflammation of substance of, 268 (see 
 
 Pneumonia) 
 abscess of. £67, 270 
 emphysema of, 271. 389 
 acute oedema of, 298 
 
 generally succeeds to scarlatinal 
 dropsy — illustrative cases, 299 
 post-mortem appearances, 299 
 treatment of, 300 
 chronic oedema of, 300 
 gangrene of, 301 
 
 to be regarded as a blood disease, 
 
 303 
 symptoms of, 303 
 treatment of, 303 
 tubercle of, table of 132 cases of, 404 
 
 miliary, and gray granulations, often 
 
 exist alone, 404 
 yellow infiltration frequent, 404 
 cavities from, rare, 405 
 
 small cavities or vacuoles, 405 
 frequent affection of bronchial 
 
 glands, 405 
 of bronchial glands, characters of, 
 406 
 sometimes got rid of and 
 how, 406 
 
 Malingering in childhood, 220 
 
 Measles and scarlatina, mortality from, 803 
 
672 
 
 INDEX. 
 
 Measles and scarlatina, resemble, but essen- 
 tially different, 644 
 essentially a disease of early childhood, 
 
 644 
 contagion of, 644 
 symptoms of, 645 
 
 characters of the eruption, 645 
 
 congestive form of, 647 
 
 diagnosis of, from scarlatina, 644, 659 
 
 complications of, with bronchitis and 
 
 pneumonia, 649 
 
 with croup, 366 
 
 in early stage of, 646 
 relation of, to hoopiug-cough, 387 
 treatment of, 649 
 
 of symptoms of affection of chest in, 
 650 
 Meat, raw, in infantile diarrhoea, 537 
 Melaena, 497 (see Haemateniesis) 
 Meningitis, simple, 101 (see Encephalitis) 
 
 tubercular, 71 (see Tubercular Meningitis) 
 of spinal cord — cases illustrative of, 149 
 post-mortem appearances in, 
 ]52 (see Spinal Cord) 
 Mercury, rules for its employment, 30 
 
 in treatment of tubercular meningitis, 
 95 
 pneumonia. 296 
 croup, 334 
 
 infantile syphilis, 603 
 Mesenteric glands, tumors from enlargement 
 
 of, 596 
 Microcephalus, 128 
 
 Milk, human, composition of. 446, 453 
 and of anima's compared, 454 
 peculiar adaptation of, to nourishment of 
 
 child, 445 
 its spontaneous coagulation in the stom- 
 ach, 492 
 healthy, characteristics of, 453 
 deterioration of. in scrofulous subjects; 
 
 Klencke's remarks on, 424, 425 
 best substitutes for, 454 
 of cow, occasionally unhealthy, 425 
 Mind, peculiarities of, in childhood, 219 
 disorders of, 219 
 
 from overwork, 224 
 
 perversion of moral faculties, 220, 
 
 226 
 in epileptics, 179 
 in chorea, 191 
 Moral insanity in children, 219, 226 
 Morphia, hypodermic injection of, 33 
 Mumps, 486 
 
 Narcotics, general rules for employment of, 
 32 
 in treatment of tubercular meningitis, 97 
 Neuralgia, in childhood, 213 
 Nervous system, diseases of, extremely fre- 
 quent in early life, 38 
 frequency of, accounted for, 39 
 deaths from, at different ages, 
 note, 44 
 and fi obi other causes, note 
 235 
 difficulties of study of, 39 
 symptoms of, 41 
 disorders of, complicating diarrhoea, 
 132, 521, 527 
 influence of malaria in produc- 
 ing, 530 
 
 Nervous system, diseases of, treatment of, 534 
 Nephritis, albuminous, 562 (see Kidneys, In- 
 flammation of) 
 Night cough of children, 282 
 
 terrors of children, description of an 
 attack of, 215 
 not indicative of primary mischief 
 
 in the brain — cases, 217 
 dependent on gastric disorder, 218 
 treatment of, 218 
 Noma, 471 (see Stomatitis, Ulcerative) 
 Nurse, statements of, not to be undervalued, 
 25 
 
 Odontitis infantum. 464. 467 (see Dentition) 
 (Edema of lungs, 298 (see Lungs, (Edema of) 
 Ophthalmoscope, its use in investigating dis- 
 ease of brain, 41 
 tubercular meningitis, 87 
 Opium, general rules for its employment, 32 
 and antimonv in head-symptoms of ty- 
 phoid fever, 628 
 Otitis, 104 (see Ear, Inflammation of) 
 Otonhoea. importance of head symptoms in, 
 105 
 chronic, treatment of, 106. 606 
 Ovaries, malignant tumor of, 596 
 Ozgena, scrofulous, 607 
 
 Pacchionian bodies, difference from granula- 
 tions of arachnoid, note, 74 
 Paracentesis of chest in pleurisy, 315 
 Paralysis, import of, less serious in child 
 ' than in adult, 201 
 sometimes congenital, 201 
 infantile, its characteristics, 203 
 diagno.-is, 205 
 nature, 206 
 prognosis, 203, 207 
 of portio dura from injury in birth, 212 
 causes of, 202 
 
 deformity consequent on, 207 
 treatment of, 20y 
 Duchenne's, note, 212 
 sequela of diphtheria, 357 
 Paralytic chorea, 19 I 
 
 Passion, ungovernable, in childhood, 220, 225 
 Percussion, general rules for, 21 
 Pericarditis, usually connected with rheu- 
 matism, 429 
 sometimes associated with pleurisy — cases 
 
 of, 430 
 with congenital malformation of heart, 
 
 430 
 symptoms of, 431 
 
 idiopathic — case of, 433 (see Heart, Dis- 
 eases of) 
 Pericardium, white spots on ; attrition theory 
 
 of, 435 
 Peritonitis in the foetus sometimes connected 
 with syphilis, 541 
 in early infancy, 541 
 
 sometimes acute and epidemic, 541 
 in childhood, acute idiopathic rare, 541, 
 542 
 symptoms, case illustrating, 543 
 discharge of pus through abdominal 
 
 walls in, 108, 544 
 secondary to scarlatina, 545, 548 
 to inflammation of caecum — cases of, 
 546 
 
INDEX. 
 
 673 
 
 Peritonitis in childhood, treatment of, 548 
 chronic, usually tubercular, 549 
 morbid appearances in, 549 
 symptoms and general course of, 551 
 varieties in its onset and course, 552 
 relations of to tabes mesenterica, 553 
 (see Tabes Mesenterica) 
 Phimosis a cause of incontinence of urine, 574 
 Phlebitis of sinuses of dura mater, 107 
 
 of umbilical vein not a cause of tris- 
 mus, 159 
 Phthisis, differences between disease in child 
 and adult, 401 
 tables illustrative of various peculiarities, 
 
 note, 403 
 affects different organs in child ; illustra- 
 tive table, 403 
 recent microscopic researches on, 408 
 assumes different furms, 404 
 symptoms of, their peculiarities. 409, 417 
 auscultatory, 413, 416 
 congenital, 246, 412 
 in early infancy, 412 
 of bronchial phthisis, 410, 416 
 spasmodic cough in, 370 
 auscultatory, 413 
 diagnosis of, from worms and remittent 
 fever, 409 
 tuberculous pneumonia, 418 
 import of frequent attacks of catarrh, 
 262 
 duration of, 420 
 
 rapid course of, 421 
 chronic course of — cases, 421 
 prognosis of, more hopeful in child than 
 in adult, 425 
 in bronchial phthisis — case of recov- 
 ery from, 41 1 
 death from, various modes of, 424 
 head symptoms sometimes obscure in, 83 
 supervention of tubercular meningitis in, 
 ' 82, 92 
 
 head symptoms, 424 
 treatment of, 424 
 Pia mater, its changes in tubercular menin- 
 gitis, 73 
 Pigeon breast, how produced, 252, 612 
 
 connection of with enlarged tonsils, 480 
 influence of rickets in causing it, 612 
 Pleura, effusion into, after scarlatina, 565 
 Pleurisy, acute idiopathic, rare in early child- 
 hood, 304 
 post-mortem appearances of, 304 
 symptoms and physical signs of, some 
 
 peculiarities in, 305 
 diagnosis of, errors in, frequent, 313 
 from head affection, 306 • 
 
 affections of the abdomen, 
 
 309 
 pneumonia, its difficulty, 
 290, 308 
 diaphragmatic, obscurity of symptoms of, 
 
 307 
 auscultatory signs of improvement in, 
 
 306 
 latent, 309 
 
 sudden death in, 309 
 termination in empyema, 311 
 associated with scarlatinal dropsy, 565 
 treatment of, 313 
 paracentesis of chest in, 315 
 
 Pneumonia, causes and frequency of, illustra- 
 tive table, 272 
 post-mortem appearances in, 269 
 termination in abscess, 270 
 association with emphysema, 279 
 idiopathic, symptoms of first stage of, 285 
 second, 286 
 third, 288 
 results of, death in 'second stage oc- 
 casional, 287 
 imperfect recovery from third 
 stage occasional, 288 
 auscultatory signs of third 
 stage, 289 
 recurrence of, 273 
 diagnosis of, temperature in, 291 
 from pleurisy, 291, 308 
 
 affeetion of the brain, 133, 
 
 291 
 gastric disorder, 292 
 dentition, 293 
 treatment of, 293 
 expectant treatment, 294 
 tartar emetic in, 295 
 mercurials in, 296 
 stimulants and blisters in, 297 
 secondary to bronchitis, a point of differ- 
 ence from disease in adult, 263 
 hooping-cough, 379 
 measles, 648 
 lobular, cases properly so called, 266 
 
 description under this name of col- 
 lapse of the lung, 248 
 scrofulous, morbid anatomy of, 408 
 Potassium, iodide of, in tubercular meningitis, 
 96 
 in epilepsy, 185 
 
 pleuritic effusion, 314 
 bromide of, as sedative, 33 
 Prescribing, general rules for, 35 
 Pseudo-hypertrophie paralysis, note, 212 
 Psoas abscess, characters of tumors formed by, 
 
 595 
 Puerile breathing not heard in early infancy, 
 
 and why, 237 
 Pulse, great variations in its frequency, 20 
 frequency of in infaney and childhood, 
 236 
 and that of respiration to be com- 
 pared in sick children, 20 
 peculiarities in tubercular meningitis, 80, 
 84, 90, 91 
 Purgatives, remarks on different kinds of, 31, 
 170 
 in congestion of brain, 51 
 in tubercular meningitis, 95 
 
 Rectum, imperforate, three varieties of, 507 
 its rarity, its symptoms, 508 
 circumstances modifying prognosis, 
 
 510 
 various operations for its cure, 510 
 Remittent fever identical with typhoid fever, 
 
 617 (see Typhoid Fever) 
 Respiration, artificial, modes of inducing, 241 
 peculiarities of, in early life, 235 
 its frequency in infancy and childhood, 
 
 236 
 feebleness of inspiratory power, 237 
 similarity of its characters in infancy and 
 old age, 254 
 
 43 
 
674 
 
 INDEX. 
 
 Respiration, its general characters to be no- 
 ticed in sick children, 19, 21 
 peculiarities of in cerebral disease, 43 
 organs of, death from diseases of, and 
 other causes, compared, note, 235 
 susceptibility of their mucous mem- 
 brane, 259, 262 
 ' this susceptibility less at birth than 
 afterwards, 259 
 Rest, importance of in diseases of heart, 441 
 Retro-cesophageal abscess, 485 
 Retro-pharyngeal abscess, 482 
 symptoms and cases of, 483 
 dependent on disease of cervical vertebrae, 
 
 485 
 diagnosis of, 485 
 treatment, 486 
 Revaccination, reasons in favor of, 639 
 Rheumatism, connection of with chorea, 192 
 simulating disease of spine, 148 
 acute, followed even when slight by heart 
 
 disease, 429 
 chroiiie, its connection with excess of lith- 
 ates in the urine. 575 
 Rickets, a distinct disease, 609 
 its general characters, 610 
 connection with hypertrophy of the brain, 
 
 123 
 alleged cause of chronic hydrocephalus, 
 
 116 
 influence on the skull, 611 
 chest, 612 
 long bones, 613 
 spine and pelvis, 614 
 a cause of abdominal enlargement, 581 
 curative changes in the bones, 615 
 connection of with spasm of the glottis, 
 
 165 
 causes of death in, 615 
 treatment of. 616 
 
 Salaam convulsion, 176 
 Santonin, as vermifuge, 560 
 Scalp, sanguineous tumor of, 60 (see Cephal- 
 hematoma) 
 Scarlatina, varieties of, 651 
 simplex, symptoms of, 651 
 
 characters and progress of the erup- 
 tion, 652 
 anginosa, symptoms of,. affection of throat 
 
 in, 653 
 maligna, symptoms of, 654 
 
 affection of throat and parotids in, 
 
 654, 656 
 various complications of, 656 
 supervention of endocarditis in course of, 
 
 430 
 acute peritonitis, as sequela of, 545, 549 
 post-mortem appearances in, 657 
 diagnosis of, from measles, 659 
 sequelae of, 658 
 
 albuminuria after, its varying frequency, 
 563 
 dropsy, 562 
 
 exciting causes of, 563 
 symptoms of, 563 
 composition of urine in, 567 
 state of kidneys in, 568 
 causes of death in, 565 
 treatment of, 659 
 use of inunction in, 659 
 
 Scarlatina, caution as to depletion in head 
 affections in, 661 
 the coryza and affection of throat in, 
 662 
 dropsy, 569 
 prophylaxis of, 662 
 Scrofula, not identical with tuberculosis, 604 
 its different manifestations, 605 
 abscesses, 605 
 glandular swellings, 605 
 otorrhoea and ozsena, 606 
 leucorrhcea, 607 
 
 associated with albuminoid liver, 586 
 Sedatives in treatment of hooping-cough, 392 
 Sinuses, cerebral, thrombosis of, 107 
 Sleep, frequency of pulse and respiration di- 
 minished during it, 25 
 its characters to be observed in sick chil- 
 dren, 19 
 caution concerning, in tubercular menin- 
 gitis, 90 
 Small-pox, influence of inoculation and of 
 vaccination on, 632. 640 
 mortality from, 633, 640 
 symptoms of, and diagnosis from other 
 eruptive fevers, 633 
 progress of the eruption, 634 
 peculiarities of the confluent form, 
 
 635 
 secondary fever, its dangers, 636 
 treatment of, 637 
 
 the secondary fever of, 637 
 
 local symptoms — prevention of 
 pitting, 639 
 after vaccination, its usually mild char- 
 acter, 640 
 peculiarities of its course and symp- 
 toms, 641 
 Spasm of the glottis, 163, 164 
 symptoms of, 164, 167 
 
 carpopedal contractions in, 168 
 various causes of, 163J&165 
 connection of, with rickets, 166 
 enlarged thymus gland, 370 
 treatment of, 170 
 
 caution as to lancing the gums in, 
 
 171 
 case illustrative of occasional neces- 
 sity for depletion, 174 
 use of bromide of potass and chloral 
 
 in, 174 
 caution as to sudden exposure to air, 
 
 173 
 the paroxysm, use of chloroform, 173 
 Speech, temporary loss of power of, after long 
 
 illness, 128 
 Spinal cord, predominance of, in early life, 44 
 special obscurity of disease of, in the 
 
 child, 147 
 Dr. Weber's observations on vascularity 
 
 of, 159 
 irritation and congestion of- — cases, 147 
 membranes of, usually involved in simple 
 
 encephalitis, 102 
 inflammation of its membranes sometimes 
 
 epidemic, note, 149 
 cases illustrative of inflammation of, 149 
 acute inflammation of substance of, 154 
 chronic inflammation of substance of, 155 
 softening of, generally connected with 
 disease of vertebrae, 155 
 
INDEX. 
 
 675 
 
 Spinal cord, softening of, remarkable case of, 
 
 without disease of the bones, 157 
 Spine, cervical, disease of, with retropharyn- 
 geal abscess, 485 
 Spleen, albuminoid enlargement of, 591 
 
 enlarged, associated with leucaemia, 591 
 Stimulants, use of, in treatment of diarrhoea, 
 
 534 
 Stomach, peculiarities of, in infancy, 445, 447 
 softening of, different opinions concern- 
 ing, 494 
 characters of, 495 
 alleged influence of mode of death 
 
 on, 496 
 its frequency in infancy, theories ac- 
 counting for, 497 
 Stomatitis, three varieties of, 468 
 
 follicular, symptoms an-d course of. 457, 
 468 
 treatment of, 470 (see Thrush) 7 
 ulcerative or noma, symptoms and course 
 of, 471 
 relations to diphtheria. 471 
 tendency to pass into gangrene very 
 
 slight, 472 
 treatment of, 472 
 gangrenous, fatality of, 473 
 
 its connection with blood diseases, 
 
 473 
 does not depend on administration of 
 
 mercury, 473 
 point of departure of gangrene, 474 
 symptoms and course of, 474 
 morbid appearances in, 476 
 treatment ; importance of cauteriza- 
 tion, 477 
 Strychnine in chorea, 200 
 
 in infantile paralysis, 210 
 
 incontinence of urine, 580 
 Sunstroke, 49, 54 
 Sulphate of magnesia, use of small doses of, in 
 
 diarrhoea, 494, 531 
 Sulphuric acid, in diarrhoea, 531 
 Sylvester, Dr., on artificial respiration, 241 
 Syphilis, infantile, 599 
 
 dependent on congenital taint. 599 
 produced by vaccination, note, 599, 640 
 relation of, to foetal and infantile peri- 
 tonitis, 541 
 symptoms of, 599 
 
 coryza, sometimes the only one, 261, 
 
 600 
 rarity of affection of bones, 601 
 syphilitic cachexia, 602 
 relapses and tertiary symptoms, 602 
 affections of liver, thymus, &c, in, 
 602 
 treatment of, 603 
 
 local applications in, 604 
 
 Tabes mesenterica, relation of, to tubercular 
 peritonitis, 553 
 anatomical characters of, 554 
 symptoms not pathognomonic of, 554 
 treatment of, and of tubercular periton- 
 itis, 554 
 Tartar emetic ointment as counter-irritant in 
 
 tubercular meningitis, 98 
 Temperature, in infancy and childhood, 236 
 importance of ascertaining, 20 
 in disease of brain, 86, 135 
 
 Temperature in pneumonia. 291 
 in typhoid fever, 86, 625 
 as premonitory sign of phthisis, 410 
 Thermometer, use of, important, 20 
 Thirst, indications of, in the infant, 25 
 Threadworms, santonin in their treatment, 
 
 560 
 Thrombosis of cerebral sinuses, 107 
 Thrush, its characters described, 457 
 disorder of health attending it, 459 
 microscopic characters of, 459 
 causes and treatment of, 460 
 Thymic asthma, note, 370 
 Thymus, suppuration of, in infantile syphilis, 
 
 663 
 Tongue, in infants, how to examine the, 22 
 Tonsils, inflammation of, 479 
 
 hypertrophy of, its symptoms, 479 
 
 its influence on the form of the 
 
 mouth and chest, 480 
 its treatment, 481 
 Tracheotomy, in croup, 339 
 
 difference of results in England and 
 
 France, 339 
 results of, influenced by rickets, 339 
 objections to performance of, 341 
 reasons for not rejecting, 341 
 conditions of success, 343 
 after-management, 344 
 Trismus, infantile, symptoms of, 157 
 post-mortem appearances in, 158 
 opinions as to its cause, 159 
 modes of prevention, and of treatment, 
 160 
 Tubercle, gray granulations, original form of, 
 408 
 of brain, 136 (see Brain, Tubercle of) 
 mesenteric glands, 553 (see Tabes 
 Mesenterica) 
 Tubercular meningitis, 71 
 
 ages at which it occurs, 92 
 predisposition to, in phthisical families, 
 
 92 
 morbid appearances in, two kinds of, 71 
 at base of brain, 72 
 granulations of the membranes, 73 
 
 their tubercular nature, 74 
 state of cerebral substance in, and 
 
 relation to fluid in ventricles, 75 
 softening not due to imbibition of 
 fluid, 76 
 result of inflammation ; its 
 relation to changes in 
 lining of ventricles, 76 
 tubercular deposits in brain in, 78 
 complications of, 78 
 symptoms of first stage, 78 • 
 second stage, 79 
 third stage, 80 
 vary in different cases, 82 
 approach sometimes very grad- 
 ual, 82, 86 
 obscure in phthisical subjects, 83 
 three stages of, not always distinct, 91 
 occasional occurrence of diarrhoea in, 96 
 diagnosis of, from inflammation of in- 
 ternal ear, 106 
 from night terrors, 217 
 from pneumonia, 292 
 from typhoid fever, 85 
 remissions in, irregular, 86, 90 
 gastric disorder in, 86 
 
676 
 
 INDEX, 
 
 Tubercular meningitis, diagnosis of, from 
 pleurisy, 307 
 use of ophthalmoscope in, 87 
 prognosis in, very unfavorable, 88 
 appearances of improvement delu- 
 sive, 89 
 occasional recovery from, 88 
 caution as to sleep in, 89 
 duration of, 91 
 
 treatment of, prophylaxis of, 92 
 depletion in, 94 
 purgatives in, 95 
 use of mercurials and iodide of 
 
 potassium in, 95, 96 
 local application of cold in, 96 
 use of tartar emetic ointment 
 
 in, 98 
 diet, use of narcotics, applica- 
 tion of blisters in, 97, 98 
 last stage of, 99 
 Tubercular peritonitis, 549 (see Peritonitis, 
 
 Chronic) 
 Tuberculosis, not identical with scrofula, 604 
 Tumors, abdominal, 580, 581 (see Abdominal 
 
 Tumors) 
 Typhoid fever, identity of, in child and adult, 
 618 
 post-mortem appearances of, 619 
 symptoms of milder form of, 619 
 temperature in, 86, 624 
 
 appearance of eruption in, 622 
 severer form of, 622 
 delirium in, 623 
 cerebral mischief in, 624 
 convulsions in, 623 
 death rare in, 624 
 signs of recovery from, 623 
 diagnosis of, from simple gastric dis- 
 order, 624 
 from acute tuberculosis, 420, 625 
 tubercular meningitis, 85 
 pneumonia, 292 
 treatment of, 626 
 abdominal symptoms in, 628 
 cerebral disturbance in, 628 
 diet and stimulants in r 629 
 
 Umbilicus, discharge of pus from, in periton- 
 itis, 108 
 hemorrhage from, in new-born children, 
 503 
 
 Urea, excess of, 576 
 
 Urine, incontinence of — causes, 578 
 
 Urine, incontinence of, sometimes due to phi- 
 mosis, 574 
 treatment, 579 
 condition of, in diphtheria, 353 
 in scarlatinal dropsy, 567 
 
 Vaccination, drawbacks from its universal 
 success, 640 
 great benefits of, 632, 640 
 adoption of, followed by increase of 
 
 measles and scarlatina, 643 
 communication of syphilis by, note, 599, 
 640 
 Van der Kolk. on atrophy of brain, 130 
 Varicella, 641 (see Chicken-pox) 
 Variola, 632 (see Small-pox) 
 Vertebrae, disease of the cervical, extending 
 to brain, 103 
 affection of spinal cord in cases 
 
 of, 155 
 as cause of retropharyngeal ab- 
 scess, 485 
 Vomiting, in infants, its frequency accounted 
 for, 489 
 treatment of, 489, 491 
 as a sign of dyspepsia. 490, 491 
 in course of diarrhoea, 524, 533 
 important as a sign of cerebral disease, 
 
 42, 49 
 in first stage of tubercular meningitis, 
 
 78, 79 
 persistent, of great importance as a sign 
 
 of tubercular meningitis, 86 
 in hooping-cough, 381, 385 
 of blood, 497 (see Hsemateuiesis) 
 Von Dusch, on thrombosis of cerebral sinuses, 
 
 109 
 Vulva, discharges from, 607 
 
 circumstances in which they oc- 
 cur, 607, 608 
 treatment of, 608 
 
 Waterstroke, ease of, 101 
 Waxy liver, 585 
 
 Whytt, Dr., his observations on acute hydro- 
 cephalus, 70 
 Worms, intestinal, five varieties of, 557 
 
 symptoms of, 558 
 
 convulsions from, 559 
 
 treatment of, 560 
 
 Zinc, sulphate of, in treatment of chorea, 
 199 
 
INDEX TO FOEMUL^E. 
 
 Acid mixture for hooping-cough, . 
 Alterative saline, .... 
 
 tonic, .... 
 Alum mixture for hooping-cough, . 
 Antimonial, nauseating, 
 Aperient, aloetic, .... 
 febrifuge, 
 
 saline, .... 
 for tapeworm, 
 Astringent, 
 
 aromatie, opiate, . 
 
 gallic acid, opiate, 
 
 lead and opium, 
 
 sulphate of iron and opium, 
 Cinchona and hydrocyanic acid mixture, 
 Cough mixtures, . . . . 
 Decoction blanche, . . . . 
 Demulcent, ..... 
 Diuretic, saline, .... 
 Ethereal stimulant, for fever, 
 Expectorant, stimulating, 
 Febrifuge, aperient, 
 
 sedative, 
 Hooping-cough, alum mixture for, 
 acid mixture for, . 
 Hydrocyanic acid, .... 
 
 with bark, . 
 Iodide of potass, mixture for pleuritic- effusion, 
 Iron, expectorant mixture for chronic bronchitis 
 
 hooping-cough, 
 Liniment, stimulating, for the chest, 
 Nitro-muriatic acid mixture, . 
 Oleaginous opiate, for diarrhoea, . 
 
 NO. 
 
 PAGE 
 
 XIX. 
 
 399 
 
 XXVIII. 
 
 494 
 
 XXIX. XXXVII. 
 
 507, 556 
 
 XVIII. 
 
 399 
 
 XIV. 
 
 332 
 
 XXV. 
 
 491 
 
 I. 
 
 52 
 
 VI. 
 
 93 
 
 XXXVII. 
 
 556 
 
 XXX. XXXII. 
 
 532, 535 
 
 XXXIII. 
 
 535 
 
 XXXIV. 
 
 536 
 
 XXXV. 
 
 536 
 
 XXXVI. 
 
 536 
 
 XXI. 
 
 400 
 
 VIII. IX. X. 
 
 261, 263 
 
 
 57 
 
 XXIII. 
 
 466 
 
 XIII. 
 
 314 
 
 XXXIX. 
 
 630 
 
 XII. 
 
 279 
 
 I. 
 
 52 
 
 II. III. 
 
 52, 53 
 
 XVIII. 
 
 399 
 
 XIX. 
 
 399 
 
 XV. XVI. 
 
 392 
 
 XXI. 
 
 400 
 
 XIII. 
 
 314 
 
 XX. 
 
 400 
 
 XI. 
 
 278 
 
 XXII. 
 
 426 
 
 XXXI. 
 
 533 
 
m 
 
 INDEX TO FORMULA. 
 
 Opiate powder, .... 
 Saline, antimonial, .... 
 
 with iodide of potass, . 
 
 sedative, with bromide of potass 
 Sedative, hydrocyanic acid, . 
 
 opiate powder, 
 Stimulant, ethereal, 
 
 expectorant, . 
 Tan-bath, 
 Tonic, alterative, 
 
 aperient, 
 
 astringent, 
 
 chalybeate, 
 
 alum and sulphuric acid, 
 
 chalybeate, expectorant, 
 
 cinchona, and hydrocyanic acid, 
 
 hydrochloric acid, 
 
 nitro-muriatic acid, . . 
 
 vegetable, alkaline, 
 
 with mineral acids, 
 
 NO. 
 
 PAGE 
 
 XVII. 
 
 393 
 
 XIV. 
 
 332 
 
 XIII. 
 
 314 
 
 II. 
 
 52 
 
 XV. XVI. 
 
 392 
 
 XVII. 
 
 393 
 
 XXXIX. 
 
 630 
 
 XII. 
 
 279 
 
 
 126 
 
 XXIX. XXXVII. 
 
 507, 556 
 
 VII. 
 
 93 
 
 IV. 
 
 57 
 
 V. 
 
 57 
 
 XVIII. 
 
 399 
 
 XX. 
 
 400 
 
 XXI. 
 
 400 
 
 XIX. 
 
 399 
 
 XXII. 
 
 426 
 
 XXVI. 
 
 493 
 
 XXIV. XXVII. 
 
 491, 493 
 
HENRY C. LEA'S SON & CO.'S 
 
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2 Henry C. Lea's Son & Co.'s Publications — (Am. Journ. Med. Set.). 
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Henry C. Leas's Son & Co.'s Publications — (Am. Joum. Med. Sri.). 3 
 
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4 Henry C. Lea's Son & Co.'s Publications — (Dictionaries). 
 
 JJUNGLISON [ROBLEY), M.D., 
 
 Late Professorof Institutes of Medicine in Jefferson Medical College, Philadelphia. 
 
 MEDICAL LEXICON; A Dictionary op Medical Science: Con- 
 taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
 Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
 Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulae for 
 Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
 the Terms, and the French and other Synonymes ,- so as to constitute a French as well as 
 English Medical Lesicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
 ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
 someroyaloctavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50; 
 half Russia, $8. (Jiist Issued.) 
 The object of the author from the outset has not been to make the work a mere lexicon or 
 dictionary of terms, but to afford, undereach, a condensed view of its various medical relations, 
 and thus to render the work an epitome of the existing condition of medical science. Starting 
 with this view, the immense demand which has existed forthe work has enabled him, in repeated 
 revisions, to augment its completeness and usefulness, until at length it has attained the position 
 of a recognized and standard authority wherever the language is spoken. 
 
 Special pains have been taken in the preparation of the present edition to maintain this en • 
 viable reputation. During the ten years which have elapsed since the last revision, the additions 
 to the nomenclature of the medical sciences have been greater than perhaps iD any similar perio d 
 of the past, and up to the time of his death the authorlabored assiduously to incorporate every- 
 thing requiring the attention of the student or practitioner. Since then, the editor has been 
 equally industrious, so that the additions to the vocabulary aremore numerous than in any pre- 
 vious revision. Especial attention has been bestowed on the accentuation, which will be found 
 marked on every word. The typographical arrangement has been much improved, rendering 
 reference much more easy, and every care has been taken with the mechanical execution. The 
 work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
 the additions have been incorporated with an increase of but little over a hundred pages, and 
 the volume now contains the matter of at least four ordinary octavos. 
 
 may safely confirm the hope ventured hy the editor 
 
 A book well known to our readers, and of which 
 every American ought to be proud. When the learned 
 author of the work passed away, probably all of us 
 feared lest the book should not maintain its place 
 in the advancing science whose terms it defines. For- 
 tunately, Dr. Richard J. Dunglison, having assisted his 
 father in the revision of several editions of the work, 
 and having been, therefore, trained in the methods and 
 imbued with the spirit of the book, has been able to 
 edit it. not in the patchwork manner so dear to the j 
 heart of book editors, so repulsive to the taste of intel- 
 ligent book readers, but to edit it as a work of the kind 
 should be edited— to carry it on steadily, without jar 
 or interruption, along the grooves of thought it has 
 travelled during its lifetime. To show the magnitude 
 of the task which Dr. Dunglison has assumed and car- 
 ried through, it is only necessary to state that more 
 than six thousand new'subjects have been added in the 
 present edition.— Phila. Med. Times, Jan . 3, 1874. 
 
 About the first book purchased by the medical stu- 
 dent is the Medical Dictionary. The lexicon explana- 
 tory of technical terms is simply a sine qua non . In a 
 science so extensive, and with such collaterals as medi 
 cine, it is as much a necessity also to the practising 
 physician. To meet the wants of students and most 
 physicians, the dictionary must be condensed while 
 comprehensive, and practical while perspicacious. It 
 was because Dunglison's met these indications that it 
 became at once the dictionary of general use wherever 
 medicine was studied in the English language. In no 
 former revision have the alterations and additions been 
 so great. More than six thousand new subjects and terms 
 have been added. The chief terms have been set in black 
 letter, while the derivatives follow in small caps; an 
 arrangement which greatly facilitates reference. We 
 
 that the work, which possesses for him a filial as well 
 as an individual interest, will be found worthy a con- 
 tinuance of the position so long accorded to it as a 
 standard authority." — Cincinnati Clinic, Jan. 10, 1874. 
 
 It has the rare merit that it certainly has n« rival 
 in the English language for accuracyand extent of 
 references. — London Medical G-a.zettf 
 
 As a standard work of reference, as one of the best, 
 if not the very best, medical dictionary in the Eng- 
 lish language, Dunglison's work has been well known 
 for about forty years, and needs no words of praise 
 on our part to recommend it to the members of the 
 medical, and, likewise, of the pharmaceutical pro 
 fession. The latter especially are in need of such a 
 work, which gives ready and reliable information 
 on thousands of subjects and terms which they are 
 liable to encounter in pursuing their daily avoca- 
 tions, but with which they cannot be expected to be 
 familiar. The work before us fully supplies this 
 want. — Am. Journ. of Pharm., Feb. 1S74. 
 
 A valuable dictionary of the terms employed is 
 medicine and the allied sciences, and of the rela- 
 tions of the subjects treated under each head. It re- 
 flects great credit on its able American author, and 
 well deserves the authority and popularity it has 
 obtained. — British Med. Journ., Oct. 31, 1874. 
 
 Few works of this class exhibit a grander monu- 
 ment of patient research and of scientific lore. The 
 extent of the sale of this lexicon is suflicient to tes- 
 tify to its usefulness, and to the great service con- 
 ferred by Dr. Robley Dunglison on the profession, 
 and indeed on others, hy its issue. — London Lancet , 
 May 13, D375. 
 
 TJOBLYN {RICHARD D.), M.D, 
 11 A DICTIONARY OF THE TERMS USED IN MEDICINE AND 
 
 THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
 M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
 l2mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00 
 It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
 Med. and Surg. Journal. 
 
 T>ODWELL [G. F.), F.R.A.S., frc. 
 
 A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
 istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
 Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
 History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
 many illustrations : cloth, $5. 
 
Henry C. Lea's Son & Co.'s Publications — (Manuals). 5 
 
 A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Doctors E. H. 
 
 -**- Clarke, H- J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- 
 some 12mo. volume of about 350 pages : cloth, $2 25. (Lately Issued.) 
 This work appeared in the pages of the American Journal of the Medical Sciencesduring the 
 year 1876. As a detailed account of the development of medical science in America, by gentle- 
 men of the highest authority in their respective departments, the professionwill no doubt wel 
 come it in a form adapted for preservation and reference. 
 
 l^EILL {JOHN), M.D., and VMITH {FRANCIS G.), M.D., 
 
 -*- ' Prof, of the Institutes of Medicine in the Univ. of Penna . 
 
 AN ANALYTICAL COMPENDIUM OF THE VARIOUS 
 
 BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
 new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
 volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in 
 leather, with raised bands, $4 75. 
 
 H 
 
 ARTSHORNE {HENRY), M.D., 
 
 Professor of Hygiene in the University of Pennsylvania. 
 
 A CONSPECTUS OF THE MEDICAL SCIENCES; containing 
 
 Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
 Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
 royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
 wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 
 We can say with the strictest truth that it is the worthy. If students must have a conspectus, they 
 best work of the kind with which we areacquainted. | will be wise to procure that of Dr. Hartshorne.— 
 It embodies in a condensed form ail recent con tribu- ' Detroit Rev. of Med. and Pharm., Aug. 1S74. 
 tions to practical medicine, and is therefore useful j The work bef()re however, has many redeem- 
 to every busy practitioner throughout our country, , ing features not possessed by others, and is the best 
 besides being admirably adapted to the use of stu- | we haveseen . Dr . Hartshorne exhibits much skill in 
 dents of medicine. The book is faithfully and ably , condenS ation. It is well adapted to the physician in 
 executed.— Charleston Med. Journ., April, lS7o. j active practice, who can give but limited time to the 
 The work is intended as an aid to the medical \ familiarizing of himself with the important changes 
 student, and as such appears to admirably fulfil its j which have been made since he attended' lectures, 
 object by itsexcellent arrangement, the full compi- ; The manual of physiology has also been improved 
 lationaf facts, the perspicuity and terseness of Ian- \ and gives the most comprehensive view of the latest 
 guage, and the clear and instructive illustrations j advances in the science possible in the space devoted 
 
 in some parts of the work.— American Jotcrn. of 
 Pharmacy, Philadelphia, July, 1874. 
 
 The volume will be found useful, not only to stu 
 dents, but to many otherswhomay desire torefresh 
 
 to the subject. The mechanical exscution of the 
 book leaves nothing to be wished for. — Peninsular 
 Journal of Medicine, Sept. 1874. 
 
 After carefully looking through this conspectus, 
 
 their memories with the smallest possible expendi-, we are constrained to say that it is the most com- 
 ture of time.— N. T. Med. Journal, Sept. 1874. j plete work, especially in its illustrations, of its kind 
 
 The student will find this the most convenient and ! that we have seen.— Cincinnati Lancet, Sept. 1S74. 
 useful book of the kind on which he can lay his j The favor with whicll the first edition of this 
 hand.— Pacific Med. and Surg. Journ., Aug. 1874. Compendium was received, was an evidence of its 
 
 This is the best book of its kind that we have ever I various excellences. The present edition bears evi- 
 examined. It is an honest, accurate, and concise | dence of a careful and thorough revision. Dr. Harts- 
 compend of medical sciences, as fairly as possible J home possesses a happy faculty of seizing upon the 
 representing their present condition. The changes j salientpoints of each subject, and of presenting them 
 and the additions have been so judicious and tho- | in a concise and yet perspicuous manner. — Leaven- 
 rough as to render it, so far as it goes, entirely trust- | worth Med. Herald, Oct. 1S74 
 
 TUDLOW {J.L.), M.D. 
 A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 
 
 Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
 Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
 and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
 l2mo. volume of 816 large pages, cloth, $8 25 ; leather, $3 75. 
 The arrangement of this volume in the form of question and answer renders it especially suit- 
 able for the office examination of students, and for those preparing for graduation. 
 
 T 
 
 BANNER {THOMAS HAWKES), M.D., frc. 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
 
 NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
 Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
 &c. In one neat volume small 12mo., of about 375 pages, cloth, $150. 
 *■%* On page 3, it will be seen that this work is offered as a premium for procuring new 
 sabscribers to the "American Journal of the Medical Sciences.'' 
 
6 
 
 Henry C. Lea's Son & Co.'s Publications — {Anatomy). 
 
 QRAY {HENRY), F.R.S., 
 
 Leeturer on Anatomy at St. George's Hospital, London. 
 
 ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 
 
 H. V. Cakter, M.D., and Dr. Westmacott. The Dissectionsjointly by the Author and 
 Dr. Carter. With an Introduction on General Anatomy and Development by T. 
 Holmes, M.A., Surgeon to St. George's Hospital. A new American, from the eighth 
 enlargec and improved London edition. To which is added " Landmarks, Medical and 
 Surgical," by Luther Holden, F.R.C.S., author of " Human Osteology," "A Manual 
 of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 
 522 large and elaborate engravings on wood. Cloth, $6; leather, raised bands, $7; 
 half Russia, $7 50. {Just Ready.) 
 The author has endeavored in this work to cover a more extendedrange of subjects than is cus- 
 tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
 also the application of those details in the practice of medicine and surgery, thusrendering it both 
 a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
 gravings form a special feature in the work, many of them being the size of nature, nearly all 
 original, and having the names of the various parts printed on the body of the cut, in place of 
 figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
 which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
 refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
 the details of the dissecting room ; while combining, as it does, a eomplete Atlas of Anatomy, with 
 a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
 essential use to all physicians who receive students in their offices, relieving both preceptor and 
 pupil of much labor in laying the groundwork of a thorough medical education. 
 
 Since the appearance of the last American Edition, the work has received three revisions at the 
 hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
 requisite to maintain its reputation as a complete and authoritative standard text-book and work 
 of reference. Still further to increase its usefulness, there has been appended to it the recent 
 work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" 
 which gives in a clear, condensed, and systematic way, all the information by which the prac- 
 titioner can determine from the external surface of the body the position of internal parts. Thus 
 complete, the work, it is believed, will furnish all the assistance that can be rendered by typeand 
 illustration in anatomical study. No pains have been spared in the typographical execution of 
 the volume, which will be found in all respects superior to former issues. Notwithstanding the 
 increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
 at a price rendering it one of the cheapest works ever offered to the American profession. 
 
 The recent work of Mr. Holden, which was no- 
 ticed by us on p. 53 of this volume, has been added 
 as an appendix, so that, altogether, this is the mot t 
 practical and complete anatomical treatise available 
 to American students and physicians. The former 
 finds in it the necessary guide in making dissec- 
 tions ; a very comprehensive chapter on minute 
 anatomy ; and about all that can be taught bim on 
 general and special anatomy; while the latter, in 
 its treatment of each region from a surgical point of 
 view and in the valuable edition of Mr Holden, 
 will 'find all that will be essential to him in his 
 practice —New Remedies, Aug. 1878. 
 
 This work is as near perfection as one could pos- 
 sibly or reasonably expect any book intended as a 
 text-book or a general reference book on anatomy 
 to be. The American publisher deserves the thanks 
 of the profession for appending the recent work of 
 Mr. Holden, '■'Landmarks, Medical and Surgical," 
 which has already been commended as a separate 
 book. The latter work—treating of topographieal 
 anatomy— has become an essential to the library of 
 every intelligent practitioner. "We know of no 
 book that can take its place, written as it is by a 
 most distinguished anatomist. It would be simply 
 a waste of words to say anything further in praise 
 of Gray's Anatomy, the text-book in almost every 
 medical college in this country, and the daily refer- 
 ence book of every practitioner who has occasion 
 
 to consult his books on anatomy. The work is 
 simply indispensable, especially this present Amer- 
 ican edition.— Fa. Med. Monthly, Sept. 187?. 
 
 The addition of the recent work of Mr. Holden, 
 as an appendix, renders this the most practical and 
 complete treatise available to American students, 
 who find in it a comprehensive chapter on minute 
 anatomy, about all that can be taught on geueral 
 and special anatomy, while its treatment of each 
 region, from a surgical point of vie v, in the valu- 
 able section by Mr. Holden, is all that will be essen- 
 tial to them in practice. — Ohio Medical Recorder, 
 Aug 1S7S. 
 
 It is difficult to speak in moderate terms of this 
 new edition of " Gray." It seems to be as nearly 
 perfect as it is possible to make a book devoted to 
 any braneh of medical science. The labors of the 
 eminent men who have successively revised the 
 eight editions through which it has passed, would 
 seem to leave nothing for future editors to do. The 
 addition of Holden : s " Landmarks" will make it as 
 indispensable to the practitioner of medicine and 
 surgery as it has been heretofjre to the student. As 
 regards completeness, ease of reference, utility, 
 beauty, and cheapness, it has no rival. No stu- 
 dent should enter a medical school without it ; no 
 physician can afford to have it absent from his 
 library.— Si. Louis Olin. Record, Sept. 1878. 
 
 Also for sale separate — 
 TTOLDEN {LUTHER), F.R.C.S., 
 
 JlI Surgeon to St. Bartholomew' s and the Foundling Hospitals. 
 
 LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 
 
 Ed. Inonehandsome volume, royal 12mo., of 128 pages : cloth, 88 cents. (Now Ready.) 
 EATH {CHRISTOPHER), F.R.C.S., 
 
 Teacher of Operative Surgery in University College, London. 
 
 PRACTICAL ANATOMY: A Manual of Dissections. From the 
 
 Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
 M. L\, Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
 In one handsome royal 12mo. volume of 578 pages, with 247illustrations. Cloth, $3 50 ; 
 leather, $4 00. 
 
 H 
 
Henry C. Lea's Son & Co.'s Publications — {Anatomy). 
 
 7 
 
 A LLEN (HARRISON), M.D. 
 
 •^*- Proftssor of Physiology in the, Univ. of Pa. 
 
 A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 
 
 and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an 
 Introductory Chapter on Histology. By E. 0. Shakespeare, M D., Ophthalmologistto the 
 Phila. Hosp. In one large and handsome quarto volume, with several hundred original 
 illustrations on lithographic plates, and numerous wood-cuts in the text, (hi Press.) 
 In this elaborate work, which has been in active preparation for several years, the author has 
 sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
 the practical applications of the science to medicine and surgery. The workthus has claims upon 
 the attention of the general practitioner, as well as of the student, enabling him not only to re- 
 fresh his recollections of the dissecting room, but also to recognize the significance of all varia- 
 tions from normal conditions. The marked utility of the object thus sought by the author is 
 self- evident, and his long experience and assiduous devotion to its thorough development are a 
 sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
 spared with the illustrations. Those of normal anatomy are from original dissections, drawn on 
 stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
 after the manner of " Holden" and " Gray, " and in every typographical detail it will be the 
 effort of the publisher to render the volume worthy of the very distinguished position which is 
 anticipated for it. 
 
 PLLIS {GEORGE V1NER). 
 
 •U Emeritus Professor of Anatomy in University College, London. 
 
 DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- 
 
 ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
 of Anatomy in University College, London. From the Eighth and Revised London 
 Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
 Cloth, $4.25 ; leather, $5.25. {Just Ready.) 
 This work has long been known in England as the leading authority on practical anatomy, 
 and the favorite guide in the dissecting-room, as is attested by the numerous editions through 
 which it has passed. In the last revision, which has just appeared in London, the accomplished 
 author has sought to bring it on a level with the most recent advances of science by making the 
 necessary changes in his account of the microscopic structure of the different organs, as devel- 
 oped by the latest researches in textural anatomy. 
 
 its leadership over the English manuals upon dis- 
 secting. — Phila. Med. Times, May 24, 1879. 
 
 As a dissector, or a work to have in hand and 
 studied while one is engaged in dissecting, we re 
 gard it as the very best -work extant, which is cer- 
 tainly saying a very great deal. As a text-book to 
 be studied in the dissecting-room, it is superior to 
 any of the works upon anatomy.— Cincinnati Med. 
 News, May 24, 1879. 
 
 We most unreservedly recommend it to every 
 practitioner of medicine who can possibly get it. — 
 Va. Med. Monthly, June, 1879. 
 
 Ellis's Demonstrations is the favorite text-book 
 of the English student of anatomy. In passing 
 through eight editions it has been so revised and 
 adapted to the needs of the student ihat it would 
 seem that it had almost reached perfection in this 
 special line. The descriptions are clear, and the 
 methods of pursuing anatomical investigations are 
 given with such detail that the book is honestly 
 entitled to its name. — St. Louis Clinical Record, 
 June, 1879. 
 
 The success of this old manual seems to be as well 
 deserved in the present as in the past volumes. 
 The book seems destined to maintain yet for years 
 
 w 
 
 ILSON {ERASMUS), F.R.S. 
 
 A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 
 
 by W. H. Gobrecht, M.D,, Professor of General and Surgical Anatomy in the Medical Col- 
 lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood . In 
 one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather. $5. 
 
 s 
 
 s 
 
 and JJORNER { WILLIAM E.),M.D., 
 
 &c. Late Prof, of Anatomy in the Unit). ofPenna. 
 
 MITH {HENRY H), M.D., 
 
 Prof, of Surgery in the Univ. of Penna. 
 
 AN ANATOMICAL ATLAS ; illustrative of the Structure of the 
 
 Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
 fifty beautiful figures. $4 50. 
 
 CHAFER {ED WARD ALBERT), M.D. , 
 
 Assistant Professor of Physiology in University College, London. 
 
 A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 
 
 the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with 
 numerous illustrations: cloth, $2 00. (Just Issued.) 
 
 HORNER'S SPECIAL ANATOMY AND HISTOL- 
 OGY. Eighth edition, extensively revised and 
 modified. In 2 vols. Svo., of over 1000 pages, 
 with 320 wood-cuts : cloth, $6 00 
 
 SHARPEY AND QUAIN'S HUMAN ANATOMY. 
 Revised, by Joseph Leidy, M.D.,Prof of Anat. 
 in Uuiv. of Penn. In two octavo vols, of about 
 1300 pages, with 511 illustrations Cloth, $6 00. 
 
 BELLAMY'S STUDENT'S GUIDE TO SURGICAL 
 ANATOMY: A Text-book for Students preparing 
 
 for their Pass Examination. With engravings on 
 wood. In one handsome royal 12mo. volume 
 Cloth, $2 25. 
 
 CLELAND'S DIRECTORY FOR THE DISSECTION 
 OF THE HUMAN BODY. In one small volume, 
 royal 12mo. of 182 pages: «loth $1 25. 
 
 HARTSHORNE'S HANDBOOK OF ANATOMY AND 
 PHYSIOLOGY. Second edition, revised. In one 
 royal 12mo. vol., with 220 wood- cuts ; cloth, 
 $175. 
 
8 
 
 Henry C. Lea's Son & Co.'s Publications — (Physiology). 
 
 ffARPENTER ( WILLIAM B.), M.D., F.R.S., F.G.S., F.L.S., 
 
 ^ Registrar to University of London, etc . 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, 
 
 M.B. Lond., F R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
 American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
 tions, by Francis G. Smith, M.D., Professor of the Institutes of Medicine in the Univer- 
 sity of Pennsylvania, etc. In one very large andhandsome octavo volume, of 1083 pages, 
 with two plates and 373 engravings on wood,- cloth, $5 50 ; leather, $6 50 ; half Russia, 
 $7. (Jiist Issued.) 
 
 We have been agreeably surprised to find the vol- 
 ume so complete in regard to the structure and func- 
 tions of the nervous system in all its relations, a 
 subject that, in many respects, is one of the most diffi- 
 cult of all, in the whole range of physiology, upon 
 which to produce a full and .satisfactory treatise of 
 the class to which the one before us belongs. The 
 additions by the American editor give to the work as 
 it is a considerable value beyond that of the last 
 English edition. In conclusion, we can give our cor- 
 dial recommendation to the work as it now appears. 
 The editors have, with their additions to the only 
 work on physiology in our language that, in thefull- 
 est sen-e of the word, is the production of a philoso- 
 pher as well as a physiologist, brought it up as fully 
 as could be expected, if not desired, to the standard 
 of our knowledge of its subject at the present day. 
 It will deservedly maintain the place it has always 
 had in the favor of the medical profession. — Journ. 
 of Nervous and Mental Dn-ease, April, 1877. 
 
 Such enormous advances have recently been made in 
 our physiological knowledge, that what was perfectly 
 
 new a year or two ago. looks now as if it had been a 
 received and established fact for years. In this ency- 
 clopaedic way it is unrivalled. Here, as it seems to 
 us. is the great value of the book; one is safe in sending 
 a student to it for information on almost any given 
 subject, perfectly certain of the fulness of information 
 it will convey, and well satisfied of the accuracy with 
 which it will there be found stated. — London Med. 
 Times and Gazette, Feb. 17, 1877. 
 
 The merits of" Carpenter's Physiology" are so widely 
 known and appreciated that we need only allude briefly 
 to the fact that in the latest edition will be found a com- 
 prehensive embodiment of the results of recent physio- 
 logical investigation. Care has been taken to preserve 
 the practical character of the original work. In fact 
 the entire work has been brought up to date, and bears 
 evidenceof the amount of labor that has been bestowed 
 upon it by its distinguished editor, Mr. Henry Power. 
 The American editor has made the latest additions, in 
 order fully to cover the time that has elapsed since the 
 last English edition. — iV. T. Med. Journal, J an. 1877 . 
 
 JjTOSTER {MICHAEL), M.D., F.R.S., 
 
 J- Prof, of Physiology in Cambridge Univ., England. 
 
 TEXT-BOOK OF PHYSIOLOGY. A new American, from the third 
 
 English edition. Edited with notes and additions by Edward T. Reichert, M.D., 
 Demonstrator of Experimental Therapeutics in Univ. of Penna. In one handsome royal 
 12mo. volume of 1030 pages, with 259 illustrations. Cloth, $1 50. Leather, $2 00. 
 (Just Ready.) 
 
 American Editor's Preface. 
 
 The high reputation acquired on both sides of the Atlantic by Dr. Foster's "Text-Book on 
 Physiology," as a lucid exposition of functional physiology, in its most modern aspect, has seemed 
 to call for an edition more thoroughly adapted to the wants of the American student. The plan 
 of the author has presupposed an acquaintance with the details of physiological anatomy such as 
 the student is accustomed to look to in his treatises on physiology. The absence of these 
 details has rendered many parts of the work vague, if not altogether incomprehensible, and has 
 therefore proved a serious drawback to the usefulness of the book as an accompaniment to lec- 
 tures on physiology, as it is usually taught in our schools, and this deficiency the editor has 
 endeavored to supply, by brief notes and the introduction of a large number of illustrations. 
 
 The almost limitless amount of material accumulated by modern research has rendered diffi- 
 cult the task of selection and compression, without exceeding the reasonable limits of a conve- 
 nient text-book. In his selection the editor has been guided by his experience in the wants of 
 students, and has endeavored merely to present, in the most concise form, such facts as would seem 
 to be indispensable to a correct appreciation of the structure and function of the important 
 organs. In accomplishing this, his additions have considerably exceeded his expectations, 
 amounting to about 140 pages, including the illustrations which have been increased in number 
 from 72 to 259. If he shall thus have succeeded in rendering this admirable work better fitted 
 for the wants of the American student, he will feel abundantly rewarded. 
 
 Nothing has been omitted from the English edition, and all additions have been distin- 
 guished by insertions in brackets [ — ]. 
 
 The great popularity of "Foster's Text-book of 
 Physiology," both in England and in this country, 
 readers it unnecessary to say anything further re- 
 garding its merit. We shall, therefore, simply 
 point out that, in the American edition, numerous 
 important additions have been made to the text of 
 the third English edition whereby the usefulness of 
 the work as a text-book for students has been greatly 
 increased.— -Phila. Med. and Surg. Reporter, April 
 24, 1880. 
 
 Foster's Physiology is a most excellent book, not 
 only for the student, but especially for the physician 
 who wishes to revise and increase his physiological 
 knowledge. The style of the author is clear, his ar- 
 rangement and classification of subjects very satis- 
 factory, and he has presented in this volume a most 
 valuable exposition of physiology as now known. — 
 The Am. Practitioner, April, 1880. 
 
 Every sentence shows careful and mature thought, 
 
 and the student, at the outset, will have to make up 
 his mind that Foster's work requires stzidy, and not 
 simply a cursory reading. The work is well illus- 
 trated, and its method clear and logical, and emi- 
 nently practical, and fully up to the present ad- 
 vanced status of this most important branch of 
 medicine. Foster's work is a credit to his scholar- 
 ship and research, and will be accepted everywhere 
 by the student and practitioner as reliable authority. 
 It should be in the hands of every medical student. 
 — St. Louis Clin. Record, April, 1S80. 
 
 In the presentation of the latest and the most 
 serviceable facts the work is peculiarly rich, and 
 the author is also decidedly happy in his freedom 
 from tedium or useless details, and omission of so 
 very little that a book for students needs to teach. 
 The style is scholarly, and the volume a thoroughly 
 welcome one. — Cincinnati Med. Gaz. and Recorder, 
 April, 18S0. 
 
 THE SAME. English Student's Edition, without notes or additions. 
 
 one small 12mo. volume of 804 pages with 72 illustrations. Cloth, 75 cents. 
 
 In 
 
Henry C. Lea's Son & Co.'s Publications — (Physiology, Chemistry). 9 
 nALTON {J. C), M.D., 
 
 ■U Professor of Physiology in the College of Physicians and Surgeons, New YorTt,&c. 
 
 A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 
 
 of Studentsand Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
 with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
 ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50 ; half Russia, $7. [Just Issued.) 
 
 of its old time popularity. The mechanical execution 
 of the work is all that could be desired. — Peninsular 
 Journal of Medicine, Dec. 1875. 
 
 This popular texi-book ou physiology comes to us in 
 its sixth edition with the addition of about fifty percent, 
 of new matter, chiefly in the departments of patho- 
 logical chemistry and the nervous system, where the 
 principal advances have been realized. With so tho- 
 rough revision and additions, that keepthe work well 
 up to the rimes, its continued popularity may be confi- 
 dently predicted, notwithstanding? the competition it 
 may encounter. The publisher's work is admirably 
 done. — St. Louis Med. and Surg. Journ , Dec. 1875. 
 
 We heartily welcome this, the sixth edition of this 
 admirable text book, than which there are none of equal 
 brevity more valuable. It iscordially recommended by 
 the Professor of Physiology in the University of Louisi- 
 ana, as by all competent teachers in the United States, 
 and wherever the English language is read, this book 
 has been appreciated. The present edition, with its 316 
 admirably executed illustrations, has been carefully 
 revised and very tnuch enlarged, although its bulk does 
 not seem perceptibly increased. — New Orleans Medical 
 and Surgical Journal, March, 1876. 
 
 The present edition is very much superior to every 
 other, not only in that it brings the subject up to the 
 times, but that i+ do«s so more fully and satisfactorily 
 than any previous edition . Takeit altog^therit remains 
 inourhumbleopinion.thebest text book on physiology 
 in any land or language. — The Clinic, Nov. 6, 1875. 
 
 During the past few years several new works on phy- 
 siology, aud new editions of old works, have appeared, 
 competing for the favor of the medical student, but 
 noue will rival this new edition of Dalton As now en- 
 larged, it will be found also to be. in general, a satisfac- 
 tory work of reference for the practitioner. — Chicago 
 Med. Journ. znd Examiner, itrn. 1876. 
 
 Prof. Daltou has discussed conflicting theories and 
 conclusions regarding physiological questions with a 
 fairness, a fulness, and a conciseness which lend fresh- 
 ness and vigor to the entire book. But his discussions 
 have been s<"> guarded by a refusal of admission to those 
 speculative and theoretical explanations, which ai best 
 exist in the minds of observers themselves as only pro- 
 babilities, that none of his readers need be led into 
 grave errors while making them a study.— The Medical 
 Record, Feb. 19, 1876. 
 
 The revision of this great work has brought it forward 
 with the physiological advances of the day. and renders 
 it, as it has ever been, the finest work for students ex- 
 tant.— Nashville Journ. of Med. and Surg., Jan. 1876. 
 
 For clearness and perspicuity, Dalton's Physiology 
 commended itself to the student years ago. and was a 
 pleasant relief from the verbose productions which it 
 supplanted. Physiology has. however, made many ad- 
 vances since then— and while the style has been pre- 
 served intact, the work in the present edition has been 
 brought up fully abreast of the times. The new chemical 
 notation and nomenclature have also been introduced 
 into the present edition. Notwithstanding the multi- 
 plicity of text-books on physiology, this will lose none 
 
 QREENE [WILLIAM H.), 31. D., 
 
 " Demonstrator of Chemistry in Med. Dept , Univ. of Penna. 
 
 A MANUAL OF MEDICAL CHEMISTRY. Forthe Use of Students. 
 
 Based upon Bowman's Medical Chemistry. In one royal 12mo. volume of 312 pages. 
 With illustrations. Cloth, $1 75. (Jicst Issued.) 
 
 It is well written, and gives the latest views on 
 vital chemistry, a subject with which m->st phy-i- 
 cians are not sufllciently familiar. To those who 
 may wish to improve their knowledge in that direc 
 tion, we can heartily recommend this work as being 
 worthy of a careful perusal.— Phila. Med. and Surg. 
 Reporter, April 21, 1SS0. 
 
 The little work before us is one which we think 
 will be studied with pleasure and profit The de- 
 scriptions, though brief, are clear, and in most cases 
 sufficient for the purpose This book will, in nearly 
 all cases, meet general approval. — Am. Journ. of 
 Pharmacy, April, 1SS0. 
 
 (JLASSEN [ALEXANDER), 
 
 ^-s Professorin the RoyaJ Polytechnic School, Aixla-Chapelle. 
 
 ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 
 
 notes and additions by Edgar F. SivriTH, Ph.D., Assistant Prof, of Chemistry in the 
 Towne Scientific School, Univ. of Penna. In one handsome royal 12ino. volume, of 324 
 pages, with illustrations ; cloth, $2 00. {Just Ready.) 
 
 advancing to the analysis of minerals and such pro- 
 ducts as are met with in applied chemistry. It is 
 an indispensable book for students in chemistry. — 
 Boston Journ. of Chemistry, Oct. 1878. 
 
 It is probably the best manual of an elementary 
 nature extant, insomuch as its methods are the best. 
 It teaches by examples, commencing with single 
 determinations, followed by separations, and then 
 
 QALLOWAY [ROBERT), F.C.S., 
 
 ^ Prof of Applied Chemistry in the Royal College of Science for Ireland, etc. 
 
 A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
 don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $2 75. (Lately 
 Issued.) 
 
 J£EMSEN[IRA), M.D., Ph^LX, 
 
 Professor of Chemistry in the Johns Ropkins University, Baltimore. 
 
 PRINCIPLES OF THEORETICAL CHEMISTRY, with special reference 
 
 to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
 232 pages : cloth, $1 50. {Just Issued.) 
 
 BOWMAN'S INTRODUCTION TO PRACTICAL 
 CHEMISTRY, INCLUDING ANALYSIS. Sixth 
 American, from the sixth and revised London edi- 
 tion. With numerous illustrations. In one neat 
 vol., royal 12mo., cloth, $2 25. 
 
 WOHLER AND FITTIG'S OUTLINES OF ORGANIC 
 CHEMISTRY. Translated with additions from the 
 Eighth German Edition. By Ira Remsen. M D , 
 Ph.D., Prof, of Chemistry and Physics in Williams 
 
 College, Mass. In one volume, royal 12mo. of 550 
 pp., cloth, $3. 
 
 LEHMANN'S MANUAL OF CHEMICAL PHYSIOL- 
 OGY. Translated from the German, with Notes 
 and Additions, by J. Cheston Morris, M.D. With 
 illustrations on wood. In one octavo volume of 
 336 pages. Cloth, $2 25. 
 
 LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- 
 plete in two large octavo volumes of 10 '"" 
 with 200 illustrations: clot> *" 
 
10 Henry C. Lea's Son & Co.'s Publications — (Chemistry). 
 
 POWNES {GEORGE), Ph.D. 
 
 A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 
 
 Practical. Revised and corrected by Henry Watts, B.A., F.R.S., author of "A Diction- 
 ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
 trations. A new American, from tht twelfth and enlarged London edition. Edited by 
 Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; 
 cloth, $2 75 5 leather, $3 25. (Just Issued.) 
 Two careful revisions by Mr. Watts, since the appearance of the last American edition of 
 " Fownes," have so enlarged the work that in England it has been divided into two volumes. In 
 reprinting it, by the use of a small and exceedingly clear type, cast for the purpose, it has been 
 found possible to comprise the whole, without omission, in one volume, not unhandy for study and 
 reference. The enlargement of the work has induced the American Editor to confine his additions 
 to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- 
 nounced since the very recent appearance of the work in England, and has added the standards 
 in popular use to the Decimal and Centigrade systems employed in the original. 
 
 Among the additions to this edition will be found a very handsome colored plate, representing 
 a number of spectra in the spectroscope. Every care has been taken in the typographical execu- 
 tion to render the volume worthy in every respect of its high reputation and extended use, and 
 though it has been enlarged by more than one hundred and fifty pages, its very moderate price 
 will still maintain it as one of the cheapest volumes accessible to the chemical student. 
 
 This work, inorganic and orgauic,is complete in ] what formidable magnitude with its more than a 
 one convenient volume. In its earliest editions it j thousand pages, but with less than this no fair repre- 
 was fully up to the latest advancements and theo- j sentation of chemistry as it now is can be given. The 
 ries of that time. In its present form, it presents, I type is small but very clear, and the sections are very 
 in a remarkably convenient and satisfactory man- | lucidly arranged to facilitate study and reference. — 
 ner, the principles and leading facts of the chemistry j Med. and Surg. Reporter, Aug. 3, 1878. 
 of to-day. Concerning the manner in which the , The work is too well known to American students 
 various subjects are treated, much deserves to be | to need any extended notice; suffice it to say that 
 said, and mostly, too, in praise of the book. A re- the revision by the English editor has been faithfully 
 view of such a work as Fownes's Chemistry within done , and that Professor Bridges has added some 
 the limits of a book-notice for a medical weekly is I fr esh and valuable matter, especially in the inor- 
 simply out of the question.— Cincinnati Lancet and j ganic chemistry. The book has always been a fa- 
 Clinic, D^c. 14, 1S-S. vorite in this country, and in its new shape bids 
 
 When we state that, in our opinion, the present j fair to retain all its former prestige. — Boston Jour. 
 edition sustains in every respect the high reputation | of Chemistry, Aug. 1S78. 
 
 which its predecessors have acquired and enjoyed, I it W1 \i be entirely unnecessarv for us to make any 
 we express therewith our full belief in its intrinsic remarks relating to" the general character of Fownes' 
 
 value as a text-book and work of reference. — Am 
 Journ. of Pharm., Aug. 1878. 
 
 The conscientious care which has been bestowed 
 upon it by the American and English editors renders 
 it still, perhaps, the best book for the student and the 
 practitioner who would keep alive the acquisitions 
 of his student days. It has, indeed, reached a some- 
 
 Manual. For over twenty years it has held the ton 
 most place as a text-book, and the elaborate and 
 thorough revisions which have been made from time 
 to timeleavelittlechance for any wide awakerival to 
 step before it. — Canadian Pharm. Jour., Aug. 1878. 
 As a manual of chemistry it is without a superior 
 in the language.— Md. Med. Jour., Aug. 1S78. 
 
 A TTFIELD {JOHN), Ph.D., 
 
 ^~ Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Sec. 
 
 CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; 
 
 including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
 
 of the Science, and their Application to Medicine and Pharmacy. Eighth edition revised 
 
 bv the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. 
 
 Cloth, $2 50 ; leather, $3 00. (Jtist Ready.) 
 
 We have repeatedly expressed our favorable of chemistry in all the medical colleges in the 
 
 opinion of this work, and on the appearance of a United States. The present edition contains such 
 
 new edition of it, little remains for us to say, ex- alterations and additions as seemed necessary for 
 
 cept that we expect this eighth edition to be as the demonstration of the latest developments of 
 
 indispensable to us as the seventh and previous chemieal principles, and the latest applications of 
 
 editions have been. While the general plan and chemistry to pharmacy. It is scarcely necessary 
 
 arrangement have been adhered to, new matter for us to say that it exhibits chemistry in its pre- 
 
 has been added covering the observations made sent advanced state. — Cincinnati Medical News, 
 
 since the former edition The present differs from April, 1S79. 
 
 the preceding one chiefly in these alterations and 
 in about ten pages of useful tables added in the 
 appendix.— Am. Jour, of Pharmacy, May, 1879. 
 A standard work like Attfield's Chemistry need 
 
 The popularity which this work has enjoyed is 
 owing to the original and clear disposition of the 
 facts of the science, the accuracy of the details, and 
 the omission of much which freights many treatises 
 
 only be mentioned by its name, without further, heavily without bringing corresponding instruction 
 comments The present edition contains such al- to the reader. Dr. Attfield writes for students, and 
 terations and additions as seemed necessary for primarily for medical students; he always has an 
 the demonstration of the latest developments of eye to the pharmacopoeia and its oflicinal prepara- 
 chemical principles, and the latest applications of tions; and he is continually putting the matter in 
 chemistry to pharmacy. The author has bestowed ; the text so that it responds to the questions with 
 arduous labor on the revision, and the extent of which each section is provided. Thus the student 
 the information thus introduced may be estimated \ learns easily, and can always refresh and test his 
 from the fact that the index contains three hun- ' knowledge.— Med and Surg. Reporter, Apritl9, '79. 
 dred new references relating to additional mater- [ We noticed only abou t two vears and a half ago 
 i&\.— Druggists' Circular and Chemieal Gazette, j the publication of the preceding edition, and re- 
 May, 1879. | mar ked upon the exceptionally valuable character 
 This very popular and meritorious work has t of the work. The work now i icludes the whole of 
 now reached its eighth edition, which fact speaks j the chemistry of the pharmacopoeia of the United 
 in the highest terms in commendation of its excel- | States, Great Britain, and India. — New Remedies, 
 lence. It has now become the principal text-book I May, 1S79. 
 
Henry C. Lea's Son & Co.'s Publications — {Chemistry). 
 
 11 
 
 B 
 
 LOXAM (C.L.), 
 
 Professor of Chemistry in King's College, London. 
 
 CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 
 don Edition. In one very handsome octavo volume, of 700 page6, with about 300 illus- 
 trations. Cloth, $4 00 ; leather, $5 00. {Lately Issued.) 
 
 Wehave in this work a completeand most excel- 
 lent text-book for the use of schools, and can heart- 
 ily recommend it as such.— Boston Med. and Surg. 
 Journ., May 28, 1S74. 
 
 Theaboveis the title of a work which we can most 
 conscientiously recommend to students of chemis- 
 try. It is as easy as a work on chemistry could be 
 made, at the. same time that it presentsa full account 
 of thatscience as it now stands. We have spoken 
 o-f the work as admirably adapted to the wants of 
 students ; it is quite as well suited to the require- 
 ments of practitioners who wish to review their 
 cJhemistry, or have occasion to refresh their memo- 
 ries on any point relating to it. In a word, it is a 
 book to be read by all who wish to know what is 
 the chemistry of the presentday. — American Prac- 
 titioner, Nov. 1873. 
 
 It would be difficult for a practical chemist and 
 teacher to find any material fault with this most ad- 
 mirable treatise. The author has given us almost a 
 cjclopsedia within the limits of aconvenient volume, 
 and has done so without penning the useless para- 
 graphs too commonly making up a great part of the 
 bulk of many cumbrous works. The progressive 
 scientist is not disappointed when he looks for the 
 record of new and valuable processes and discover- 
 ies, while the cautious conservative does not find its 
 pages monopolized by uncertain theories and specu- 
 lations. A peculiar point of excellence is the crys- 
 tallized form of expression in which great truths are 
 expressed in very short paragraphs. One is surprised 
 at the brief space allotted to an important topic, and 
 yet, after reading it, he feels that little, if any more 
 should have been said. Altogether, it is seldom yoa 
 see a text-book so nearly faultless. — Cincinnati 
 Lancet Nov. 1S73. 
 
 fILO WES (FRANK), D.Sc, London. 
 
 ^ Senior Science-Master at the High School, Neweastle-unde.r Lyme, etc. 
 
 AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY 
 
 AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
 Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 
 English Edition, with about fifty illustrations on wood. In one very handsome royal 
 12mo. volume of 372 pages : cloth, $2 50. (Just Issued.) 
 Itis short, concise, and eminently practical. We \ are so simple, and yet concise, as to be interesting 
 
 and intelligible. The work is unincumbered with 
 theoretical deductions, dealing wholly with 
 
 therefore heartily commend it to students, and espe- 
 cially to those who are obliged to dispense with a 
 master. Of course, a teacher is in every way desi- 
 rable, but a good degree of technical skilland prac- 
 tical knowledge can be attained with no other 
 instructor than the very valuable handbook now 
 under consideration. — St. Louis Clin. Record, Oct. 
 1877. 
 
 The work is so written and arranged that it can be 
 comprehended by the student without a teacher, and 
 the descriptions and directions for the various work 
 
 the 
 
 practical matter, which it is the aim of this compre- 
 hensive text-book to impart. The accuracy of the 
 analytical methods are vouched for from the fact 
 that they have all been worked through by the 
 author and the members of his class, from the 
 printed text. We can heartily recommend the work 
 to the student of chemistry as being a reliable and 
 comprehensive one. — Druggists' 1 Advertiser, Oct. 
 15,1877. 
 
 KNAPP'S TECHNOLOGY ; or Chemistry Applied to 
 the Arts, and to Manufactures. With American 
 additions by Prof. Walter R. Johnson. In two 
 
 very handsome octavo volumes, with 500 wood 
 engravings, cloth, $6 00. 
 
 pARRISH [EDWARD), 
 
 Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 
 
 A TREATISE ON PHARMACY. Designed as a Text-Book for the 
 
 Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
 
 Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
 
 handsome octavo volume of 977 pages, with 280 illustrations ; cloth. $5 50 ; leather, $6 50; 
 
 half Russia, $7. {Lately Issued.) 
 
 Of Dr. Parrish's great work on pharmacy it only the work, not only to pharmacists, but also to the 
 
 remains to be said that the editorhas accomplished multitude of medical practitioners who are obliged 
 
 his work so well as to maintain, in this fourth edi- to compound their own medicines. It •will ever hold 
 
 tion, the high standard of excellence which it had an honored place on our own bookshelves. — Dublin 
 
 attained in previous editions, under the editorship of Med. Press and Circular, Aug. 12, 1874. 
 
 its accomplished author. This has not been accom- 
 
 plished without much labor, and many additions and 
 improvements, involving changes in the arrange- 
 ment of the several parts of the work, and the addi- 
 tion of much new matter. With the modifications 
 thus effected it constitutes, as now presented, a com 
 
 We expressed our opinion of a former edition in 
 terms of unqualified praise, and we are in no mood 
 to detract from that opinion in reference to the pre- 
 sent edition, the preparation of which has fallen into 
 competent hands. It is a book with which nopharma- 
 
 pendium of the science and art indispensable to the cist can dispense, and from which no physician can 
 
 pharmacist, and of the utmost value to every 
 practitioner of medicine desirous of familiarizing 
 himself with the pharmaceutical preparation of the 
 articles which he prescribes for his patients. — Chi- 
 cago Med. Journ., July, 1874. 
 
 The work is eminently practical, and has the rare 
 merit of beingreadableandinteresting, while itpre- 
 serves astrictly -cientificcharacter. The whole work 
 reflects the greatest credit on author, editor, and pub- 
 lisher. It will eonvey some idea of the liberality which 
 has been bestowed upon its production when we men- 
 tion that there are no less than 2S0 carefully executed 
 illustrations. In conclusion, we heartily recommend 
 
 fail to derive much information of value to him 
 practice. — Pacific Med. and Surg. Journ., June, '74. 
 
 Perhaps one, if not the most important book upon 
 pharmacy which has appeared in the English lan- 
 guage has emanated from the transatlantic press. 
 " Parrish's Pharmacy" is a well-known work on this 
 side of the water, and the factshowsus that a really 
 useful work never becomes merely local in its fame. 
 Thanks to the judicious editing of Mr. Wiegand, the 
 posthumous edition of " Parrish" has been saved to 
 the public with all the mature experience of its au- 
 thor, and perhaps none the worse for a dash of new 
 blood.— Lond. Pharm. Journal, Oct. 17, 1874. 
 
12 Henry C. Lea's Son & Co.'s Publications — {Mat. Med. and Therap.), 
 
 WARQUHARSON {ROBERT), M.D. , 
 
 Lecturer on Materia Mediea at St. Mary's Hospital Medical School. 
 
 A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- 
 
 cond American edition, revised by the Author. Enlarged and adapted to the U. S. 
 Pharmacopoeia. By Frank Woodbury, M.D. In one neat rojal 12ino. volume of 498 
 pages: cloth, $2.25. (Just Ready.) 
 
 copious notes have been introduced, embodying the 
 latest revision of t>e Pharmacopoeia, together wi'h 
 the antidotes to the more prominent poisons, and 
 such of the newer remedial agents as seemed neces- 
 sary co the completeness of the work. Tables of 
 weights and measures, and a good alphabetical in- 
 dex end the volume. — Druggists' Circular and 
 Chemical Gazette, June, 1S79. 
 
 The appearance of a new edition of this conve- 
 nient and handy book in less than two years may 
 certainly be taken as an indication of its useful 
 ness. Its convenient arrangement, and its terse- 
 ness, and, at the same time, comoleteness of the 
 information given, make it a handy book of refer- 
 ence.— Am. Journ. of Pharmacy, June, 1879. 
 
 This work contains in moderate compass such 
 well-digested facts concerning the physiolog ral 
 and therapeutical action of remedies as are reason- 
 ably established up to the present time. By a con- 
 venient arrangement the corresponding effects of 
 each article in health and disease are presented in 
 parallel cclnmns, not only rendering reference 
 easier, but also impressing the facts more strongly 
 upon the mind of the reader. The book has been 
 adapted co the wants of the American student, and 
 
 It is a pleasure to think that the rapidity with 
 which a second edition is demanded may be taken 
 as an indication that the sense of appreciation of the 
 value of reliable information regarding the use of 
 remedies i< not emirelj overwhelmed in the cultiva- 
 tion of pathologicalstudies, characteristic of the pre- 
 sent day. This work certainly merits the success it 
 has so quickly achieved. —New Remedies, July, '79. 
 
 OTILLE [ALFRED), M.D., 
 
 Professor of Theory and Practice of Medicine in the University of Penna. 
 
 THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 
 
 on the Action and Uses of Medicinal Agents, including their Description and History. 
 Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 
 pages. Cloth, $10; leather, $12; half Bussia, $13. {Lately Issued.) 
 
 It is unnecessary to do much more than to an- 
 nounce the appearance of the fourth edition of this 
 well known aud excellent work. — Brit, and For. 
 Med.-Chir. Review, Oct 1875. 
 
 For all who desire a complete work o n therapeutics 
 and materia mediea for reference, in case.-iuvulving 
 medico-legal questions, as well as for information 
 concerning remedial agents, Dr. Still6's is "par ex- 
 cellence''' the work. The work being out of print, by 
 the exhaustion of former editions, the author has laid 
 the profession under renewed obligations, by the 
 careful revision, iinportantadditions, and timely re 
 issuing a work not exactly supplemented by any 
 other in the English language, if in any language. 
 The mechanical execution handsomely sustains the 
 well-kuown skill and good taste of the publisher. — 
 St. Louis Med. and Surg. Journal, Dec 1874. 
 
 From the publication of the first edition "Stille's 
 Therapeutics" has been one of the classics; its ab- 
 sence from our libraries would create a vacuum 
 which could be filled by no other work in the lan- 
 guage, and its presence supplies, in the two volumes 
 
 of the present edition, a whole cyclopsedia of thera- 
 peutics. — Chicago Medical Journal, Feb. 1S75. 
 
 The rapid exhaustion of three editions and the uni- 
 versal favor with which the work has been received 
 by the medical profession, are sufficient proof of its 
 excellence as a repertory of practical and useful in- 
 formation for the physician. The edition before us 
 fully sustainsthis verdict, as the work hasbeencare- 
 fully revised and in some portions rewritten, bring- 
 ing it up to the present time by the admission of 
 chloral and crotonchloral. nitrite of amyl, bichlo- 
 ride of methylene, methylic ether, lithium com- 
 pounds, gelseminum, and other remedies. — Am. 
 Journ. of Pharmacy, Feb. 1875. 
 
 We can hardly admit that it has a rival in the 
 multitade of its citations and the fulness of its re- 
 search into clinical histories, and we must assign it 
 a place in the physician's library; not, indeed, as 
 fully representing the present siate of knowledge in 
 pharmacodynamics, but as byfar the most complete 
 treatise upon the clinical and practical side of the 
 question. — Boston Med. and. Surg. Journal, Nov. 5, 
 1874. 
 
 flRIFFITH {ROBERT E.), M.D. 
 
 A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
 ing and Administering Officinal and other Medicines. The whole adapted to Physiciars and 
 Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. 
 Maisch, Professor of Materia Mediea in the Philadelphia College of Pharmacy. In one large 
 andhandsome octavo volume of about800pp., cl., $450; leather, $5 50. (Lately Issxted.) 
 
 To the druggist a good formulary is simply indis- 
 pensable, and perhaps no formulary has been more 
 extensively used than the well-kuown work before 
 us. Many "physicians have toofficiate, also, as drug- 
 gists. This is true especially of the country physi- 
 cian, and a work which shall teach him the mean? 
 by which to administer or combine his remedies in 
 the most efficacious and pleasant manner, will al- 
 ways hold its place upon his shelf. A formulary of 
 this kind is of benefit also to the city physician in 
 largest practice.— Cincinnati Olinic, Feb. 21. 1874. 
 
 A more complete formulary than it is in its pres- 
 ent form the pharmacist or physician could hardly 
 desire. To the first some such work is indispensa- 
 ble, and it is hardly less essential to the practitioner 
 who compounds his own medicines. Much of what 
 is contained in the introduction ought to be com- 
 mitted to memory by every student of medicine. 
 As a help to physicians it will be found invaluable, 
 and doubtless will make its way into libraries not 
 already supplied with a standard work of the kind . 
 — The American Practitioner, Louisville, July, '74. 
 
 CHRISTISON'S DISPENSATORY. With copious ad- 
 ditions, and 213 large wood engravings. By R. 
 Eglesfield Griffith, M.D. One vol. 8vo., pp. 
 1000, cloth. $4 00. 
 
 CARPENTER'S PRIZE ESSAT ON THE USE OF 
 Alcoholic Liquors in Health and Disease. New 
 edition, with a Preface by D. F. Condie. 31. D., and 
 explanations of scientific words. In oneneat!2mo. 
 volume, pp. 178, cloth. 60 cents. 
 
Henry C. Lea's Son & Co.'s Publications—- {Mat. Med. and Therap.). 13 
 
 &TILLE {ALFRED), M.D., LL.D., and JlfAISCH (JOHN M.). Ph. 
 
 O Pro/, of Theory and Practice of Medicine ■*-*-*- Prof, of Mat. Med. and Bat. 
 
 in Phil a . 
 and of Clinical Med. in Univ. of Pa. Coll. Pharmacy, Secy, to the American 
 
 Pharmaceutical Association. 
 
 THE NATIONAL DISPENSATORY : Containing the Natural History, 
 
 Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
 the Pharmacopoeias of the United States, Great Britain, and Germany, with numer- 
 ous references to the French Codex. Second edition, thoroughly revised , with numerous 
 additions. In one very hanisome octavo volume of 1692 pas:es,with 239 illustrations. 
 Extra cloth, $6 75 ; leather, raised bands, $7 50 ; half Russia, raised bands and open 
 back, $8 25. {Now Ready.) 
 
 Preface to the Second Edition. 
 
 The demand which has exhausted in a few months an unusually large edition of Ihe National 
 Dispensatory is doubly gratifying to the .authors, as showing that they were correct in th'nking 
 that the want of such a work was felt by the medical and pharmaceutical professions, and that 
 their efforts to supply that want have been acceptable. This appreciation of their labors has 
 stimulated them in the revision to render the volume more worthy of the very marked favor 
 with which it has been received. The first edition of a work of such magnitude mu«t necessarily 
 be more or less imperfect ; and though but Htt'e that is new and important has been brought 
 to light in the short interval since its publication, yet the length of time during which it was 
 passing through the press rendered the earlier portions more in arrears than the la'er. The 
 opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to 
 introduce alterations and additions whereve* there has seemed to be occasion for improve- 
 ment or greater completeness. The principal changes to be noted are the introduction of seve- 
 ral drugs under separate heading", and of a large number of drugs, chemicals, and pharma- 
 ceutical preparations classified as allied drugs and preparations under the heading of more 
 important or better known articles : these additions comprise in part nearly the entire German 
 Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
 came to the authors' notice up to the time of publication have received due consideration. 
 
 The series of illustrations has undergone a corresponding thorough revision. A number have 
 been added, and still more have been substituted for such as were deemed less satisfactory. 
 
 The new matter embraced in the text is equal to nearly one hundred pages of the first edition. 
 Considerable as are these changes as a whole, they have been accommodated by an enlargement 
 of the page without increasing unduly the size of the volume. 
 
 While numerous additions have been ma^e to the sections which relate to the physiological 
 action of medicines and their use in the treatment of disea=e, great care has been taken to 
 make them as concise as was possible without rendering them incomplete or obscure. The 
 doses have been expressed in the terms both of troy weight and of the metrical system, for the 
 purpose of mak ; ng those who employ the Dispensatory familiar w^th the latter, and paving the 
 way for its introduction into general use. 
 
 The Therapeutical Index has been extended by about 2250 new references, making the total 
 number in the present edition about 6000. 
 
 The articles there enumerated as remedies for particular diseases are not only those which, 
 in the authors' opinion, are curative, or even beneficial, but those also which have at any time 
 been employed on the ground of popular belief or professional authority. It is often of as 
 much consequence to be acquainted with the worthlessness of certain medicines or with the 
 narrow limits of their power, as to know the well attested virtues of others and the conditions 
 under which they are displayed. An additional value posse-sed by such an Index is, that it 
 contains the elements of a natural classification of medicines, founded upon an analysis of the 
 results of experience, which is the only safe guide in the treatment of disease. 
 
 This evidence of success, seldom paralleled, l intend to let the grass grow under their feet, but to 
 shows clearly how well the authors have met the ! keep the work up to the time. — New Remedies , Nov. 
 existing needs of the pharmaceutical aDd medical j 1879. 
 
 professions. Grntifying as it must be to tbem, they 
 
 This is a great work by two of the ablest writers on 
 
 have embraced the opportunity offered for a thor- ; materia m | diea in America The Huthors have pro 
 
 ough levision of the whole work, striving to em- 
 
 duced a work which, for accuracy and comprehensive- 
 
 brace within it all that might have been omitted in | n ess. is unsurpassed by any work on th- sabject. There 
 the former edition, and all that has newly appeared { [g n0 book in the English i an g Uage wh ich contains so 
 of sufficient importance during the time of its col- . much valuable i n f ormat ion on the various articles of 
 laboration, and the short interval elapsed since the , the materia me dica. The work has cost the authors 
 previous publication. After hiving gone carefully , s of laboriou s study, but they have succeeded in 
 
 through the volume we must admit that the authors ; producillg a dispensatory which is not only national, 
 have labored faithfully, and with success, in main- ; but will be a i asting memorial of the learning and 
 
 taining the high character of their work as a com- 
 pendium meeting the requirements of the day, to 
 which one can safely turn in quest of the latest in- 
 formation concerning everything worthy of notice in 
 connection with Pharmacy, Materia Medica, and 
 Therapeutics. — Am. Jour, of Pharmacy, Nov. 1879. 
 It is with great pleasure that we announce to our 
 readers the appearance of a second edition of the 
 National Dispensatory. The total exhaustion of the 
 first edition in the short space of six months, is a 
 sufficient testimony to the value placed upon the 
 work by the profession. It appears that the rapid 
 sale of the first edition must have induced both the 
 editors and the publisher to make preparations for 
 a new edition immediately after the first had been 
 issued, for we find a large amount of new matter 
 added and a good deal of the previous text altered 
 and Improved, which proves that the authors do not 
 
 ability of the authors who produced it. — Edinburgh 
 Medical Journal, Nov. 1879. 
 
 It is by far more international or universal than 
 any other book of the kind in our language, and 
 more comprehensive in every sense. — Pacific Med. 
 and Surg. Jou^n., Oct. 1879. 
 
 The National Dispensatory is beyond dispute the 
 very best authority. It is throughout complete in 
 all the necessary details, clear and lucid in its ex- 
 planations, and replete with references to the most 
 recent writings, where further particulars can be 
 obtained, if desired. Its value is greatly enhanced 
 by the extensive iudices — a general in ex of materia 
 medica, etc., and also an index of therapeutics. It 
 would be a work of supererogation to say mors about 
 this well-known work. No practising physician can 
 afford to be without the National Dispensatory. — 
 Canada Med. and Surg. Journ., Feb. 18S0. 
 
14 Henry C. Lea's Son & Co.'s Publications — {Pathology, &c). 
 
 (10RNIL {V.), 
 
 ^ Pmf. in the Faeul 
 
 T>ANVIER (L. 
 
 -*-v Prof in the Co 
 
 AND 
 
 Prof, in the Faculty of Med., Paris. -*-«'' Prof in the College of France. 
 
 MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 
 
 Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
 to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
 of Penna., and by Henry C. Simes. M D., Demonstrate r of Pathological Histology in 
 the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 
 350 illustrations. Cloth, S5 50; leather, $6 50; half Russia, $7. (Just Ready.) 
 The work of Cornil and Ranker is so well known as a lucid and accurate text-book on its 
 important subject, that no apology is needed in presenting a translation of it to the American 
 profession. It is only necessary to say that the labors of Drs. Shakespeare and Simes have 
 been by no means confined to the task of rendering the work into English. As it appeared in 
 France, in successive portions, between 1868 and 1876, a part of it, at least, was somewhat in 
 arrears of the present state of science, while the diffuseness of other portions rendered conden- 
 sation desirable. The translators have, therefore, sought to bring the work up to the day, 
 and, at the same time, to reduce it in size, aj far as practicable, without impairing its com- 
 pleteness These changes will be found throughout the volume, the most extensive being in 
 the sections devoted to Sarcoma, Carcinoma, Tuberculosis, the Bloodvessels, the Mammae, and 
 the classification of tumors. Corresponding modifications have been made in the very exten 
 sive and beautiful series of illustrations, and every care has been taken in the typographical 
 execution to render it one of the most attractive volumes which have issued from the American 
 press. 
 
 The translators have done their work very well 
 indeed, rendering it into smooth and excellent Eng- 
 lish, and in their selection of new material they 
 have in the main used good discrimination. We 
 heartily commend the book as one of the best works 
 on the subject. — Boston Med. and Surg. Journal, 
 March 11, 1880. 
 
 Their book is not a collection of the work of others, 
 but has been written in the laboratory beside the 
 microscope. It bears the marks ef personal knowl- 
 edge and investigation upon every page, controlled 
 by and controlling the work of others. ... In 
 short, its translation has made it the best work in 
 pathology attainable in our language, one that every 
 student, certainly, ought to have.— Archives of Med- 
 icine, April, 18S0. 
 
 with unusual interest. The illustrations are by no 
 means the least valuable part of the work. Indis- 
 pensable as they are to any work of this nature, 
 in the work before us the artist has succeeded in 
 producing cuts which will prove unusually valuable 
 to the reader. The translation is well done, and 
 gives evidence throughout the volume that it was 
 made by a person thoroughly conversant with the 
 subject.— N. Y. Med. Gazette, Feb. 28, 1880. 
 
 This will be found an exceedingly interesting 
 and valuable work by all who are engaged in the 
 study of, or take an interest in, histology — normal 
 or morbid. The material which was utilized in its 
 preparation was derived from autopsies and opera- 
 tions in the hospitals of Paris, which are so very 
 I rich in it. Nothing was taken for granted, but 
 This work, in the original, has for years past everything verified by microscopical investigation 
 occapied a prominent place in the library of Freuch by the authors themselves in their own laboratories 
 pathologists, as we should naturally be led to be- ] assisted by their pupils. As an aid to microscopists 
 lieve from the reputation of the distinguished an- in 'heir investigations it will be found invaluable — 
 thors. Now thai it has been presented to the Eng- in fact, the very best with which we are acquainted, 
 lish student for the first time, it will be perused —Cincinnati Med. News, February, 18S0. 
 
 JPENWICK (SAMUEL), M.D., 
 
 ■*- Assistant Physician to the London Hospital* 
 
 THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 
 
 Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
 In one very handsome volume, royal 12mo., cloth, $2 25. (Just Isstied.) 
 
 /IRE EN (T. HENRY), M.D., 
 
 ^~" Lecturer on Pathology and Morbid Anatomy a,t Charing-Cross Hospital Medical School, etc. 
 
 PATHOLOGY AND MORBID ANATOMY. Third American, from 
 
 the Fourth and Enlarged and Revised English Edition. In one very handsome octavo 
 volume of 332 pages, with 132 illustrations ; cloth, $2 25. (Now Ready.) 
 This is unquestionably one of the best manuals on j ciently numerous, and usually well made. In the 
 
 present edition, sueh new matter has been added as 
 was necessary to embrace the later results in patho- 
 logical research. No doubt it will continue to enjoy 
 the favor it has received at the hands of the profes- 
 sion. — Med and Surg. Reporter, Feb. 1, 1S79. 
 
 For practical, ordinary daily use, this is undoubt- 
 edly the best treatise that is offered to students 
 
 the subject of pathology and morbid anatomy that 
 ean be placed in the student's hands, and we are 
 glad to see it kept up to the times by new editions. 
 Each edition is carefully revised by the author, with 
 the view of making it include the most recent ad- 
 vances in pathology, and of omitting whatever may 
 have become obsolete. — N. ¥. Med. Jour., Feb. 1879. 
 
 The treatise of Dr. Green is compact, clearly ex- ! pathology and morbid anatomy, 
 pressed, up to the times, and popular as a text-book, j cet and Clinic, Feb. 8, 1S79. 
 both in England and America. The cuts are suffi- I 
 
 -Cincinnati Lan- 
 
 GLTJGE'S ATLAS of PATHOLOGICAL HISTOLOGY 
 Translated, with Notes and Additions, by Joseph 
 Lekdy, M. D. In one volume, very large imperial 
 quarto, with 320 copper-plate figures, plain and 
 colored, cloth. $4 00. 
 
 PAVY'S TKEATISE ON THE FUNCTION OF DI- 
 GESTION: its Disorders and their Treatment. 
 From the second London edition. In one hand- 
 some volume, small octavo, cloth, $2 00. 
 
 LA ROCHE ON YELLOW FIVER. considered in its 
 Historical, Pathological, Etiological, and Thera- 
 peutical Relations. In two large and handsome 
 octavo volumes of nearly 1500 pp., cloth. $7 00. 
 
 ! aOLLAND'S MEDICAL NOTES AND REFLEC- 
 i tions. 1 vol. 8vo., pp.500, cloth. $3 50. 
 
 BARLOW'S MANUAL OF THE PRACTICE OF 
 MEDICINE. With Additions by D. F. Conbje 
 M D. 1 vol. 8vo., pp 600. cloth. $2 50. 
 
 'TODD'SCLINICAL LECTURES ok CERTAIN ACUTE 
 Diseases. In one neat octavo volume, of 320 pp., 
 
 I cloth. *2 50. 
 
 ! STOKES' LECTURES ON FEVER. Edited by Jown 
 Wilt.iam Moore, M.D., Assistant Physician to the 
 Cork Street Fever Hospital. In one neat 8vo. 
 
 I volume cloth, $2 00. 
 
Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 15 
 
 fiTLINT {AUSTIN), M.D., 
 
 ■*■ Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. 
 
 A TREATISE ON THE PRINCIPLES AND PRACTICE OF 
 
 MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 
 edition, revised and enlarged. In one large and closely printed octavo volume of about 
 1100 pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Lately 
 Issued.) 
 
 Tliis excellent treatise on medicine has acquired 
 for itself in the United States a reputation similar to 
 that enjoyed in England by the admirable lectures 
 of Sir Thomas Watson. "We have referred to many 
 of the most important chapters, and find the revi- 
 sion spoken of in the preface is a genuine one, and 
 that the author has very fairly brought up his matter 
 to thelevelofthe knowledge of the present day. The 
 work has this great recommendation, that it is in one 
 volume, and therefore will not be so terrifying to the 
 student as the bulky volumes which several of our 
 English text-books ofmedicinehavedevelopedinto. 
 —British and Foreign Med.-Chir. Rev., Jan. 1875. 
 
 Itisofcourseunnecessarytointroduce or eulogize 
 this now standard treatise. The present edition 
 has been enlarged and revised to bring it up to the 
 author's present level of experience and reading. 
 
 His own clinical studies and the latest contribu- 
 tions to medical literature both in this country and 
 in Europe, have received careful attention, so that 
 some portions have been entirely rewritten, and 
 about seventy pages of new matter have been ad- 
 ded. — Chicago Med Jour., June, 1873. 
 
 Has never been surpassed as a text-book for stu- 
 dents and a book of ready reference for practition- 
 ers. Theforce of its logic, its simple and practical 
 teachings, have left it without a rival in the field. 
 N. Y.—Med. Record, Sept. 15, 1874. 
 
 It is given to very few men to tread in the steps of 
 Austin Flint, whose single volume on medicine, 
 though here and there defective, is a masterpiece of 
 lucid condensation and of general grasp of an enor- 
 mously wide subject. — Loud. Practitioner, Dec. '7 3. 
 
 T>Y THE SAME AUTHOR. 
 
 CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 
 
 and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
 one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 50; 
 half Russia, $6. {Now Ready.) 
 It is here that the skill and learning of the great 
 clinician are displayed He has given us a store- 
 house of medical knowledge, excellent for the stu- 
 dent, convenient for the practitioner, the result of a 
 long life of the most faithful clinical work, collect- 
 ed by an energy as vigilant end systematic as un- 
 tiring, and weighed by a judgment no less clear 
 than his observation is close.— Archives of Medi- 
 cine, Dec. 1879. 
 
 The author of the above work has anticipated a 
 want long felt by those for whom it was especially 
 written— the clinical student during his pupilage, 
 and the busy practitioner. He has given to the 
 medical profession a very necessary and useful 
 work, complete in detail, accurate in observation, 
 brief in statement.— St. Louis Courier of Med., 
 Oct. 1879. 
 
 There is every reason to believe that this book 
 will be well received. The active practitioner is 
 frequently in need of some work that will enable 
 him to obtain information in the diagnosis and 
 treatment of cases with comparatively little labor. 
 Dr. Flint has the faculty of expressing himself 
 
 clearly, and at the same time so concisely as to 
 enable the searcher to traverse the entire ground 
 of his search, and at the same time obtain all that 
 is essential, without plodding through an intermi- 
 nable space.— N. Y. Med. Jour., Nov. 1879 
 
 The eminent teacher who has written the volume 
 under consideration has recognized the needs of 
 the American profession, and the result is all that 
 we could wish. The style in which it is written is 
 peculiarly the author's ; it is clear and forcible, and 
 marked by those characteristics which have ren- 
 dered him one of the best writers and teachers this 
 country has ever produced. We have not space for 
 so full a consideration of this remarkable work as 
 we would desire. — S. Louis Clin. Record, Oct. 1879. 
 
 It is venturing little to say that there are few men 
 so well fitted as Dr. Flint to impart information on 
 these last mentioned subjects, and the present work 
 is a timely one as relates both to the author's ca- 
 pacity to undertake it and the need for it as an 
 accompaniment to the multitude now issued, in 
 which the subject of treatment is but little consid- 
 ered. — New Remedies, Nov. 1879. 
 
 2J F THE SAME A UTHOR. 
 
 ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 
 
 TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. (Just Issued.) 
 
 JT/ATSON [THOMAS), M.D., frc. 
 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF 
 
 PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
 vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
 tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
 sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Lately 
 Published.) 
 
 H 
 
 ARTSHORNE [HENRY), M.D., 
 
 Professor of Hygiene in the University of Pennsylvania 
 
 ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 
 
 CINE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- 
 proved. With about one hundred illustrations. In one handsome royal 12mo. volume, 
 of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Lately Issued.) 
 
 DAYIS'S CLINICAL LECTURES ON VARIOUS 
 IMPORTANT DISEASES ; being a collection of the 
 Clinical Lectures delivered in the Medical Wards 
 <jf Mercy Hospital, Chicago. Edited by Frank H 
 Davis, M.D. Second edition, enlarged. In one 
 handsome royal 12mo. volume. Cloth, $1 75. 
 
 THE CYCLOPEDIA OF PRACTICAL MEDICINE: 
 comprising Treatises on the Nature and Treatment 
 ef Diseases, Materia Medica andTherapeuties, Dis- 
 
 eases of "Women and Children, Medical Jurispru- 
 dence, etc. etc. By Dunglison, Forbes, Tweedie, 
 and Conolly. In four large super-royal octavo 
 volumes, of 3254 double-columned pnges, strongly 
 and handsomely bound in leather, $15; cloth, $11. 
 STURGES'S INTRODUCTION TO THE STUDY OF 
 CLINICAL MEDICINE. Being a Guide to the In- 
 vestigation of Disease. In one handsome 12mo. 
 volume, cloth, $1 25. (Lately Isstied.) 
 
16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 
 7DRISTOWE{JOHN SYER), M.D.. F.R.C.P., 
 
 JD Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. 
 
 A TREATISE ON THE PRACTICE OF MEDICINE. Second 
 
 American edition, revised by the Author. Edited, with Additions, by James H. Hutch- 
 inson, M.D., Physician to the Penna. Hospital. In one handsome octavo volume of 
 nearly 1200 pages. With illustrations. Cloth, $5 00; leather, $6 00; half Russia, 
 $6 50. {Now Ready.) 
 In reprinting this work from the recent thoroughly revised second English edition, the 
 author has made such corrections as seemed advisable, and has added a chapter on Insanity. 
 The Editor has likewise revised his additions in the light of the latest experience, and the 
 work is presented as reflecting in every way the most modern aspect of medical science, and 
 as fully entitled to maintain the distinguished position accorded to it on both sides of the 
 Atlantic as an authoritative guide for the student, and a complete though concise book of 
 reference for the practitioner. Notwithstanding the author's earnest effort at compression, 
 the additions have amounted to about one-tenth of the previous edition : but by the use of an 
 enlarged page these have been accommodated without increasing the size of the volume, while 
 a reduction in the price renders it one of the cheapest works accessible to the profession. 
 
 The second edition of this excellent work, lite the The popularity of the work depends, no doubt, 
 first, has received the benefit of Dr. Hutchinson's upon the clear and incisive way in which it is 
 annotations, by which the phases of disease which written, and the attention to details likely to occur 
 are peculiar to this country are indicated, and thus j in practice, rather than the discussion of questions 
 treatise which was iuteuded for British practi- of theory.— New Remedies, Jan. 1S80. 
 
 tiouers and students ^s made more practically useful 
 on this side of the water. We see no reason to 
 
 What we said of the first edition, we can, with 
 -ncreased emphasis, repeat concerning this: "Every 
 modify the high opinion previously expressed with pag e is characterized by the utterances of a thought- 
 regard to Dr. Bnstowe s work except by adoing ful man Waat has been gaid has been well said 
 our appreciation of the careful labors of the author i and the book ig a fah . reflex of all - bat is certain1 y 
 ™, fol i OW]D S the lateral growth of medical science. knrwn on the subjects considered. "-Ohio Med. 
 The chapter on diseases of the skin and of the nerv- | g eeor ^ ftr j an- 7 1550 
 ous system, with a new one on insanitv compiled _ ' ' ' , , 
 
 from the best sources outside of the a ut tor's own ; Thl * ls not onl y oae of ,n3 late ^ and m ° s } com ; 
 long experience, and the valuable portion relating: prehensive works out on the general subject of 
 to general patholouv, aid greatlv in completing an Theory and Practice of Medicine, but it is uuques- 
 exceptionally good 'book for purposes of reference; ^ouably one of the best.— So. Med. Practxivner, 
 and ins ruction — Boston Medical and Surgical j ^ an 18S0. 
 Journal, February, 1SS0. I 
 
 J^ICRARDSON (BENJ. TV), 31.1)., F.R.S., M.A., LL.D., F.S.A., 
 
 Fellow of the Royal College of Physicians, London. 
 
 PREVENTATIVE MEDICINE. In one octavo volume of over 400 
 
 pages, {hi Press.) 
 
 ffiOODBURY {FRANK), M.D., 
 
 Physician to the German Hospital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College 
 Hospital, etc. 
 
 A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF 
 
 Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook 
 of Practice. In one neat volume, royal 12mo. {Preparing.) 
 
 LJABERSHON {S. O.). M.D. 
 
 -*"*- Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's 
 
 HospitaJ, etc. 
 
 ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 
 
 of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes- 
 tines, and Peritoneum. Second American, from the third enlarged and revised Eng- 
 lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
 Cloth, $3 50. {Now Ready.) 
 
 amended by the author. Several new chapters have 
 been added, bringing the wo^k fully up to the times, 
 and making it a volume of interest to the practitioner 
 in every field of medicine and surgery. Perverted 
 nutrition is in some form associated with all diseases 
 we have to combat, and we need all the light that 
 can be obtained on a subject so broad and general. 
 
 This valuable treatise on diseases of the stomach 
 and abdon en has been out of print for several years, 
 and is therefore not so well known to the profession 
 as it deserves to be. It will be found a cyclopedia 
 of information, systematically arranged, on all dis- 
 eases of the alimentary tract, from the mouth to the 
 rectum A fair proportion of each chapter is devot 
 
 ed to symptoms, pathology, and therapeutics. The Dr Habershon's work is one that every practitioner 
 present edition is fuller tnan former ones in many should read and study for himself. — N. T. Med. 
 particulars, and has been thoroughly revised and I Journ., April, 1S79. 
 
 J^OTHERGILL {J. MILNER),M.D. Edw., M.R.C.P. Land., 
 
 *- Asst. Phys. to the West Lond Hosp.; Asst. Phyf,-. to the City of Lond. Hosp.,etc. 
 
 THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, Hie 
 
 Principles of Therapeutics. Second edition, revised and enlarged. In one very neat 
 octavo volume of about 700 pages. {In Press.) 
 
 jDF THE SAME AUTHOR. 
 
 THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT 
 
 IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal 
 12mo. of 156 pages; cloth, $1 00. {Jiist Ready.) 
 
Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 17 
 T>EYNOLT)S {J. RCTSSELL). M.D., 
 
 -*-+' Prof, of the Principles and Practice of Medicine in Univ. College, London. 
 
 A SYSTEM OF MEDICINE wtth Notes and Additions by Hfnry Harts- 
 horne, M.D., late Professor of Hygiene in the University of Penna. In three large and 
 handsome octavo volumes, containing 30o2 closely printed double-columned pages, "with 
 numerous illustrations. Sold only by subscription. Price per vol., in cloth, $5.00 ; in 
 sheep, $6.00 : half Russia, raised bands, $6.50. Per set in cloth, $15 ; sheep, $18 ; half 
 Russia, $19.50 
 Volume I. (just ready) contains General Diseases and "Diseases of the Nervous System. 
 Volume II. {just ready) contains Diseases of Respiratory and Circulatory Systems. 
 Volume III. (just ready) contains Diseases op the Digestive and Blood Glandular 
 Systems, op the Urinary Organs, of the Female Reproductive System, and of the 
 Cutaneous System. 
 Reynolds's System of Medicine, recently completed, has acquired, since the first appearance 
 of the first volume, the well-deserved reputation of being the work in which modern British 
 medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
 view of the fact that it is the result of the collaboration of the leading minds of the profession, 
 each subject being treated by some gentleman who is regarded as its highest authority — as for 
 instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
 Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
 eases of the Spine by Charles Bland Radcliffe, Pericarditis by Francis Sibson. Alcoholism 
 by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde Salter, 
 Cerebral Affections by if. Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
 rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson 
 Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
 kenzie, Diseases of the Rectum by Blizard Curling, Diabetes by Lauder Brunton, Intes- 
 tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- 
 bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
 sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain 
 have contributed their best men in generous rivalry, to build up this monument of medical sci- 
 ence. St. Bartholomew's, Guy's, St Thomas's, University College, St Mary's in London, while 
 the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical 
 School at Netley, the military and naval services, and the public health boards. That a work 
 conceived in such a spirit, and carried out under such auspices should prove an indispensable 
 treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
 the success which it has enjoyed in England, and the reputation which it has acquired on this 
 side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 
 Its large size and high price having kept it beyond the reach of many practitioners in this 
 country who desire to possess it, a demand has arisen for an edition at a price which shall ren- 
 der it accessible to all. To meet this demand the present edition has been undertaken. The 
 five volumes and five thousand pages of the original have, by the use of a smaller type and doubl-e 
 columns, been compressed into three volumes of over three thousand pages, clearly and hand- 
 somely printed, and offered at a price which renders it one of the cheapest works ever presented 
 to the American profession. 
 
 But not only is the American edition more convenient and lower priced than the English; 
 it is also better and more complete. Some years having elapsed since the appearance of a 
 portion of the work, additions are required to bring up the subjects to the existing condition 
 of science. Some diseases, also, which are comparatively unimportant in England, require more 
 elaborate treatment to adapt the articles devoted to them to the wants of the American physi- 
 cian ; and there are points on which the received practice in this country differs from that 
 adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts - 
 horne, M.D.,late Professor of Hygiene in the University of Pennsylvania, who has endeavored 
 to render the work fully up to the day, and as useful to the American physician as it has proved 
 to be to his English brethren. The number of illustrations has also been largely increased, and 
 no effort spared to render the typographical execution unexceptionable in every respect. 
 
 Really too much praise can scarcely be given to 
 this noble book. It is a cyclopaedia of medicine 
 written by some of the best men of Europe. It is 
 full of useful information such as one finds frequent 
 need of in one's daily work ; for no one head can 
 possibly carry all the knowledge one needs in gen- 
 eral practice, and one must refer sometimes to one's 
 library. As a book of reference it is invaluable. It 
 is up with tbe times. It is clear and concentrated 
 in style, and its form is worthy of its famous pub- 
 lisher.— Louisville Med. News, Jan. 31, 1S80. 
 
 "Reynolds' System of Medicine" is ju c tly con- 
 sidered the most popular work on the principles and 
 practice of medicine in the English language The 
 
 house of information, in regard to so many of the 
 subjects with which he should be familiar. — Gail- 
 lard's Med. Journ., Feb. 1SS0. 
 
 There is no medical work which we have in times 
 past more frequently and fully consulted when per- 
 plexed by doubts as to treatment, or by having un- 
 usual or apparently inexplicable symptoms pre- 
 sented to us than "Reynolds' System of Medicine." 
 Among its contributors are gentlemen who are as 
 well known by reputation upon this side of the 
 Atlantic as in Great Britain, and whoss right to 
 speak with authority upon the subjects about 
 which they have written, is recognized the world 
 over. They have evidently striven to make their 
 
 contributors to this work are gentlemen of well- , es as prac Hcala S possible, and while these are 
 
 known reputation on both sides of the Atlantic. : 8uffl c ientl f full I0 entitle them to the name of 
 
 Each gentleman has striven to make his part of the 
 work as practical as pos-ible, and the information 
 contained is such as is needed by the busy practi- 
 tioner.— St. Louis Med. and Surg. Journ., Jan. 20, 
 1880. 
 
 Dr. Hartshorne has made ample additions and 
 revisions, all of which give increased value to the 
 volume, and render it more useful to the Ameri- 
 can practitioner. There is no volume in English 
 medical literature more valuable, and every pur- 
 haser will, on becoming familiar with it, congrat- 
 ne himself on the possession of this vast store- 
 
 monographs, they are not loaded down with such 
 an amount of detail as to render them wearisome 
 to the general reader. In a word, they contain just 
 that kiDd of information which the bu^y practitioner 
 frequently finds himself in need of. In order that 
 any deficiencies may be supplied, ihe publishers 
 have committed the preparation of the book for the 
 press to Dr. Benry Hartshorne, who-e judicious 
 notes distributed throughout the volume afford abun- 
 dant evidence of the thoroughness of ihe revision to 
 which he has subjected it. — Am. Jour. Med. Sciences, 
 Jan. 1880. 
 
18 Henry C. Lea's Son & Co.'s Publications — (Prac. of Med., &c). 
 
 B 
 
 ARTHOLOW [ROBERTS), A.M., M.D.. LL.D. 
 
 Prof, of Materia Medica and General Therapeutics in the Jeff. Med. Coll. of Phila., etc. 
 
 A PRACTICAL TREATISE ON ELECTRICITY IN ITS APPLI- 
 CATION TO MEDICINE. In one very handsome octavo volume of about 450 pages, 
 with illustrations. {Preparing.) 
 
 JpiNLAYSON {JAMES), M.D., 
 
 Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary , etc. 
 
 CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 
 
 titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
 tions. Cloth, $2 63. {Just Issued.) 
 The book is an excellent one, clear, concise, conve- ! live from preface to the final page, and ought to be 
 nient, practical. It is replete with the very know- ; gi ven a place on every office table, because if contains 
 
 ledge the student needs when he quits the lecture- 
 room and the laboratory for the ward and sick-room, 
 and does not lack in information that will meet the 
 wants of experienced and older men. — Phila. Med. 
 Times, Jan. 4, 1S79. 
 This is one of the really useful books. It is attrac- 
 
 iu a condeusedform all that is valuable in semeiology 
 and diagnostics to be found in bulkier volumes, and 
 because in its arrangement and complete index, it is 
 unusually convenient for quick reference in any 
 emergency that may come upon the busy practitioner. 
 — N. C. Med, Journ., Jan. 1S79. 
 
 TJAM1LTOS {ALLAN McLANE), M.D., 
 
 Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. T., 
 and at the Out- Patients' 1 Department of the New York Hospital. 
 
 NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. 
 
 In one handsome octavo volume of 512 pages, with 53 illus. ; cloth, $3 50. (Just Issued.) 
 This is unquestionably the best and most com- readers a succinct and lucid survey of all that is 
 plete text-book of nervous diseases that has yet ap- knowu of the pathology of the nervous system, 
 
 viewed in the light of the most recent researches. 
 From the preliminary description of the methods of 
 examination and study, and of the instruments of 
 precision employed in the investigation of nervous 
 diseases, up till the final collection of formulae, the 
 book is eminently practical. — Brain, London, Oet. 
 1S78. 
 
 peared, and were international jealousy in scientific 
 affairs at all possible, we might be excused for a 
 feeling of chagrin that it should be of American 
 parentage. This work, however, has been performed 
 in New York, and has been so well performed that 
 no room is left for anything but commendation. 
 With great skill, Dr. Hamilton has presented to his 
 
 /JHARCOT {J. M.), 
 
 Professor to the Faculty of Med.. Paris, Phys. to La Salpetriere, etc. 
 
 LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- 
 lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, 
 etc., Cath. Univ. of Ireland. With illustrations. 1 vol. 8vo. of 288 pages. Cloth, $1 75. 
 (Just Ready.) 
 
 CLTNICAL OBSERVATIONS ON FUNCTIONAL 
 NERVOUS DISORDERS By C. Handfisld Jones, 
 M.D., Physician to St. Mary's Hospital, &c. Sec- 
 
 ond American Edition. In one handsome octavo 
 volumeof 318 pages,eloth, $3 25 . 
 
 MORRIS {MALCOLM), M.D., 
 
 -I'J- Joint Lecttirer on Dermatology, St. Mary's Hospital Med. School. 
 
 SKIN DISEASES, Including their Definitions, Symptoms, Diagnosis, 
 
 Prognosis, Morbid Anatomy, and Treatment. A Manual for Students and Practitioners. 
 In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (Now Ready.) 
 To^physicians who would like to know something appliances of cutaneous medicine. He has produced 
 about skin diseases, so that when a patient presents ' a plain, practical book, by aid of which, who so 
 himself for relief they can make a correct diagnosis chooses may train his eye to the recognition of 
 and prescribe a rational treatment, we unhesitatingly light but significant differences. The descriptions 
 recommend this little book of Dr. Morris. The affec- are neither too vaatue nor over-refined; the direc- 
 
 tions of the skin are described in a terse, lucid man- 
 ner, and their several characteristics so plainly set 
 forth that diaguosis will be easy. The treatment 
 in each case is such as the experience of the most 
 eminent dermatologists advise. — Cincinnati Medi- 
 cal News, April, 1SS0. 
 
 This is emphatically a learner's book ; for we can 
 
 tions for treatment are clear and succinct. — London 
 Brain, April, 18S0. 
 
 The author has handled his subject in a clear and 
 concise manner, and as a text-book to students his 
 manual will be found useful.— Medical and Surgi- 
 cal Reporter, March 27, 1SS0. 
 
 The author's task has been well done and has pro- 
 
 safely say, so far as our judgment goes, that in the duced one of the best recent works upon the difficult 
 
 whole range of medical literature of a like scope, subject of which it treats ; there is no work published 
 
 there is no book which for clearness of expression, which gives a better view of the elementary facts 
 
 and methodical arrangement is better adapted to and principles of dermatology. — New Orleans Medi- 
 
 promote a rational conception of dermatology, a cal and Surgical Journal, April, 1880. 
 
 braneh confessedly difficult and perp'exing to the This excellent little book is the first work of a 
 
 beginner.— St. Louis Courier of Medicine, April, distinguished pupil of Jonathan Hutchinson; it re- 
 
 The author of this manual has evidently a full and 
 intimate acquaintance with the literature of derma- 
 tology, and with the most reeent developments and 
 
 commends itself above all by its clearness, method, 
 and precision. — Paris Annales de Dtrmatologie et 
 de Syphiligraphie, 25 April, 18S0. 
 
 F°- 
 
 X { TILBURY), M.D., F.R.C.P., and T. C, FOX, B.A., M.R.C.S., 
 
 Physician to the Department for Skin Diseases, University College Hospital. 
 
 EPITOME OF SKIN DISEASES. WITH FORMULAE. For Stu- 
 
 dents and Practitionkrs. Second edition, thoroughly revised and greatly enlarged. In 
 one very handsome 12mo. volume of 216 pages. Cloth, $1 38. (Just Issued.) 
 
Henry C. Lea's Son & Co.'s Publications — (Dis.ofthe Chest, dc). 19 
 PLINT {AUSTIN), M.D., 
 
 Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 
 
 A MANUAL OF PERCUSSION AND AUSCULTATION; of the 
 
 Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. 
 
 Second edition. In one handsome royal 12mo. volume: cloth, $1 63. (Just Ready.) 
 Prof. Flint is so well known as a medical teacher | physician's library.— Med. and Surg. Reporter, 
 and writer that it seems superfluous to state that March IS, 1S80. 
 
 the subject has been treated in a thorough and sys- The mtle work before us has already become a 
 tematic manner. In revising it for a second edition 8tandard one% and has become extensively adopted 
 the author has confined himself to such additions as j as a text-book. There is certainly none better. Tt 
 seem likely to render it more useful, not only to , contains t he substance of <he lessons which the 
 students engaged in the practical study of the sub- I aiUhor has for m rs give n,in connection with 
 
 ject, but also to practitioners as a hand book for ; practical instruction in auscultation and percussion, 
 ready reference, and we do not hesitate m saying \ tQ private classes, composed of medical students and 
 that it would prove a valuable addition to every | practitioners.— OTneinnatt Med. News, Feb. 1S80. 
 
 DF THE SAME AUTHOR. 
 
 PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
 ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
 MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
 Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
 College, New York. In one handsome octavo volume : $3 50. (Lately Issued.) 
 
 T>Y THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 
 
 AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
 
 edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 
 
 Dr. Flint chose a difficult subject for his researches, ; and clearest practical treatise on those subjects, and 
 
 and has shown remarkable powers of observation \ should be in the hands of all practitioners and stu- 
 
 and reflection, as well as great industry, in his treat- ; lents. It is a credit to American medical literature. 
 
 ment of it. His book musi be considered the fullest ! — Araer. Journ. of the Med. Sciences, July, 1860. 
 
 JD T THE SAME A UTHOR . 
 
 A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
 TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
 RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
 of 595 pages, eloth, $4 50. 
 
 'DROWN (LENNOX), F.R.G.S. Ed., 
 
 Senior Surgeon to the Central London Throat and Ear Hospital, etc. 
 
 THE THROAT AND ITS DISEASES. With one hundred Typical 
 
 Illustrations in colors, and fifty wood engravings, designed and executed by the author. 
 In one very handsome imperial octavo volume of 351 pages ; cloth, $5 00. (Just Ready.) 
 
 s 
 
 E1LER {CARL), M.D., 
 
 Lecturer on Laryngoscopy at the Univ. of Penna., Chief of the Throat Dispensary at the 
 Univ. Hospital, Phila., etc. 
 
 HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF 
 
 THE THROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume, 
 of 156 pages, with 35 illustrations; cloth, $1. (Just Ready.) 
 
 We-most heartily commend this book as showing A convenient little handbook, clear, concise, and 
 60und judgment in practice, and perfect familiarity accurate in its method, and admirably fulfilling its 
 with the literature of the specialty it so ably epi- purpose of bringing the subject of which it treats 
 tomizes. — Philada. Med. Times, July 5, 1S79. j within the comprehension of the general practi- 
 
 I tioner. — N. C. Med. Jour., June, 1S79. 
 
 WILLIAMS'S PULMONARY CONSUMPTION ; its i FULLER ON DISEASES OF THE LUNGS AND AIR- 
 
 Nature, Varieties, and Treatment. With an An- 
 alysis of One Thousand Cases to exemplify its 
 duration. In one neat octavo volume of about 
 350 pages; cloth, $2 50. 
 
 SLADE ON DIPHTHERIA; its Nature.and Treat- 
 ment, with an account of the History of its Pre- 
 valence in various Countries. Second and revised 
 edition. In one neatroval 12mo. volume, eloth, 
 $1 25. 
 
 WALSHE ON THE DISEASES OF THE HEART AND 
 GREAT VESSELS. Third American Edition. In 
 1 vol. Svo., 420 pp., eloth, $3 00. 
 
 CHAMBERS'S MANUAL OF DIET AND REGIMEN 
 IN HEALTH AND SICKNESS. In one handsome 
 oofcavo volume. Cloth, $2 75. 
 
 PASSAGES. Their Pathology, Physical Diagnosis, 
 Symptoms, and Treatment. From the second and 
 revised English edition. In one handsome ocatvo 
 volume of about 500 pages : cloth, $3 50. 
 
 SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
 MEDIABLE STAGES. 1 vol.8vo.,pp.254. $2 25. 
 
 BA8HAM ON RENAL DISEASES : a Clinical Guid« 
 to their Diagnosis and Treatment. With Illustra- 
 tions. Inonel2mo. vol. of 30t pages, cloth, $2 00. 
 
 LECTURES ON THE STUDY OF FEVER. By A. 
 Hudson, M.D., M.R.I. A., Physician to the Meath 
 Hospital. In one vol. Svo., cloth, $2 50. 
 
 A TREATISE ON FEVER. By Robert D. Lyons, 
 K.CC. In one octavo volume of 362 pages, cloth 
 *2 25. 
 
 L W^ HE ° N P N . SU ^ 0NIA - 1 voL 8 ™-- cl °th, I HILLIER'S HANDBOOK OF SKIN DISEASES, for 
 of 500 pages. Price, $3 00. Students and Practitioners. Second Am Ed. In 
 
 WILSON'S STUDENT'S BOOK OF CUTANEOUS I one royal 12mo. vol. of 358 pp. With illustrations. 
 MEDICINE and Diseases of the Skin. In one i Cloth, $2 25. 
 very handsome royal 12mo volume. $3 50. I 
 
20 Henry C. Lea's Son & Co.'s Publications — ( Venereal Diseases, &c). 
 
 T>UMSTEAD {FREEMAN J.), M.D.,LL.D., 
 
 **-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, Sec. 
 
 THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
 
 EASES. Including the results of recent investigations upon the subject. Fourth edition, 
 revised and largely rewritten with the co-operation of R. W. Taylor, M.D., of New 
 York, Prof, of Dermatology in the Univ. of Vt. In one large and handsome octavo 
 volume of 835 pages, with 138 illustrations. Cloth, $4 75; leather, $5 75; half Russia, 
 $6 25. (Just Ready.) 
 This work, on its first appearance, immediately took the position of a standard authority on 
 its subject wherever the language is spoken, and the success of an Italian translation shows 
 that it is regarded with equal favor on the Continent of Europe. In repeated editions the author 
 labored sedulously to render it more worthy of its reputation, and in the present revision no 
 pains have been spared to perfect it as far as possible. Several years having elapsed since 
 the publication of the third edition, much material has been accumulated during the interval 
 by the industry of syphilologists, and new views have been enunciated. All this so far as 
 confirmed by observation and experience, has been incorporated; many portions of the volume 
 been rewritten, the series of illustrations has been enlarged and improved, and the whole may 
 be regarded rather as a new work than as a new edition. It is confidently presented as fully on 
 a level with the most advanced condition of syphilology, and as a work to which the practi- 
 tioner may refer with the certainty of finding clearly and succinctly set forth whatever falls 
 within the scope of such a treatise. 
 
 We have to congratulate our countrymen upon | will more than repay him for the outlay. — Archives 
 
 of Medicine, April, 18«0. 
 
 This now classical work on venereal disease comes 
 to us in its fourth edition rewritten, enlarged, and 
 materially improved in every way. Dr. Taylor, as 
 
 the truly valuable addition which they have made 
 
 to American literature. The careful estimate of the 
 
 value of the volume, which we have made, justifies 
 
 us in declaring that this is the best treatise on 
 
 venereal diseases in the English language, and, we ^ e "had every reason to expect, has performed this 
 
 might add, if there is a better in any other tongue | pavt of his wovk with unusual excellence. We feel 
 
 we cannot name it ; there are certainly no books in j that what has been written has done but SC anty jus- 
 
 which the student or the general practitioner can J tice to the merits of tMs tral great treatise. -St 
 
 find snch an excellent rtsumt of the literature of ; Louis Courier of Medicine, Feb. 18S0 
 
 any topic, and such practical suggestions regarding I ' . ' 
 
 the treatment of the various complications of every ^ e 4 fi ° d that We haV f ^re practically a new book 
 
 venereal disease. We take pleasure in repeating I -^ a * l ? e %x ^™^ °[ the title-page, as to the fact 
 
 that we believe this to be the best treatise on vene- i tha * Tt has beea freely rewritten, is a sufficiently 
 
 real disease in the English language, and we con- modest announcement for the important change 
 
 gratulate the authors upon their brilliant addition j 
 
 to American medical literature. — Chicago Med. Jour- 
 
 rial and Examiner, February, 18S0. 
 
 It is, without exception, the most valuable single 
 work on all brnnches of the subject of which it treats 
 in any language. The pathology is sound, the work 
 is, at the same time, in the highest degree practical, 
 and the hints that he will get from it for the man- 
 agement of any one case, at all obscure or obstinate, 
 
 od< 
 the text. A f ter a thorough examination of the pre- 
 sent edition, we can assert confidently that the enor- 
 mous labor we have described has been here most 
 faithfully and conscientiously performed. — Amer. 
 Journ. Med. Sci., Jan. 1SS0. 
 
 It is one of the best general treatises on venereal 
 diseases with which we are acquainted, and is espe- 
 cially to be recommended as a guide to the treatment 
 of syphilis. — London Practitioner, March, 1SS0. 
 
 (1ULLERIER {A.), and 
 
 **/ Surgeon to the Hopital du Midi. 
 
 JDUMSTEAD {FREEMAN J.), 
 
 -*-* Professor of Vsnereal Diseases in the College of 
 Physicians and Surgeons, N. Y. 
 
 AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 
 
 Freeman J. Bumstead. In one large imperial 4to. volume of 32S pages, double-columns, 
 with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
 life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
 Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
 lars a Part, thus placing it within the reach of all who are interested in this department of 
 practice. Q-entlemen desiring early impressions of the plates would do well to order it without 
 delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
 
 LEE'S LECTURES ON SYPHILTS AND SOME HILL OX SYPHILIS AND LOCAL CONTAGIOUS 
 
 FORMS OF LOCAL DISEASE AFFECTING PRIN- DISORDERS. In one handsome octavo volume; 
 
 CIPALLY THE ORGANS OF GENERATION. In cloth, $3 25. 
 one handsome octavo volume; cloth, $2 25. 
 
 V^TEST {CHARLES), M.D., 
 
 Physician to the Hospital for Sick Children, London, &c. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
 HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
 and handsome octavo volume of 678 pages. Cloth, $4 50; leather, $5 50. {Lately Issued.) 
 
 T>Y THE SAME AUTHOR. (Lately Issued.) 
 
 ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
 HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
 London, in March, 1871. In one volume small 12mo., cloth, $1 00. 
 
 T> Y THE SAVE A UTHO R . ~ 
 
 LECTURES ON THE DISEASES OF WOMEN. Third American, 
 
 from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
 $3 75; leather, $4 75. 
 
Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, &c). 21 
 
 C*MITH{J. LEWIS), M.D., 
 
 Clinical Professor of Diseases of Children in the Bellevue Hospital Med. College, N T. 
 
 A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 
 
 CHILDREN. Fourth Edition, revised and enlarged. In one handsome octavo volume 
 of about 750 pages, with illustrations. Cloth, $4 50 ; leather, $5 50 ; half Russia, $6. 
 {Now Ready.) 
 The very marked favor with which this work has been received wherever the English lan- 
 guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spare 
 no pains in the endeavor to render it worthy in every respect of a continuance of professional 
 confidence. Many portions of the volume have been rewritten, and much new matter intro- 
 duced, but by an earnest effort at condensation, the size of the work has not been materially 
 increased. 
 
 In the period which has elapsed since the third 
 edition of the work, so extensive have been the ad- 
 vances that whole chapters required to be rewritten, 
 and hardly a page could pass without some material 
 correction or addition. This labor has occupied the 
 writer closely, and he has performed it conscien- 
 tiously, so that the book may be considered a faith- 
 ful portraiture of an exceptionally wide clinical 
 experience in infantile diseases, Corrected by a care- 
 ful study of the recent literature of the subject. — 
 Med. and Surg. Reporter, April 5, 1S79. 
 
 It is scarcely necessary for us to say the work be- 
 fore us is a standard work upon diseases of children, 
 and that no work has a higher standing than it upon 
 those affections. In consequence of its thorough re- 
 ifcsion, the work has been made of more value than 
 ever, and may be regarded as fully abreast of the 
 times. We cordially commend it to students and 
 physicians. There is no better work in the language 
 on diseases of children. — Cincinnati Med. News, 
 March, 1879. 
 
 The author has evidently determined thatit shall 
 not lose ground in the esteem of the profession for 
 want of the latest knowledge on that important 
 department of medicine. He has accordingly in- 
 corporated in the present ed'tion the useful and 
 practical remits of the latest study aDd experience, 
 bcth American aDd foreign, especially those bearing 
 e-n therapeutics. Altogether the book has been 
 greatly improved, while it has not been gi-eatly 
 increased in size. — New York Medical Journal, 
 June, 1879. 
 
 This excellent work is so well known that an 
 ex'ended notice at this time would be superfluous. 
 The author has taken advantage of the demand for 
 another new edit on to revise in a most careful 
 manner the entire book ; and the numerous correc- 
 tions and additions evince a determination on his 
 part to keep fully abreast with the rapid progress 
 that is being made in the knowledge and treatment 
 of children's diseases. By the adoption of a some- 
 what closer type, an increase in size of only thirty 
 pages has been necessitated by the new subject 
 matter introduced. — Boston Med. and Sztrg. Jour., 
 May 29, 1879. 
 
 Probably no other work ever published in this 
 country upon a medical subject has reached such a 
 heighth of popularity as has this well-known trea- 
 tise. As a text and reference-book it is pre-emi- 
 nently the authority upon diseases of children. It 
 stands deservedly higher in the estimation of the 
 profession than any other work upon the same sub- 
 ject. — Nashville Journ. of Med. and Surg., May, 
 1879. 
 
 The author of this work has acquired an immense 
 experience as physician to three of the large char- 
 ities of New York in which children are treated. 
 These asylums afford unsurpassed opportunities for 
 observing the effects of different plans of treatment, 
 and the results as emb >died in this volume may be 
 accepted with faith, and should be in the possession 
 of all practitioners now. in vi^w of the approaching 
 season when the diseases of children always increase. 
 —Nat. Med. Review, April, 1879. 
 
 s 
 
 WAYNE {JOSEPH GRIFFITHS), M.D., 
 
 Physician-Accoucheur to the British General Hospital, &c. 
 
 OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
 MENCING MIDWIFERY PRACTICE Second American, from the Fifth and Revised 
 London Edition, with Additions by E. R. Hutchins, M.D. With Illustrations. In one 
 neat 12mo. volume. Cloth, $1 25. {Lately Issued.) 
 *** See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
 subscribers to the " American Journal of the Medical Sciences." 
 
 CHURCHILL ON THE PUERPERAL FEVER AND 
 OTHER DISEASES PECULIAR TO WOMEN, lvol. 
 8vo., pp 150, cloth. $2 50. 
 
 DEWEES'S TREATISE ON THE DISEASES OF FE- 
 MALES. With illustrations. Eleventh Edition, 
 with the Author's lastimprovementsand correc- 
 tions. In one octavo volume of 536 pages, with 
 plates, cloth. $3 00. 
 
 MEIGS ON THE NATURE, SIGNS, AND TREAT- 
 MENT OF CHILDBED FEVER. 1 vol. 8vo., pp. 
 365, cloth. $2 00. 
 
 ASHWELL'S PRACTICAL TREATISE ONTHE DIS- 
 EASES PECULIAR TO WOMEN. Third American, 
 from the Third and revised London edition. 1 vol. 
 8vo., pp. 52S, cloth. $3 50. 
 
 H 
 
 ODGE {HUGH L.), M.D. , 
 
 Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 
 
 ON DISEASES PECULIAR TO WOMEN; including Displacements 
 
 of the Uterus. With original illustrations. Second edition, revised and enlarged 
 one beautifully printed octavo volume of 531 pages, cloth, $4 50. 
 
 In 
 
 O 
 
 HURGHILL {FLEETWOOD), M.D., M.R.I.A. 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 
 
 American from the fourth revised and enlarged London edition. With notes and additions 
 by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- 
 dren," <fec. With one hundred and ninety four illustrations. In one very handsome octavo 
 volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 
 
 MONTGOMERY'S EXPOSITION OF THE SIGNS 
 AND SYMPTOMS OF PREGNANCY. With two 
 exquisitecolored plates, and numerous wood-cuts. 
 Tn 1 y<H. K™.. of nearly 600 pp., cloth, $3 75. 
 
 CONDTE'S PRACTICAL TREATISE ON THE DIS- 
 EASES OF CHILDREN. Sixth edition, revised 
 and augmented. In one large octavo volume of 
 nearly 8^0 closely-printed pages, cloth, $5 25 ; 
 leather $6 25. 
 
 RIGBY'S SYSTEM OF MIDWIFERY. With notes 
 and Additional Illustrations. Second American 
 edition. One volume octavo, cloth 422 pages, 
 $2 50. 
 
 SMITH'S PRACTICAL TREATISE ON THE WAST- 
 ING DISEASES OF INFANCY AND CHILDHOOD. 
 Second American, from the second revised and 
 enlarged English edition. In one handsome octa- 
 vo volume, cloth, $2 50. 
 
Henry C. Lea's Son & Co.'s Publications — (Dis. of Women). 
 
 JTHOMAS (T.GAILLARD),M.D., 
 
 *■ Professor of Obstetrics, &c. , in the College of Physicians and Surgeons, N. T., &c 
 
 A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 
 
 edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 
 
 800 pages, with 191 illustrations. Cloth, $5 00 ; leather, $6 00. (Just Issued.) 
 
 A work which has reached a fourth edition, and isclassical withoutbeingpedantic, full in the details 
 
 that, too. in the short space of fire years, has achieved of anatomy and pathology, without ponderous 
 
 a reputation which places it almost beyond the reach i translation of pages of German literature, describes 
 
 of criticism, and the favorable opinions which we hare distinctly the details and difficulties of each opera- 
 
 already expressed of the former editions seem to re 
 quire that we should do little more than announce 
 this new issue. We cannot refrain from saying that, 
 as a practical work, this is second to none in the Eng- 
 lish, or, indeed, in any other language. The arrange- 
 ment of the contents, the admirably clear manner in 
 which the subject of the differential diagnosis of 
 several of the diseases is handled, leave nothing to be 
 desired by the practitioner who wants a thoroughly 
 clinical work, one to which he can refer in difficult 
 eases of doubtful diagnosis with the certainty of gain- 
 ing light and instruction. Dr. Thomas is a man with a 
 very clear head and decided views, and there seems to 
 be nothing which he so much dislikes as hazy notions 
 of diagnosis and blind routine and unreasonable thera 
 
 tion, without wearying and useless minutiae, and is 
 in all respects a work worthy of confidence, justify- 
 ing the high regard in which its distinguished au- 
 thor is held by the profession.— Am. Supplement, 
 Obstet. Journ., Oct. 1S74. 
 
 Professor Thomasfairly took the Profession of the 
 United States by storm when his book first made its 
 appearance early in IS6S. Its reception was simply 
 enthusiastic, notwithstanding a few adverse criti- 
 cisms from our transatlantic brethren, the first large 
 edition was rapidly exhausted, and in six mouths a 
 second one was issued, and in two years a third one 
 was announced and published, and we are now pro- 
 tbe fourth. The popularity of this work 
 
 peuties. The student who will thoroughly study this ( not ephemeral, and itssuccesswasunprecedentedin 
 
 book and test its principles by clinical observation, will 
 certainly not be guilty of these faults. — London Lancet, 
 Feb. 13, 1875. 
 
 Reluctantly we are obliged to close this unsatis- 
 factory notice of so excellent a work, and in conclu- 
 sion r would remark that, as a teacher ofgynaecology. 
 both didactic and clinical, Prof. Thomashas certainly 
 taken the lead far ahead of his confreres, and as an 
 author he certainly has met with unusual and mer- 
 ited sueeess. — Am. Journ. of Obstetrics, Nov. 1874. 
 
 This volume of Prof. Thomas in its revised form 
 
 the annals of American medical literature. Six years 
 is a long period in medical scientific research, but 
 Thomas's work on " Diseases of Women" is still the 
 leading native production of the United States. The 
 order, the matter, the absence of theoretical disputa 
 tiveness, the fairness of statement, and the elegance 
 of diction, preserved throughout the entire range of 
 the book, indicate that Professor Thomas did not 
 overestimate his powers when he conceived the idea 
 and executed the work of producing a new treatise 
 upon diseases of women. — Prof. Pallen, in Louis- 
 ville Med. Journal, Sept. 1874. 
 
 ~DARNES [ROBERT), M.D., F.R.C.P., 
 
 •*~* Obstetric Physieian to St. Thomas' s Hospital, &e. 
 
 A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
 CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
 English Edition. In one handsome octavo volume, of 784 pages, with 181 illustrations. 
 Cloth, $4 50; leather, $5 50; half Russia, $6. {Just Ready.) 
 The call for a new edition of Dr. Barnes's work on the Diseases of Females has encouraged 
 the author to make it even more worthy of the favor of the profession than before By a rear- 
 rangement and careful pruning space has been found for a new chapter on the Gynaecological 
 Relations of the Bladder and Bowel Disorders, without increasing the size of the book, whir* 
 many new illustrations have been introduced where experience has shown them to be needed. It 
 is therefore hoped that the volume will be found to reflect thoroughly and accurately the present 
 condition of gynaecological science. 
 
 Dr Barnes stands at the head of his profession in 
 the old country, and it requires but scant scrutiny 
 of his book to show that it has been sketched by a 
 master. It is plain, practical common sense ; shows 
 very deep research without being pedantic ; is emi- 
 nently calculated to inspire enthusiasm without in- 
 culcating rashness; points out the dangers to be 
 avoided as well as the success to be achieved in the 
 various operations connected with this branch of 
 medicine ; and will do much to smooth the rugged 
 path of the young gynaecologist and relieve the per- 
 plexity of the man of mature years. — Canadian 
 Journ. of Med. Science, Nov. 187S. 
 
 We pity the doctor who, havins 
 
 the work is a valuable one, and should be largely 
 consulted by the profession. — Am. S? r pp Obstetrical 
 Journ. Gt. Britain and Ireland, Oct. 1S78. 
 
 No other gynaecological work holds a higher posi- 
 tion, having beeome an authority everywhere in 
 diseases of women. The work has been brought 
 fully abreast of present knowledge. Every practi- 
 tioner of medicine should have it upon the shelves 
 of his library, and the student will find it a superior 
 text-book. — Cincinnati Med. News, Oct. 1S7S. 
 
 This second revised edition, of course, deserves all 
 
 the commendation given to its predecessor, with the 
 
 additional one that it appears to include all or nearly 
 
 any consider- all the additions to our knowledge of its subject that 
 
 able practice in diseases of women, has no copy of \ have been made since the appearance of the first edi- 
 " Barnes" for daily consultation and instruction. It '' tion. The American references are, for an English 
 is at once a book of great learning, research, and | work, especially full and appreciative, and we can 
 individual experience, and at the same time erai- cordially recommend the volume to American read- 
 nently practical. That it has been appreciated by ers.— Journ. of Nervous and Mental Disease, Oct. 
 the profession, both in Great Britain and in this 
 country, is shown by the second edition following 
 so soon upon the first.— Am. Practitioner, Nov. 
 1S78, 
 
 Dr. Barnes's work is one of a practical character, 
 largely illustrated'from eases in his own experience, 
 but by no means confined to such, as will be learned 
 from the fact that he quotes from no less than 62S 
 
 medical authors in numerous countries. Coming students and practitioners. — N. 
 from such an author, it is not necessary to say that ! Oct. 1878. 
 
 1878. 
 
 This second edition of Dr. Barnes's great work 
 comes to us containing many additions snd improve- 
 ments which bring it up to date in every feature. 
 The excellences of the work are too well known to 
 require enumeration, and we hazard the prophecy 
 that they will for many years maintain its high po- 
 sition as a standard text-book and guide book for 
 C. Med. Journ., 
 
 a 
 
 'HAD WICK (JAMES R.), A.M., M.D. 
 
 A MANUAL OF THE DISEASES PECULIAR TO WOMEN. 
 
 neat volume, royal 12mo., with illustrations. (Preparing.) 
 
 In one 
 
Henry C. Lea's Son & Co.'s Publications — [Dis. of Women). 23 
 fMMET [THOMAS ADDIS), M.D. 
 
 -*-* Surgeon to the Woman's Hospital, New York, etc. 
 
 THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 
 
 use of Students and Practitioners of Medicine. Second Edition. Thorougly Revised. 
 In one large and very handsome octavo volume of 875 pages, with 133 illustrations. 
 Cloth, $5; leather, $6 ; half Russia, $6 50. (Just Ready.) 
 
 Pbeface to the Second Edition. 
 
 The unusually rapid exhaustion of a large edition of this work, while flattering to the author 
 as an evidence that his labors have proved acceptable, has in a great measure heightened his 
 sense of responsibility. He has therefore endeavored to take full advantage of the opportunity 
 afforded to him for its revision. Every page has received his earnest scrutiny; the criticisms 
 of his reviewers have been carefully weighed ; and while no marked increase has been made in 
 the size of the volume, several portions have been rewritten, and much new matter has been 
 added. In this minute and thorough revision, the labor involved has been much greater than 
 is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering 
 the work more worthy of the favor which has been accorded to it by the profession. 
 
 In no country of the world has gynaecology re- not careless reading but profound study. Its value 
 ceived nioreatt^ntion thanin America. It is, then, ; as a contribution f o gynecology is, perhaps, greater 
 with a feeling of pleasure that we welcome a work than that of all previous literature on the subject 
 on diseases of women from so eminent a gynsecolo- combined. — Chicago Med. Gaz., April s, 1S80. 
 gist as Dr. Emmet, and the work is essentially cliai- The wide repu tation of the author makes its pub- 
 cal, and leaves a strong impress of the author sin- i ica tion an event in the gynecological world ; and 
 dividaality. To criticize with the care it merits, a , nce thro h its pa es shows that it is a work 
 the book throughout, would demand tar more space [ to be studied with care . . . . it must always he a 
 
 than is at our command. In parting, we can say 
 that the work teems with original ideas, fresh and 
 valuable methods of practice, and is written in a 
 clear and elegant style, worthy of the literary repu- 
 tation of the country of Longfellow and Oliver Wen- 
 dell Holmes.— Brit. Med. Journ., Feb. 21, 18S0. 
 
 No gynecological treatise has appeared which 
 contains an equal amount of original and useful 
 matter; nor does the medical and surgical history 
 of America include a hook mor» novel and useful 
 
 work to be carefully studied and frequently con- 
 sulted by those who practise this branch of our pro- 
 fession. — Lond. Med. Times and Gaz., Jan. 10, 18S0. 
 The character of the work is too well known to 
 require extended notice — suffice it to say that no 
 recent work upon any subject has attained such 
 great popularity so rapidly. Asa work of general 
 reference upon the subject of Diseases of Women it 
 is invaluable. As a record of the largest clinical 
 experience and observation it has no equal. N-o 
 The tabular and statistical information which it | physician who pretends to keep up with the ad- 
 contains is marvellous, both in quantity and accu- ] vances of this department of medicine can afford to 
 racy, and cannot be otherwise than invaluable to be without it. — Nashville Journ. of Medicine and 
 future investigators. It is a work which demands [ Surgery, May, 1SS0. 
 
 f)UNCAN [J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. 
 
 CLINICAL LECTURES ON THE DISEASES OF WOMEN, 
 
 Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 
 
 pages. Cloth, $1 50. (Just Ready.) 
 They are in every way worthy of their author ; ] The author is a remarkably clear lecturer, and 
 indeed, we look upon them as among the most valu- ' his discussion of symptoms and treatment is full 
 afole of his contributions. They are all up>n mat- and suggestive. It will be a work which will not 
 ters of great interest to the general practitioner. ; fail to be read with benefit by practitioners as well 
 Some of them deal wi:h subjects that are not, as a ! as by students. — Phila. Med. and Surg. Reporter, 
 rule, adequately handled in the text-books; others ! Feb. 7, 18S0. 
 
 of them, while bearing upon topics that are usually ! We have read this book witil a great deal of 
 treated of at length in such works, yet bear such a pj eagare . It is full of good things. The hints on 
 stamp of individuality that, if widely read, as they j pa thol.»gy and treatment scattered through the book 
 certainly deserve to be, they eannot fail to exert a are 80uad trustworthy, and of great" value. A 
 wh-olesome restraint upon the undue eagerness with healthy scepticism a large experience, and a clear 
 which many yonng physicians seem bent upon fol- , judgment are everywhere manifest. Instead of 
 lowing the wild teachings which so infest the gynse- ; bristling with advice of doubtful value and un- 
 cology of the present day.— N. T. Med. Journ., b0and character, the book is in every respect a safe 
 Mareh, 1880. | guid e._Z7ie London, Lancet, Jan. 21, 1880. 
 
 ffAMSBOTHAM [FRANCIS H.), M.D. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
 CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
 edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
 Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one Lirge 
 and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
 bands : with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
 all nearly 200 large and beautiful figures. $7 00 
 
 TXTINCKEL [F.), 
 
 ' * Professor and Director of the Gynaecological Clinic in the University of Rostock . 
 
 A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
 MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent 
 of the author, from the Second German Edition, by James Read Chadwick, M.D. In 
 one octavo volume. Cloth, $4 00. (Lately Issued.) 
 
 qiANNER [THOMAS H.), M.D. 
 
 ON THE SIGNS AND DISEASES OF PREGNANCY. First American 
 
 from the Second and Enlarged English Edition. With four colored plates and illustra- 
 tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
 
24 Henry C. Lea's Son & Co.'s Publications— {Midwifery). 
 
 PLAYFAIR ( W. S.\, M.D., F.R.C.P.. 
 Professor of Obstetric Medicine in King's College, etc. etc. 
 
 A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 
 
 Third American edition, revised by the author. Edited, with additions, by Robert P. 
 Harris, M D. In one handsome octavo volume of about 700 pages, with nearly 2C0 
 illustrations. Cloth, $4 ; leather, $5 ; half Russia, $5 50. {Just Ready ) 
 
 EXTRACT FROM THE AUTHOR'S PREFACE. 
 
 The second American edition of my work on Midwifery being exhausted before the corre- 
 sponding English edition, I cannot better show my appreciation of the kind reception my book 
 has received in the United States than by acceding to the publisher's request rhnt I should 
 myself undertake the issue of a third edicion. As little more than a year has elapsed since 
 the second edition was issued, there are naturally not many changes to make, but I have, 
 nevertheless, subjected the entire work to careful revision, and introduced info it a notice of 
 most of the more important recent additions to obstetric science. To the operation of gastro- 
 elytrotomy — formerly described along with the Cesarean section — I have now devoted a sepa- 
 rate chapter. The editor of the Second American edition, Dr. Harris, enriched it with many 
 valuable notes, of which, it will be observed, I have freely availed myself. 
 
 The med'eal profes.-ion has now the opportunity | a very intelligent idea of them, yet all details not 
 
 of adding to then- stock of standard medical work 
 one of the best volumes on midwifery ever published. 
 The subject is taken up with a master hand. The 
 part devoted to laborin all its various presentations, 
 the management and results, is admirably arranged, 
 aud the views entertained will be found esseutially 
 modern, and the opinions expressed trustworthy 
 The work abounds with plates, illustrating various 
 obstetrical positions; they are admirably wrought, 
 and afford great assistance to the student. — N. 0. 
 Med. and Surg, fourn., March, 1880. 
 
 If inquired of by a medical student what work on 
 obstetrics we should recommend for him, as par 
 excellence, we would u doubtedly advise him to 
 choose Playfair's. It is of convenient size, but what 
 is of chief importance, i's treatment of the various 
 subjects is concise aud plain. While the discussions 
 and descriptions are sufficiently elaborate to render 
 
 necessary for t full understanding of the subject are 
 omitted. — Cincinnati Med. News, Jan. 1880. 
 
 The rapidity with which one edition of this work 
 follows another is proof alile of ir s excellence and 
 of the estimate that the profession has lormed of it. 
 It is indeed so well known and so highly valued 
 that nothing need be said of it as a whole. All 
 things considered, we regard this treatise as the very 
 best on Midwifery in the English language.— N. Y. 
 Medical Journal, May, 1880 
 
 It certainly is an admirable exposition of the 
 Science aud Practice of Midwifery. Of course the 
 additions made by the American editor, Dr. R. P. 
 Harris, who never utters an idle word, and whose 
 studious researches in some special departments of 
 obstetrics are so well known to the profession, are 
 of great value — The American Practitioner, April, 
 1880. 
 
 ~DARNES [FANCOURT), M.D., 
 
 -*~* Physician to the General Lying-in Hospital, London. 
 
 A MANUAL OF MIDWIFERY FOR MIDWIFES AND MEDICAL 
 
 STUDENTS. With 50 illustrations. In one neat royal 12mo. volume of 200 pages; 
 
 cloth, $1 25. (Now Ready.) 
 The book is written in plain, and as far as pos- I will be popular with those for whom it has been 
 sible in untechnical language. Any intelligent mid- j prepared. The exam ning questions at the back 
 wife or medical student can easily comprehend the i will be found very useful. — Cincinnati Med. News, 
 directions. It will undoubtedly fill a want, and I Aug. 187.9. 
 
 JTHE OBSTETRICAL JOURNAL. {Free of postage for 1880.) 
 
 THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 
 
 Including Midwifery, and the Diseases op Women and Infants. A monthly of 
 64 octavo pages, very handsomely printed. Subscription, Three Dollars per annum 
 Single Numbers. 25 cents each. 
 With the January number will terminate Vol. VII. of the Obstetrical Journal. The first 
 No. of Vol. VIII. will be issued about Feb. 1st; the "American Supplement" of 16 pages 
 per No. will be discontinued, and the periodical will thenceforth consist of 64 pages per number, 
 at the exceedingly low price of Three Dollars per annum, free of postage. For this trifling 
 turn the subscriber will thus obtain more than 750 pages per annum, containing an extent and 
 variety of information which may be estimated from the fact that Vol. VI. of the "Obstetri- 
 cal Journal" contains in 
 
 44 Articles 
 4 " 
 
 onthly Summary, Gynecic 28 Articles 
 " " Pediatric 4 " 
 
 Original Communications . 
 Hospital Practice . . . 
 
 General Correspondence . . 5 " News 
 
 Reviews of Books .... 
 Proceedings of Societies . . 101 " 
 In Monthly Summary, Obstetric 73 
 and that it numbers among it^ contributors the distinguished names of Lombe Atthill, J. H. 
 Aveling, Robert Barnes, J. Henry Bennet, Nathan Bozeman, Thomas Chambers, Fleet- 
 wood Churchill, Charles Clay, John Clay, J. Matthews Duncan, Arthur Farre, Robert 
 Greenhalgh, W. M. Graily Hewitt, J. Braxton Hicks, William Leishman, Angus Mac- 
 donald, Alfred Meadows, Alex. Simpson, J. G. Swayne, Lawson Tait, Edward J. Tilt, 
 E. H. Trenholme, T. Spencer Wells, Arthur Wigglesworth, and many other distin- 
 guished practitioners. Under such auspices it has amply fulfilled its object of presenting to 
 the physician all that is new and interesting in the rapid development of obstetrical and gynae- 
 cological science. 
 
 As a very large increase in the subscription list is anticipated under this reduction in price, 
 gentlemen who propose to subscribe, and subscribers intending to renew their subscriptions, 
 are recommended to lose no time in making their remittances, as the limited number printed 
 may at any time be exhausted. 
 
Henry C. Lea's Son & Co.'s Publications — {Midwifery^ Surgery). 25 
 
 TEISHMAN ( WILLIAM), M.D., 
 
 "^ Regius Professor of Midwifery in the. University of Glasgow, &c. 
 
 A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 
 
 PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by 
 the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia 
 Hospital, &c. In one large and very handsome octavo volume, of 733 pages, with over 
 two hundred illustrations. Cloth, $4 50 ; leather, $5 50 ; half Russia, $6. {Just Ready.) 
 
 Few works on this subject have met withas great 
 a demand a*- this one appears to have. To judge 
 by the frequency with which its authcr's views are 
 quoted, and its s aiements referred toiu obstetrical 
 literature, one would judge that there are few phy- 
 sicians devoting much attention to obstetrics who 
 are without it. The author is evidently a man of 
 ripe experience and conservative views, and in no 
 branch of medicine are these more valuable than in 
 this.— New Remedies, Jan. 1SS0. 
 
 We gladly welcome the new edition of this excel- 
 lent text book of midwifery. The former editions 
 have been most favorably received by the profes- 
 sion on both 8 des of the Atlantic In the prepara- 
 tion of the prestnt edition the author has made such 
 alterations as the progress of obstetric il science 
 seems to require, and we cannot but admire the 
 ability with which the task has been performed. 
 "We consider it an admirable text-book for students 
 during their attendance upon lectures, and have 
 great pleasure in recommending it. As an exponent 
 of the midwifery of the present day it has no supe- 
 
 rior in the English language. — Canada Lancet, Jan. 
 1S80. 
 
 The book is greatly improved, and as such will be 
 welcomed by those who are trying to keep posted in 
 the rapid advances which are being made in the 
 study of obstetrics. — Boston Med. and burg Journ., 
 Nov '27, 1879. 
 
 To the American student the work before us must 
 prove admirably adapted, complete in all its parts, 
 essentially modern in its teachings and with dem- 
 onstrations noted for clearness and precision, it will 
 gain in favor and be recognized as a woik of stand- 
 ard merit. The work cannot fail to be popular, and 
 is cordially recommended.— N. 0. Med. and Surg. 
 Journ., March, 1SS0. 
 
 Irishman's is certainly one of the best systematic 
 workf on midwifery. It is very complete in all the 
 parts essential for such a treati.e To practitioners 
 and students it is to be strongly recommended as a 
 safe and reliable guide to the" modern practice of 
 midwifery.— Canada Med. and Surg. Journal, 
 March, 18S0. 
 
 pARRY {JOHN S.), M.D., 
 
 Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Obstet. Society of Philadelphia. 
 
 EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 
 
 DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
 Cloth, $2 50. {Lately Issued.) 
 
 TJODGE (HUGH L.), M.D., 
 
 Emeritus Professor of Midwifery, &e.,inthe University of Pennsylvania, Sec. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. TAus- 
 
 trated with large lithographic plates containing one hundred and fifty-nine figures from 
 original photographs, and with numerous wood-cuts. In one large and beautifully printed 
 quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
 The work of Dr. Hodge is something more than 
 
 a simple presentation of his particular views in the 
 
 department of Obstetrics; it is something more 
 
 than an ordinary treatise on midwifery; it is, in fact, 
 
 a cyclopaedia of midwifery. He has aimed to em- 
 
 Dody in a single volume the whole science and art of 
 Obstetrics. An elaborate text is combined with ac- 
 curate and varied pictorial illustrations, so that no 
 fact or principle is left unstated or unexplained. 
 — Am. Med. Times, Sept. 3, 1S64. 
 
 ** # Specimens of the plates and letter-press will be forwarded to any address, free by mail 
 on receipt of six cents in postage stamps. 
 
 OTIMSON {LEWIS A.), A.M. r M^> 
 
 *3 Surgeon to the Presbyterian Hospital. 
 
 A MANUAL OF OPERATIVE SURGERY. In one very handsome 
 
 royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. {Just Issued.) 
 The work before us is a well printed, profusely performing them. The work is handsomely illus- 
 illustrated manual of over four hundred and seventy \ trated, and the descriptions are clear and well drawn 
 pages. The novice, by a perusal of the work, will It is a clever and useful volume; everv student 
 gain a good idea ol the general domain of operative | should possess one. The preparation of this work 
 surgery, while the practical surgeon has presented I does away with the necessity of pondering over 
 to him within a very concise and intelligible form larger works on surgery for descriptions of opera- 
 
 the latest and most approved selections of operative 
 procedure. Theprecision ard conciseness with which 
 the different operations are described enable the 
 author to compress an immense amount of practical 
 information in a very small compass.— N. Y. Medical 
 Record, Aug. 3, 187S. 
 
 This volume is devoted entirely to operative sur- 
 gery, and is intended to familiarize the student with 
 the details of operations and the different modes of 
 
 opera- 
 tions, asit presents in a nut-shell just whatis wanted 
 by the surgeon without an elaborate search to find 
 it. — Md. Med Journal, Aug. 1878. 
 
 The author's conciseness and the repleteness of 
 the work with valuable illustrations entitle it to be 
 classed with the text-books for students of operative 
 surgery, and as one of reference to the practitioner. 
 — Cincinnati Lancet and Clinic, July 27, 187S. 
 
 SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 
 cl., of 650 pages ; withabout lOOwood-cuts. $3 25. 
 
 COOPER'S LECTURES ON THE PRINCIPLES AND 
 Practice of Surgery. Inl vol. Svo.cl'h,750p. $2. 
 
 GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
 GERY. Eighth edit'n, improved and altered. With 
 thirty-four plates. In two handsome octavo vol- 
 umes, about 1000pp., leather, raised bands. $6 50. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. 
 By William Pirrie,F.R.S.E., Profes'r of Surgery ; 
 in the University of Aberdeen. Edited by John j 
 
 Netll, M.D., Professor of Surgery in thePenna 
 MedicalCollege.Surg'n to the Pennsylvania Hos- 
 pital, &c. In one very handsome octavo vol of 
 780 pages, with 316 illustrations, cloth, $3 75. 
 MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- 
 rican, from the Third Edinburgh Edition. In one 
 large 8vo. vol. of 700 pages, with 340 illustration « 
 eloth,$3 75. ' 
 
 MILLER'S PRACTICE OF SURGERY. Fourth Am e- 
 rican, from the last Edinburgh Edition. Eevised by 
 the American editor. In onelargeSvo. vol. of nearly 
 7 00 pages, with 364 illustrations: cloth, $3 75. 
 
26 
 
 Henry C. Lea's Son & Co.'s Publications — (Surgery). 
 
 SiROSS {SAMUEL D.), M.D., 
 
 ^-A Professor of Surgery in the Jefferson Medical College of Philadelphia. 
 
 SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 
 
 and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition 
 carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
 umes of about 2300 pp., strongly bound in leather, with raised bands, $15 ; half Russia, 
 raised bands, $16. 
 The continued favor, shown by the exhaustion of successive large editions of this great work, 
 proves that it has successfully supplied a want felt by American practitioners and students. In 
 the present revision no pains have been spared by the author to bring it in every respect fully 
 up to the day. To effect this a large part of the work has been rewritten, and the whole en- 
 arged by nearly one-fourth, notwithstanding which the price has been kept at its former very 
 moderate rate. By the use of a close, though very legible type, an unusually large amount of 
 matter is condensed in its pages, the two volumes containing as much as four or five ordinary 
 octavos. This, combined with the most careful mechanical execution, and its very durable bind- 
 ing renders, it one of the cheapest works accessible to the profession. Every subject properly 
 belonging to the domain of surgery is treated in detail, so that the student who possesses this 
 work may be said to have in it a surgical library. 
 
 We have now brought our task to a conclusion, and 
 have seldom read a work with the practical value of 
 which we have heen moreimpressed. Every chapter is 
 so concisely put together, that the busy practitioner, 
 when in difficulty, can at once find the information he 
 requires. His work, on the contrary, is cosmopolitan, 
 the surgery of the world being fully represented in it. 
 The work, in fact, is so historically unprejudiced, and 
 so eminentlypractical,that it is almost a false compli- 
 ment to say that we believe it to be destined to occupy 
 a foremost place as a work of reference, while a system 
 of surgery like the present system of surgery is the 
 practice of surgeons. The printing and binding of the 
 work is unexceptionable; indeed.it contrasts, in the 
 latter respect, remarkably with English medical and 
 surgical cloth-bound publications, which are generally 
 so wretchedly stitched as to require re- binding before 
 they are any time in use. — Dub. Journ. of Med. Sci., 
 March, 1874. 
 
 Dr. Gross's Surgery, a great work, has become still 
 greater, both in size and merit, in its most recent form. 
 The difference in actualnumber of pages is not more 
 than 130, but. the size of the page having been in- 
 creased to what we believe is technically termed "ele- 
 phant." there has been room for considerable additions, 
 which, together with the alterations, are improve- 
 ments. — Lond. Lancet. Nov. 16, 1872. 
 
 It combines, as perfectly as possible, the qualities of 
 a text-book and work of reference. We think this last 
 
 edition of Gross's "Surgery," will confirm his title of 
 •' Primus inter Pares." It is learned, scholar-like, me- 
 thodical, precise, and exhaustive. We scarcely think 
 any living man could write so complete and faultless a 
 treatise, or comprehend more solid, instructive matter 
 in the given number of pages. The labor must have 
 been immense, and the work gives evidence of great 
 powers of mind, and the highest order of intellectual 
 discipline and methodical disposition, and arrangement 
 of acquired knowledge and personal experience. — N.Y. 
 Med. Journ., Feb. 1873. 
 
 As a whole, we regard the work as the representative 
 "System of Surgery" in the English language. — St. 
 Louis Medical and Surg. Journ., Oct. 1872, 
 
 The two magnificent volumes before us afford a very 
 complete view of the surgical knowledge of the day. 
 Some years ago we had the pleasure of presenting the 
 first edition of Gross's Surgery to the profession as a 
 work of unrivalled excellence; and now we have the 
 result of years of experience, labor. and study, all con- 
 densed upon the great work before us. And to students 
 or practitioners desirousof enriching theirlibrary with 
 a treasure of reference, we can simply commend the 
 purchase of these two volumes of immense research — 
 Cincinnati Lancet and Observer, Sept. 1672. 
 
 A complete system of surgery — not a mere text-book 
 of operations, but a scientific account of surgical theory 
 and practice in all its departments. — Brit, and For. 
 Mod Chir.Rev., Jan. 1873. 
 
 B 
 
 Y THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 
 
 and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third 
 Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
 the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
 trations: cloth, $4 50. (Just Issued.) 
 
 eases of the urinary organs. — Atlanta Med. Journ., Oct. 
 
 1876. 
 
 For referenceandgeneralinformation, the physician 
 or surgeon can find no work that meets their necessities 
 more thoroughly than this, a revised edition of an ex- 
 cellent treatise, and no medical library should be with- 
 out it. Replete with handsome illustrations and good 
 ideas, it has the unusual advantage of being easily 
 comprehended, by the reasonable and practical manner 
 in which the various subjects are systematized and 
 arranged We heartily recommend it to the profession 
 
 It is with pleasure we now again take up this old 
 work in a decidedly new dress. Indeed, it must be re- 
 garded as a new book in very many of its parts. The 
 chapters on "'Diseases of the Bladder," "Prostate 
 Body," and "Lithotomy," are splendid specimens of 
 descriptive writing; while the chapter on "Stricture' 
 is one of the most concise and clear that we have ever 
 
 as a valuable addition to the important literature of dis- 1 rea d.— JVew York Med. Journ., Nov. 187 6 
 TD Y THE SAME A UTHOR . 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN 
 
 AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 
 
 THE 
 
 D 
 
 RUITT {ROBERT), M.R.C.S., &c. 
 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 
 
 A new and revised American, from the eighth enlarged and improved London edition. Illus- 
 trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
 volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 
 
 All that the surgical student or practitioner could 
 desire. — Dublin Quarterly Journal. 
 
 It is a most admirable book. We do not know 
 when we have examined one with more pleasure. — 
 Boston Med. and Surg. Journal. 
 
 In Mr . Druitt's book , though containingonly some 
 seven hundred pages, both the principles and the 
 
 practice of surgery are treated, and so clearly and 
 perspicuously, as to elucidateeveryimportanttopic. 
 We have examined thebook mostthoroughly, and 
 can say that this saccessis well merited. His book 
 moreover, possesses the inestimable advantages of 
 having the subjects perfectly well arranged and 
 classified and of being written in a style at once 
 clear and succinct. — Am. Journal of Meii. Sciences. 
 
Henry C. Lea's Son & Co.'s Publications — (Surgery). 
 
 27 
 
 A SHHURST (JOHN, Jr.), M.D., 
 
 -"- Prof, of Clinical Surgery . Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Second 
 
 edition, enlarged and revised. In one very large and handsome octavo volume of over 
 1000 pages, with 542 illustrations. Cloth, $6; leather, $7; half Russia, $7.50. (Jtcst 
 Ready.) 
 
 Conscientiousness and thoroughness are two very I 
 marked traits of character in the author of this ! 
 book. Out of these traits largely has grown the i 
 success of his mental fruit in the past, and the pre- 
 sent offer seems in no wise an exception to what has 
 gone before. The general arrangement of the vol- i 
 ume is the same as in the first edition, but every part ! 
 has been carefully revised, and much new matter 
 added.— Phila. Med. Times, Feb. 1, 1S79. 
 
 We have previously spoken of Dr. Ashhurst's 
 work in terms of praise. We wish to reiterate those 
 terms here, and to add that no more satisfactory ! 
 representation of modern snrgery has yet fallen I 
 from the press. In point of judicial fairness, of; 
 power of condensation, of accuracy and conciseness j 
 of expression and thoroughly good English, Prof. 
 Ashhurst has no superior among the surgical writers 
 in America. — Am. Practitioner, Jan. 1S79. 
 
 The attempt to embrace in a volume of 1000 pages 
 the whole field of surgery, general and special, 
 would be a hopeless ta>k unless through the most 
 tireless industry in collating and arranging, and 
 the wisest judgment in condensing and excluding. 
 These facilities have been abundantly employed by 
 the author, and he has given us a most excellent 
 treatise, brought up by the revision for the second 
 edition to the latest date. Of course this book is not 
 designed for specialists, but as a course of general 
 surgieal knowledge and for general practitioners, 
 and as a text-book for students it is not surpassed 
 by any that has yet appeared, whether of home or 
 foreign authorship. — N. Carolina Med. Journal, 
 Jan. 1879. 
 
 Ashhurst's Surgery is too well known in this 
 country to require special commendation from us. 
 This, its second edition, enlarged and thoroughly 
 revised, brings it nearer our idea of a model text- 
 book than any recently published treatise. Though 
 numerous additions have been made, the size of the 
 work is not materially increased. The main trouble 
 of text-books of modern times is that they are too 
 cumbersome. The student needs a book which will 
 furnish him the most information in the shortest 
 time. In every respect this work of Ashhurst is 
 the model text-book- full, comprehensive and com- 
 pact.— Nashville Jour, of Med. and Surg., Jan. '79. 
 
 The favorable reception of the first edition is a 
 guarantee of the popularity of this edition, which is 
 fresh from the editor's hands with many enlarge- 
 ments and improvements. The author of this work 
 is deservedly popular as an editor and writer, and 
 his contributions to the literature of surgery have 
 gained for him wide reputation. The volume now 
 offered the profession will add new laurels to those 
 already won by previous contributions. We can 
 only add that the work is well arranged, filled with 
 practical matter, and contains in brief and clear 
 language all that is necessary to be learned by the 
 student of surgery whilst in attendance upon lec- 
 tures, or the general practitioner in his daily routine 
 practice.— Md. Med. Journal, Jan. 1879. 
 
 The fact that this work has reached a second edi- 
 tion so very soon after the publication of the first 
 one, speaks more highly of its merits than anything 
 we might say in the way of commendation. It 
 seems to have immediately gained the favor of stu- 
 dents and physicians.— Cincin. Med. News, Jan. '79. 
 
 T>RYANT (THOMAS), F.R.C.S., 
 
 *-* Surgeon to Guy's Hospital. 
 
 THE PRACTICE OF SURGERY. Second American, from the Sec- 
 
 ond and Revised English Edition. With Six Hundred and Seventy-two Engravings on 
 Wood In one large and very handsome imperial octavo volume of over 1000 large and 
 closely printed pages. Cloth, $6 ; leather, $7. (Just Ready.) 
 
 This work has enjoyed the advantage of two thorough revisions at the hand of the author since 
 the appearance of the first American edition, resulting in a very notable enlargement of size and 
 improvement of matter. In England this has led to the division of the work into two volumes 
 which are here comprised in one, the size being increased to a large imperial octavo, printed on 
 a condensed but clear type. The series of illustrations has undergone a like revision, and will 
 be found correspondingly improved. 
 
 The marked success of the work on both sides of the Atlantic shows that the author has suc- 
 ceeded in the effort to give to student and practitioner a sou id and trustworthy guide in the 
 practice of Surgery; while the simultaneous appearance of the present edition in England and 
 in this country affords to the American reader the benefit of the most recent advance's made 
 abroad in surgical science. 
 
 There are so many text-books of surgery, so many , Another edition of this manual having been called 
 written by skilled and distinguished hands, that to ob I for, the author has availed himself of the opportunitv 
 tain the honor of a third edition in England is no light j to make no few alterations in the substance as well 
 praise. Mr. Bryant merits this, by clearness of style, j as in the arrangement of the work, and, with a view 
 and good judgment in selecting the operations he re- ; to its improvement, has recast the materials and re- 
 commends, in his new editions he goes carefully over vised the whole. We oHrselves are of the opinion 
 
 the old grounds, in light of later research. On these fk - f f ^"-" «- -~ *-~ « >- 
 
 and many allied points, Mr. Bryant is a calm and un- 
 partisan observer, and his book throughout has the 
 great merit of maintaining the true scientific, judicial 
 tone of mind. — Med. and Surg. Reporter, March 22, 
 1879. 
 
 The work before us is the American reprint of the 
 last London edition, and has the advantage over the 
 hitter in being of more convenient size, and in being 
 compressed into one volume. The author has rewrit- 
 ten the greater part of the work, and baa succeeded, 
 in the amount of new matter added, in making it mark- 
 edly distinctive from previous edkions. A few extra 
 pages have been added, and also a few new illustrations 
 
 pages lidve ueeu auueu, auu aisu a lew uew umsmuons l ;, TO :n u,, :„ „ nmn ^nn •..' -•— v..v 8 , cl , 
 
 introduced. The publishers have presented the work J^i feff'tff'KS U ™J "V^m er 7° rk ' latel 
 in a creditable style. As a concise and practical manual I oMorJin^la^JTi, >v, ' t ? e t . dlfficQ lt *■ 
 •y it is perhaps without an e.ual and B^aTa^s^ 
 
 td Match diet th *b con8 f„ e , r .« l S the high excellence of bot^ 
 ' arCB many others will likewise be forced to hesita.r* i M ' 
 
 trgery it is perhaps 
 will doubtless always be a favorite text-book 
 student and practitioner. — JY. 1\ Med. Record 
 22, 18T9. 
 
 that there is no better work on surgery qi at — 
 Cincinnati Med. News, March, 1S79. 
 
 Bryant's Surgery has been favorably received from 
 the first, and evidently grows in the esteem of the 
 profession with each succeeding edition. In glanc- 
 ing over the volume before us we fiud proof in almost 
 every chapter of the thorough revision which the 
 work has undergone, many parts having been cut 
 out and replaced by matter entirely fresh —N Y 
 Med. Journ., April, 1879. ' ' 
 
 Welcome as the new edition is, and as much as it 
 
 is entitled to commendation, yet its appearance at 
 
 i is, in a eertain sense, a matter of regret as 
 
 lately 
 k 
 of 
 
 foroed to hesitate long 
 a making choice between them.-Mneinnati Lan- 
 cet and Clinic, March 22, 1879. 
 
Henry C. Lea's Son & Co.'s Publications — (Surgery). 
 
 JjJRICHSEN {JOHN E. ), 
 
 Professor of Surgery in University College, London, etc. 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Bur- 
 
 gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
 Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- 
 gravings on wood. Id two large and beautiful octavo volumes of nearly 2000 pages : 
 cloth, $8 50 ; leather, $10 50; half Russia, $11 50. (Now Ready.) 
 
 In revising this standard work the authorhas spared no painsto render it worthy of a continu- 
 ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
 level with the advance in the science and art of surgery made since the appearance of the 
 last edition. To accomplish this has required the addition of about two hundred pages of text, 
 while the illustrations have undergone a marked improvement. A hundred and fifty additional 
 wood-cuts have been inserted, while about fifty other new ones have been substituted for figures 
 which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
 sented with the confident anticipation that it will maintain its position in the front rank of 
 text-books for the student, and of works of reference for the practitioner, while its exceedingly 
 moderate price places it within the reach of all. 
 
 The seventh edition is before the world as the last 
 word of surgical science. There may be monographs 
 which excel it upon certain points, but as a con- 
 spectus upon surgical principles and practice it is 
 unrivalled. It will well reward practitioners to 
 read it, for it Las been a peculiar province of Mr. 
 Erichsen to demonstrate the absolute interdepend- 
 ence of medical and surgical science We need 
 scarcely add, in conclusion, that we heartily com- 
 mend the work to students tbat they may be 
 grounded in a sound faitb, and to practitioners as 
 an invaluable guide at tbe bedside. — Am Practi- 
 tioner, April, 1S78. 
 
 It is no i lie compliment to say that this is the t»est 
 edition Mr. Erichsen has ever produced of his well- 
 known book. Besides inheriting the virtues of its 
 predecessors, it possesses excellences quite its own. 
 Having stated that Mr. Erichsen his incorporated 
 into this edition every recent improvement in the 
 science and art of surgery, it would be a supereroga- 
 tion to give a detailed criticism. In short, we un- 
 hesitatingly aver that we know of no other single 
 work where the student and practitioner can gain at 
 oncesoclear an insight into the principles of surgery, 
 and so complete a knowledge of the exigencies of 
 surgical practice.— London Lancet, Feb. 14, 187S. 
 
 For the past twenty years Erichsen's Surgery has 
 maintained its place as the leading text-book, not only 
 in this country, but in Great Britain. That it is able 
 to hold its ground, is abundantly proven by the tho- 
 roughness with which the present edition has been 
 revised, and by the large amount of valuable mate- 
 rial that has been added. Aside from this, one hun- 
 dred and fifty new illustrations have been inserted, 
 including quite a number of microscopical appear- 
 ances of pathological processes. So marked is this 
 change for the better, that the work almost appears 
 as an entirely new one. — Med. Record, Feb. 23,1878. 
 
 I Of the many treatises on Surgery which it has been 
 our task to study, or our pleasure to read, there is none 
 j which in all points has satisfied us so well as the classic 
 j treatise of Erichsen. His polished, clear style, hisfree- 
 ; dom from prejudice and hobbies, his unsurpassed grasp 
 | of his subject, and vast clinical experience, qualify him 
 : admirably to write a model text-book. "When we wish, 
 at the least cost of time, to learn the»most of a topic in 
 ! surgery, we turn, by preference, to his work. It is a 
 | pleasure, therefore, to see that the appreciation of it is 
 , general, and has led to the appearance of another edi- 
 : tion. — Med. and Surg. Reporter, Feb. 2, 1878. 
 
 Notwithstanding the increase in size, we observe that 
 j much old matter has been omitted. The entire work 
 I has been thoroughly written up, and not merely amend- 
 I ed by a few extra chapters A great improvement has 
 I been made in the illustrations. One hundred and fifty 
 new ones have been added, and many of the old ones 
 i have been redrawn. The author highly appreciates the 
 > favor with which his work has been received by Ameri- 
 can surgeons, aud has endeavored to render his latest 
 ; edition more than ever worthy of their approval. That 
 I he has succeeded admirably, must, we think, be the 
 general opinion. We heartily recommend the book to 
 , both student and practitioner. — N. Y.Med. Journal, 
 Feb. 1878. 
 Erichsen has stood so prominently forward for 
 , years as a writer on Surgery, that his reputation is 
 world wide, and his name is as familiar to the med- 
 ; ical student as to the accomplished and experienced 
 \ surgeon. The work is not a reprint of former edi 
 tions, but has in many places been entirely rewrit- 
 i ten. Recent improvements in surgery have not e6- 
 . caped his notice, various new operations have been 
 thoroughly analyzed, and their merits thoroughly 
 discussed. One hundred and fifty new wood-cuts 
 add to the value of this work. — If. O. Med. and Surg. 
 Journal, March, 187S. 
 
 TJOLMES {TIMOTHY), M.D., 
 
 -*■-*- Surgeon to St. George's Hospital, London. 
 
 SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
 some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6 ; leather, $7 : 
 half Russia, $7 50. (Just Issued.) 
 
 This is a work which has been lookedfor on both 
 sides ofthe Atlantic with muchinterest. Mr. Holmes 
 is a surgeon ol large and varied experience, and one 
 of the best known, and perhaps the most brilliant 
 writer upon surgical subjects in England. It is a 
 book for students — and an admirable one — and for 
 the busy general practitioner. It will give a student 
 all the knowledge needed to pass a rigid examina- 
 tion. The book fairly justifiesthe high expectations 
 that were formed of it. Its style is clear and forcible, 
 even brilliant at times, and the conciseness needed 
 to bringit withinitsproperiimitshas notimpaired 
 
 its force and distinctness. — If. Y. Med. Record, April 
 14, 1876. 
 
 It will be found a most excellent epitome of sur- 
 gery by the general practitioner who has not the 
 time togiveattentionto more minute and extended 
 works and to the medicalstudent. Infact, weknow 
 of no one we can more cordially recommend. The 
 author has succeeded well in giving a plain and 
 practical account of each surgical injury and dis- 
 ease, and of the treatment which is most com- 
 monly advisable. It will no doubt become a popu- 
 lar workin the profession, and especially as a text- 
 book. — Cincinnati Med. News, April, 1S76. 
 
 ASHTON ON THE DISEASES, INJURIES, and MAL- 
 FORMATIONS OF THE RECTUM AND ANUS: 
 with remarks on Habitual Constipation. Second 
 American, from the fourth and enlarged London 
 Edition. With illustrations. In one 8vo. vol. of 
 287 pages, cloth, $3 25. 
 
 SARGENT ON BANDAGING AND OTHER OPERA- 
 TIONS OF MINOR SURGERY. New edition, with 
 an additional chapter on Military Surgery. One 
 12mo. vol.of383pag3s withlSl wood-cuts. Cloth, 
 $175. 
 
Henry C. Lea's Son & Co.'s Publications — {Ophthalmology). 29 
 
 HAMILTON {FRANK H.), M.D., 
 
 *■-*- Professor of Fractures and Dislocations, &c.,in Bellevue Hosp. Med. College, New York. 
 
 A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
 
 TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume 
 of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. {Lately Issued.) 
 There is no better -work on the subject in existence 
 
 than that of Dr. Hamilton. It should be in the posses- 
 sion of every general practitioner and surgeon.— The 
 Am. Journ. of Obstetrics, Feb. 1876. 
 
 The value of a work like this to the practical physi- 
 cian and surgeon can hardly be over-estimated, and the 
 necessity of having such a book revised to the latest 
 dates.notmerely onaccountoftbe practical importance 
 
 of its teachings, but also by reason of the medico-legal 
 bearings of the cases of whichit treats, and which have 
 recently been the subject of useful papers by Dr. Hamil- 
 ton and others, is sufficiently obvious to every one. The 
 present volume seems to amply fill all the requisites. 
 We can safely recommend it as the best of its kind in 
 the English language, and notexcelled in any other — 
 Journ. of Nervous and Mental Disease, J an. 1876. 
 
 XTETTLESHIP (EDWARD), FR.G.'S., 
 
 -L- » Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' 1 Hospital, London 
 
 MANUAL OF OPHTHALMIC MEDICINE, 
 
 volume of over 350 pages, with 89 illustrations. Cloth, $2 
 
 In one royal 12mo. 
 
 (Just Ready.) 
 
 The book is written in a careful and logical man- 
 ner, and though extremely concise, we have failed 
 to notice any evidence of ambiguity. It is rendered 
 more compact and homogeneous by frequent refer- 
 ences, by page number, to other portions of the 
 work; repetitions are thus avoided, and we have 
 been surprised to find how much information onr 
 author has succeeded in conveying in so small a 
 space. A careful study of the book will well repay 
 the general practitioner, even though it should 
 serve only as a monitor. It is particularly useful 
 in the latter regard, as the subject of treatment is 
 presented in a thoroughly conservative manner.— 
 X Y. Med. Record, March 6, 1S80. 
 
 The author has succeeded in touching upon about 
 all the points, operations, diseases of the eye in 
 relation to general diseases, and has prepared a very 
 acceptable book. — Cincinnati Lancet and Clinic, 
 Feb. 7, 1880. 
 
 It is multum in parvo, containing all the leading 
 points to be remembered in the pathology, descrip- 
 tion, and treatment of diseases of the eye. It will 
 be found especially valuable in preparing for exam- 
 inations. Practitioners will find it convenient as a 
 work of reference, when they wish to refresh their 
 
 memories in respect to the features of some affec- 
 tions. — Cincinnati Med. News, Jan 1SS0. 
 
 The author is to be congratulated upon the very 
 successful manner in which he has accomplished his 
 task; he has succeeded iu being concise without 
 sacrificing clearness, and, including the whole 
 ground covered by more voluminous text-books, 
 has given an excellent resume of all the practical 
 information they contain. We do not hesitate to 
 pronounce Mr. Nettleship's book the best manual on 
 ophthalmic surgery for the use of students and 
 " busy practitioners" with which we are acquain- 
 ted. — Am. Jour. Med. Sciences, April, 1880. 
 
 A careful examination has convinced us that it is 
 the best work of its class that has come to our notice. 
 While all matter is condensed to the utmost, there 
 aie few points that are obscured thereby, and all 
 are rendered really attractive to the average student. 
 We can only hope that every medical student shall 
 be compelled to master the entire volume ere re- 
 ceiving his degree. General practitioners who take 
 care of eye cases would do well to refresh their 
 memories by its careful study. — Detroit Lancet, 
 April, 18S0. 
 
 a 
 
 'ARTER {R. BRUDENELL), F.R.C.S., 
 
 Ophthalmic Surgeon to St. George's Hospital, etc. 
 
 PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 
 
 ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
 handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75 . (Just 
 Issued.) 
 
 chapter is devoted to a discussion of the usesand selec- 
 tion ofspectacles, and is admirably compact, plain, and 
 useful, especially the paragraphs on the treatment of 
 presbyopia and myopia. In conclusion, our thanks are 
 due the author for many useful hints in the great sub- 
 ject of ophthalmic surgery and therapeutics, afield 
 
 It is with great pleasure that we can endorse the work 
 as a most valuable contribution to practical ophthal- 
 mology. Mr. Carter never deviates from the end he has 
 in view, and presents the subjectin a clear and concise 
 manner, easy of comprehension, and hence the more 
 valuable. We would especially commend, however, as 
 
 worthy of high praise, the manner iu which the thera- I where of late years we glean but a few grains of sound 
 peutics of disease of the eye is elaborated, for here the wheatfrom amass of chaff. — Neiv York Medical Record , 
 author is particularly clear and practical, where other i Oct. 23, 1875. 
 writers are unfortunately too often deficient. The final I 
 
 TXTELLS {J.SOELBERG), 
 
 ' ' Professor of Ophthalmology in King's College Hospital, Sec. 
 
 A TREATISE ON DISEASES OF THE EYE. Third American, 
 
 from the Third London Edition. Thoroughly revised, with copious additions, by Chas. 
 S. Bull, M D. , Surgeon and Pathologist to the New York Eye and Ear Infirmary. Illus- 
 trated with about 250 engravings on wood, and six colored plates. Together with selec- 
 tions from the Test-types of Jaeger and Snellen. In one large and very handsome 
 octavo volume of 900 pages. (In Press.) 
 
 ROWNE [EDGAR A.), 
 
 Surgeon to the Liverpool Eye and Ear Infirmary, and to the Dispensary for SMn Diseases. 
 
 HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 
 
 structionsin Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- 
 tions. In one small volume royal l2mo. of 120 pages: cloth, $1. (Now Ready.) 
 
 B 
 
 LAURENCE'S HANDF-BOOK OF OPHTHALMIC 
 SURGERY, for the use of Practitioners. Second 
 edition, revised and enlarged. With numerous 
 illustrations. In one very handsome octavo vol- 
 ume, cloth, $2 75. 
 
 LAWSON'S INJURIES TO THE EYE, ORBIT, 
 AND EYELIDS: their Immediate and Remote 
 Effects. With about one hundred illustrations. 
 In one very handsome octavo volume, cloth, 
 *3 50. 
 
30 Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence). 
 
 J^URNETT {CHARLES H.), M.A., M.D., 
 
 -U Aural Surg to the Presb. Hosp., Surgeon-in-iharge of the Infir . for Dis . of the Ear, Phila. 
 
 THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. 
 
 A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
 some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, 
 $5 50 ■ half Russia, $6 00. {Now Ready.) 
 Recent progress in the investigation of the structures of the ear, and advances made in the 
 modes of treating its diseases, wouldseem to render desirable a new work in which all the re- 
 sources of the most advanced science should be placed at the disposal of the practitioner. This 
 it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in 
 the special study of the subject are a guarantee that the result of his labors will prove of service 
 to the profession at large, as well as to the specialist in this department. 
 
 medical student, and its study will well repay the 
 busy practitioner in the pleasure he will derive from 
 the agreeable style in which many otherwise dry 
 and mostly unknown subjects are treated. To the 
 specialist the work is of the highest value, and his 
 sense of gratitude to Dr. Burnett will, we hope, be 
 proportionate to the amount of benefit he can obtain 
 from the careful study of the book, and a constant 
 reference to its trustworthy pages. — Edinburgh 
 Med. Jour., Aug. 1878. 
 
 The book is designed especially for the use of stu- 
 dents and general practitioners, and places at their 
 disposal much valuable material. Such a book as 
 the present one, we think, has long been needed, and 
 we may congratulate the author on his success in 
 filling the gap. Both student and practitioner can 
 study the work with a great deal of benefit. It is 
 profusely and beautifully illustrated. — N. T. Hos- 
 pital Gazette, Oct. 15, 1877. 
 
 Dr. Burnett is to be commendedfor having written 
 the best book on the subject in the English language, 
 and especially for the care and attention he has 
 given to the scientific side of the subject. — iV. J. 
 Med. Journ., Dec. 1877. 
 
 Foremost among the numerous recent contribu- 
 tions to aural literature will be ranked this work 
 of Dr. Burnett. It is impossible to do justice to 
 this volume of over 600 pages in a necessarily brief 
 notice. It must suffice to add that the boofc is pro- 
 fusely and accurately illustrated, the references are 
 conscientiously acknowledged, while the result has 
 been to produce a treatise which will henceforth 
 rank with the classic writings of Wilde and Von 
 Trolsch.— The Lond. Practitioner, May, 1879. 
 
 On account of the great advances which have been 
 made of late years in otology, and of the increased 
 interest manifested in it, the medical profession will 
 welcome this new work, which presents clearly and 
 concisely its present aspect, whilst clearly indi- 
 cating the direction in which further researehes can 
 be most profitably carried on. Dr. Burnett from his 
 own matured experience, and availing himself of 
 the observations and discoveries of others, has pro- 
 duced a work,whieh as a text-book, stands facile 
 princeps in our language. We had marked several 
 passages as well worthy of quotation and the atten- 
 tion of the general practitioner, but their number and 
 the space at our command forbid. Perhaps it is bet- 
 ter, as the book ought to be in the hands of every 
 
 J AYLOR {ALFRED S.),M.D., 
 
 Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 
 
 POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Third American, from the Third and Revised English Edition. In one 
 large octavo volume of 850 pages; cloth, $5 50; leather, $6 50. {Just Issued.) 
 
 The present is based upon the two previous edi- 
 tions ; "but the completeievision rendered necessary 
 by time has converted it into a new work." This 
 statement from the preface contains all that It is de- 
 sired to know in reference to the new edition. The 
 works of this author are already in the library of 
 every physician who is liable to be called upon for 
 medico-legal testimony (and what one is not?), so that 
 all that is required tu be known about the present 
 book is that the author has kept it abreast with the 
 times. What makes it now, as always, especially 
 valuable to the practitioner is its conciseness and 
 practical character, only those poisonous substances 
 
 being described which give rise to legal investiga- 
 tions.— The Clinic, Nov. 6, 1876. 
 
 Dr. Taylor has brought to bear on the compilation 
 of this volume, stores of learning, experience, and 
 practical acquaintance with his subject, probably far 
 beyond what any other living authority on toxicol- 
 ogy eould have amassed or utilized. He has fully 
 sustained his reputation by the consummate skill 
 and legal acumen he has displayed in the arrange- 
 ment of tiie subject-matter, and the result is a work 
 on Poisons which willbeindispensable to every stu- 
 dent or practitioner in law and medicine. — The Dub- 
 lin Journ. of Med. Set., Oct. 1875. 
 
 B 
 
 T THE SAME AUTHOR. 
 
 MEDICAL JURISPRUDENCE. 
 
 by John J. Reese, M.D., Prcf. of Med. 
 octavo volume of nearly 900 pages. Olo 
 
 To the members of the legal and medical profes- 
 sion it is unnecessary to say anything eommenda- 
 tory'of Taylor's Medical Jurisprudence. We might 
 as well undertake to speak of the merit of Chitty's 
 Pleadings.— Chicago Legal News, Oct. 16, 1873. 
 
 It is beyond question the most attractive as well 
 as most reliable manual of medical j urisprudence 
 published in the English language.— Am. Journal 
 of Syphilography, Oct. 1873. 
 
 It is altogether superfluous for us to offer anything 
 in behalf of a work on medical j urisprudence by an 
 author who isalmost universally esteemed tobe the 
 
 Seventh American Edition. Edited 
 
 Jurisp. in the Univ. of Penn. In one large 
 th, $5 00; leather, $6 00. {Lately Issued.) 
 best authority on this specialty inour language. On 
 this point, however, we will say that weeonsiderDr. 
 Taylor to be the safest medico-legal authority to fol- 
 low, in general, with whieh we are acquainted in any 
 language. — Va. Clin. Record, Mov. 1873. 
 
 This last edition of the Manual is probably the best 
 of all, as it contains more material and is worked up 
 to the latest views of the author asexpressedin the 
 last edition of the Principles. Dr. Reese, the editor 
 of the Manual, has done everything to make his 
 work acceptable to his medical countrymen. — N. Y. 
 Med. Record, Jan. 15, 1874. 
 
 JDY THE SAME AUTHOR. 
 
 THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 
 
 DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 
 
 volumes, cloth, $10 00 ; leather, $12 00 
 This great work isnow recognized in England as the fullest and most authoritative treatise on 
 every department of its important subject. In laying it, in its improved form, before the Amer- 
 ican profession, the publisheis trust that it will assume the same position in this country. 
 
Henry C. Lea's Son & Co.'s Publications — (Miscellaneous). 31 
 -ROBERTS {WILLIAM), M.D., 
 
 J-*> Lecturer on Medicine in the Manchester School 0/ Medicine, etc. 
 
 A PRACTICAL TREATISE ON URINARY AND RENAL DIS 
 
 EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third 
 American, from the ThirdRevised and Enlarged London Edition. In one largt and 
 handsome octavo volume of over 600 pnges. Cloth, $4. {Just Ready.) 
 
 rPHOMPSON {SIR HENRY), 
 
 J- Surgeon and Professor of Clinical Surgery to University College Hospital. 
 
 LECTURES ON DISEASES OF THE URINARY ORGANS. With 
 
 illustrations on wood. Second American from the Third English Edition. In one neat 
 octavo volume. Cloth, $2 25. {Just Issued.) 
 
 T> Y THE SA ME A UTHOR . 
 
 ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 
 
 THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
 third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
 ( Lately Published.) 
 
 rpUKE {DANIEL HACK), M.D., 
 
 JL Joint author of ' ' The Manual of Psychological Medicine" &c. 
 
 ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 
 
 THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
 Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. {Lately Issued.) 
 
 -DLANDFORD {G. FIELDING), M.D., F.R.C.P., 
 
 JLJ Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 
 
 INSANITY AND ITS TREATMENT: Lectures on the Treatment, 
 
 Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
 
 United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
 
 handsome octavo volume of 471 pages ; cloth, $3 25. 
 
 It satisfies a want -which must have been, sorely actually seen in practice and the appropriate treat- 
 
 feltbythebusygeneralpractitionersof thiscountry. ment for them, we find in Dr. Blandford's work a 
 
 It takes the form of a manual of clinical description , considerable advance over previous writings on the 
 
 ofthe various forms of insanity, with a description! subject. His pictures of the various forms of mental 
 
 of the mode of examining persons suspected of in- 1 disease are so clear and good that no reader can fail 
 
 sanity. We call particular attention to this feature 
 of the book, as givingit a unique value to the gene 
 ral practitioner. If we pass from theoretical conside 
 rations to descriptions ofthe varieties of insanity a; 
 
 to be struck with their superiority to those given in 
 ■>idinary manuals in the English language or (sofar 
 as our own reading extends jin any other. — Londor* 
 Practitioner, Feb. 1S71. 
 
 TEA {HENRY C). 
 
 SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 
 
 LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised 
 
 and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
 
 $2 50. {Just Ready.) 
 
 This valuable work is in reality a history of civi- 1 more accurate than either of the preceding, but, 
 
 lizatioa as interpreted by the progress of jurispru- | from the thorough elaboration is more like a har- 
 
 dence. ... In " Superstition and Force*' we have i monious concert and less like a batch of studies. — 
 
 a philosophic survey of the long period intervening j The Nation, Aug. 1, 187S. 
 
 between primitive barbarity and civilized enlight- I Manv will b8 tempted to say that this, like the 
 enment. There is not a chapter m the work that «i)eelineandFall,"isone of the uncriticizable books 
 should not be most carefully studied, and however Its fac ts are innumerable, its deductions simple and 
 well versed the reader may be in the scieace of iQev itable, and its ohevaux-dt-frise of references 
 jurisprudence he will find much in Mr. Lea's vol- • bristling and dense enough to make the keenest, 
 ume of which he was previously ignorant. The > 8toutes t and best equipped assailant think twice 
 book is a valuable addition to the literature of j betore advancing. Nor is there anvthing contro- 
 social science.- Westminster Review, Jan. 1880. j versial in it t0 pl . ovoke assault. The author is no 
 The appearance of a new edition of Mr. Henry C. polemic. Though he obviously feels and thinks 
 Lea's "Superstition and Force" is a sign that our , strongly, he succeeds in attaining impartiality. 
 highest scholarship is not without honor in its na- j Whetr. er looked on as a picture or a mirror, a work 
 tire country. Mr. Lea has met every fresh demand I such as this has a lasting value. — LippincotVs 
 for his work with a careful revision of it, and the \ Magazine, Oct. 1S7S. 
 present edition is not only fuller and, if possible, | 
 
 Jf 7 THE SAME A UTHOR. {Lately Published.) 
 
 STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
 PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large 
 royal 12mo. volume of 516 pp.; cloth, $2 75. 
 The story was never told more calmly or with , has a peculiarimportanceforthe English student, and 
 greater learning or wiser thomght. We doubt, indeed, 1 is a chapter on Ancient Law likely to be regarded as 
 if any other study of this fieldcan be compared with ; final. We can hardly pass from our mention of such 
 this for clearness, accuracy, and power. — Chicago j works as these — with which that on "Sacerdotal 
 Examiner, Dec. 1870. Celibacv' - should be included — without noting tbe 
 
 Mr. Lea's latest work," Studiesin Church History." literary phenomenon that the head of one ofthe first 
 fully sustains the promise of the first. It deals with I American houses is also the writer of some of its most 
 three subjects— the Temporal Power, Benefit of j original books.— London Athenceum, Jan. 7, 1871. 
 Clergy, and Excommunication, the record of which I 
 
32 
 
 Henry C. Lea's Son & Co.'s Publications. 
 INDEX TO CATALOGUE. 
 
 American Journal of the Medical Sciences 
 Allen's Anatomy ..... 
 Anatomical Atlas, by Smith and Horner 
 Ashton on the Rectum and Anns 
 Attfield's Chemistry .... 
 Ashwell on Diseases of Females 
 *A.shhurst's Surgery .... 
 Browne on Ophthalmoscope . 
 Bro"wne on tbe Throat .... 
 *Bur«iett on the Ear .... 
 *3arnes on Diseases of Women . 
 Barnes' Midwifery .... 
 
 Bellamy's Surgical Anatomy 
 Bryant's Practice of Surgery 
 Bloxam's Chemistry .... 
 Blandford on Insanity . 
 Basham on Renal Diseases . 
 Bartholow on Electricity 
 Barlow's Practice ol Medicine . 
 Bowman's (John E.) Practical Chemistry 
 *Bristowe's Practice . 
 
 * Jumstead on Venereal 
 Bumstead and Cullerier's Atlasof Venereal 
 *Oarpenter's Human Physiology 
 Carpenter on the Use and Abuse of Alcohol 
 *Cornil and Ranvier .... 
 
 Carter on the Eye 
 
 Cleland's Dissector .... 
 Classen's Chemistry .... 
 Clowes' Chemistry . . 
 Century of American Medicine . 
 Chadwick on Diseases of Women 
 Charcot on the Nervous System . 
 Chambers on Diet and Regimen . 
 Christison and Griffith's Dispensatory 
 Churchill's System of Midwifery 
 Churchill on Puerperal Fever . 
 Condie on Diseases of Children . 
 Cooper's (B. B.) Lectures on Surgery 
 Callerier's Atlas of Venereal Diseases 
 Cyclopaedia of Practical Medicine 
 Duncan on Diseases of Women . 
 *Dalton's Human Physiology 
 Davis's Clinical Lectures 
 Dewees on Diseases of Females . 
 
 • ruitt's ModernSurgery 
 *Dunglison's Medical Dictionary 
 Ellis's Demonstrations in Anatomy 
 *Erichsen'8 System of Surgery 
 *Emmet on Diseases of Women 
 Farquharson's Therapeutics 
 Foster's Physiology . . 
 Fenwick's Diagnosis . 
 Finlayson's Clinical Diagnosis 
 Flint on Respiratory Organs 
 Flint on the Heart 
 Flint's Practice of Medicine. 
 Flint's Essays 
 ^Flint's Clinical Medicine . 
 Flint on Phthisis . 
 Flint on Percussion 
 Fothergill's Handbook ofTreatment 
 Fothergill's Antagonism of Therapeutic Agents . 
 Fownes's Elementary Chemistry 
 Fox on Diseases of the Skin 
 Fuller on the Lungs, &c. . 
 Green's Pathology and Morbid Anatomy 
 Greene's Medical Chemistry 
 
 Gibson's Surgery 
 
 Gluge's Pathoxogical Histology, by Leidy 
 
 *Gray's Anatomy^ 
 
 Galloway's Analysis .... 
 
 Griffith's (R. E.) Universal Formulary 
 
 Gross on Urinary Organs . 
 
 Gross on Foreign Bodies in Air-Passages 
 
 *3ross's System of Surgery 
 
 Habershon on the Abdomen . 
 
 Hamilton on Dislocations and Fractures 
 
 Hartshorne's Essentials ofMedicine . 
 
 Hartshorne's Conspectus of the MedicalSci 
 
 Hartshorne's Anatomy and Physiology 
 
 Hamilton on Nervous Diseases . 
 
 Heath's Practical Anatomy 
 
 Hoblyn's Medical Dictionary . 
 
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 &7 
 
 Hodge on Women .... 
 
 Hjdge's Obstetrics .... 
 
 Holland's Medical Notes and Reflections 
 
 *Ho'rnes's Surgery 
 
 Holden's Landmarks 
 
 Horner's Anatomy and Histology 
 
 Hudson on Fever .... 
 
 Hill on Venereal Diseases . 
 
 Hillier's Handbook of Skin Disease 
 
 Toaes (C, Handfield) on Nervous Di 
 
 Knapp's Chemical Technology . 
 
 Lea's Superstition and Force 
 
 Lea's Studies in Church History 
 
 Lee on Syphilis .... 
 
 *Leishman's Midwifery . . 
 
 La Roche on Yellow Fever. 
 
 La Roche on Pneumonia, &c. 
 
 Laurence and Moon's Ophthalmic Su 
 
 Lawson on the Eye 
 
 Lehmann's Physiological Chemistry 
 
 Lehmann's Chemical Physiology 
 
 Ludlow's Manual of Examinations 
 
 Lvons on Fever .... 
 
 Medical News and Abstract 
 
 Morris on Skin Diseases 
 
 Meigs on Puerperal Fever . 
 
 Miller's Practice of Surgery 
 
 Miller's Principles of Surgery . 
 
 Montgomery on Pregnancy 
 
 Nettleship's Ophthalmic Medicine 
 
 Neill and Smith's Compendium of Med 
 
 Obstetrical Journal 
 
 Parry on Extra-Uterine Pregnancy 
 
 Pavy on Digestion 
 
 *Parrish's Practical Pharmacy . 
 
 Pirrie's System of Surgery . 
 
 *Playfair's Midwifery . 
 
 Quain and Sharpey's Anatomy, by L 
 
 *Reynolds' System of .Medicine . 
 
 Richardson's Preventative Medicine 
 
 Roberts on Urinary Diseases 
 Ramsbotham on Parturition 
 
 Remsen's Principles of Chemistry 
 
 Rigby's Midwifery 
 
 Rodwell's Dictionary of Science . 
 
 Stimson's Operative Surgery 
 
 Swayne's Obstetric Aphorisms . 
 
 Seiier on the Throat 
 
 Sargent's Minor Surgery 
 
 Sharpey and Quain's Anatomy, by Le 
 
 Skey's Operative Surgery . 
 
 Slade on Diphtheria 
 
 Schafer's Histology 
 
 *Smith (J L.) on Children . 
 
 Smith (H. H.) and Horner's Anatomica 
 
 Smith (Edward) on Consumptio 
 
 Smith on Wasting Diseases in Children 
 
 *S'till6's Therapeutics . 
 
 *Stille & Maisch's Dispensatory 
 
 Sturges on Clinical Medicine 
 
 Stokes on Fever . 
 
 Tanner's Manual of Clinical Medicine 
 
 Tanner on Pregnancy . 
 
 Taylor's Medical Jurisprudence 
 
 Taylor's Principles and Practice of Med 
 
 Taylor on Poisons 
 
 Tuke on the Influence of the Mind 
 
 *Thomas on Diseases of Females 
 
 Thompson on Urinary Organs 
 
 Thompson on Stricture . 
 
 Todd on Acute Diseases 
 
 Woodbury's Practice . 
 
 Walshe on the Heart . 
 
 Watson's Practice of Physic 
 
 Wells on the Eye .... 
 
 West on Diseases of Females 
 
 West on Diseases of Children 
 
 West on Nervous Disorders of Childre 
 
 Williams on Consumption . 
 
 Wilson's Human Anatomy . 
 
 Wilson's Handbook of Cutaneous Medicin 
 
 Wohler's Organic Chemistry 
 
 Winckel on Childbed . 
 
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 Books marked * are also bound in half Russia. 
 
 HENRY C. LEA'S SON & CO.— Philadelphia.