Qass. Book. COPYRIGHT DEPOSIT ON THE DISEASES INFANTS AND CHILDREN. BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., HON-. FELLOW OF THE COLLEGE OF PHYSICIANS, IRELAND J HON. MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY, ETC. ETC. SECOND AMERICAN EDITION, ENLARGED AND REVISED BY THE AUTHOR. EDITED WITH ADDITIONS, WILLIAM Y. KEATING, M.D., A.M., PHYSICIAN TO ST. JOSEPH'S HOSPITAL; LECTURER ON OBSTETRICS AND DISEASES OF WOMEN IN THE PHILADELPHIA MEDICAL ASSOCIATION ; PHYSICIAN TO ST. JOSEPH'S ASYLUM FOR ORPHANS ; FELLOW OF THE COLLEGE OF PHYSICIANS ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. ETC. ETC. PHILADELPHIA: B L A N CHARD AND LEA. 1856. to Entered according to the Act of Congress, in tlie year 1856, by BLANCHARD AND LEA, in the Clerk's Office of the District Conrt for the Eastern District of Pennsylvania. PHILADELPHIA : T. K. AND P. G. COLLINS, PRINTERS. TO ROBERT M. HUSTON, M. D., ISAAC HAYS, M. D., AND GEORGE- SHATTXJCK, Jun., M. D., THIS WORK IS DEDICATED, AS AN EXPRESSION OF THE HIGHEST ESTEEM FOE THEIR PERSONAL FRIENDSHIP AND PROFESSIONAL ATTAINMENTS. PKEEACE AMERICAN EDITOR. The American Publishers having confided to my care the Author's revised copy of the present work, I have bestowed every attention in the revision of the press to secure accuracy. The difficulty of this has been much enhanced by the fact that a large portion of the work was in MS. The extent of the additions made by Dr. Churchill is manifested by the increase of a hundred pages in the volume, notwithstanding an enlargement in the size of the page ; and the special reference which he has made to American authorities, with a view of adapting the work to the wants of American practitioners, has rendered unnecessary many additions from me. Such as I have considered advisable have been generally introduced in brackets, to distinguish them from the text. In its present improved form, the work can hardly fail to maintain the high reputation previously acquired. Philadelphia, 111 South 4th Street, July, 1856. AUTHOR'S PREFACE SECOND AMERICAN EDITION In preparing this Edition for the press, I have endeavored carefully to add all the information we have derived from recent researches. I have gone over every paragraph, with a view to correct any inaccuracy and to remedy any indefiniteness of expression. I have cautiously weighed every suggestion made by those who have reviewed the work, and where these seemed to me to be correct, I have adopted them, and made the requisite alterations, and I have added several entire new chapters, as well as portions of chapters, so that I hope that the work may be deemed more worthy of the kindness it has received at the hands of my American brethren, to whom once more I desire to offer my sincere thanks for the welcome they have accorded to this, as well as my other volumes. 15 Stephen's Green, North Dublin, February, 1856. PREFACE It is with much gratification that I acknowledge this volume to owe its existence to the solicitations of my excellent American publishers. After making a considerable collection of works on Diseases of Chil- dren, I had laid them aside, hopeless of accomplishing the task of writing the work I had contemplated ; but it was impossible to decline an invitation so flattering, from a country which had shown so much indulgence to my former works. I have, therefore, in such leisure as I have been able to command during the last three years, written this volume, not as the exponent of my own experience alone, but as embracing the information recorded by all the authors within my reach, of which I have freely availed myself ; and, if it prove useful and acceptable to my American brethren, I shall be richly repaid. There is one portion of the history of infantile diseases which has hardly received the attention it deserves. I allude to the secondary diseases ; those which occur in the course of other disorders, and are, in some intimate but obscure way, connected with them almost in the relation of cause and effect. They complicate, and often confuse the symptoms of the primary affection, always seriously increase its danger, and often render it hopeless of cure. Their early detection, or what is far better, their anticipation and prevention, forms a very important part of the physician's duty; and I have endeavored, as far as I could, to facilitate this object by carefully noticing both the complications to which each disease is liable, and the primary disorders to which it may become secondary. Another point of great importance, in the treatment of the diseases of children, is to observe and remember the prevailing epidemic, or the atmospheric constitution of the time. All diseases are more or less thus modified, and with children this is very remarkable, not merely as regards the symptoms, but the treatment also. Without a careful attention to this matter, we shall often aggravate, instead of relieving the condition of the child. X PREFACE. I have found it extremely difficult to lay down minute and specific plans of treatment for individual cases, or for the various modifications of disease ; and, I fear, in this respect, my book may be thought defi- cient. I have, however, always indicated the principles, which must guide us in the management of the disorder ; and I have preferred leaving their adaptation to the sagacity and judgment of the practi- tioner. I have sought information wherever I had reason to believe it was to be found ; I have consulted all the authorities within my reach, and have carefully referred to those from whom I have quoted, but yet I fear that many faults, both of omission and commission, will be observ- ed. In these, I must request the indulgence of the reader, who, I hope, will bear in mind, that the work has been written in the midst of the distractions of professional business, or at hours which are usually devoted to rest. F. CHURCHILL. 137 Stephen's Green, Dublin, October, 1849. CONTENTS. PART 1. ON THE MANAGEMENT OF INFANCY AND CHILDHOOD. CHAPTER I. PAGE PRELIMINARY OBSERVATIONS ON THE MANAGEMENT OF INFANCY AND CHILDHOOD. 15 CHAPTER II. MANAGEMENT OF THE INFANT AT BIRTH. . . .32 Dress Sleep Medicine CHAPTER III. THE FOOD OF INFANCY AND CHILDHOOD. CHAPTER IV. CLEANLINESS. CHAPTER V. AIR AND EXERCISE. 37 52 PART II. THE DISEASES OF INFANCY AND CHILDHOOD. SECTION I. DISEASES OF THE CEREBROSPINAL SYSTEM. CHAPTER I. INTRA-UTERINE OR CONGENITAL DISEASES. Convulsions ....... Hydrocephalus ....... Absence of Brain or Skull ..... Hernia Cerebri. — Encephalocele .... Spina Bifida. — Hydrorachitis ..... . 71 . 71 . 72 . 73 75 CONTENTS. CHAPTER II. PAGE CEPHALHEMATOMA. — FRACTURES OF THE CRANIUM. . . 82 Sub-aponeurotic Cephalhematoma . . . . . .84 Sub-pericranial Cephalhematoma . . . . . .85 Sub-cranial Cephalgematoma . . . . . .87 CHAPTER III. IRRITATION OF THE NERVOUS SYSTEM. — TRISMUS NASCENTIUM. Nervous Irritation ........ 90 Trismus Nascentium. — Nine-day fits . . . . . .94 CHAPTER IV. CHOREA. — ST. VITUS' DANCE. . . . 102 CHAPTER V. CONVULSIONS. . . . .114 CHAPTER VI. ACUTE MENINGITIS. — ACUTE ARACHNITIS. — ACUTE HYDROCEPHALUS. . 134 CHAPTER VII. CHRONIC HYDROCEPHALUS. . . . 1G0 CHAPTER VIII. INFLAMMATION OF THE BRAIN. Encephalitis ......... 176 Hypertrophy and Induration of the Brain ..... 178 Ramollissement, or Softening ....... 183 Abscess of the Brain ........ 184 CHAPTER IX. TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. . 186 CHAPTER X. CONGESTION AND APOPLEXY OF THE BRAIN. . . 195 CHAPTER XI. PARALYSIS. .... 202 SECTION II. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. INTRA-UTERINE DISEASES. . . . 213 Coryza . . . . . . . . . .213 Epistaxis ......... 215 CONTENTS. Xlll CHAPTER II. PAGE SPASM OF THE GLOTTIS. — THYMIC ASTHMA. — LARYNGISMUS STRIDULUS. . 216 CHAPTER III. PERTUSSIS. — HOOPING-COUGH. . . . 229 CHAPTER IV. CROUP. — CYNANCHE TRACHEALIS. . . . 259 CHAPTER V. ATELECTASIS PULMONUM. .... 292 CHAPTERVI. BRONCHITIS. .... 300 CHAPTER VII. INFLAMMATION OF THE LUNGS. PNEUMONIA. . .315 CHAPTER VIII. PLEURISY. — PLEURITIS. .... 341 CHAPTER IX. PULMONARY PHTHISIS. .... 356 SECTION III. DISEASES OF THE HEART. CHAPTER I. MALFORMATIONS. — INTRA-UTERINE DISEASES. . . 376 Cyanosis .......... 377 CHAPTER II. INFLAMMATION OF THE PERICARDIUM.— PERICARDITIS. . „ 385 CHAPTER III. INFLAMMATION OF THE LINING MEMBRANE OF THE HEART. — ENDOCARDITIS. 397 SECTION IT. DISEASES OF THE DIGESTIVE SYSTEM. CHAPTER I. INTRA-UTERINE DISEASES.— CONGENITAL MALFORMATIONS. . . 405 XIV CONTENTS. CHAPTER II. PAGE DENTITION. ..... 416 CHAPTER III. INFLAMMATION OF THE MOUTH. — ERYTHEMATOUS STOMATITIS. . 426 CHAPTER IV. MUGUET. PSEUDO-MEMBRANOUS STOMATITIS. . . 427 CHAPTER V. APHTHAE. — THRUSH. — FOLLICULAR STOMATITIS. . . 437 CHAPTER VI. ULCERATED SORE MOUTH. — ULCERATED STOMATITIS. . . 442 CHAPTER VII. GANGRENE OF THE MOUTH. — CANCRUM ORIS. — GANGRENOUS STOMATITIS. . 446 CHAPTER VIII. TONSILLITIS. — CYNANCHE TONSILLARIS. — QUINSY. . . 460 CHAPTER IX. PAROTITIS.— C FN ANCHE PAROTIDEA. — MUMPS. . . 464 CHAPTER X. PSEUDO-MEMBRANOUS PHARYNGITIS. — DIPHTHERITE. — ANGINA PSEUDO-MEMBRANOSA. 468 CHAPTER XI. PUTRID SORE THROAT. — GANGRENOUS ULCERATION OF THE PHARYNX. . 475 CHAPTER XII. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. . . 481 CHAPTER XIII. DISEASES OF THE STOMACH. . . . 483 CHAPTER XIV. INDIGESTION. — VOMITING. — WEANING BRASH. . . 488 CHAPTER XV. GASTRITIS. — INFLAMMATION AND SOFTENING OF THE STOMACH. . 496 CONTENTS. CHAPTER X'VI. PAGE DIARRHOEA. .... 503 Cholera Infantum ........ 506 Enteritis .......... 509 CHAPTER XVII. DVSENTERY. — COLITIS. .... 521 CHAPTER XVIII. HELMINTHIASIS. INTESTINAL WORMS. . . . 530 CHAPTER XIX. I. JAUNDICE. II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. . 538 CHAPTER XX. TABES MESENTERICA. .... 545 CHAPTER XXI. PERITONITIS. .... 554 SECTION V. DISEASES OF THE SKIN. CHAPTER I. STROPHULUS. — PRURIGO. — PTTRIASIS. — ROSEOLA. Strophulus, or Red Gum . . . . ... . 567 Prurigo .......... 568 Pityriasis . . . . . . . . . 569 Roseola . . . . . . . . . . 570 CHAPTER II. HERPES. ECZEMA. — RUPIA. Herpes . . . . . . . . . .571 Eczema .......... 572 Rupia .......... 574 CHAPTER III. Impetigo . . . . . . . . .576 Porrigo, or Scald Head ........ 578 Porrigo Scutulata, or Ringworm of the Scalp ..... 578 Porrigo Favosa . . . . . . . . .583 CONTENTS. SECTION VI. ERUPTIVE FEVERS. CHAPTER I. PAGE MEASLES. RUBEOLA. — MORBILLI. . . . 589 CHAPTER II. SCARLET FEVER. — SCARLATINA. . . . 610 CHAPTER III. VARICELLA. — CHICKEN-POX.— SWINE-POX. . . 645 CHAPTER IV. SMALLPOX. VARIOLA. PETITE VEROLE, . . 649 CHAPTER V. VACCINIA.— COWPOX. .... 668 CHAPTER VI. (EDEMA OF THE CELLULAR TISSUE. — SCLEROMA. . . 677 SECTION VII. FEVERS. CHAPTER I. INFANTILE REMITTENT FEVER. . . . 684 CHAPTER II. TYPHOID FEVER. .... 695 SECTION VIII. INFANTILE SYPHILIS. . . .705 ON THE DISEASES OF CHILDREN *c. ore former may subside, but the latter generally terminate the disease fatally. The frequency of this occurrence will explain the dispropor- tionate amount of cases of convulsions in the list of mortality. In some cases the attack has terminated in a state (probably of partial asphyxia) which has been mistaken for death. Brachet mentions a child which recovered after having been abandoned as dead. Mr. North relates a similar case which occurred to Dr. Johnson ; and Bouchut refers to one in Paris : the child was put into its coffin, and placed in a " chapelle," but the next morning it was found sitting up and playing with the ornaments by which it was surrounded. I need hardly say that the stethoscope will enable us to settle this question correctly. Lastly, the intensity and frequency of the fits may augment instead of diminishing, and so terminate fatally. This, according to Brachet, " may occur in two ways, either primarily through the brain, which, being over-excited, ceases to act upon the other organs, hsematosis does not take place, and death is certain ; or primarily in the lungs, in which case respiration, impeded by the irregular and violent contractions of the respiratory muscles, is imperfectly performed; the lungs become con- gested, the blood only circulates partially through them, suffocation is threatened, and does take place if more regular efforts do not restore the respiration and circulation. Lastly, syncope may occur, and be so prolonged as to prohibit a return to life." So far, these are modifications of the ordinary kind of convulsion only. I shall notice a very curious variety, which has been called Salaam convulsions by Sir C. Clarke, and Eclampsia mutans by Mr. Newnham. It is a very rare disease. I believe Mr. West was the first in these countries to bring it under the notice of the profession. Sir C. Clarke had seen but three cases in his practice, up to 1839, and Dr. Locock only one. Mr. Newnham has published four cases 1 (including Mr. West's); another has been related by Dr. Willshire; 2 two others have been published in the London Journal of Medicine, translated from the German, 3 and two have been described by Dr. Faber. 4 A case very much resembling this affection is described by Dr. Wright, of Montreal, 5 but it appears to have been connected with catamenial disturbance. The essential symptom of the disease, is a bowing forward and down- ward of the head, so as sometimes almost to touch the knees ; at first the movement is slow, but it increases in frequency until it attains great rapidity, so much as to be repeated fifty or 140 times in succession ; when so rapid it degenerates into a mere nodding of the head. The at- tack, in some cases, is preceded by sleepiness, heaviness about the eyes, or casting them upwards. An attack not unfrequently comes on after awaking from sleep, and in other cases the child seems worn for sleep, which may be disturbed by spasms or screaming. Sooner or later other 1 British Record of Obstetric Medicine, No. 6, vol. ii. p. 3. 2 London Journal of Med., June, 1850. 3 Journal fiir Kinderkrankheiten, March, 1850. 4 Medico-Chir. Review, July, 1851. 5 British American Journal, April, 1850, p. 311. 124 CONVULSIONS. automatic movements occur, and the attack may ultimately involve general or local convulsions, paralysis or idiocy. In Dr. Newnham's first case, the child was attacked by paralysis, and her intellect became weak, but she ultimately recovered. The second case (Mr. West's) became idiotic, although the bowing ceased. In the third, there was partial paralysis of the upper extremities, with intellec- tual deficiency, and the fourth ultimately died, the attack continuing with intervals nearly to the end. In Dr. Willshire's case there was neither paralysis nor permanent in- jury to the intellect, and the patient recovered under the treatment adopted. One of the cases recorded in the Journal der Kinderkrankheiten became epileptic and semi-idiotic; the other improved under the use of iron. I shall take the liberty of giving some of Mr. Newnham's conclu- sions, as he has seen more of the disease than any other practitioner. He says : "This affection appears to be spinal in its origin; for although it will have been established by the foregoing cases that, previously to the attack, there had been some peculiar expression of the eyes, and some degree of heaviness, or of unwonted irritability, yet, as all the earlier phenomena are spinal, it must be classed as an eccentric affection; and the little disturbance of the cerebral manifestations may be explained by the reflex irritation of this morbid spinal agency which has com- menced, is proceeding, but has not reached that culminating point at which it interferes with the established harmony of the voluntary or semi-voluntary muscles. Though spinal in its origin, it will have been noticed that in every instance general convulsions will soon make their appearance, and cerebral symptoms will occur. The effect upon the manifestations of mind is most marked, consisting not in a simple arrest of development and defective nutrition, for then it would remain just as when the disease supervened, whereas it will have been seen that a desolating influence is at work; a morbid action has been established; and although this shall seem to be at rest for a time, and the mind shall grow during intervals of freedom from the attack, yet on a renewal of the distress- ing symptoms, it will be seen that the downward action is progressive, that the early sparklings of intelligence are obscured, and that the mis- chievous influence is proceeding surely, to the extinction of intellect in fully formed idiocy. " Not only have the manifestations of mind been blighted, but in many instances paralysis has been a consequence, either in the form of paraplegia or hemiplegia; the kind of paralysis therefore has not been uniform, though in some form or other, and in a greater or less degree, it has been invariable. "It is to be remarked that in each of the recorded cases, the severe attacks of the peculiar bowing have always been preceded by sleep ; they have been always noticed to occur with especial severity in the morning after the night's sleep, or after the customary morning nap. "There is evidently in this malady a family alliance with epilepsy, and hence, as has been demonstrated by the foregoing cases, it often passes into epilepsy, or some other form of infantile convulsions. Te- tanoid symptoms do also sometimes occur during its progress. CONVULSIONS. 125 "There are some differences in the phenomena described, which it would be right to notice : a. During the paroxysm the hands were closed in Nos. 2 and 3, but they were expanded in No. 4, showing, that in the former cases, irritation of the flexor muscles, in the latter of the exten- sors, was predominant, b. The throwing the head backward in No. 2, appears only to have been a consequence of muscular and general feeble- ness, whence the head, from its own weight, fell backward for the want of adequate support, c. In No. 2 the irritation of the decaying teeth seems to have been the greatest in 1843, when the peculiar bowing af- fection was relieved ; but in No. 4 the bowing affection was aggravated when teething irritation was greatest. "The fondness for music, pictures, or gay colors, has been so marked in some of the above cases, that it should be noticed, as it shows that the injurious impression has not been made upon the organs of sense, and as the judicious employment of these senses would form a most im- portant part of the future educational treatment, because affording large inlets of knowledge, and to the development of sentiment and affec- tion." 1 Mr. Newnham inclines to the opinion that the essential character of the disease is inflammatory action of a weak and strumous nature, of the membranes investing the medulla oblongata, afterwards extending to other parts. Dr. Willshire considers it probable that the disease is purely centric in its origin, having its first seat in the sensorium, or in those import- ant parts placed between the "hemispheric ganglia" and the top of the spinal cord, and afterwards in the lower or non-sensorial portion of the spinal apparatus, as proved by the general automatic movements being in some cases of a decided tetanoid character. In others these movements were distinctly epileptiform, and moreover hemiplegia has followed, the former circumstance still further indicating, as the seat of mischief, the assemblage of ganglionic centres between the cerebrum and spinal cord, whilst the latter and the supervening affection or obli- teration of the intellectual powers appears to prove the secondary in- volvement of the great hemispheric lobes. The essential peculiarity of the disease, Dr. Willshire thinks, may be some change in the circulation of the minute vessels of a scrofulous character. 155. There is a species of convulsive affection which has been de- scribed by Jadelot and Guersent, and which is deserving of notice. It is not a general convulsion, but a tonic contraction of the muscles of the upper and lower extremities. It is observed in young infants, and also in children approaching the age of puberty. The wrists and fingers be- come remarkably rigid, both being partially flexed, and when the lower extremities are also affected, they are stretched out instead of being bent. The muscles are felt to be rigid and tonic, and their outline may be distinctly traced underneath the skin. The tonic contraction may continue for hours or days, and in some cases it has lasted for years, but its duration is generally shorter. It may cease spontaneously, or under the influence of treatment, and re- 1 British Record of Obstetric Med., vol. ii. No. 6. p. 18. 126 CONVULSIONS. turn. It is seldom accompanied with disturbance of other muscles, or of the intellect, respiration or digestion. The pulse is sometimes, though rarely, contracted. It is evidently a disease of reflex irritation, and may in general be traced to a gastro-intestinal irritation of some kind, or to dentition, or to a vitiated atmosphere. It rarely terminates fatally, and in cases where an autopsy was made, neither Jadelot nor Guersent found any appreciable alteration in the brain or spinal marrow. Diagnosis. — I. From Epilepsy. A single convulsion and a single epileptic fit resemble each other so closely, that it would be difficult to point out any marked distinction ; there may be a difference in the intensity and extent of the convulsive movements ; in the sudden onset and frequency of the fits ; in the history of the case and its termination ; but time is, after all, the principal test, the course of the two diseases being very different. II. From Chorea the distinction is easy, for in it the motions are slighter, not altogether involuntary, nor accompanied by insensibility. Even at the commencement of an attack of chorea there is but little resemblance to the involuntary violent motions, partial or general, of convulsions, and there is no loss of consciousness. 156. But the diagnosis of the cause of the convulsions is of far greater importance, as Rilliet and Barthez have observed, than the differential diagnosis. Suppose we are called to a child from one to six years old, strong, and hitherto healthy, who has had a convulsion following a fright, blow, fall, indigestion, &c. The convulsion may, of course, be primary, sympathetic, or symptomatic, but upon further inquiry we find that the child was perfectly well up to the moment of the attack, that the ex- citing cause is plain, the constitution sound, the access not very violent, and that there are no other head symptoms. So far, then, the case is one of primary or sympathetic convulsions ; but further investigation proves that there is no disease of the chest, abdomen, &c, and we con- clude that the convulsions are primary or essential. But if, on examination, we discover evidences of pectoral or abdomi- nal disease, acute or of long standing, we must then infer that the convulsions are sympathetic, and we cannot be too minute in our ex- amination of all the organs in every case, as the treatment as well as the diagnosis will depend upon it. In these primary and sympathetic attacks the brain and nervous system are only in a state of sympathetic irritation, in most cases, but we cannot be quite sure of this when the fit comes on in the course of some chronic disease, as, for instance, in tuberculous affections, in which it is quite probable that the brain may be the seat of a similar deposit. Such cases render the diagnosis very difficult. After six or eight years of age, it is rather rare to find a child at- tacked with either primary or sympathetic convulsions; they are almost always symptomatic of disease of the nervous system. MM. Balliet and Barthez state that, with one exception, all the twenty-five cases of sympathetic convulsions observed by them were under seven years of CONVULSIONS. 127 age. 1 Moreover, the absence of adequate exciting causes, the freedom from organic disease of the chest and abdomen, -will exclude the pri- mary and sympathetic forms, and we shall generally be able to detect other symptoms of head disease existing at the time, and previously, in addition to the convulsions. 157. Prognosis. — The prognosis in primary convulsions will depend upon their intensity and frequency, upon the age and strength of the patient, and in some degree upon the cause ; for instance, when they arise from indigestion, cold, &c, they are less dangerous than when they are caused by a fright or wound, or any mechanical cause. If the attacks be partial or slight, with long intervals, without much acceleration of the pulse or congestion about the face and head, and with recovery of intelligence during the intervals, the child will almost certainly recover; but if they be general, with a quick pulse, great congestion, and a frequent repetition of the fit, the danger is very great. I have no doubt that Bouchut is right in stating that primary convulsions are the least fatal. Sympathetic convulsions have a more serious character, because of the complication ; the child has to contend not merely against the affection of the nervous system, but against the organic disease giving rise to it, and the danger is more than doubled. Moreover, in some complications, as in hooping-cough, for example, the original disease is a perpetually recurring cause ; each fit of coughing throws so much stress upon the brain, that the convulsions are reproduced at the very moment when they seem to have been relieved. 2 The convulsions which occur in the course of fever, and which assume, as it were, the place of delirium, are rather favorable, according to Sydenham ; and certainly those which are preceded, and perhaps caused by diarrhoea are more manageable than the other varieties of sympa- thetic convulsions. In symptomatic convulsions the prognosis is always serious, and generally unfavorable when they occur in the course of the disease of the nervous system ; less so when at the commencement. 3 Mr. North remarks, that the younger, and the more susceptible the child, the less is the danger, and also that they are less serious in girls than in boys. 158. Treatment. — In proceeding to treat a case of convulsions, we should first ascertain to which of the varieties it belongs, whether it is 1 Rilliet and Barthez, Mai. des Enfans, &c, vol. ii. pp. 274, 275. 2 " Inasmuch as convulsions are a frequent attendant on diseases of the brain, it is certainly very natural to turn our attention first to the nervous centre. It often happens, however, if much care be not taken to investigate a case thoroughly, that leeches and cold applications to the head are hastily ordered, and calomel given, when the presence of pneumonia is afterwards detected, or some cause of gastric disturbance found to exist, without due attention to which no permanent amendment can result from any treatment. Inflammations of the chest are peculiarly liable to lead into this kind of error. Their real symptoms are marked by convulsive seizures ; the medical attendant fancies on the first day that the case is one of inflammation of the brain, on the next day he thinks it must be pneumonia, and thus the uncertain diagnosis leads to vacillating treatment, and much mischief is the result." — Mauthner on Diseases of the Brain, $c, in Children, British and Foreign Review, April, 1846, p. 392. 3 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 277. 128 CONVULSIONS. primary, sympathetic, or symptomatic; we must bear in mind, also, the constitution of the child, its previous state of health, previous attacks, &c. &c. The treatment also will vary in some degree according as we are called during the fit, or during an interval. If we see the child during a fit of partial convulsions, our first duty is to remove any exciting cause which may be present. Thus, all tight bandages should be loosened, all pins removed, the dress made quite easy, and the child placed in a recumbent position, exposed to plenty of fresh air. If the gums be swollen or congested, they must be freely lanced down to the teeth, and beyond those teeth which are pressing forward. If we do not cut deeply or extensively enough, very little relief will be afforded. After this the child should have a warm bath for a few minutes, and then be carefully dried, and wrapped in a warm blanket. 159. It may be that these measures will relieve the paroxysm, but whether or not, the next question is as to the propriety of abstracting blood. Almost all writers are in favor of it, and whatever experience I have had only confirms their opinions, with very few exceptions. If the convulsion be very slight or partial, if there be no flushing of the face, no quickening of the pulse, it is probable that lancing the gums, a warm bath, and a smart purgative, may be sufficient. Again, in some cases of sympathetic convulsions, in the course of, or at the termination of other organic diseases, when the infant is much reduced, it may not be able to bear the additional loss of blood ; in such cases we must have recourse to counter-irritation. Lastly, in symptomatic convulsions, the propriety of bloodletting must be in a great measure determined by the nature and extent of the original disease. But in severe cases of primary convulsions, when the pulse is quick, the face and head flushed, and the paroxysm well marked — in sympa- thetic convulsions, at the commencement of diseases of the lungs or abdomen — in the febrile diseases of children, or during their course, if the child be strong — and in symptomatic convulsions, at the outset of cerebral disease — there is no doubt in my mind that a liberal application of leeches is of the greatest service. It is not enough to apply one or two leeches, but, e. g., to a child of a year old, six at least ought to be applied, and the bleeding stopped token the leeches detach themselves. I must strongly protest against the ordinary plan of allowing the leech- bites to bleed indefinitely; more blood is thus often lost than was intended, and it is quite impossible to form any precise estimate of the quantity desired or actually taken, unless by arresting the hemorrhage at a given time. If the convulsions return, the leeching must be repeated, nor need we fear for the child if it be strong and healthy; there is more danger of our not bleeding sufficiently than of the other extreme in these cases, especially in cases of threatened meningitis. My friend Dr. M'Donnell's child, of four months old, was attacked by meningitis ushered in by violent and almost incessant convulsions. I applied eighteen leeches in the course of twelve hours with perfect success ; the convulsions altogether ceased after the last application, and the child recovered. CONVULSIONS. 129 As to the best situation for applying the leeches, some advise the fore- head or behind the ears, others the back of the hand or foot, the ankles, or the anus. I prefer the forehead as being nearer the seat of the disease, and requiring fewer leeches to produce an equal impression, and because it is easy to stop the bleeding. North advises that " blood should be drawn from the jugular vein, or from the temples by cupping." 160. At the same time we may diminish the vascular action of the brain by the application of cold lotions or ice in a bladder. Dashing cold water upon the face will sometimes terminate the fit ; and next in efficacy to this, according to Dr. John Clarke, is the effluvia of volatile alkali plentifully inhaled. 1 For the purpose of preventing or diminishing cerebral congestion, MM. Dezeimeris and Trousseau have proposed compression of the caro- tids, and, it is said, with success. Drs. Bland and Stroehlin have published some favorable cases, 2 and Mr. North thinks favourably of it in cases of great weakness and exhaustion. Barrier, however, states that it rarely succeeds. 161. So far the remedies I have mentioned may be employed during the paroxysm ; our treatment, however, must be continued during the interval of quiet which succeeds. The repetition of leeching must be decided by the repetition of the convulsion, or the occurrence of slight convulsive twitchings, or of much starting in sleep. If these are absent, and if the infant sleep calmly, no further leeching will be necessary ; but measures must be taken to act briskly upon the bowels by means of calomel and jalap, or rhubarb, castor oil, infusion of senna, &c. Or a purgative enema may be given in order to produce the effect more quickly, or whilst the child is unable to swallow. The advantage of evacuating the bowels is twofold ; any indigestible or irritating matter is removed, and we establish a derivation from the brain. Dr. Condie speaks highly of the effects of spirits of turpentine in cases dependent upon derangement of the alimentary canal, and my own experience amply confirms his observation; combined with castor oil it acts promptly and beneficially. M. Brachet recommends calomel pretty largely; two grains every two hours. Mr. North objects to this ; but although I have not given it in the full doses recommended by M. Brachet, I have certainly found benefit from smaller ones, say half a grain three times a day, in combina- tion with as much Dover's powder, and a grain of James's powder. Next to intestinal derivatives, those applied to the surface are the most effectual. Fomentations of hot water with mustard to the feet and legs, and blisters to the neck, upon the head, or behind the ears, will be advisable. Mr. North recommends mustard sinapisms to the feet ; Sydenham a blister between the shoulders ; Dr. John Clarke one to the calves of the legs, or between the shoulders. The blister should not be applied too soon ; it will be quite time enough after the baths, leeching, and the free evacuation of the bowels ; I think also that a succession of small blisters is much preferable to one large one : 1 Commentaries on Diseases of Children, p. 109. 2 Med. Chir. Journal, April, 1839. 130 CONVULSIONS. a narrow strip may be applied across the forehead, then one behind each ear, or, if necessary, the upper part of the head may be shaved and then blistered. With children of delicate constitution, or who have been much exhausted by any cause, leeching is sometimes impossible, and then our principal reliance must be upon a succession of blisters. When the attacks are often repeated, so that the disorder becomes chronic, I have seen great benefit result from a seton of three or four silk threads in the arm, and continued for some time, particularly in the convulsions arising from dentition. An argument for the use of counter-irritation to the scalp has been derived from the fact, more than once observed, that convulsions have ceased on the appearance of an eruption of crusta lactea. Professor (Ettinger has recommended that the eruption should be produced by inoculation, but a blister will act just as effectively. M. Husson states that he has relieved convulsions by vaccination. Dr. Grantham considers non-ossification of the fontanelles as one cause of convulsions, which he proposes to remedy by compression of the head generally, with a calico bandage applied moderately tight, and he quotes one case in which he succeeded. 162. Antispasmodics of various kinds have been strongly recom- mended; by German writers camphor and valerian are especially praised, by others ether, assafoatida, musk, bismuth, ammonia, &c. Drs. Under- wood 1 and Stewart 2 speak very highly of musk given freely, that is, from half a grain to two grains every two hours. Dr. John Clarke, however, states, that he has seen no good effects from any, with the exception of ether and ammonia : " It does not appear to him that they derive any additional good quality from mixing them with assa- fcetida, valerian, castor, musk, tinctura fuliginis, amber, and other fetid substances." 3 How far the inhalation of ether in certain cases may be advantageous is as yet unknown ; I am inclined to think, however, that it might be beneficial after the removal of the exciting cause, and when the fits are not accompanied by high vascular action. I have used it in a case of convulsion complicating hooping-cough, with apparent benefit. My friend Dr. Simpson has also used it with perfect success in the case of an infant five weeks old, who had had severe convulsions for nearly a fortnight, allowing him to wake for food ; he was under its influence for nearly twenty-four hours, and emerged from the sleep per- fectly well with no return of the fits. Mr. Williamson, of Manchester, has recorded the case of an infant six weeks old, whom he kept constantly under the influence of chloroform for sixty hours, sixteen ounces having been used and with complete success. 4 Dr. Locock speaks highly of the subcarbonate of iron in cases where the child has been much exhausted by other diseases. The oxide of zinc has been much relied upon by M. Zangerl, who gives one and a half to three centigrammes every two hours ; by M. Brachet, who combines it with the extract of hyoscyamus, ten centi- 1 On Diseases of Children, p. 264. 2 On Diseases of Children, p. 493. 8 Comment, on Diseases of Children, p. 108. * Lancet, June 11, 1853, p. 535. CONVULSIONS. 131 grammes of the former and twenty of the latter in the twenty-four hours ; and by MM. Guersent, Blache, and Barrier. 163. Narcotics have been sometimes advised, but they are rarely necessary, and when given require great watchfulness in their adminis- tration ; perhaps the best mode is to combine a little Dover's powder with calomel or James's powder. Mr. North recommends Dover's pow- der when the infant is restless, with startings and twitchings. Brachet, Blundell, Condie, and others, prefer hyoscyamus, either alone or in combination. The external application of opium has also been advised. If used at all, we would begin with very small closes, watching their effects, and only increasing them very gradually. They should never be given when the pulse is full, when there is much fever, general plethora, or determination to the head. When diarrhoea is present, or when the nervous irritability is very great, I have seen them very useful. Dr. John Clarke remarks : " It requires the greatest consideration and the exercise of great circumspection to determine when and in what quantity opium may with propriety be exhibited in convulsions. It may fairly, however, be laid down as an axiom, that it should never be employed on any account, until it is clearly ascertained that no danger is likely to arise from pressure on the brain ; that there is not any existing inflammation of that organ ; and never until the bowels have been completely unloaded, lest the stupor arising from a com- pressed brain should be attributed to opium ; and the time when alone relief could have been given in inflammation of the brain should be allowed to pass by, never to be recalled. When the medical attendant has reason to believe that no danger is to be apprehended from any of those circumstances, opium in small doses, cautiously repeated, may be administered with advantage, and it will sometimes diminish pain by lessening the sensibility and irritability of the patient. Great care must, however, be taken, during the use of it, to keep the intestinal canal free. 1 Dr. Russell, of Limerick, has mentioned to me, that he has derived great benefit from the use of prussic acid, in doses of one-twelfth of a drop every hour, and in a few cases in which I have tried it, it seemed to soothe the child and diminish the convulsion. It is particu- larly suited to cases of convulsions complicating hooping-cough. Alkaline medicines will be of service, when we are satisfied of the presence of acid in the stomach. 164. Thus we find that primary convulsions may be arrested and relieved by cold affusion, warm baths, bleeding, &c, after removing all apparent causes; that during an interval the principal remedies are, perhaps, a repetition of the bleeding, purgatives, counter-irritation, anti- spasmodics, and narcotics; and that in a chronic state of the disease, when the fits are repeated, great benefit is derived from a permanent drain upon the constitution. But a little deviation from the ordinary treatment is often advisable. When the patient is delicate and weakly, or run down from other dis- eases, it may be necessary to give tonics and stimulants: Barrier and others speak highly of ammonia. In some cases we are obliged to give 1 Comment, on Diseases of Children, p. 108. 132 CONVULSIONS. wine, with great caution, however, and nourishing diet ; in other cases a change of air is highly beneficial, or, if the infant be suckling, a change of nurse : this is strikingly the case when hooping-cough is complicated with convulsions. In sympathetic convulsions, the treatment of the secondary affection must necessarily in a great measure depend upon the state of the pri- mary disease and the condition of the child. In the majority of cases we shall have to content ourselves with measures of less activity, such as counter-irritation, cold to the head, antispasmodics, &c; leeches or cupping will only be admissible in few cases. But as a compensation, we shall generally find that the remedies which benefit the original dis- ease will relieve the convulsions. In febrile diseases ushered in by fits, however, the local treatment may be pretty active. The same observations will apply to symptomatic convulsions, except those cases where the convulsion ushers in the disease, or occurs at a very early period in an inflammatory affection; then, indeed, so far from diminishing the activity of our treatment, we must rather increase it. The convulsions which accompany the chronic organic diseases of the brain require delicate management, and a nice adjustment of remedies, but of these I shall speak at length when I treat of those diseases. The treatment of eclampsia nutans so far has not been satisfactory. Every species of irritation must be removed, the gums lanced, bad teeth removed, the bowels freed, the diet regulated, &c. The food should be nutritious, but unstimulating, and as far as may be of a dry character, according to Mr. Newnham. Calomel and preparations of steel seem to have been beneficial in some of Mr. Newnham's cases, and rather in- jurious in others. Prussic acid seems to have palliated the symptoms, and opium to have aggravated them. Dr. Willshire's remedies were blisters behind the ears, keeping the bowels freed by castor oil, and the internal exhibition of the iodide of potassium and the disulphate of quinine. In one of Dr. Faber's cases, purgations, baths, cold effusions, antispas- modics, embrocations, &c. ; all failed to mitigate the disease, and in the other little or no benefit was derived from frictions to the nape of the neck with tartar emetic ointment; quinine and antispasmodics, cold effusions, and warm douches seemed to do harm, but the patient improved somewhat under the use of iron. The treatment for tonic convulsions of the extremities consists of frictions and warm or vapor baths, and gentle purgatives. M. Jadelot recommends cold effusions, frictions with ether or tincture of digitalis, and internally camphor or valerian. M. Guersent advises frictions with a liniment containing laudanum, and if this fail, laudanum internally. Diaphoretics have also been recommended, and the sesquicarbonate of iron in large doses. With patients of a full habit, venesection may be necessary. Contrivances for the extension of the limbs may be tried in conjunc- tion with warm baths, emollient frictions, and in some cases they seem to have succeeded. Section of the contracted muscles has been proposed, but it seems to me a very unscientific proceeding, and I believe has not been attended with any success. CONVULSIONS. 133 165. The diet of children attacked by convulsions should in general be simple and bland; milk in any form, rice, arrowroot, &c, will be suitable and sufficient until the severity of the disease is subdued. Ani- mal food and wine should in general be prohibited, except, as I have already said, where there is great exhaustion, or in some cases of sym- pathetic convulsions, In them it may be necessary to allow a little broth. Cool, fresh air in a large room is very desirable, and in many cases assuming a chronic character a complete change of air is most beneficial. I need not dwell upon the necessity of a warm, loose dress, and the re- moval of everything which can irritate. But perhaps the most important and most neglected hygienic arrange- ment is perfect quietness; the nervous system has been so shattered that quietness is essential to its recovery, and yet if there be any im- provement the nurse and parents are so delighted, that they invariably set about amusing and exciting the child, to obtain renewed evidence of its restoration. The room should be darkened, and nothing done to excite the child; the longer it sleeps the better. 166. As to the consequences of convulsions, little direct treatment is necessary; the weakness of the limbs or of one side will in most cases gradually diminish ; gentle frictions or salt water baths may be employed, and, with country air and exercise, will generally succeed. In like manner the squinting gradually diminishes in many cases: for the more marked cases various contrivances have been proposed. Mr. North relieved it by an ivory instrument, covering each eye, and pierced with a minute aperture ; or we may sometimes succeed by tying up the sound eye, and using the distorted one. Dr. Jurin prefers the following method: "Place the child before you, and let him close the undistorted eye and look at you with the other. When you find the axis of this eye fixed directly upon you, bid him endeavor to keep it in that situation, and open his other eye. You will immediately see the distorted eye turn away from you towards his nose, and the axis of the other will be pointed at you; but with patience and repeated trials he will by degrees be able to keep his distorted eye fixed upon you, at least for some little time, after the other is opened; and when you have brought him to continue the axes of both eyes fixed upon you as you stand directly before him, change his posture; put him first to one side of you, and then to the other. When in these different situations he can perfectly and readily turn the axes of both eyes towards you, the cure is effected." 1 1 North on Convulsions, p. 215. 134 ACUTE HYDROCEPHALUS. CHAPTER VI. ACUTE MENINGITIS — ACUTE ARACHNITIS — ACUTE HYDROCEPHALUS. 167. The disease I purpose describing in this chapter has been termed by some dropsy of the brain, water in the head, internal hydro- cephalus ; by Cullen, hydrocephalic apoplexy ; by Macbride, hydro- cephalic fever ; by Bricheteau, hydrocephale aigue ; by Gardien, Capu- ron, and others, fievre cerebrale ; by Brachet, hydrocephalite ; by Rufz, Piet, Guersent, Green, Barrier, Rilliet and Barthez, &c, meningite tuberculeuse ; by the Germans, hitzige gehirnhohlenwassersucht. By whatsoever name described, and however various the theories as to the nature of the disease, it appears to me that both the symptoms and the post-mortem appearances indicate an affection of the mem- branes of the brain as the essential character of the disease, whether primary or secondary ; and as that affection exhibits evidences of inflammation or of its results, I prefer using the simple terms prefixed to this chapter. Modern writers, indeed, particularly the French, have drawn a marked distinction between acute meningitis and tubercular meningitis ; but as the distinction during life is in many cases impos- sible, and in almost all very obscure, I have thought it better to include both under the one name, and to describe them as two (out of many) phases of the same disease. 168. The earliest record of the disease is by M. Duvernay in 1701, and by Messrs. St. Clair and Paisley in 1782-3, in the Edinburgh Medical Essays. In 1768, Dr. Whyte's essay " On the Dropsy of the Brain" was published, and as a minute and accurate description of the disease, it is admirable, but his pathological reasoning is incorrect. In the same year, Dr. Fothergill and Dr. Watson read their papers on the subject to a society in London, and afterwards published them in the fourth volume of the Medical Observations and Inquiries. The former physician regarded the disease as incurable, and so would Dr. Watson but for one case of recovery, which hardly appears to have been owing to the treatment. A case of hydrocephalus internus, published by Dr. Dobson in 1775, was the first in which mercury was used, and as it was successful it made a considerable impression, and led to the general use of this remedy in the disease. As yet the theory of Whytt and others, that the effusion of fluid into the ventricles depended upon debility of the vessels, or an attenuated state of the blood, prevailed. In 1779, however, Dr. Charles Quin published an inaugural essay, founded upon information derived from his father, Dr. Henry Quin, an eminent phy- sician of this city, in which he attributed the disease to determination of blood to the brain, to increased arterial action, and effusion of fluid as a consequence. The practical result of this theory was the em- ACUTE HYDROCEPHALUS. 135 ployment of antiphlogistic remedies, as venesection and cold applica- tions to the head. In a more advanced stage of the disease he recom- mended mercury, on the principle laid down by Dobson, for the purpose of stimulating the absorbents of the brain. This essay was afterwards enlarged into a treatise. Dr. Withering, in his Account of the Fox- glove, published in 1785, agrees with Dr. Quin in regarding the disease as inflammatory, and the effusion as the consequence, not the cause, of the illness. Dr. Rush, in the Medical Observations and Inquiries for 1789, added some important information to the previous knowledge of the disease. Admitting the occurrence of primary hydrocephalus, he showed that it may be caused by other diseases ; and he carried blood- letting to a greater extent than his predecessors, even affirming that hydrocephalus may be cured by the lancet. In 1791, Dr. Perceval, of Manchester, published a valuable paper in the first volume of the Medical Tracts and Observations, containing a post-mortem examina- tion of a case in which death took place before effusion, and recom- mending the combination of opium with calomel. Dr. Garnett, in 1801, maintained that the disease consists in a plethoric state of the vessels of the brain, occasioning a considerable degree of inflammation, and generally, though not always, giving rise to effusion. In 1808, Dr. Cheyne's first essay was published, confirming the value of mercury in the disease, and clearly establishing the secondary character of some varieties of hydrocephalus. To this work, confessedly of very high value, I shall refer more particularly by and by. Although at this time it was pretty well agreed that the disease was inflammation, there continued to be some dispute as to its exact locality, although Briche- teau and others regarded the effusion as the principal phenomenon. Golis (1815), Piorry (1822), placed the seat in the arachnoid; Coindet in the cerebral ventricles ; Brachet in the lymphatics ; Abercrombie in the brain ; M. Senn (1825) in the pia mater, and he first applied to it the term meningitis ; M. Piorry (1823), and MM. Parent-Duchatelet and Martinet (1825), in the arachnoid. In this country and America, we have had valuable essays and monographs by J. Clarke, Monro, Duncan, Yates, Mills, D. Davis, Burnett, Griffiths, J. R. Bennett, H. Smith, &c. &c. ; and more or less space devoted to its consideration in the works of Underwood (late editions), Dewees, Burns, Maunsell and Evanson, Eberle, Stewart, Condie, Coley, and Hood. The recent com- munications to the. different periodicals will be found in Braithwaite or Banking's Retrospect, and to which I shall hereafter refer. More recently great light has been thrown upon the pathology of the disease by the valuable essays of Guersent, 1 Papavoine, 2 Fabre and Constant, Gherard, 3 Rufz, 4 Piet, 5 Green, 6 Schweninger, 7 &c, who have demonstrated the existence of tuberculous meningitis. Dr. J. R. Bennett, in his excellent treatise, gives the following statistics : Of 1,000,000 of each sex, the annual mortality by hydro- ' Diet, de Me"d., p. 392. 2 Journ. Hebdom., vol. vi. p. 113, 1830. 3 American Journal of Medical Science, April, 1834. 4 Thesis, 1835. 5 Thesis, 1836. . 6 Lancet. 7 Ubsr Tuberculose als die gewohnlichste Ursache der Hydrocephalus acutus. 136 ' ACUTE HYDROCEPHALUS. cepalus, in 1837. was 562 males and 460 females ; in 1838 it was 574 males, and 450 females; in 1839 it was 571 males, and 439 females. In Berlin, in the year 1833, the deaths below 15 were 4,009, of which 196 were from cerebral inflammation and hydrocephalus. In 1835, the deaths below 15 were 3,477, of which 257 were from acute hydroce- phalus. Coindet states that on an average 21 children die annually in Geneva of hydrocephalus, out of a population of 22,000. Bouvier estimates that in Paris 1,000 children are attacked annually, of whom 750 die. Hasse considers that from 32,000 to 36,000 children die annually from this disease in the Prussian States, and 100,000 throughout Germany. Dr. Alison states that of 201 deaths below the age of 15, at Edin^ burgh Newtown Dispensary, 40 died of hydrocephalus ; of 1862 cases, under 7 years, at the Marylebone Dispensary, Dr. Boyd says that 67 were inflammation of the brain or membranes. At the Rains Institute for children, of 56 death 9 were from this disease. Of 62 deaths at the Bonn Chirgon, 12 were from this disease. 169. After this brief historical notice, I shall endeavor to sketch some of the various phases or forms of the disease sufficiently distinct to merit especial mention, and having corresponding pathological con- ditions. The first corresponds to the acute hydrocephalus of Golis and others, and to the " meningite simple aigue" of Barrier and Rilliet and Barthez. It is not the most common, but very far from being rare. The different stages into which authors have divided hydrocephalus are not always to be clearly distinguished in this form. Conradi and Bush made two stages ; Whytt, Cheyne, Tissot, Vanhoven, Baader, Plenck, Sprengel, &c, three; Golis four stages : but most frequently but two stages will be remarked, that of excitement and effusion. 170. In some cases a formative period may be observed, during which the child loses his spirits and cheerfulness, exhibits a distaste for his usual amusements and toys ; the eye has lost some of its lustre, the face is somewhat collapsed and pale, and there is a kind of creeping or chilliness over the body. The pulse is uncertain — sometimes quick, perhaps irregular, in other cases but little altered from its natural state. In most cases, however, the development of the disease is sudden, and marked by high fever, thirst, heat of skin generally, and particu- larly of the head, sometimes, as I have seen more than once, by a convulsion. 1 The child complains of severe pain in the head, if old enough to express its sensations; and if too young, we find it clasping its head ; or constantly raising its hand to that part ; unable to support the weight and suffering, it seeks to rest it upon something, rolling it about incessantly; or lying still, heavy, and dull, with an occasional cry of pain. In some cases the eyes have a heavy, muddy expression; more fre- quently they are bright and restless, moving quickly from one object to another, and the conjunctiva more or less injected. There is a 1 Dr. John Clarke's Comment, on Diseases of Children, p. ISO, 188Q. ACUTE HYDKOCEPHALUS. 137 peculiar stare, a wide opening of the eyes, so that the white is visible all round the iris, which I have found very characteristic of the com- mencement of meningitis. The infant is generally very wakeful, or sleeps restlessly, drowsy, but waking up suddenly, crying or screaming as if from fright ; if it sleep continuously, we may observe frequent startings and twitchings of the limbs. When awake, it is evidently oppressed, sighing, agitated, and utter- ing a cross, whining cry; complaining, if old enough, of pains in different parts of the body, about the neck, shoulders, or stomach. Dr. Mills mentions an irritative cough in the first stage. 1 Alibert adds to this an extreme difficulty of respiration, which he considers to indicate the commencement of compression. Dr. H. Smith notices this cough as occurring in all the stages ; 2 and I saw this difficulty of respi- ration precede every other symptom in one of my own children attack- ed by the disease. It was remarkable, too, that the difficulty was in expiration, not in inspiration. The stomach almost immediately sympathizes with the cerebral dis- turbance ; there is complete loss of appetite, and in almost every case vomiting, sometimes concurrently, in others alternating with the head- ache. The tongue is white and loaded, the bowels generally constipated, and occasionally most obstinate ; when they are free the stools are peculiar, greenish, tenacious, glairy, and fetid. The urine is frequently scanty and high-colored or cloudy. 171. If not at the beginning, yet before the disease has lasted long, a convulsion occurs, complete or partial, with only a temporary loss of consciousness. Generally speaking, it is not repeated until a later period of the disease, but in some severe cases I have known them to recur at short intervals. By this it may often be distinguished from the convulsions ushering in the eruptive fevers. Thus far the disease advances with different degrees of rapidity in different individuals, nay, in some cases, as Golis has remarked, there is an occasional remission, as if the child were about to recover, after which the symptoms return with greater violence. The fever rapidly becomes intense, with occasional intermissions, the heat of head is great, the headache is severe, with delirium, generally moderate, but in many cases with loud outcries, especially, as Parent- Duchatelet and Martinet have remarked, when the convexity of the arachnoid is principally affected ; 3 the head is declared to be the seat of the suffering, either by words or gestures ; and the face is pale and livid, or with a circumscribed hectic flush on one or both cheeks. The eyes are generally bright but sunk, the pupils contracted, and painfully sensitive to light, as the ears are to sound, and the whole expression of the countenance is not to be mistaken. The pulse is quick at first, then occasionally irregular, and at last intermitting ; but these changes are by no means so regular as in some of the other varieties. The respiration is at first hurried, then unequal, sometimes slow and 1 Transactions of the Association of the College of Physicians in Ireland, vol. v. p. 438. 2 On Hydrocephalus, p. 12. 3 De 1' Arachnitis, p. 207. 138 ACUTE HYDROCEPHALUS. oppressed, and ultimately irregular, a few rapid respirations being fol- lowed by an interval of rest; the accordance between the pulse and the respiration is no longer observed. The vomiting in most cases continues, and generally the constipa- tion increases. The child is restless and uneasy, seldom lying still, and awaking from sleep with loud cries, or when asleep disturbed by startings and twjtehings. 172. There is a sign which has been recorded by some American phy- sicians, which I ought to mention here, although I can give no opinion as to its precise value. I allude to the information derived from cere- bral auscultation. Dr. Fisher, of Boston, was the first to apply auscul- tation to the brain, and he published a valuable paper in the American Medical Journal. 1 He has since been followed by Dr. Whitney, 2 who certainly deserves great credit for the care and labor he has bestowed upon the subject. He describes four sounds heard in the brain in cer- tain diseases: 1. The cephalic bellows sound; 2. Cerebral cegophony; 3. Fremissement cataire, and 4. The cooing sound. The first, or bellows sound, is heard in "cerebral congestion, acute cerebral inflammation, hydrocephalus, compression of the brain, scirrhous induration with softening, ossification of the arteries of the brain, and the hydrocephaloid disease." This is the only sound with which we have to do, and its value is, of course, diminished by the extremely dif- ferent diseases in which it is heard, and occasionally by the difficulty of detecting it. Still it is a subject worthy of minute attention, and may ultimately lend important aid to the diagnosis. 173. As the disease advances, the symptoms gradually change from those of excitement to those consequent upon effusion or pressure, and earlier in those cases where the sutures and fontanelles are closed than in those where they are incomplete. 3 The headache is less complained of, although the head is still rolled about uneasily, or retracted ; the de- lirium subsides, or occurs occasionally; the sensibility of the eye is gra- dually lost, and the pupil is generally dilated, and it is evident the child can no longer see ; the eye is rolled about, turned upward, or squinting takes place; the hearing may for a time appear acute, but at length it diminishes, and the infant appears unconscious of sound ; the sense of touch remains longer than any other, and at a period of apparent in- sensibility I have noticed the child uneasy at being touched or moved. Dr. Hennis Green has noticed a temporary but firm contraction of the eyelid, which for a time prevents our exposing the eyeball. When the effusion (or pressure) is moderate, the convulsions increase in frequency, and sometimes in strength; or perhaps there may be con- vulsions of one side of the body, and paralysis of the other; when the effusion is rapid and excessive, there is often neither convulsion nor para- lysis, but coma and rapid sinking. And a new symptom is developed about this time, which adds much to the distress of the mother. I allude to the sharp, piercing scream of agony which the child utters from time to time, and which, I am sure, is the result of pressure upon some par- 1 March, 1838. 2 American Medical Journal, October, 1843, p. 282. 3 Dr. John Clarke, Commentai-ies on Diseases of Children, p. 130. ACUTE HYDROCEPHALUS. 139 ticular portion of the brain, and not of pain, as the face at the time is not expressive of suffering. This peculiar hydrocephalic scream, which occurs in no other disease, and not in every case of this, has been noticed by almost all writers, but they differ as to the time when it ap- pears. Some, as Stewart and Conclie, place it during the inflammatory stage, others at a more advanced period, at the commencement or after the occurrence of effusion. My own experience confirms the latter view. 174. During the intervals of the convulsions, consciousness and sensi- bility diminish until they are finally lost. Sometimes local spasms occur ; I have seen well-marked spasm of the glottis and crowing inspiration. The child now lies quiet, occasionally moving the head, or throwing about an arm or leg unconsciously; the eyes are open or only half closed, and acquire a glazed appearance, with mucus at the corners of the eyelids ; the face is pallid, sometimes waxlike, without expression; sometimes sunken and anxious, as representing the last conscious feeling. The vomiting rarely continues; the bowels are sometimes evacuated uncon- sciously, generally confined ; the urine may accumulate or be passed at long intervals, and the belly is sunk, concave. The attack terminates by a convulsion, or in coma. The duration of this form of the disease varies from thirty-six hours to ten or twelve days, rarely so much as the latter; it is much more rapid than most of the other varieties of meningitis. 175. II. Dr. Monro has described a variety of the disease, which he calls "the most acute species of hydrocephalus," and which differs from the foregoing, especially in its commencement : "It begins," says the professor, "like the croup. The child awakes in the night, in a state of extreme agitation, and much flushed, and with a quick pulse; he is hoarse, and the sound of his voice, when he inspires, is similar to that in croup; the sound seems to come from a brazen tube which is con- tracted at a certain part." 1 This croupy breathing, in a case he relates, was changed for asthmatic respiration, and the little patient gradually gave evidence of cerebral disease — high fever, quick pulse, partial con- vulsions, dyspnoea, squinting, and insensibility. On dissection, besides serum in the ventricles and spinal canal, and gelatinous effusion on the upper surface of the brain, "the eighth pair of nerves was of a deep, uniform red color along its whole tract, as far as its branches going to the lungs." 2 Dr. Monro believes that the peculiarity of this case de- pended upon the state of the eighth pair, as he has found an analogous condition in patients affected in the same way. Professor Burns has noticed a similar deviation from the ordinary form of hydrocephalus, and attributes it to the same cause. It is very rapid in its progress, and proves fatal in three, four, or five days. 176. in. The next phase or form of the disease is much more frequent than the first ; it is more deliberate in its commencement and progress, though probably not less fatal. The stages, too, are much more marked, although the irregularities are so frequent that any arrangement based upon them has but comparatively little value. The child in this case usually exhibits evidences of deranged health 1 On the Morbid Anatomy of the Brain, p. 70. 2 Ibid. 140 ACUTE HYDROCEPHALUS. some time before the characteristic symptoms appear. The appetite may have been lost ; the tongue is generally whitish, often loaded ; the bowels relaxed or constipated, with erratic pains in different regions. Occasionally, there is some complaint of headache, a crick in the neck, or the child in walking is observed to be more feeble on one leg than the other, or to drag one leg. These symptoms may excite little atten- tion at first ; but they will be found to be accompanied with disturbed temper, indifference or irritability, languor, pale countenance, occasional chills, and other indications of ill health. In cases where hydrocephalus is secondary to organic diseases of the lungs or intestinal canal, the symptoms of these diseases will mask those of the beginning of the former until their full development. 177. In ordinary cases, Dr. Golis thus states the symptoms of tur- gescence, or of the first stage: "Indifference succeeding to increased sensibility and irritability ; a constipated state after habitual looseness or diarrhoea ; a scanty, unusually yellow urine, with or without sedi- ment; dryness of the skin, which previously, on the slightest exercise, even on eating and drinking, and particularly during sleep, perspired profusely; sleep without medicine often suddenly occurring in restless children ; remarkable gravity and earnestness, which had never been previously noticed. These, taken together with the symptoms, are the signs by which the turgescence of hydrocephalus may with great justice be suspected." 1 In the majority of cases, the child complains of headache, or, if an infant, gives signs of it by putting its hands to its head, rolling it uneasily about, and being unable or unwilling to support it. To this succeeds vomiting of ingesta, and of bilious or greenish matter ; the child becomes dull and heavy, complaining of weariness, disliking the light, and sensitive to noise ; often in the dark seeing flashes of light, and having the pupils contracted, giving a sharp expression to the eye. As I have remarked, the tongue is white and loaded, the bowels sometimes free, but often confined ; the stools are clay-colored at first, but afterwards of a green color, like chopped spinach, and of a gelati- nous consistence, or in some cases resembling tar, and with a peculiar smell, compared by Dr. Cheyne to the " smell of the breath in the beginning of some of the exanthemata." The child sometimes com- plains of pain in the bowels. The pulse varies a good deal ; in some cases, it remains long unal- tered, in others it is permanently quick, in others sometimes slow and sometimes quick. Dr. Whytt states, as I have already mentioned, that it is quick in the first stage, irregular and quick in the second, and intermitting in the third; but Dr. Cheyne seldom observed this regular division. In some cases, no doubt, it exists ; in many, it is certainly absent. 178. Thus the disease may go on for some days, without any very marked change, but by degrees we may perceive the child getting worse. Febrile paroxysms are observed, with heat of skin, thirst, quicker pulse, rapid respiration, and a bad smell from the breath. 1 On Water in the Head, p. 15. ACUTE HYDROCEPHALUS. 141 The countenance becomes altered, thin, and pale, with a peculiar expression, as Sprengel has observed; in some cases, it is oedematous. Portenschlag remarks that the glance, the features and complexion, the voice, the movements, the actions and sentiments of patients in acute hydrocephalus, if they have been known to the physician before the commencement of the disease, are very different to what he remembers in health. 179. The headache and heat of head may continue or diminish; and there may, perhaps, be some delirium, but it is not so loud or violent as in the first species. The vomiting continues, especially in the upright position ; the bowels are generally torpid, although we see occasionally an attack of bilious purging; the region of the stomach and liver is often tender on pressure; and the belly is concave and not tumid. The urine is scanty, and frequently voided, generally with sediment ; some- times, as Coindet observed, with a white micaceous sediment. The senses, which were morbidly sensitive, and the intellect, which may have at first been unusually active, gradually lose their power, and the child becomes dull and stupid. He lies more quietly in bed, throw- ing his head back, and moving about the legs, and picking his nose and ears, or rather thrusting his fingers into his nostrils or ears. He becomes greatly emaciated, the skin hangs about his arms and legs, the pulse increases in quickness and irregularity, the respiration is more interrupted by sighing, and very decided symptoms of pressure show themselves in the form of twitchings, starting, screaming, and partial or complete convulsions, with insensibility, glazed eye, squinting, &c. The conjunctiva frequently becomes highly injected with an unusual puriform secretion ; and Dr. Stoben, of Strasburg, has remarked a semilunar yellow speck at the lower margin of the cornea without undue vascularity, but which became an ulcer if the case were protracted. Drs. Cheyne and Golis remarked, in several instances, a temporary restoration of intellect before death. This condition may continue for some days, with but little variation, until at length it is terminated by a convulsion or coma. 180. The duration of this form of disease is greater than the former. Perceval, Fothergill, and Vanhoven say from fourteen to twenty-one days; Golis from thirteen to twenty-four days; Dr. Cheyne that it is almost always over in three weeks ; Dr. Whytt that it lasts four, five, or six weeks. Peter Frank saw a case last six weeks ; Drs. Letl and Adelt more than two months. This form of meningitis, which corresponds with Dr. Cheyne's first species, 1 will, with some little modification, apply to those cases in which the meningitis occurs in the course of measles, scarlatina, or infantile remittent, or when it is secondary to disease of the bowels or liver. In most cases it terminates fatally, but in cases of recovery Dr. Cheyne remarked the occurrence of large bilious stools, an increased flow of urine, or an abundant perspiration. 181. IV. Dr. Brockman has described, under the term meningitis en- cephalica, a species of local meningitis in which the membranes of the 1 On Acute Hydrocephalus, p. 2. 142 ACUTE HYDROCEPHALUS. pons Varolii and medulla oblongata are chiefly affected. I quote the following description from Dr. Condie's excellent work: "It is some- times associated with general disease of the brain ; at others it is uncom- plicated. Notwithstanding in its earlier stages it is unattended by any serious symptoms, it is an affection fully as dangerous as cerebral meningitis. The first stage, or that of simple hypersemia, generally continues for one or two days. The child is dull and heavy, and the occiput is often hot ; the bowels, however, are regular ; there is no vom- iting, no intolerance of light, nor any disturbance of sleep. The general dulness of the patient, and vague complaints of some uneasy sensation in the head, increase as the inflammatory stage sets in ; the heat of the occiput is augmented; the head becomes retracted, as in the ordinary cases of acute meningitis; and convulsive twitching of the limbs occur, similar to the effects of slight electric shocks, which recur every few minutes while the patient is awake, but cease during sleep. The general febrile symptoms continue during the third stage; the pulse, however, diminishes in frequency and fulness, but does not become eicher irregular or intermittent. The general disquietude of the child subsides by de- grees into a comatose condition, in which the head becomes still more retracted, but unattended with strabismus or any morbid condition of the pupil: the peculiar air of stupidity which characterizes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of effusion. One of these is deafness, the other is difficult articulation and difficulty in moving the tongue, both of which occur at the same time, probably from paralysis of the motor nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; sometimes they are first observed upon the child awak- ing from a quiet sleep. They are, according to Dr. Brockman, the earliest and most certain indications of the occurrence of effusion. This stage continues sometimes for three, sometimes for fourteen days. Its termination is in fatal paralysis, the occurrence of which is often pre- ceded by various singular nervous phenomena, as sudden pauses in the respiration, or equally sudden syncope. In some cases, however, the paralysis does not follow, but the anomalous symptoms subside, and the patients gradually recover. Until, indeed, the paralytic stage is fully established, the recovery of the patient is still possible. "In the uncomplicated cases of the disease, upon examination after death, the cerebrum in general presents an extremely pallid and anae- mic condition, in striking contrast with the cerebellum, the vessels of wdiich are turgid with blood, while its substance also is often in a state of marked hypersemia. The hyperemia also increases in intensity towards the central portions of the encephalon; and the membranes covering the pons Varolii and medulla oblongata are found in a most decided state of inflammation ; the portion of inflamed membrane is per- fectly isolated, and not more, usually, than a square inch in extent; the membrane of the cerebellum being entirely free from any indications of inflammation. There is ordinarily an effusion of a serous fluid into the subarachnoid tissue, sometimes to the extent of several ounces ; occa- sionally a gelatinous matter is effused, and in some instances the effu- sion is of a purulent character. ACUTE HYDROCEPHALUS. 148 "This form of the disease is most frequently observed in children from three to ten years of age, and who had previously enjoyed good health. "The treatment recommended by Dr. Brockman, in its first two stages, is depletion by leeches to the posterior part of the head, cold applications to the scalp, and the free administration of calomel, which latter may be continued during the stage of effusion. Here, however, it becomes necessary to support the strength of the patient ; for this purpose ammonia, is directed by Dr. Bockman, but he remarks that in some cases the administration of wine may be required. According to his experience, powerful counter-irritants, as a large blister, or the actual cautery, prove also sometimes beneficial." 1 182. v. The next form I shall describe is the tubercular meningitis of the French authors, upon which so much light has recently been thrown. According to Rilliet and Barthez, the progress of the disease corresponds pretty accurately with the three stages of Dr. Whytt : the first characterized by loss of appetite, paleness, quick pulse, vomiting, and headache; the second by a slower but irregular pulse, sleep, de- lirium, and outcries; the third, by acceleration of pulse, paralysis of eyelids, dilated pupils, convulsions, subsultus, &c. Senn and Guersent adopt these three periods: Rufz makes only two, including the two first of Whytt in one; and Piet makes none. From the researches of late years it would appear that this form of the disease is much more frequent than any other. Rufz, Piet, and Gerhard scarcely met with two cases of simple meningitis to twenty of tubercular; M. Becquerel found one case of simple meningitis in six of hydrocephalus, Barrier four in thirty. M. Guersent observes: "From the observations I have made at the hospital for many successive years, it appears that in children from two to fifteen years the proportion of simple meningitis to tubercular is as two to twelve ; after puberty simple meningitis becomes more frequent." 2 183. The disease very generally attacks a child in good health, but it may supervene in the course of some other affection, especially those of a tubercular or scrofulous character. The most common symptoms are headache, attended with vomiting and constipation, and these may be the first to attract attention ; but in some cases a series of slighter disturbances have been noticed, especially by German writers, as fan- tastic desires, caprices, uneasiness, sleepiness, giddiness, uncertain walk, quick pulse. Formey speaks of a fine dry eruption of the color of the skin, milky urine, crossness, irregular walk, nausea, vomiting, &c. I saw one case in which, before cerebral symptoms were very marked, the child was greatly distressed by optical delusions, visions of animals walking before him or around his bed. Restlessness, staring eyes, or semi-rotation of the head are also common, with heat of scalp. The appetite is not always immediately lost, nor is the thirst great until after the eighth day, although the tongue may be dry at an earlier period. 1 Condie on Diseases of Children, p. 423. ' Diet, de Mel., vol. xix. p. 411. 144 ACUTE HYDROCEPHALUS. The vomiting is sometimes very slight or not persistent, and the headache in some few cases is less remarkable. The pulse is generally quickened, and the child preserves its intelligence. The strength is but slightly depressed. As the disease advances, the vomiting continues, or perhaps increases, at first of bilious matter or of the food taken ; the pulse becomes irre- gular, whether quick or slow; the child is cross, dull, grinds its teeth, and has a frightened staring look, evidently distressed by the light. Then the respiration becomes unequal and irregular, with sighing or yawning. The face is sometimes flushed, at others pale, the eye oscil- lating or turning upwards, the expression of the face that of surprise, or wonder, or indifference, sometimes utterly smooth and without expres- sion, like a wax face. 184. Now these symptoms may last some time before the more decided symptoms of cerebral disease develop themselves. At length, however, a degree of agitation is observed, with some incoherence, either persist- ent or alternating with intervals of perfect intelligence ; an increase of somnolence, or starting, clenching the hands, the thumbs being firmly flexed inwards, and the ankles bent, and convulsions or coma. The convulsion may be general or confined to one side, the other being paralyzed. In some cases the coma comes on very gradually, in others suddenly ; the eyes become dull and glazed, the corners of the eyelids encrusted, and the nares dry. The bowels, at first constipated, are afterwards much relaxed, and the stools green and glairy. Occasion- ally the jaws are firmly closed, the trunk rigid, the pupils dilated, or one dilated and the other contracted ; sharp cries are occasionally uttered ; the eyes squint, either divergent or convergent ; the pulse is small, quick and irregular ; the respiration irregular ; the skin is covered with cold sweat, the stools and urine are passed involuntarily, and the coma is persistent and constant. Shortly before death the face becomes red or violet, covered with sweat ; the eyes hollow and filmy ; nares dry and crusted ; respiration loud, almost stertorous; pulse smaller and weaker, with occasional convulsions, until death closes the scene. 185. The duration of this form of disease is pretty much as the last. Rilliet and Barthez have never seen death before the seventh day, but most commonly from the eleventh to the twentieth day; in some cases the patients lived sixty and sixty-seven days. Of 117 cases collected by Dr. Green, thirty-one died before the seventh day ; forty-nine before the fourteenth ; thirty-one before the twentieth ; and six after the twentieth. Of thirty cases noted by Dr. West, the average duration was twenty days and a half ; in one, death took place in five days ; in ten, before the fourteenth day ; in eleven, during the third week ; and in three, during the fourth week. 1 186. Although I have given this description of the disease with appa- rent precision, I should wish to caution my readers against supposing that they will always find the exact series of symptoms here laid down ; nothing can be more variable than they are : but, on the other hand, 1 Lectures in Medical Gazette, August 16, 1847, p. 92. ACUTE HYDROCEPHALUS. 145 there are always sufficient to show that the brain is the part affected, even in those cases related by Rush, Mills, and others, in which there was neither pain in the head, nausea, dilated pupil, nor strabismus. Moreover, it must strike every one that between several of the forms here described there is comparatively little difference of symptoms, although their succession and intensity, and duration vary a good deal, nor do I think that they will be found more unlike in practice. Every one who has seen much of this fearful disease must have been struck with the general resemblance of all cases, and yet with the infinite variations in minute points, so that it is almost impossible, in a general description, to include even the majority of cases. This must be my apology, if one be needed, for apparently multiplying the forms of the disease. I have written partly from my own experience, and partly from the works of others, most of which I have carefully consulted. 187. VI. The last form of the disease which I shall notice has been called the water stroke ; wasserschlag, by the Germans ; apoplexia hydrocephalica, by Cullen and others ; and is described by Golis, 1 but omitted by most writers. It consists in a sudden, almost instantaneous, effusion of fluid within the brain, and may occur either idiopathically or as the result of obstructed secretion from some other organ, or as a secondary affection in the course of some other disease, as smallpox, measles, or other, febrile eruptions, or on the sudden stoppage of diar- rhoea, dysentery, or profuse perspiration. Though there are evidences of inflammation occasionally found on a post-mortem examination, the suddenness and rapidity of the disease prevent the development of the usual symptoms. Those which are to be observed rather correspond to the latter stages of hydrocephalus. The child may go to bed in its ordinary state of health, or suffering from some other disease, and in the morning it may be found dead from a cause which is only detected by a post-mortem examination. Or it may suddenly be attacked by a convulsion, followed by paralysis or apparent apoplexy, with insensibility, stertorous breathing, dilated or contracted pupils, and subsultus, terminating in death after a few hours. Almost all, if not all, the patients die, and die too quickly for the employment of remedies. 188. Pathology. — It is very rarely that any pathological change is discovered in the bones of the cranium ; in one case, Rilliet and Bar- thez found some infiltration beneath the pericranium, and the coronal suture contained a small quantity of blood. The head being enlarged, the bones are more or less separated, and the sutures more widely apart than usual. The dura mater is generally injected; sometimes the sinus is filled with dark blood or gelatinous clots. The cerebral veins contain dark, solid clots. 189. The arachnoid membrane is frequently injected, either gene- rally or partially, 2 and in some parts rendered opaque ; in other cases l A Treatise on the Hydrocephalus Acutus, &c, by It. A. Golis, translated by R. Gooch, M. D., p. 5. 2 Piorry, de 1' Irritation Encephalique, p. 28. Eberle on Diseases of Children, p. 379» 10 146 ACUTE HYDROCEPHALUS. it is smooth and polished, but with the products of inflammation in its cavity. Occasionally thick, abundant, and inodorous pus is found, as described by Golis, Rilliet and Barthez ; or the more fluid portion being absorbed, it may lie close upon the serous tissue, and resemble false membrane very much, but it is not smooth, and it breaks up under the finger. This disposition may be either general or partial. The most common result, however, is effusion of serum. The pia mater exhibits similar appearances ; purulent matter, more or less fluid, occasionally concrete, and more frequently on its convex surface, in five out of six cases at the base, and varying in quantity in different places. M. Legendre has observed with the microscope that the pus globules are large, round, and transparent, without central nucleus. The ventricles also often exhibit marks of inflammation ; the lining membrane may be vascular and softened, and the fluid contained may be discolored or muddy ; occasionally pus, more or less fluid, is found. But more frequently the ventricles are distended, with a limpid fluid resembling serum, but which differs from serum in the proportion of its constituents. Dr. Davis says that it is " a fluid sui generis, and is the product exclusively of inflammation of the serous membranes investing the brain, and. of the vascular tissues concerned in supplying the ence- phalon with blood. This is not blood, nor serum, nor purulent matter, nor fibrin, but a fluid already stated sui generis." 1 Berzelius gives the following analysis : — Albumen 1.66 Matter soluble in alcohol with lactate of soda 2.32 Chlorides of potassium and sodium . . . 7.09 Soda 0.28 Animal matter, insoluble in alcohol . . . 0.26 Earthy phosphates 0.09 Water 988.30 1000.00 That is, the serum of the blood, diluted with about seven times its volume of pure water. 2 The quantity of this fluid varies. Whytt and Golis state it to be from two to three ounces ; Coindet, Bright, and Nasse from one to four or six ounces ; Brachet as much as twenty-four ounces ; Dr. Copland not more than eight ounces. Sometimes, however, the fluid is nearly absent. Parent-Duchatelet and Martinet state that in eight cases out of twenty-six there was scarcely a trace. Ford and Underwood make a similar observation. In some cases the fluid is present with few if any traces of inflamma- tion. These cases, however, are comparatively rare. 190. Occasionally the central portions of the brain are diseased, sof- tened, and reduced to a mere pulp ; when the effusion is considerable, the brain has a compressed appearance and the convolutions are flat- tened. The vessels of the brain are considerably congested. According to Laennec, Jadelot, Bricheteau, &c, the substance of the 1 On Hydrocephalus, Preface, p. 10. 2 Traiti de Chimie, vol. vii. p. 141. ACUTE HYDROCEPHALUS. 147 brain is very firm, and, as it were, hypertrophied, and in these cases the effusion is slight. It is very probable that in many cases the membranes of the spinal marrow may participate in the inflammatory action. In one of M. Legendre's cases there was serum containing pus globules underneath the arachnoid, and yellow purulent matter in the meshes of the pia mater ; and in six out of thirty cases of convulsions M. Billard found inflammation of the membranes of both brain and spinal marrow. 1 191. These post-mortem appearances are more or less common to all the forms or varieties of hydrocephalus I have noticed, but others are superadded in tubercular meningitis ; there we find a peculiar sticky condition of the arachnoid, and in the laminoe of the pia mater a depo- sition of tubercular matter at different points of the hemispheres, or at the base of the brain. These granulations vary in size, although they are generally small, and sometimes opaline or white, and semi-trans- parent ; in other cases gray and opaque. In most cases we find also secretion of concrete pus, or what appears to be false membrane, on some portion (generally the base) of the pia mater, which is thickened and greenish or yellowish, friable, and sometimes adherent to the brain. The central portions of the brain, the septum lucidum, &c, are also generally softened, and occasionally there is tubercular deposition in the substance of the brain and in other organs. " I found in the water-stroke," says Grolis, "the brain commonly firmer than in the acute hydrocephalus ; also the bloodvessels of the brain and its membranes less enlarged and less turgid than in the latter," and "from two to four or six ounces of turbid fluid." 192. Morbid changes in other organs are rare in any of the varieties, except when the meningeal affection is secondary. In such cases we may find inflammation or ulceration of the mucous membrane of the stomach and bowels, evidences of follicular enteritis, &c. Dr. Cheyne mentions that he found in many cases proofs of increased arterial action on the surface of the liver, that it was adherent to the peritoneum, enlarged, and studded with tubercles. M. Rilliet states that in general meningitis and meningitis of the convexity tubercles in the lungs or abdominal organs are never met with, but that in meningitis of the base alone they are : and we know that in tubucular meningitis they are uncommon in the lungs, &c. From this short statement of the morbid appearances discovered on a post-mortem examination, we may come to some conclusions as to the nature of the disease. With some exceptions, in which we find merely a collection of fluid, in each form we find traces of inflammation in the membranes of the brain, with its results in the form of serum, or pus, or lymph. In a large class of cases, in addition to evidences of inflamma- tion of the membranes and certain changes in portions of the brain itself, we have a deposition of tubercular matter, but whether the latter be the consequence of inflammation seems hardly decided as yet. Mr. Trousseau believes it to be so, but Rilliet and Barthez incline to the opposite view. M. Bouchut considers it a constitutional affection. I 1 Mai. des Enfans, p. 604. 148 ACUTE HYDROCEPHALUS. cannot resist the temptation to give the conclusion at which Dr. J. R. Bennett has arrived in his excellent work on this subject. " 1. That in many instances the disease consists simply in inflammation of the hrain and its membranes ; the symptoms and the post-mortem appearances vary- ing according as the inflammatory action is seated primarily in the sub- stances of the brain or in the meninges, and according as it is more acute or chronic ; and that in some of the more acute forms, rapidly termina- ting in death, little or no effusion may be found. 2. That in by far the largest class of cases, the disease is essentially the result of scrofulous action, and may or may not be attended by the signs of inflammation : that the most characteristic lesions in these cases are the softening of the central parts of the brain and the effusion of serum ; but that menin- gitis, chiefly of the base, is a very frequent secondary lesion, and is usually of a manifestly strumous character, and that therefore in this the largest and most fatal class, acute hydrocephalus is but a modification of scrofulous disease. 3. That there are cases, from these symptoms hardly to be distinguished from the last class, in which effusion into the ventricles is the only morbid appearance to be met with after death ; and that in these instances, the essence of the disease appears to consist in some alteration in the condition of the nervous matter, probably allied to irritation and that they may therefore be said to constitute a purely nervous variety of hydrocephalus. 4. That there is a class of cases distinct from the above, but closely allied to them, which may generally be traced to some source of exhaustion, either direct or indirect, in which the post-mortem appearances are generally indistinct and of a trifling kind, consisting for the most part of some degree of congestion of the large vessels and a little effusion of serum ; and that in some of these cases, the effusion has probably resulted from injudicious treatment had recourse to with a view to cure an imaginary inflammation : these being the cases described by Dr. M. Hall, and others, under the designation of hydrocephaloid disease." 1 198. Causes. — Age appears to have considerable influence in predis- posing to the disease, and this we should expect from the susceptibility of the brain during its growth. Certainly in these countries it is much more frequent during the first six years of life than afterwards. It is chiefly during infancy that the first or second forms I have described, are seen ; tubercular meningitis occurs both during infancy and up to ten or twelve years of age. Drs. Perceval and Coindet found it most frequent between the ages of two and seven years ; and Dr. Emerson, of Philadelphia, found that, out of 1602 cases, 1395 occurred before the fifth year, or between the ages of five and ten. Dr. Green found it more frequent between the ages of five and seven. There is some little difference in the liability of the two sexes ; rather more males than females attacked during the first six years, and fully as many females, or perhaps more, for some years subsequently. Afterwards three times as many men as women are attacked, according to Parent-Duchatelet. 1 On Acute Hydrocephalus, p. 156. ACUTE HYDROCEPHALUS. 149 The disease is more frequent in some countries than in others. Dr. Cheyne considers it more frequent in Scotland than in Ireland, and in summer than winter. I cannot, of course, say how frequent it may be in Scotland, but I have reason to believe it very frequent in this city. Dr. Steward mentions that it is a frequent disease in America ; Camper and Tissot that it is rare in Holland and Switzerland. Guersent states that tubercular meningitis is more common in summer or autumn ; Piet that it occurs more frequently in March and July. Rilliet and Barthez are doubtful whether the season makes any difference. 194. There can be little doubt that the disease is hereditary, especially tubercular meningitis, and we frequently see several children of the same family successively cut off by it ; this has been noted by almost all writers, Sauvage, Ludwig, Cheyne, Odier, Formey, Gcilis, Bouchut, &c. Dr. West mentions that " in sixteen out of twenty cases in which the health of the relatives was made the subject of special inquiry, it was ascertained that either the father, mother, aunt, or uncle, had died of phthisis." 1 Something also may be attributed to the constitution of the child. No doubt children of good constitutions, and in perfect health, may be attacked by any form of the disease ; but certainly those of leuco- phlegmatic habit, or tainted with scrofula, are especially liable ; and where there is any disposition to scrofulous tubercle, it will favor the production of tubercular meningitis. In a large proportion of cases Dr. Mills found unequivocal appearances of scrofula; and eleven out of twen- ty-two cases observed by Dr. Perceval were "decidedly scrofulous." It is a common opinion that a certain form of the head predisposes to this disease, but I have carefully watched children with large heads and prominent foreheads without finding sufficient grounds for the belief. 195. An attack, described as acute hydrocephalus by Dr. Albert, 2 is said to have prevailed as an epidemic from March to May, 1825. During this period more than 150 infants were attacked, and twenty- eight of them treated by Dr. Albert. The disease commenced by shivering; followed by heat, intense headache, vomiting, constipation, scanty urine, epigastric tenderness, &c. The child was constantly rolling the head about, the sleep was broken by starting and cries, there was delirium, oscillation of the eyeballs, and automatic movements of the extremities. The face was pale, the tongue white or brown, the mouth and nares dry, the conjunctiva injected, and the eyes intolerant of light. Afterwards the child lay still, unable to support the head, the face changed, the eyes sunk and turned upwards, the hand raised to the head, respiration labored, with deep sighs, sordes on the tongue and mouth, emaciation increasing, and the pulse small and quick generally, but occasionally slow. From this state very few recovered. I may add that it occurred as an epidemic in 1840, 1841, and 1842, 1 Lectures in Medical Gazette, July 16, 1847, p. 93. 2 Hufeland's Journal du Prat. Heilkunde, Aug., 1830. 150 ACUTE HYDROCEPHALUS. among the conscripts at Versailles, Lyons, Metz, Strasburg, Avignon, Nantz, and Poitiers. More recently it has appeared epidemically in this country, at first at Bray, Co. Wicklow, in January, 1846 ; in the South Dublin Work- house in the following months ; and in April and May in the Belfast Workhouse (as we find from a valuable paper by Dr. Mayne) ; attacking chiefly boys under twelve years of age, and proving rapidly fatal, in some cases in fifteen hours, in others in forty-eight hours, in the greater number in four days, whilst in some it was prolonged a fortnight or three weeks. There w T ere no premonitory symptoms ; it sometimes commenced by pain in the abdomen, followed by vomiting, and subse- quently by purging ; at this time the patients had all the appearance of collapse, then followed reaction, fever, quick pulse, rigidity of the muscles, those of the neck in particular, with a tetanic expression of face. Soon after severe general convulsions occurred, or a semi- comatose condition supervened, with grinding of the teeth and crying incessantly. Towards the close, this state merged into coma, with the pulse slow and labored, failure of power of speech and deglutition, and involuntary evacuations. 1 An epidemic also occurred in Milbury and Sutton, U. S., and has been recorded by Dr. Jos. Sargent, of Worcester. 2 Of 16 cases, scarcely one recovered. Death took place from the 6th to the 13th day. It was not, however, confined to children, and it is remarkable that in several cases there occurred petechias over the body. The appearances I have described presented themselves on post-mortem examination, with the exception of the deposition of tubercular matter. 196. Among the exciting causes may be enumerated milk that disa- grees with the child, mental distress in the mother or nurse, of which I have seen several examples, prolonged lactation, 3 indigestible food, the sudden suppression of an eruption on the head, retrocession of fe- brile eruptions, dentition, exposure to the heat of the sun, fright, anger, cold, blows or falls on the head. Golis mentions that children born immediately after the bombardment of Vienna, in 1809, were shortly seized with convulsions, and died : within the cranium were found traces of inflammation, and effusion of lymph and serum in the ventricles. Sir H. Halford and Dr. Abercrombie mention suppressed secretion of the kidneys as one cause. 197. Lastly, either variety may occur as a secondary disease to some other affection. Thus we may observe meningitis in the course of in- fantile remittent fever, towards the termination of measles, or scarlatina, or hooping-cough ; after a severe bowel complaint (gastro-enteritis, fol- licular enteritis, cholera infantum) or diseases of the liver, as stated by Harris, Curry, Yates, Thompson, Cheyne, &c. 4 1 Dublin Quarterly Journal of Medical Science, for August, 1846, p. 95. 2 American Journal of Medical Science, July, 1849, p. 35. 3 Observations on the healthy and diseased Condition of the Breast, Milk, &c, by Ed. Morton, M. D., p. 24. 4 Cheyne on Hydrocephalus, p. 49. Piorry de 1'IrritationEncephal., p. 52. Golis, p. 71. Eberle on Diseases of Children, p. 382. ACUTE HYDROCEPHALUS. 151 It is occasionally, but rarely, connected with bronchitis, 1 pneumonia, and phthisis. I ought to observe that in these secondary attacks there is some little difference in the symptoms : there is generally less headache and fewer premonitory symptoms ; the attack seems to come on more suddenly, often by convulsions, and the duration is less prolonged. 198. Diagnosis. — The most characteristic symptoms of the first stage, according to Dr. Mills, are, " the peculiar expression of counte- nance, indicative of oppression, pain, and despondency ; frequent sighing ; a disposition to retirement ; a heat, weight, pain, or heaviness of the head, or all these combined; waywardness and fretfulness : a low, irregular fever ; frequent nausea or retching ; an irregular state of the appetite and bowels, and the continuance of the diarrhoea," not- withstanding the remedies. The second stage is marked by " the heavy sigh, the deep moan, the wild scream, the preternatural dilatation or contraction of the pupils, imperfect or lost vision, delirium, difficult deglutition, paralysis of one hand, arm, or leg, and of the sphincters ; the head permanently bent back ; a slow, intermitting, or rapid pulse ; frequent vomiting, or convulsions." 2 M. Trousseau has pointed out two symptoms of importance in the diagnosis of meningitis ; one is a pecu- liar suspicious breathing, and the other a redness of the skin produced by the slightest friction. The former is very remarkable ; the child takes a long breath, and then remains without breathing for an irregular period of from ten to fifty seconds. I have repeatedly observed this occurrence, although not so constantly as M. Trousseau. The cutaneous phenomenon exhibits itself several days before death, and is produced even by a slight pressure of the finger : it does not appear to be con- nected with febrile action, as it is absent in many children who have high fever. There are not many diseases likely to be permanently mistaken for meningitis, nor can we easily confound a well-marked case of the latter with another disease ; but in their commencement some diseases do exhibit somewhat similar symptoms, and some cases of me- ningitis terminate like other diseases. 199. i. In cerebral congestion we have a marked series of head symptoms not unlike the commencement of hydrocephalus ; there is sleep, stupor, even coma, with agitation of the limbs, or rigidity, some- times partial paralysis ; the face sometimes flushed, or unaltered, or spasmodically twisted ; the pupils, perhaps, dilated ; pulse quick, &c. Now as meningitis may be accompanied with cerebral congestion, it is not always easy or possible to draw an accurate distinction at first ; but as the disease advances, especially if it be prolonged, we shall find considerable difference. In meningitis there is less stupor, coma does not come on until late; convulsions generally occur; the respiration and pulse are more irregular ; the face has a sunken look ; and the disease is more prolonged. ir. Erujrtive Fevers. — As these sometimes commence by convulsions and headache, with quick pulse, we may for a while be in doubt, but 1 Mills, Trans, of Association, vol. v. p. 861. 2 Transactions of Association of College of Physicians in Ireland, vol. v. p. 446. 152 ACUTE HYDROCEPHALUS. there is seldom more than one or two convulsions in such cases, and in a short time the occurrence of eruption will decide the question : the delay is of no consequence, as the treatment, so far as the head symp- toms are concerned, must be similar. III. Infantile remittent or gastric fever seldom presents sufficiently marked head symptoms, at the beginning, to be mistaken for hydro- cephalus, but towards its termination, especially when there is follicular ulceration, the aspect of the case is very similar. The stupor and in- sensibility, however, are never so complete ; remissions almost always occur ; the head is often cool ; the headache is not so acute ; there is great emaciation, but not that drawn look about the face, or its peculiar expression, or the concave condition of the belly, which is generally tumid; and we rarely have convulsions or paralysis, or even the twitch- ings, startings, and screams ; moreover, it is rare in children under four or five years of age. Of course, these observations do not apply to those cases of infantile remittent which run on into hydrocephalus. IV. Golis considers the difference between hydrocephalus and typhus fever to be marked by the shorter duration of the period of turgescence in the former, the less frequent pulse in the early period, and its irregu- larity in the latter; the marked stages; the greater sensibility of the eye and ear; the interrupted respiration; the emaciation, and the fallen state of the belly, &c. V. The fourth variety, or water-stroke, may very likely be mistaken for apoplexy, but the history of the disease, the age of the patient, &c, will correct this opinion, unless we choose to regard it as a variety of the serous apoplexy of authors, the symptoms being very similar. vi. An attempt has been made to distinguish between simple acute meningitis and tubercular meningitis, but I confess I do not think this easy, except in extreme cases. Certainly those cases of the former which commence with high fever, delirium, convulsions, and terminate fatally in two or three days, do differ widely from the gradual develop- ment and slower progress of the latter ; but these cases are by no means the most common, and in the majority of cases the course and symptoms are so similar, that unless we have some collateral circumstances to guide us (as, for instance, a disposition to tuberculosis in other localities, or a strongly marked scrofulous diathesis), I should not feel much confidence in a positive diagnosis. The principal grounds of distinction laid down by Mr. Rilliet, are: 1. That tubercular meningitis occurs in delicate, often precocious chil- dren, and in those subject to glandular enlargements and chronic erup- tions of the skin ; whereas in simple meningitis, the subjects are vigor- ous, well developed, and healthy. 2. That the former disease is always sporadic. 3. That the child previously pines away, and suffers from disorder of the stomach and bowels. 4. That tubercular meningitis never commences by convulsions, and that the transition from the first to the second stage is insensible, the advent of the latter being marked by headache, vomiting, and constipation. 5. That the headache is more intense, vomiting not so urgent, constipation obstinate, and fever moderate. 6. That the progress is slow, and 7. That its duration is more prolonged. ACUTE HYDROCEPHALUS. 153 200. Prognosis. -^Every form of the disease is extremely fatal ; very little chance remains for the patient, if the first stage, as we may call it, be neglected. Rilliet and Barthez state that they have never seen a single case of tubercular meningitis cured, and in this they only confirm the testimony of Rufz, Piet, Gerhard, &c. 201. On the other hand, Henri states that he cured thirty cases, Odier four out of six, Golis forty-one, and Formey nearly all to whom he was called at an early period of the disease. Guersent admits that tubercu- lar meningitis may be cured during the first period, but not one per cent, at a more advanced stage ; l nor is Dr. West's opinion more favor- able. 2 Drs. Perceval and Whytt give one case of cure. Dr. Cheyne men- tions three cases of cure. M. Piorry relates fourteen cases, nine of which recovered. Various cases of recovery may be found scattered through the peri- odicals, such as those by Thompson, 3 Uwins, 4 Watson, 5 Heinekin, 6 in the older journals, and more recently in the pages of the Edinburgh Jour- nal, Lancet, Medical Gazette, &c. &c. I have no doubt that all, or nearly all, must have been in the early stage. The fourth variety, or water-stroke, always ends fatally. I have seen a considerable number of cases, and although when symp- toms of effusion are present the case is hopeless, yet at an earlier period I have succeeded in curing a much larger proportion than one might have expected, considering the importance of the organ affected, and the severity of the disease. 202. Terminations. — Some German writers have related cases where acute hydrocephalus terminated by a critical discharge. Meissner men- tions one case in which epistaxis occurred, and another in which there was a copious serous discharge from the eyes, with considerable mitiga- tion of the symptoms, and a third who recovered after a similar evacu- ation. Tortual observed the discharge of serum from the nose, and Riecke from the right ear. Jahn mentions the case of an infant in whom effusion had taken place, but who was cured after a discharge from the ears and eyes. Nasse, Cheyne, &c, enumerate other critical evacu- ations, such as profuse sweating, excessive secretion of urine, eruptions on the face, &c. 203. The favorable signs which give hope of recovery after judicious treatment are, the occurrence of tranquil sleep, the diminution of the startings, the pulse becoming slower, the eyes more steady and less sensitive to light, and the expression of the face more natural and calm. On the other hand, the rapid, small pulse ; quick, irregular respira- tion; dry, furred tongue; livid face ; injected conjunctiva; glazed eyes ; increase of the startings and twitchings ; disturbed sleep ; wakefulness, or coma, all announce a fatal termination. In some cases, but very rarely, the severe symptoms are mitigated, and the disease subsides down into chronic hydrocephalus, as in a case 1 Diet, de MeU, vol. xix. p. 403. 2 Lectures, Med. Gazette, July 16, 1847. 3 Lond. Med. Repos., Jan. 1814. 4 Med. and Phys. Journal, Aug. 1816. 5 Lond. Med. Repository, Feb. 1816. 6 Ibid., Sept. 1819. 154 ACUTE HYDROCEPHALUS. of Dr. Monro's; and probably this may be favored in young infants by the distensibility of the cranium, for certainly symptoms of compression are more marked in children whose sutures are ossified than in very young infants. 204. Treatment. — Believing, as I do, that hydrocephalus consists essentially in inflammation of the membranes of the brain, with or with- out deposition of tubercular matter, and agreeing with Dr. Davis, that, when attacked early, a considerable proportion of cases may be cured, I cannot too strongly express my sense of the importance of early and vigorous treatment. I am convinced that many children are lost by the usual moderate remedies, who might be saved if more active measures were adopted. Let me illustrate what I mean by a case. My friend Dr. M'Donnell's child, aged four months, strong and healthy, was sud- denly attacked by acute meningitis of the most severe character. Six leeches were applied immediately to the forehead, and the bleeding stopped ; the convulsions became less frequent, and the fever dimi- nished ; in about eight hours six leeches were again applied, and we found that the convulsions did not return, but the starting, and crying, and restlessness continued ; and consequently after the lapse of six or eight hours we repeated the six leeches, i.e., eighteen in twenty-four hours, stopping the bleeding as soon as the leeches fell, and from that moment all the symptoms rapidly subsided, and the child recovered his health in two or three weeks. But, of course, one rule will not apply to all cases. Many things must be taken into consideration ; first, the constitution of the child ; secondly, the cause and character of the disease ; thirdly, whether the disease be primary or secondary ; and, lastly, the period of the attack at which we are called to the child. These circumstances will neces- sarily modify the treatment. You cannot bleed a child of a weak con- stitution so extensively as one who is strong and healthy ; nor does the disease, when secondary, or in an advanced stage, admit of such active treatment. Let us examine the principal remedial agents in use. 205. Bloodletting. — In all forms of the disease, whatever be the con- stitution of the child, whether the disease be primary or secondary, if the attack be recent, I believe bloodletting to be necessary, either by opening the jugular vein or the vein in the arm, by cupping, or by leeching. And the quantity taken should be in most cases larger than in other diseases, or even large in proportion to the age of the child. Moreover, if the good effect be not produced, and the child be able to bear it, it should be repeated three or four times; but, if leeches are used, the wounds should not be allowed to bleed after the leeches have fallen. M. Piorry says: "I believe, then, that we ought to bleed, especially during the period of congestion ; that twenty, thirty, forty leeches, or even more, should be applied, or that one or more venesections should be practised — in a word, that we ought to act promptly and energeti- cally." 1 Dr. Mills recommends venesection first, and then leeching. Dr. Davis recommends that the first bleeding, if we are called early, 1 Piorry, de 1' Irritation Encephalique, p. 58. ACUTE HYDROCEPHALUS. 155 should be carried to actual fainting — " not to faintishness, but full fainting." 1 It is only right to state that Dr. Rush, of Philadelphia, was one of the first, if not the first, to recommend large bleeding in this disease. But if the child be weak, or if the disease be secondary, the amount of bleeding must be less ; and I think it better to produce an effect at once than to repeat small bleedings, afte£ which we must depend upon remedies to be noticed presently. Dr. Cheyne remarks of such cases as those he has described : " In most cases, local bleeding by leeches or cupping, or general bloodletting from the external jugular vein or temporal artery, according to the state of the pulse and strength of the patient, must be practised." "But I am convinced that bloodletting, unless in very robust constitutions, is not always to be repeated without danger." These cases answer to those I have made the second variety (17b) of the disease. In the first variety, Dr. Cheyne approves of ample and repeated bloodletting. In tubercular meningitis, bloodletting is also necessary, according to the age and strength of the patient and the intensity of the disease ; but Rilliet and Barthez do not think it should be carried to so great an extent as in simple acute meningitis. In the more advanced stage of either variety, it is rarely of any use, and may perhaps do injury by reducing the strength of the child. In the first stage, Dr. Rilliet advises leeching, mercury, purgatives, and counter-irritants ; if it be in the second stage, calomel, mercurial and iodine ointment, mustard cataplasms, and cold lotions to the head ; if in the third stage, cold applications to the head, mercurial or iodine frictions, suspension of the calomel if there be diarrhoea, and mustard cataplasms. When a child of strumous habit is threatened with menin- gitis, or is seized suddenly with some of its symptoms, he prescribes the treatment for tuberculization in general, as iodine and ferruginous preparations, iodine frictions to the head, cod-liver oil, exercise in the open air with the head uncovered, but not exposed to the perpendicular rays of the sun. 206. Cold applications may be employed by means of lint dipped in cold lotion, or, the head being wet with an evaporating lotion, a current of air may be directed upon the head. This I have found of great value and a great comfort to the patient. Or a bladder, or a water- tight bag may be partially filled with powdered ice, and allowed, when spread out, to rest lightly upon the head. The hair should be removed as completely as possible before applying the cold. All writers are agreed as to the value of this remedy, which should be employed as early as possible, and continued until the symptoms have subsided, or nearly so. Heine, Formey, Foville, and Piorry recommend affusion with iced water ; but to this Piet, Senn, and Charpentier are opposed. 207. Counter-irritation by means of sinapisms or mustard baths to the legs, blisters behind the ears or upon the head, is of great value, and ought in all cases to follow the bleeding. In those cases in which 1 On Acute Hydrocephalus, p. 241. 156 ACUTE HYDROCEPHALUS. the bleeding or its repetition is inadmissible, our main dependence must be upon counter-irritation and mercury. I think that a repetition of smaller blisters has more effect than one large one. I generally commence by blistering the forehead, and, when that begins to heal, apply another over part of the top of the head, and so by degrees irritate the whole of the scalp. This appears preferable to keeping a blister open for any length of time. Dr. Cheyne recommends that they should be dressed with mercurial ointment, so as to aid in bringing on mercurial action. Frictions to the head with tartar emetic are spoken well of by Golis. If, when the child is recovering, the head symptoms do not disappear completely and satisfactorily, great benefit will be derived from a seton of three or four silk threads in the arm, which may be removed when the child is perfectly well. 208. Mercury, we have seen, was successful in one of the first cases of cure on record, that published by Dr. Dobson in 1775; and since his time it has steadily maintained its ground as one of the most important remedies we possess. 1 In every form of the disease its use may be commenced immediately, except in the cases preceded or accompanied by diarrhoea. The bowels must be quieted, at least before we can give it internally; but should the intestinal irritation persist, we may still use inunction with the oint- ment and liniment of mercury. It is better to give calomel, or hyd. c. creta, in small doses, pretty frequently, than in large ones, as being less likely to disorder the bowels, and it may be continued until the mouth is tender ; but it must be re- membered that it is not easy to salivate a child, and I have found that mercurial diarrhoea is a tolerable proof of the constitution being affected. Whytt, Odier, Quin, Wilmer, and others, gave it in doses of two, three, or more grains at a time, and continued it for many days, not- withstanding any effects on the intestinal canal; but I quite agree with the following observations of Golis : " In little children of from one to four or five months, a quarter of a grain — in larger, of from six months to one or two years, half a grain of calomel — given internally every second hour, will be sufficient, until it has produced green slimy stools four or six times, but not purging stools, against which Perceval has already warned us; or until there occur sharp pains in the belly, which infants express by drawing up their legs, and whining, but larger chil- dren describe with words." 2 209. I have already mentioned that if diarrhoea be present it will require attention, and not merely on account of the impossibility of giving mercury internally whilst it continues, but because of the consti- tutional and cerebral irritation which it occasions. And in those cases where the bowels are torpid, we must have recourse to purgative medi- cines, which benefit by emptying the bowels, and act as derivatives also. A brisk mercurial purgative in such cases should be given at once, and repeated if necessary. Neither are we to conclude, in all cases of di- arrhoea, that purgatives are unnecessary; in many instances there are 1 Cheyne on Hydrocephalus, p. 41. 2 On Hydrocephalus, p. 111. ACUTE HYDROCEPHALUS. 157 accumulations in the bowels which must be removed before relief can be obtained, but in such cases I think it better to quiet the irritation first, and then give purgatives. So long as the stomach is irritable, enemata must supply the place of ordinary purgatives, but they do not sufficiently clear out the bowels. 210. Dr. Davis strongly recommends the administration of an emetic after bloodletting for the purpose of controlling the action of the heart and arteries ; he prescribes one-fourth or one-fifth of a grain of tartar emetic with five grains of powdered ipecacuanha. Laennec had previously found great benefit from tartar emetic, but I am not aware that he gave it so as to produce more than nausea. I have never tried the effect of emetics, nor do I think it would be wise. Vomiting for the time increases cerebral congestion, which would be injurious ; and in many cases an emetic would be unnecessary, be- cause vomiting is already present, and yet we never find that it does good. There may however be another reason for giving small doses of tartar emetic. If it be combined with the calomel, it has been found to quicken the action of the latter and so save time. I am indebted to my friend Dr. Aquilla Smith for this suggestion. 211. Drs. Cheyne and Stoker think very highly of James 's powder in full doses at the commencement of the disease, and the former mentions a case apparently cured by it. Certainly in combination with calomel it seems to act beneficially, but I should be very sorry to depend upon it alone. 212. Digitalis alone or in combination with calomel, has been recom- mended by many writers, particularly by Weaver and Eormey. Dr. Cheyne found it of great use in two cases; others with whom he had tried it were too far advanced in the disease. Golis says that he has used it for sixteen years, and in several hundred cases, but without any great advantage ; the dose he recommends is one-eighth of a grain of the powder with half a grain of calomel every two hours. 213. Very great difference of opinion exists as to whether opium is at all admissible in this disease. Cheyne thinks it useful, joined with an aromatic, in correcting bilious vomiting and purging. Golis is en- tirely opposed to it. Mills speaks favourably of it combined with the calomel. Hood strongly recommends it. 1 No doubt it requires great caution because of its effect upon the brain, but I have used it with great benefit in the cases commencing with severe diarrhoea, and with- out any injurious consequences. 214. Iodine has been used, and it is said with benefit. Dr. Evan- son is favorable to its employment, and Rilliet and others strongly recommend it. Dr. Roser tried the hydriodate of potash and recom- mends it when other remedies have failed, and even when paralysis has occurred. He dissolves a drachm of the hydriodate in half an ounce of water, and gives thirty drops of the solution in water every hour. 2 Mr. Finder, of Lymiugton, has related three cases of hydrocephalus in the 1 On the Fatal Diseases of Children, p. 192. 2 Hufeland's Journal, April, 1840. 158 ACUTE HYDROCEPHALUS. advanced stage treated successfully by half a grain of the hydriodate of potash every two hours. The only apparent effects of the medicine were diuresis and salivation. 1 So far as they go, these cases are encouraging. I have not seen such good effects from its use, hut I certainly think it deserving of a more extended trial. 215. Phosphorus has been strongly recommended by M. Coindet, in combination Avith three parts of oil of almonds. It is a very uncertain medicine, and one which may do mischief, and will require great care. Various antispasmodics, such as valerian, arnica, camphor, musk, and castor, have been employed, but very little reliance can be placed upon them. 216. When the symptoms are somewhat mitigated, or the disease is prolonged, and assumes a remittent character, Piorry and H. Cloquet recommend quinine as having been successful in saving several cases. During convalescence it is undoubtedly of great value. 217. I need hardly add, that all possible sources of irritation must be removed as speedily as possible ; if the child be teething, the gums must be completely divided all round and across ; and if the attack be secondary, our most vigilant efforts must be directed to the mitigation or removal of the primary disease. If there be the slightest suspicion that the mother's or nurse's milk does not agree with the child (when at the breast), we should instantly change it, and choose a new and healthy nurse, whose milk is a little older than the patient, if diarrhoea be present. The mother may be unhealthy, or, if healthy, she may be suffering from distress, which is quite sufficient, as I can testify, to cause hydrocephalus. 218. The diet of the child must be restricted during the first two periods, and should consist of little more than milk and water, with panada. As the disease advances, we must gradually endeavor to sup- port the strength ; and, if the termination be favorable, it will need care and caution to give sufficient food without excess. A spoonful of chicken broth may then be given two, three, or four times a day, and increased as the child can bear it. Wine whey will also be found very useful, and ultimately solid food and wine and water, if the child be old enough. 219. But far more important than the diet is it to take measures to insure absolute quiet and soothing rest for the excited brain. The room should be darkened, the air kept fresh and cool, only the necessary attendants admitted, and absolute silence enjoined as far as possible. When taken out of the cradle or bed, the infant must lie on the lap or in the arms ; and, when moving him or walking about with him, the movements should be as gentle and equable as possible. Even when recovering, all excitement, noise, and merriment should be avoided as much as sharp air after pneumonia. 220. Thus, in the first and second stages of meningitis, our remedies are : bloodletting in proportion to the age, strength, and constitution 1 Med. Gazette, Sept. 30, 1842. ACUTE HYDROCEPHALUS. 159 of the child, and the intensity of the attack, but in greater proportion than in other diseases ; cold applications, counter-irritation, purgatives, if the bowels are confined; soothing and astringent medicines, if there be diarrhoea ; calomel and James's powder ; digitalis. In the third stage, a continuance of the calomel, hydriodate of pot- ash, cold applications, iodine frictions, or repeated blistering of the head, are nearly all that we can do with any prospect of benefit. 221. Lastly, most anxious inquiries are made of us by parents who have lost one child from hydrocephalus as to the best mode of prevent- ing the disease in others. We have no medicine which will do this ; but, nevertheless, much may be done by good care and judicious ma- nagement. If the child be very young, the mother had better not nurse the child. A change of milk will do much towards changing the constitution. The bowels should be carefully watched, and any devia- tions from health corrected ; the gums should be lanced freely, the moment there are any signs of irritation ; and the child should neither be exposed to heat nor cold. As the child grows older, he should be kept much in the country and in the open air, be encouraged in running and jumping, and the ordi- nary outdoor amusements of children ; but climbing, and many of the exercises of the gymnasium, particularly those which require the head to be held down, should be avoided. A good shower-bath, or general sponging with cold water, every morning, is an excellent thing. The more healthy the skin, and the more developed the muscles, the less fear there need be for the brain. Again, in children with the least predisposition to the disease, the edu- cation should be carried on very cautiously; the attention should only be occupied for a short time together, the memory not overburdened, and every species of intellectual excitement avoided. Let the brain acquire strength before any burden be laid upon it. The sensibility should also be moderated, and passion controlled, not by indulgence, but by a mixture of reason and authority. The diet should be nutritious, but unstimulating, and the bowels should be kept in order. Should the slightest symptoms show themselves, notwithstanding our care, Odier, Quin, and Matthey recommend the application of a blister ; and Dr. Sachse succeeded by means of an issue in preserving a child whose brothers and sisters had died of the disease. I have great faith in the benefit to be derived from an issue (three or four threads are enough), from having witnessed the good effects in several cases. 160 CHRONIC HYDROCEPHALUS. CHAPTER VII. CHRONIC HYDROCEPHALUS. 222. The chronic form of hydrocephalus is much more rare than the acute, still we meet with the disease occasionally in children of different ages, from birth up to puberty. I have already spoken of hydro- cephalus as occurring during intra-uterine life, and I may add that even of those cases which occur after birth, there is good ground for believing that many commenced during intra-uterine life. Chronic hydrocephalus may be divided into two species, the congeni- tal, including those, the causes of which can be traced back to birth or previously, and acquired. 223. i. Congenital Hydrocephalus. — This may coexist with a head less than usual, of the natural size, or of increased volume. Bouchut considers the second case more frequent than the first, but Dr. Battersby denies this, and states that the first is always congenital. " Most fre- quently children with a head of diminished size have at their birth the fontanelles closed, and the sutures ossified. Most of these children die as soon as they are born, or perish in convulsions a very short time after birth. They are absolutely deprived of intellectual faculties, and their senses are obliterated. The head of these little ones is constantly pointed at its summit, and depressed laterally towards the ears. The forehead is also flattened, and the head covered with thick hair. The eyes are constantly convulsed, they rotate, and are insensible to the light ; the pupil is much dilated, and in some cases the iris has appeared to adhere to the cornea. The face, without any expression, is the image of stu- pidity. The voracity of these children is great, yet nutrition is badly performed ; liquids are swallowed with great difficulty ; they lose their breath, and excite fears for their suffocation. The stools and urine are discharged involuntarily. The voice is a feeble and hoarse sound. The feet are crossed immovably ; the thighs are flexed on the abdomen. These unfortunates can never stand nor walk. Their extremities are cold. They appear to have only a vegetative existence ; they never exhibit a spark of reason, and are one of the saddest pictures of hu- manity." 1 To this form of disease, Cruveilhier proposes to apply the term microcephalus, and he divides it into three varieties: 1. With atrophy of the brain. 2. With serous effusion into the cavity of the cranium ; and 3. Where there is atonic atrophy and effusion. 2 1 Battersby's Essay, Ed. Med. and Surg. Journal, Jan. 1851. In rewriting this chapter, I have availed myself very freely of my friend, Dr. Battersby's able and learned papers, iu which are collected nearly, if not all the facts on this subject, and in which the differ- ent points are investigated with great care and acuteness. 2 Anat. Path., Livr. 3, PI. 4. CHRONIC HYDROCEPHALUS. 161 Cases of hydrocephalus with the head of the natural size or unusually small are related by Mr. Ward 1 and Dr. Battersby. Hydrocephalus with an enlarged head is undoubtedly the most fre- quent ; there may be no evidence of the disease at birth, or so slight that it excites no attention, and yet the morbid cause may be, or may have been some time at work, and the case strictly one of congenital hydrocephalus. 2 Barrier remarks that although at birth the head may not be unusually large, yet as the functions of innervation are too feebly developed to suffer much disturbance from a slight cause, there may be more fluid than usual within the cranium without our being able to detect it. 3 224. II. Acquired chronic hydrocephalus, as Barrier observes, is some- times, though rarely essential, idiopathic, and analogous to other essential dropsies ; at other times it is symptomatic of another disease. The most common disease giving rise to it is tubercle in the brain, or a can- cerous or other tumor. Such cases are mentioned in the works of Bonetus, Morgagni, Lieutaud, and Portal. Lallemand, John Hunter, Danz, and Constant, mention tumors of the cerebellum with fluid in the ventricles ; but they do not state whether there was compression of the straight sinus. Magendie attributes hydrocephalus, among other causes, to an obstruction to the flow of the cerebro-spinal fluid through the ventricles, and has given cases of hydrocephalus with compression of the fourth ventricle by a tubercle of the cerebellum ; by an aqueous tumor upon the aqueduct of Sylvius, the valve of Vieussens, and the fourth ventricle, and also by compression made upon the mesocephalon and the fourth ventricle by an exostosis of the basilar portion of the occipital bone. He also alludes to cases of hydrocephalus with com- pression of the fourth ventricle by a fibrous tumor, developed in the valve of Vieussens, or by tumors of different kinds seated in the annular protuberance. 4 Barrier gives three cases of hydrocephalus from compression of the straight sinus, in children aged 3, 4J, and 5 years. He conceives that the anatomical conditions of this form of hydrocephalus are, 1. That the tuberculous tumor should occupy the middle lobe of the cere- bellum. 2. That it should make superiorly a projection sufficiently considerable to throw up the tentorium cerebelli, and to compress the straight sinus. 5 Rilliet and Barthez agree with M. Barrier that compression of the vense galense, or straight sinus, whether by a tumor in the neighborhood or by an obstruction in the cavity of the sinus, or by its obliteration, as related by Tonnelle, 6 is the most frequent cause. Dr. Whytt relates a case in which a scirrhous tumor, occupying the situation of the pituitary gland, by compressing the neighboring veins, gave rise to effusion. 225. Hemorrhage into the arachnoid very often resembles hydroce- phalus, either, as Rilliet and Barthez suppose, by a separation of the 1 Lond. Med. Gaz., March 27, 1846. 2 Bouchut, Mai. du Nouveaux Nes, p. 450. 3 Mai. de l'Enfance, vol. ii. p. 585. 4 Sur le Fluide Cephalorachidienne, p. 74. 5 Mai. de l'Enfance, vol. ii. pp. 594, 603. 6 Mai. des Enfans, vol. ii. p. 32 11 162 CHRONIC HYDROCEPHALUS. serum and crassamentum, or by exciting inflammation and effusion, according to Breschet and Legendre. 1 226. Lastly, it would appear that chronic hydrocephalus may be a sequence of the acute meningitis already described. 2 In such a case the symptoms subside in a great degree, but do not disappear; the fever diminishes, the headache is less acute and only occasional, the pulse may become less frequent, but the symptoms of cerebral disturbance and oppression continue, although in a mitigated form. Dr. West observes that, even where no false membrane is found within the ventricles, their lining often presents other evidence, besides mere thickening, of its having been the seat of inflammation. Sometimes it is very hard and granular, presenting an appearance closely resembling shagreen, and communicating a very perceptible sense of roughness to the finger. " These and other similar alterations of the lining of the ventricles, afford conclusive evidence of the inflammatory origin of most cases of chronic internal hydrocephalus." M. Billard thinks that chronic hydrocephalus succeeds almost con- stantly to acute meningitis, and I have seen one case at least which seems to confirm this view. At the same time I must not conceal that many authors — Barrier, Rilliet and Barthez, Breschet and Battersby — are opposed to this opinion. 227. Symiotoms. — I have already quoted a description of symptoms in those cases in which the head is smaller than usual. In other cases of congenital hydrocephalus, the symptoms at first may not be very striking, some want of muscular power or feebleness of one side seems less perfect than usual, rather less intelligence than ordinary, and no attempt at articulate speech, will probably be all the phenomena to be observed. The same may be said of most of the cases of acquired chronic hydro- cephalus in the early period and at an early age. If the attack come on at a more advanced age, there will be a sort of retrogression of development ; the child will lose its muscular power, or the natural exer- cise of it, the senses and intellect will be more or less deranged, &c. But if the case be one of chronic meningitis, the train of symptoms are a good deal changed in character. Dr. Copland thus describes them: " Chronic meningitis commonly succeeds to the acute form of the disease, but it often presents the chronic characters from the commence- ment. There is generally continued headache, with slight somnolency, sluggishness and incapacity or want of desire for intellectual exertion, moroseness, irritability of temper, sometimes confusion of ideas, embar- rassment of speech, and delirium, terminating in confirmed mania or idiocy. The motions of the limbs are slow, difficult, or painful, and their muscles are subject to involuntary motions and twitchings, and sometimes are not under the control of volition, or are altogether para- lytic. Vomiting and convulsions are rarely present, excepting in infants, where they are often the chief or only signs. In children the peculiar knitting of the eyebrows, retraction of the angles of the mouth, whin- d Revae M&L, Dec, 1842. 2 Copland's Dictionary, part i. p. 230. CHRONIC HYDROCEPHALUS. 163 ing or peevish cry, stupor, grinding of the teeth, scanty urine, obstinate costiveness, and increased heat of the head, are the chief symptoms." 1 228. At a more advanced stage, the symptoms are common to all the varieties of chronic hydrocephalus which commence after birth with some modification. The organs of sense are all more or less affected, the eyes are turned upwards or downwards, or to one side, and unequally, so that the patient squints; the pupils are dilated, and the dilatation generally increases with the amount of compression ; the sight is com- monly weakened by degrees until it is finally lost, although in some it is preserved to the end. The nares become dry and insensible to odors ; the hearing, which was delicate at first, is lost by degrees ; the taste is generally preserved longer, and in some cases is perfect to the last ; the touch is unaltered longer than any other sense, and may even be more acute than usual, although in many cases it becomes blunted. Dr. Bright observes that sometimes at birth, and sometimes within a few weeks after, the sight is lost, though the hearing generally remains acute, and as the months pass on, instead of the intellect gradually developing itself, the mind is almost stationary and the powers of the body are paralyzed. Patients so affected generally lie in bed with the body and legs much bent and contracted, and lose the power of straight- ening themselves, and some have entirely lost the power of their legs, and retain a slight power of their arms. 2 229. The state of the intellect varies in different patients. Perfect idiocy results from congenital hydrocephalus, as in the cases related by Schmitt 3 and Battersby ; and this is confirmed by Espinol's experi- ence. 4 But in acquired chronic hydrocephalus, as a general rule, after effusion has taken place to any extent, we find the intelligence more or less affected, excepting perhaps in some of those cases where the head rapidly enlarges. After a time, it is evident that the child has not the mind of his age; it has become stationary, and then it retrogrades until he acquires the look of an idiot, forgetful, scarce understanding what is said to him, babbling words without meaning, or at cross purposes, neither able to explain his sensations nor his wants, until at last he seems sunk in indifference, stupor, or coma. This is not always the case, however. Michaelis mentions the case of a man, aged twenty-nine, whose head began to enlarge three weeks after birth. He entirely lost the use of his limbs, a slight movement of the arms alone excepted. He was never able to quit his cradle unless assisted by three or four people. As he never made use of his feet, they remained extremely small, and looked like those of a boy of twelve years, forming an odd contrast with the rest of his body, which was as large as that of a full grown person. His appetite and hearing were both good. His sight was imperfect, and he squinted. His men- tal faculties were not contemptible, though he was generally considered an idiot on account of his looking so stupid. His spirits were always good, and he was glad to see people. 5 1 Dictionary of Pract. Med., part 1, p. 280. 2 Reports, vol. ii. part i. p. 424. 3 Bibliotbeq. German., vol. vi. p. 264. 4 Mai. Mentales, vol. ii. p. 335. 5 Lond. Med. Communications, vol. i. p. 404. 164 CHRONIC HYDROCEPHALUS. Dr. Monro relates the case of a child whose head at eight years old measured two feet four inches in circumference, but whose memory was strong and retentive, and who was as lively as children usually are. He states, moreover, " that it is incredible how little the powers of the mind are impaired by this disorder, considering the great enlargement of the ventricles of the brain. I have had opportunities of seeing several examples of this form of hydrocephalus, and have watched the progress of the symptoms for years, yet I have never met with any one instance in which the powers of the mind could be said to be completely deranged." 1 Dr. Spurzheim has described several cases in which the mental powers were not impaired ; one in particular, a learned man, " whose head is extraordinarily high in the anterior-superior part of the forehead, and which, according to its size, must contain from three to four pounds of water ; yet this man has extensive knowledge. The only inconvenience which results from his peculiar state is that he often falls suddenly asleep in the midst of the most interesting conversation, at table, at the theatre, and elsewhere." 2 I have a little child of four or five years old under my care at present, who has been the subject of chronic hydrocephalus, apparently follow-, ing an acute attack, and whose head measures twenty-three inches in circumference, whose intellectual faculties are apparently in a state of perfect integrity. But, as a general rule, I quite agree with Dr. Watson that " most commonly the mental and voluntary functions are maimed and per- verted, as may be seen in the cases related by Howship, Solly, Chatto, Reil, Craigie, Ecmark, and Ryan, referred to in Dr. Battersby's paper, as well as those added by himself. 230. The most striking feature of the disease is the enlargement of the head. In infants, it commences soon, and proceeds rapidly, owing to the separation of the sutures; but even when these are ossified, enlargement has taken place. The amplification is of the vault of the cranium only, the hair remaining nearly unchanged; and it has been thus described by Dr. Battersby: "The water of the cranium recedes from its centre, and the head augments in volume according as the quantity of fluid becomes considerable. The bones of the face neither participate in nor contribute anything to this enlargement. They pre- serve their natural volume and form. The bones of the cranium con- spiring to its enlargement are the frontal, parietal, the superior part of the occipital, and a small part of the squamous portion of the temporal bones. These bones become expanded, thinned, and membranous. The frontal expands, is elevated, and advances forwards over the eyes and the face, which looks narrower and shorter. The angle which the superior part of the frontal now enlarged forms with its orbital portion diminishes, and is effaced almost entirely, so that the eye is driven down and concealed by the lower lid, which ascends to the level of the centre of the pupil. Camper remarks that this disposition alone would suffice to recognize chronic hydrocephalus, even although all the rest of 1 On Hydrocephalus, p. 138. 2 Monro, Morbid Anat. of the Brain, p. 138. CHRONIC HYDROCEPHALUS. 165 the head were covered. The bones forming the vault of the cranium are separated, and the intervals, more or less large, separating them are occupied by a fine membrane, through which fluctuation of the water inside can be felt distinctly. This separation is very great between the parietal bones, especially at the fontanelles. The mem- brane filling these spaces is sometimes distended to such a degree as to form a very visible longitudinal tumor. On pressing strongly the fingers upon these parts of the head, no depression is left, and the intervals of the bones yield to the compression like a bladder full of water. On gently striking one of these intervals, the liquid can be felt at the opposite side. " Resistance is felt everywhere else, that is, in the parts naturally ossified." 1 For a considerable time the face is unaltered, or if anything, it seems to shrink, and the aspect of the enormous head with the small face gives a very peculiar expression to the child — the fades hydrocephalica, as it has been termed : an old, withered, semi-idiotic look. Dr. Monro states that in the end the bones of the face are enlarged, and the angles of the eyes more distant from each other. When the enlargement of the head is great, its weight is inconvenient, so that the child has much difficulty in supporting the head upright, and in extreme cases, when the muscles of the neck are weakened, it is quite unable to do so, and either reclines it on one shoulder or on some arti- ficial support. 231. The power of locomotion is enfeebled in all cases, and in many absolutely lost. The limbs are weak and the walk uncertain and trem- bling, requiring assistance and support, until, from the atrophy of the muscles or want of innervation, the child is unable to walk at all, and remains in the recumbent position. In other cases the paralysis is observed earlier, even from the begin- ning, and as Dr. Bright remarks, the patients lie abed with their legs bent under them, or as in Dr. Ryan's case, where the child was nearly deprived of the functions of vision, hearing, taste, smell, and touch, and entirely of voluntary motion ; and in those of Dr. Battersby's cases. In some cases one leg only is affected ; in others, the lower half of the body, and occasionally the entire extremities. Not unfrequently the child is attacked by general or partial convul- sions, and these may immediately be followed by paralysis, which may extend to the muscles of organic life, giving rise to difficult deglutition, retention of urine, or constipation, or involuntary evacuations. The respiration, circulation, and digestion are apparently unaffected for a considerable time. Many patients have a good appetite, nay, even a voracious one, and digest well, though without any increase of flesh. Vomiting, however, is observed occasionally. The pulse, which was natural or rather quicker than natural at first, becomes weak and small after a time, the heat and moisture of the skin diminish, the respiration at length becomes labored, with an access of dyspnoea. The appetite also diminishes ; there is little relish for the food taken, and emaciation advances rapidly. In short, as M. Barrier has pithily 1 On Chronic Hydrocephalus, Edin. Med. & Surg. Journal, Jan. 1850. 166 CHRONIC HYDROCEPHALUS. observed, " the patient, deprived of the exercise of the functions of volition, is reduced to a vegetative life, which in its turn is gradually extinguished. I am not aware whether the cephalic bruit exists in chronic as well as in acute hydrocephalus. Drs. M. Barthe and Roger could not detect it. Rilliet and Barthez heard it in one case resembling chronic hydroce- phalus, but on dissection the brain was found to be healthy. I tried in two of Dr. Battersby's cases and one of my own, but failed to discover it. 232. Pathology. — We have already seen how much the head is al- tered in size and shape, that the bones are widely separated, feeling as if loose underneath the skin, and that a species of secondary tumor is formed by the protrusion of the water. The bones of the cranium are sometimes of their natural thickness, but more frequently they are thin, weak, semi-transparent, resembling parchment rather than bone. They are very porous, and the radiating fibres around each point of ossification are very visible. Dr. Battersby observes " that the first lineaments of the Wormian bones are observed in hydrocephalic subjects of a very tender age. Breschet remarked little osseous needles in the membranes by which the edges are most generally united. These needles are very remarkable in the skull of a hydro- cephalic foetus preserved in the Museum of the Rotunda Lying-in Hos- pital." On the other hand, the bones are sometimes found thicker than natu- ral. Ecmark, Malaconne, and Kartell have found them of a thickness proportioned to their surface or to the volume of the head. Riedlin says he met them twice as thick as natural in a hydrocephalic head of seven- teen years. Joder speaks of a child two years old in whom all the bones of the vertex had a thickness of nine or ten lines. The cranium described by Molyneux was so thick that the physician took the head of the patient for that of a giant. Breschet met with a case of hydroce- phalus in which the bones of the skull had the thickness natural to a well-formed adult, and which were united by solid suture. The size of the head varies widely. In some cases it is very great. Meckel states that he had seen a foetus of seven months, the transverse diameter of whose head was sixteen inches. The head of another foetus come to its full time was, at birth, fifteen inches in circumference and five inches in height. Another by Willan, at twenty months, was twenty-eight inches in circumference and nineteen from ear to ear ; one by Freind at two years was twenty-nine inches. A head in the Museum of the Rotunda Hospital, Dublin, is stated to have been twenty- two inches in circumference when the mother was delivered by the crotchet. Wrisberg delivered a Jewess with the crotchet, and the head was ten inches long and thirty and a half in circumference. Dr. Monro's case, at nine years, was thirty-six and a half inches in cir- cumference. The head in Bartholin's case was forty-eight ; in Cruik- shank's, at sixteen months, fifty-two inches. The quantity of fluid found in the hydrocephalic heads is often very considerable. Willan, in a child aged twenty months, found four quarts; Ecmark eight pounds, and Duncan eight pounds eight ounces ; Wris- berg, in the Jewess's child, nine pounds ; Brittner, twenty pounds; Steg- CHRONIC HYDROCEPHALUS. 167 man, twenty-four pounds ; Cruikshank, twenty-seven pounds ; Sequard, thirty-six pounds, and Sichel, fifty pounds. 1 Breschet's analysis of the serum is as follows : — Water 9.900 Albumen . . 0.015 Osmazome 0.005 . Muriate of soda 0.005 Phosphate of soda 0.005 Carbonate of soda ....... 0.090 Other analyses by Marut, Bostock, and Berzelius give nearly the same results. The fluid withdrawn by puncture by Dr. Battersby, at eight different times, ranged from 1006.5 to 1014 spec, gravity. "Al- bumen was always present, but in very variable proportions ; the quantity was sometimes very great, as at the second and third punc- tures, when it nearly equalled that in the fluid of ascites, forming when heated a solid mass like the coagulated white of egg. It sometimes amounted to a mere trace, and the specific gravity was influenced by- the amount of it present, so that the former became a measure of the quantity present. Nearly the same salts were found in all the speci- mens, and generally in about the same proportions, viz: a large amount of the chlorides of potassium and sodium, small quantities of the sul- phate of soda and the phosphate of lime, and a little free alkali, which always gave the fluid an alkaline reaction." 2 According to Breschet 3 the fluid may be contained (a) between the dura mater and the cranium ; (b) between the dura mater and the arachnoid ; (c) in the cavity of the arachnoid ; (d) in the ventricles, or (e) in the laminae of the pia mater. The cases of ventricular hydro- cephalus are very much the more common, and in most cases there will be some fluid found in the spinal canal. A recollection of these different localities will in a great measure en- able us to understand the various conditions in which the brain has been seen by different observers. Thus the brain is said to have been found in a rudimentary state resembling a gland, and of small size, by Gall, Breschet, Baron, Billard and others, which would naturally result from compression exercised upon it by fluid on its outer surface ; or it may be, from extreme distension, assume the appearance of a thin, almost membranous bag, as in Dr. Battersby's cases and many others. Ac- cording to the amount' of distension will be the thinness of the walls of this pouch, and in extreme cases, it will be difficult to distinguish be- tween the white and gray matter, or to recognize the central portions of the brain at all. Generally we find the corpus callosum raised nearly to the skull, the septum lucidum defective or injured, the corpora striata flattened, the nerves atrophied or softened, 4 or there may be no traces of these parts at all. 5 The substance of the brain may not only be unusually diminutive, but it may be softened and more or less disorganized. 6 The membranes in all cases of congenital hydrocephalus exhibit no 1 Battersby's paper, Ed. Journal, Jan. 1850. 2 Ed. Med. and Surg. Journ., Oct. 1850. 3 Diet, des Sciences Med., art. Hydrocephale. 4 Boucbut, Mai. des Nouv. N6s, p. 453. 5 Monro, Morbid Anat. of the Brain, p. 31. 6 Stewart, Dis. of Children, p. 525. 168 CHRONIC HYDROCEPHALUS. morbid alterations ; and even in acquired hydrocephalus, these changes are not very frequent. The dura mater is seldom altered, but M. Breschet mentions the absence of the falx cerebri. The arachnoid is sometimes whiter than usual, and infiltrated with serum. The pia mater is excessively thin, but not destroyed. On the other hand, some cases occur in which there is evidence of inflammation, as in the case described by Dr. West, which I have al- ready quoted, where the membranes were thickened and rough with gran- ulations, or covered with a layer of false membrane both at the base of the brain and in the ventricles. 233. A question of some interest in pathology still remains, viz: What is the proximate or pathological cause of congenital hydroce- phal After a very careful research and a minute examination of the con- dition of the brain in these cases, Dr. Battersby has come to the con- clusion that chronic hydrocephalus is always congenital, and that congenital hydrocephalus is due to an arrest of development, thus confirming the opinion of Meckel. 1 M. Breschet observes, "there is* a circumstance to which I shall direct the attention of physicians, and which appears to explain the frequency of serous intercranial effusions in general, and especially of congenital hydrocephalus. The fine re- searches of M. Magendie on the cerebro-spinal fluid leave no doubt of the existence of this liquid at all periods of life, intra-uterine and extra- uterine, and its abundance as well as its constancy appears to demon- strate that this liquid performs important functions. Here, then, is a natural hydrocephalus, or one which is united with the regular perform- ance of the functions of the brain and spinal cord. The study of organic evolutions has caused this fluid to be recognized as more abundant at the first period of the formation of the cerebro-spinal nervous centres than at any other epoch of life. From the existence of this fluid, from its more considerable quantity during the first phases of life, to the existence of hydrocephalus, there is but a degree." 2 Now if we compare the condition of the different parts of the brain, as the corpus callosum, fornix, septum lucidum, &c, in the case of con- genital hydrocephalus, with the description by Tiedemann, of the brain of the foetus at different periods, we shall see sufficient exactness to lead to the belief that an arrest of development did take place at a certain period, whether in consequence of the increase of the head, or from some other cause. If, moreover, Dr. Todd's opinion be generally accurate, that " when an arrest of development of any portion of the cerebro-spinal axis has taken place, the space which ought to be occupied by the organ of im- perfect growth is filled with liquid," 3 we have the case pretty well proved, and may conclude with Meckel, Breschet, Duncan, and Bat- tersby, that " whatever be its remote cause, congenital chronic hydro- cephalus depends on an arrest of development of the brain, or, according to Mr. Anderson and Dr. Coste, of the proper brainy material." 1 Anat. Pathologique, vol. i. p. 262. 2 Diet. deMed., art. Hydroceph. Chronique, p. 511. 3 Cyclop, of Anat. and Phys., part xxv. p. 642. CHRONIC HYDROCEPHALUS. 169 Differing, as I do, in some degree from Dr. Battersby, in not regard- ing every case as congenital, I should not, of course, apply any such explanation to those cases caused by tumors or local pressure of any kind, or to those still fewer, the result of inflammation. 234. The duration of the disease varies so much in different cases that no general rule can be laid down. Some cases live for a year or two, and then die ; others live for twenty or thirty years a sort of vege- table life. Those who are attacked by the disease after the sutures are ossified, are carried off much more rapidly than others, because of the greater pressure upon the brain ; but if the amount is not greater than the brain can bear, and if its increase be arrested, then life may be prolonged. Sooner or later, however, almost all the cases terminate fatally, 1 either from the pressure, from an attack of acute disease, or from the absence of due nervous influence upon the organs necessary to life, and the consequent failure of those functions. 235. Causes. — I have already mentioned the proximate causes of this disease and as to exciting causes, such as blows, falls, cold, worms, &c, our information upon the subject is so vague that it would be unwise to found any definite opinion upon it. 236. Diagnosis. — The only difficulty in diagnosis which can arise is previous to the enlargement of the head, and our judgment must be formed by a careful analysis of the functional disturbances already noticed, among which M. Breschet regards as most important the vacillation of the voluntary muscles, the difficulty of equilibrium, and the inclination of the head. If there be any fever, the case might at first present some resemblance to infantile remittent, but the absence of remissions and the gradual increase of cerebral symptoms will clear up the doubt. The very rare cases of chronic hydrocephalus where no cranial enlargement takes place will be with great difficulty distinguished from tumors or tubercles of the brain, inasmuch as the muscular weakness, want of equilibrium, headache, and in some cases vomiting, are common to both. Probably the age and constitution of the child, and the dura- tion of the disease, may throw some light upon the matter, as, for instance, in a child exhibiting scrofulous tubercles, in other situations we might suspect that the head symptoms proceeded from a similar cause. After enlargement has taken place, if the sutures be ossified, it might in some cases be hard to distinguish between chronic hydrocephalus and hypertrophy of the brain, there being many symptoms in common be- tween them : if the sutures be not ossified, the presence of fluid can scarcely be mistaken, and in the former case, I should think that the history of the disease would be a tolerably safe guide. 237. Treatment. — The principal internal remedies from which we have any hope, and but very little from them, are mercury, sudorifics, diuretics, and purgatives, with the occasional abstraction of a small quantity of blood, if there be any evidence of congestion or inflam- mation such as quicker pulse, heat of scalp, or turgescence. 1 Barrier, Mai. de l'Enfance, vol. ii. p. 612. 170 CHRONIC HYDROCEPHALUS. Dr. Watson speaks in favorable terms of Dr. Graves' plan in two instances. Ten grains of crude mercury, one scruple of manna, and five grains of fresh squills are to be rubbed together for one dose, to be repeated every eight hours. The first patient, a lad who had been ill for two or three years, took the above dose three times a day for nearly three weeks, ptyalism being produced. Its effects were great prostration of strength and loss of flesh, with gradual relief of all his sufferings. It operated profusely by the kidneys. The medicine was continued twice a day, and at length once a day, for another fort- night, when all the symptoms of the disease had disappeared. The boy was greatly emaciated. He was then ordered an ounce and a half of Griffith's mixture thrice daily, and soon regained his health and strength, and got quite well. The second case, a youth of twelve years old, after resisting all other remedies, was treated in the same way, and the result was a permanent cure. The strength of the dose must of course be modified according to the age and strength of the child. I may say indeed that mercury in some form or other, from its control over the inflammation of serous surfaces, and from its power of stimulating the absorbents, and in combination with squills or digitalis, or both, from its diuretic effects, is our sheet anchor in most cases. Dr. Reid, Clanny, and others, recommend it to be given in large doses, and state that they have found it very useful. I confess from my own experience I should prefer moderate or small doses, as producing less disturbance. At the same time, we may increase the rapidity of the mercurial action by using inunction with strong mercurial ointment, or by dressing the blister with it. Mr. Wilson speaks strongly in favor of mercurial inunction as a means of reducing the size of the head. 1 Golis recommends calomel internally, mercurial frictions to the head, and slightly irritating baths, generous but not stimulating diet, and fresh air when the weather is suitable ; by which means he seems to have been very successful. M. Barrier mentions that iodine has succeeded in a few cases, 2 and from its benefit in scrofulous cases it seems deserving of a trial. Drs. Maunsell and Evanson speak favorably of it. More recently Dr. Guerond 3 and Mr. Hoskyns have published each a case in which iodide of potassium was given with great success. Half a grain may be given every four hours to a child two years old. 238. Counter-irritation by blisters or issues is doubtless of great use, and when bleeding is inadmissible it is the best means of reducing the chronic inflammation. Almost all writers are agreed upon the employ- ment of blisters to the head (after having shaved the scalp), or along the spine. Dr. Mills recommends the ung. ant. tartar, to the scalp, and that by some means a permanent drain should be established on the vertex or in its neighborhood. 4 , 239. Two other external modes of treatment have been proposed, and to a certain degree have been successful. 1 Monro, Morbid Anat. of the Brain, p. 146. 2 Mai. de l'Enfance, vol. ii. p. 614. 3 American Journal of Med. Science, 1851, Ranking, vol. xiii. p. 330. 4 Trans, of Association, vol. v. p. 457. CHRONIC HYDROCEPHALUS. 171 I. From an opinion that effusion might be the result of want of firm resistance by the unossified cranium, compression has been tried. Riverius mentions the case of a boy who was thus cured. 1 Sir Gilbert Blane used bandages around the head ; 2 Mr. Barnard straps of adhesive plaster ; 3 and M. Engelmann, of Kreusnach, both bandages and plaster. Sir G. Blane's case was cured in less than three months. In Mr. Barnard's cases considerable benefit was derived, and in Engelmann's cases, ten in number, the fluid was absorbed, and the patient recovered. 4 Other successful cases are on record. 5 M. Jadioux, however, regards it as insufficient and injurious. Mr. Hood, of Ayton, tried it, but without success ; the pressure brought on convulsions. Of course, to produce any good effect, the compression must be gradually increased, and continued for a considerable time. M. Trous- seau uses strips of diachylon plaster, about one-third of an inch broad, and applies them, "1, from each mastoid process to the outer part of the orbit of the opposite side; 2, from the hair at the back of the neck, along the longitudinal suture, to the root of the nose ; 3, across the whole head in such a manner that the different strips shall cross each other at the vertex ; 4, a strip is cut long enough to go thrice round the head, so as to make a firm and equable pressure. 6 If symptoms of compression appear they must be loosened, or if the skin be irritated they must be removed. Drs. Watson and West recommend the trial of Dr. Arnott's air press, as probably superior for the purpose of com- pression to any other means. 240. ii. Puncture of the cranium and evacuation of the fluid was proposed by some of the older surgeons (Severinus and Le Cat, &c), and in recent times has been practised by Vose, Rossi, Conquest, and many others. In the former edition I mentioned that a considerable amount of success had attended the operation, but the careful investigation of Dr. Battersby has shown that there is reason for believing this to have been overestimated. Of 5Q cases included by Dr. West in his list, 16 were said to have recovered, but the list of cases, on strict inquiry, appears by no means so favorable to the operation. Some were merely relieved, others remained the same ; others had not been seen for some time, &c, so that, according to Battersby, "the conclusion we are justified in hold- ing from an examination of the 16 cases reported by West, is, that not more than four of these (Graefe's case and three of Conquest's, which I still look upon as doubtful) were cured." Three other cases are re- ported as cured by Drs. Whitney, 7 Edward, 8 and Kitsell. 9 On the other hand, besides the 40 unsuccessful cases in Dr. West's 1 Obs. Commun., 6. 2 Lectures on the Structure and Physiology of the Bones, p. 269. 3 Lancet, No. 137, p. 52. 4 Archives Gen. de Med., June, 1838. 5 Lancet, No. 841, p. 82. 6 West's Lectures, Medical Gazette, August 16, 1847, p. 270. 7 Amer. Journ. of Med. Science, Oct, 1843, p. 303. 8 Ed. Monthly Journal, p. 398, 1846. 9 Amer. Journal, Jan. 1850, p. 218. 172 CHRONIC HYDROCEPHALUS. list, there are many other failures on record. " Monro states that at Liverpool, after Vose's case, several cases were operated on which died. Breschet operated several times without success, 2 as did also Dupuytren three times. Dr. West has given a fatal case from Fabricius Hildanus. 3 A like unsuccess attended the cases given by Tulpius, 4 Schenkius, 5 Ferdinandus, 6 Panarolius, 6 Muraltus, 6 Wepfer, 7 Forestus, 8 Francus, 9 Schenkser, 10 Zang, n Junker, 12 Sorbait, 12 Petit, 12 Loftie, 13 Froriep, 14 Lee, 15 Vose, 16 Jeffrey, 17 Dickinson, 18 as also the more recent cases of Wod- roofe, 19 Watson, 20 Dendy, 21 Parkman, 22 Whitney, 23 Bellingham, 24 Taylor, 25 Campbell, 26 Storks, 26 Martin, 2 7 Gotz, 28 Chater, 29 Fergusson, 30 Physick, 31 Taylor, 32 Pepper, 33 and Battersby. 34 We have already seen that Hol- brook, Kilgour, and Fergusson punctured the head without effect, as also did Mr. Dendy, five times, whilst Monro and Watzer opened the dura mater alone. Spengler and Barruel also appear to have punctured the brain, but with what effect I have been unable to learn. An accu- rate examination of ancient and modern medical works would very pro- bably discover other cases, but the above authorities, along with the forty cases in Dr. West's table, give about 100 unsuccessful, against seven alleged successful cases, or, in other words, one patient in 14 was cured by puncturing the head. But this proportion I do not regard as by any means exact, as I have known of the operation having been performed in Dublin about ten times unsuccessfully, and I have heard of others in the country, in which it was undertaken ineffectually. Unfavorable results are seldom recorded." 35 Now, if we could ascertain that the fluid was external to the brain, there might be some hope that in such cases, relief and even cure might be effected by letting out the water, but as I do not believe that this is possible, and as such cases are extremely rare, I believe we can scarcely make an exception in their favor. And with regard to the operation in ventricular chronic hydrocephalus the above statements are sufficient to condemn it altogether. Nay more, even if by it we could evacuate the water, and that no more was secreted, the condition of the brain is such, as I witnessed myself in Dr. Battersby's case, that there could be no hope of its reco- I On Hydrocephalus, p. 147. 2 Diet, des Sciences Me"d , vol. xv. p. 455-6. 3 Obs. Chir. Cent., 3. obs. 17. 4 Obs. Med., lib. i. p. 47. 5 Obs. Varios., p. 10. 6 Monro on the Brain, &c, p. 70. 7 Obs. Med. Pract., pp. 49, 53, 60. 8 Schol. adObserv.,30, lib.viii. Schenck., p. 10. 9 Schenk., Obs. Med., lib. i. 10 Vallisneri, Opera, vol. i. sect. 5. II Darstel. blutig. Operat., bd. ii. 3. aufl. p. 68. 12 Copland's Diet., vol. i. p. 682. 13 Med. Obs. and Inq., vol. v. p. 121. 14 Notizen aus dem Geb. der Natur und Heilk., vol. v. No. 102, p. 224. 15 N. Y. Med. and Phys. Journ., 1828. 16 Med. Chir. Trans., vol. xiv. p. 354. 17 Lancet, vol. i. p. 617. 1836-7. 18 Ibid., vol. ii. p. 42. 1838-9. 19 Dub. Med. Journ., vol. xxiii. p. 37. w Library of Med., vol. v. p. 147. 21 Winslow's Psycholog. Journal, Monograph, p. 11. 22 Araer. Journal, vol. xvi. p. 299. » Amer. Journal, Oct. 1843, p. 305. 24 Dub. Med. Press, vol. iv. p. 148. 25 Med. Gazette, Jan. 26th, 1850. 26 Fergusson's Surgery, p. 491. 21 Mem. de Med. 1835. 23 (Ester Med. Jahrbuch, June, 1846. 29 Prov. Med. and Surg. Journal, Oct. 1845. 30 System of Pract. Surgery, p. 491. 3I Med. and Phys. Journ., vol. lviii. p. 44. 32 Lond. Med. Gaz., Jan. 1850. » Amer. Journ. of Med. Science, Oct.l850,p.552. 34 Ed. Med. and Surg. Journ., July, 1850. 33 Essay, Ed. Med. and Surg. Journ., July, 1850. HYDRENCEPHALOID. 173 vering a natural healthy working condition. The operation is, as Mr. Fergusson remarks, " attended with considerable danger, not from the puncture, which is a very simple matter, nor from the sudden escape of a fluid, nor from the wounding either a vessel or the brain, but from the inflammation likely to succeed." It is usually performed with a very fine trocar, on one side of the sagittal suture, so as to avoid the sinus, and pressure should be made as the fluid escapes. 241. [Hydrbncephaloid. — There is an affection of the brain incident to the period of infancy resembling in many of its symptoms the latter stages of chronic hydrocephalus, so as very often to be mistaken for it. A more grievous error could not be committed, inasmuch as the disease to which I allude always originates from another cause, and undoubt- edly demands a very different treatment. I refer to the affection which has been so ably described by Drs. Marshall Hall and Robert Gooch, and which has been designated by the former by the term hydrencepha- loid, on account of its symptoms very often presenting a striking simi- larity to those which betoken inflammation of the brain. My experience has led me to believe that this disease is of frequent occurrence, and of so insidious and masked a character as to mislead the inexperienced members of the profession, and cause them to resort to a treatment calculated to aggravate the disorder ; hence, I have deemed it proper to insert a few remarks upon this subject. " This affection," says Dr. Marshall Hall, in his admirable essay on the subject, " may be divided into two stages ; the first, that of irrita- bility; the second, that of torpor. In the former, there seems to be a feeble attempt at reaction ; in the latter, the vital powers appear to be more prostrate. These two stages resemble in many of their symptoms the first and second stages of hydrocephalus respectively. In the first stage, the infant becomes irritable, restless, and peevish, the face flushed, the surface hot, and the pulse frequent ; there is an undue sen- sitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing, moaning, and screaming during sleep ; the bowels are generally flatulent and loose, and the evacuations disordered. If, through an erroneous notion as to the nature of the affection, nourishment and cordials be withheld, or if diarrhoea supervene, either spontaneously or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold ; the eyelids are half closed ; the eyes are unfixed, and unattracted by any object placed before them; the pupils unmoved on the approach of light; the breathing, from being quick, becomes irregu- lar and effected by sighs ; the voice becomes husky, and there is some- times a teazing cough ; eventually, if the strength of the little patient continue to decline, there is a crepitus in the breathing, the evacua- tions are usually green, and the feet cold." These symptoms will sometimes supervene in young infants to early weaning, especially if they should be subjected to improper food. Drs. Marshall Hall and West seem to attribute this condition of spurious hydrocephalus to either an enfeebled condition resulting from weaning or to an exhausting treatment applied for some previous complaint. I 174 HYDRENCEPHALOID. have seen many cases, however, in which the children affected had had no previous illness, and the exhausting treatment had been applied sub- sequent to the drowsiness and other characteristic symptoms; and these are the cases in which the practitioner is most liable to be deceived. The children thus affected have been laboring under acute chlorosis ; and I have no doubt that the drowsiness, &c, is accompanied in most cases by the distressing headache, throbbing in the head, and noises in the ears, which generally accompany this enfeebled condition of the system, one which in everyway resembles the "pale-faced" amenor- rhoea of puberty or after life. I do admit the fact that this disease is very often incident to some grave illness, which is very exhausting in itself, or for the treatment of which active measures have been necessary ; hence, it is very frequently found accompanying the earlier stages of pneumonia, where the sympa- thetic disturbance of the brain has caused a powerful treatment to be directed to that organ, which has been erroneously considered as pri- marily affected. We may have this disease originating also in cases where there has been congestion of the brain, and where, through over anxiety on the part of the practitioner, too powerful or too continued a depletory plan of treatment has been adopted. Under such circumstances, the pri- mary cerebral symptoms may be alleviated by the remedies ; but in a short time the child apparently relapses into the same condition ; there is restlessness, jactitation, moaning, flushed cheek, drowsiness, irritable stomach, and tympanitic condition of the abdomen. To the unwary, these may all seem positive indications for resorting again to the treat- ment which was so successful in arresting the same symptoms in the commencement. Should these erroneous views be carried out, the little patient will sink into a deep coma, and die, not indeed of hydrocepha- lus, but rather of pure exhaustion, or from serous effusion, the too fluid blood leaking out of the weakened vessels. Under all circumstances, therefore, of cerebral irritation, it is essen- tial for the medical attendant to inquire into the previous history of the patient. Discover whether the food of the child has been of such a quantity and quality as to sustain the increasing wants of the growing child. Examine whether it has been subjected to any exhausting dis- charges calculated to exhaust its nervous system and interfere with its nutrition. I have met with several cases of pneumonia in which the sympathetic disorder of the nervous system had induced so much cerebral disturb- ance as to mask the original disorder, all the remedies had been previ- ously directed to the brain, and as soon as the true seat of the disease was discovered the local depletion adopted for its treatment, superadded to that which under a misapprehension had been directed to the brain, were too much for the little sufferers to endure, and consequent symp- toms of cerebral disorder set in which were still supposed to be those of advancing disease. Too much caution cannot be exercised on this point, and my own experience leads me to apprehend that many a little sufferer is hurried to an untimely grave by the fear of acute hydro- HYDRENCEPHALOID. 175 cephalus, on the part of the physician, whilst in reality the opposite condition of things exists. As the diagnosis of this affection is obscure, and mistakes easily com- mitted which have the most mischievous results, where a doubt crosses the mind as to the nature of the case, an expectant plan of treatment would be more safe and judicious than any other, the mere abstinence from remedies, or a species of masterly inactivity in the case and al- lowing nature to act, often affording us a valuable hint as to the indica- tions to be pursued. When, however, our diagnosis is positively made out, there is no dis- ease which admits of more effectual prevention and treatment. As soon as the existence of any of the symptoms described is ascer- tained, the child should be put on good diet and all exhausting treat- ment immediately suspended, and tonics and stimulants should be given freely. The state of restlessness and irritability, so characteristic of this affec- tion, must be alleviated by means of anodynes. I have found it a judi- cious plan, as a general rule, to be guided by the state of the pupil ; in all cases where it is dilated, I administer sufficient doses of opium, or some of its preparations, to overcome this condition of the pupil ; the fluid extract of valerian and assafoetida, administered either by the mouth or rectum, have also an excellent effect in calming the nervous irritability. In administering opiates, a sufficient quantity, proportioned to the age of the patient, should be given to calm the excitability and produce sleep ; in smaller doses it is apt to excite, and by the want of sleep which it produces it may maintain, the very condition which we wish to combat. In the stage of coma, we must rouse the system by means of sina- pisms applied to the whole cutaneous surface, and by free administration of brandy and milk and also enemata of brandy water. In some cases of very great excitement, I have had great success with inhalations of small quantities of ether ; in one case particularly, where a little girl four years old, affected with this disease consequent upon a protracted pneumonia, screamed day and night incessantly, after having tried in vain anodynes, &c, I had recourse to the inhalation of thirty drops of washed ether dropped on a pocket handkerchief. The result was truly marvellous ; she fell into a deep refreshing sleep for three hours, and her convalescence progressed rapidly from that moment. Where tonics are required, I believe that there is no better combina- tion than a mixture consisting of the ammonio-citrate of iron and the sulphate of quinine. There is one point which must never be lost sight of, viz : that no kind of depletion must be used either directly by loss of blood or indi- rectly by exhausting purges. In cases where doubt exists as regards the affection, I have found that the employment of anodyne enemata, consisting either of laudanum or of the fluid extract of valerian soon produced such effects as to con- vince us positively of the form of the disease existing, and to justify us in pursuing a supporting and calming plan of treatment.] 176 INFLAMMATION OF THE BRAIN. CHAPTER VIII. INFLAMMATION OF THE BRAIN. — ENCEPHALITIS. — INDURATION AND HY- PERTROPHY. — SOFTENING. — ABSCESS. 242. Inflammation of the substance of the brain, as distinguished from meningitis, with which it is often partially complicated, is a very rare disease of infancy and childhood, and indeed its existence is chiefly proved by some of its terminations. And it is consequently difficult to separate the symptoms which characterize the period of inflammation from those, for example, which mark the occurrence of softening or of abscess. On this account the present description should be read in connection with the notice I shall presently give of ramollissement, &c. It does not appear peculiar to any exact age, but certainly is less frequent during infancy than childhood ; nevertheless I saw one case of a very young infant, the substance of whose brain exhibited traces of inflammation, and was extensively softened. 243. Symptoms. — The characteristics of encephalitis are much less vividly marked than those of meningitis : it is sometimes preceded by disordered health for some time, loss of appetite, deranged bowels, oc- casional headache ; or it may attack a child suddenly awaking out of sleep, trembling and frightened ; or in the daytime by headache, vom- iting, confusion, and more or less of stupor ; or it may commence by a violent convulsion ; or lastly, some defect of movement, or difficulty of speech, increasing to absolute loss of the power of articulation, as in M. Durand's case, 1 may be the earliest intimation of serious disease of the brain. The sensibility in some few cases is increased at the commencement, but soon diminished ; the eyes are heavy and the pupils dilated. The intellect is generally confused, and in some cases the patient is for a time delirious. More commonly, however, there is a degree of stupor ending often in insensibility. How far inflammation of one hemisphere, or of a portion of one hemi- sphere, may interfere with the phrenological functions of the organs there situated, and so with the mental manifestations, I am not prepared to say. 244. The convulsion may be repeated, or paralysis of one side (he- miplegia) may supervene, even during the early stage ; or the paralysis may be partial, and combined with involuntary movements, twitchings, or convulsions of other limbs. In some cases the limbs become pow- erless, and without muscular tone, so that, when raised and allowed to fall, they do so like the limbs of a dead person. 1 Rilliet and Barthez, vol. i. p. 656. INFLAMMATION OF THE BRAIN. 177 However slight the effect upon the muscular system may be, the powers of locomotion are affected ; irregularity and difficulty of walk- ing, want of equilibrium, the impossibility of standing, or sometimes of sitting, are symptoms commonly observed. Dr. Copland has remarked : " When cerebritis is general, these symptoms affect all the limbs simul- taneously ; when local, only some of them, according to the seat of the inflammation." 1 Occasionally, but much more rarely, the limbs, or some of them, be- come rigid, and much pain is experienced in attempting to straighten them. 245. The expression of the countenance is different from that in meningitis, seldom so acute or excited, generally pallid and anxious, or calm and pale, unless the muscles of the face be spasmodically affected. There is rarely much fever, the pulse is pretty quick and small, and in some cases is but little changed. Respiration is at first rapid and regular, but afterwards irregular and interrupted. The stomach is very frequently disordered, and vomiting, at least occasionally, is present. The bowels may be free or constipated. All these symptoms may be present when there is nothing but simple inflammation of the brain, nay, the disease running on into stupor and coma may end fatally, leaving no other traces in the brain than those of inflammation ; but in the majority of cases the disease is not thus arrested : it continues longer, new symptoms are developed, indicating further disorganization, and the disease terminates either in, 1, indura- tion and hypertrophy ; 2, softening ; or, 3, abscess. 246. A post-mortem examination reveals considerable congestion of all the vessels of the brain, especially of the pia mater, and a minute vascular condition of the brain generally, or of some part of it. In almost all cases, moreover, we find evidences of a more advanced state of disease, to which I shall refer by and by. 247. Causes. — All the causes which act upon the nervous system, as enumerated among the causes of meningitis, appear capable of pro- ducing encephalitis. There are some local affections which have been followed by the latter disease, and which I must not omit to notice. In a case quoted in Rilliet and Barthez, the child, aged nine years and a half, had shortly before suffered from purulent ophthalmia, by which she lost an eye, and it seems probable that this may have had some share in the subsequent cerebral attack. Other cases are on record, in which inflammation of the brain has followed disease of the ear. Dr. Abercrombie mentions a case of in- flammation and abscess, which came on in a boy who had been two months affected with headache and discharge from the ear ; and others have recorded similar cases. 248. Diagnosis. — I do not know of any symptoms sufficiently pa- thognomonic to enable us to pronounce with certainty that the sub- stance of the brain alone is affected by simple inflammation. The more 1 Diet, of Med., Part i. p. 231. 12 178 HYPERTEOPHY AND INDURATION OP THE BRAIN. rapid loss of voluntary power, the earlier occurrence of paralysis and stupor, and the inferior amount of excitement, mark certainly a differ- ence between the present disease and meningitis ; but although the history of the two diseases varies a good deal, the differences are not very characteristic. 249. Treatment. — However difficult it may be to distinguish between this and other cerebral diseases, there can be no doubt in any case that the brain is affected, and by an inflammatory disease, so that our plan of treatment is pretty clear. Abstraction of blood by leeches or venesection is essential at an early period of the disease, and the quantity must be regulated by the constitution and strength of the patient, and the intensity of the disease. Qseteris paribus, however, I do not think that excessive blood- letting is so necessary in this disease as in meningitis ; but if the symptoms continue unmitigated, the leeching should be repeated. Counter-irritation, by iodine frictions or by blisters to the head, neck, or behind the ears, will also be necessary, and it will be well to dress the blister with mercurial ointment, for our great object should also be to bring the system under the influence of mercury. Calomel, or the hyd. c. creta;, may be given in moderate doses frequently, combined with the pulv. cretee c. opio, if the bowels are too freely affected, and continued until either the gums are tender or mercurial stools produced. If the bowels are constipated, purgatives will be necessary. The diet should be mild and unstimulating during the period of in- flammation ; it may be increased when other symptoms set in, if the child can swallow. We shall now proceed to treat of the terminations of encephalitis, and first of I. HYPERTROPHY AND INDURATION OF THE BRAIN. 250. I must candidly inform my readers that there appears consi- derable doubt in the minds of pathologists as to whether hypertrophy and induration are the result of inflammation: the disease is rare, and generally obscure, and it is not easy to trace its origin, but, judging from analogy of other organs, I am inclined to regard it as the result of inflammatory action. Hufeland remarks, that any cause which gives rise to congestion of the brain may also cause hypertrophy ; and Laennec, who was one of the first to describe the disease, remarks : " It has happened to me to see several cases, which I considered internal hydrocephalus, but which, on a post-mortem examination, presented but a small quantity of water in the ventricles, although the flattened con- volutions of the brain proved that this viscus had undergone a degree of compression which could only be attributed to excessive size and consequently to too active nutrition of the cerebral substance." 1 The disease has not been long known, and we are indebted for our 1 Rilliet and Bartkez, Mai. des Enfans, vol. i. p. 654. HYPERTROPHY AND INDURATION OF THE BRAIN. 179 information chiefly to the researches of Scouttetten, Jadelot, Laennec, Eouillaud, Andral, Miinchmayer, Papavoine, Sims, Green, Lees, Mauth- ner, &c. 251. Mauthner has taken the trouble to weigh the brains of 216 children, of all ages, from birth up to the eighth year, so as to show the gradual and healthy increase of the organ. " During this time," says he, " we find a minimum of ten ounces, six drachms, rise to a maximum of forty-four ounces and a half. The average weight begins with thir- teen ounces and a half, and rises to thirty-five ounces and a half. During the first year it grows from thirteen ounces and a half to twenty ounces and a half, or seven ounces ; in the second, from twenty ounces and a half to twenty-five ounces and a half, or five ounces ; in the third, from twenty-five ounces and a half to thirty-two ounces, or three ounces and a half. Hence it appears that the brain grows most rapidly in the first year of life, that in the second and third years its increase is still consid- erable, but that its growth is slower after the fourth year. In conclu- sion, it may be observed, as a remarkable fact, that the minimum weight usually occurs in cases of atrophy or phthisis, and the maximum in pneu- monia, scarlet fever, apoplexy, and cerebral tubercle." 1 It also appears that the weight is to a great degree dependent upon the amount of blood contained in the brain. 252. Symptoms. — The early period of the disease is marked by dul- ness, drowsiness, or apathy, with an apparently excessive size of the head. There is generally irritability of temper, giddiness, and habitual headache, with severe exacerbations. 2 In passive hypertrophy, M. Mauthner remarks that the shape of the cranium is much changed, and the occiput occasionally prominent and globular; the parietal protuberances subsequently project; the coronal and sagittal sutures continue unossified up to the ninth or twelfth month, and the fontanelles much longer ; the growth of hair is scanty, and the veins of the scalp swollen. The child sleeps much, though easily startled; the head perspires a good deal, and droops forward by its weight. Attacks of crowing inspiration occur when the child cries, and not unfrequently end in convulsions, especially during the period of dentition. The digestion is impaired, and vomiting and diarrhoea are frequent. Gradually we find symptoms of compression developed, or they may suddenly appear as the result of the child being attacked by some other disease. "When hypertrophy of the brain has reached this stage, the skull deviates still more from its natural shape, the forehead sometimes be- comes prominent and globose, like the occiput, and while the skull goes on acquiring an increased curvature, the region of the temples continues flat, and thus contributes to give to the head the appearance of being formed by the union of the segments of four spheres. During this stage of the affection, the preternatural softening and thinning of the cranial bones corresponding to the prominences of the convolutions, are dis- tinctly perceptible, especially at the occiput. The functions of the brain 1 British and Foreign Review, No. 42, p. 387. 2 Condie, Diseases of Children, p. 383. 180 HYPERTROPHY AND INDURATION OF THE BRAIN. become now much disturbed ; headache, giddiness, impairment of muscu- lar power, and loss of memory, occur ; the child grows sullen, peevish, sleepless, whimpers continually, and rolls the head constantly from side to side. At the same time it seems choked with phlegm, while the skin becomes every day more flabby, the muscles shrink, the bones grow soft, and the muscular power rapidly diminishes. Hence these children usu- ally lie on the back, breathing with habitual wheezing, and suffering from constant dyspnoea, with occasional asthmatic seizures, such as have been already described. When in this condition slight causes suffice to produce a general excitement of the vascular system, and to excite dis- eased action in other parts, which render still more obvious the influ- ence of hypertrophy on the nervous system generally. If the child happen to catch a slight cold, attacks of convulsions, cough, or of asthma, occur in consequence, or convulsions come on, which terminate life in a few days." 1 253. When the disease is active (according to Mauthner), i. e., when the walls of the skull do not yield in proportion to the increase of the brain, the symptoms are those of more acute cerebral disease, the result of compression. There is also some modification of the symptoms, where the hypertrophy and induration are partial, according to the peculiar locality. Further, symptoms resembling those of hypertrophy, but very severe, have been noticed, where the skull is ossified and unu- sually thick, and does not yield to the increasing size of the brain. The intellectual faculties are generally enfeebled, but Dr. Elliotson relates a case in which they were rather increased in activity and power, and Dr. Condie mentions a child of five or six years old, whose head was as large as an adult's, and Avhose intellects were clear and acute. 2 This may be expected, if at all, in cases of such enlargement ; as the intellectual disturbance and many of the symptoms are the result of compression rather than of hypertrophy. The size of the head will vary a good deal, the younger the child the more distensible the cranium. Dr. Munchmayer 3 has noticed a peculiar prominence of the parietal protuberances, and this observation has been confirmed by Dr. Lee, who regards the symptom as a valuable distinc- tion between hypertrophy and chronic hydrocephalus. 4 The other symptoms especially noted by Dr. Lee in his cases were obtuseness of intellect, apathy, great irritability and excessive appetite. 254. Drs. Sims and Green have noticed a sensation of firmness com- municated to the finger when the pressure is made upon the fontanelles, and regard this as a valuable diagnostic sign. Andr.al observed mania to occur in one case ; others have noticed delirium, and some idiocy, with a repetition of fits like epilepsy. The duration of life in children thus affected is subject to great variation. Some arrive at puberty with but little inconvenience ; but many die during childhood from the consequences of the hypertrophy, 1 Mauthner., p. 174. British and Foreign Review, No. 42, p. 388. 2 Diseases of Children, p. 883. 3 Schmidt's Jahrbucher, vol. xxv., 1840. A Dublin Journal, vol. xxii. p. 24. HYPERTROPHY AND INDURATION OF THE BRAIN. 181 such as convulsions, &c, or from states of the brain superinduced by other diseases. 255. Patliology. — The change in the brain which strikes the eye at once is its increased size in most cases, and the evident flattening of the convolutions, diminished vascularity, and the absence of serum in the ventricles or at the base of the brain. When the head is much enlarged, the alteration in the consistence of the brain may not be very remarkable, although in general it will be found more dense than usual. But when the cranium has been ossified, or has not yielded to the pres- sure of the brain, the cerebral tissue will be found firm and elastic to the touch, and, cutting clear by the knife in thin slices, the gray matter paler than usual, and the white matter more brilliant. Or it may be still more firm, and offer some resistance to the knife or to pressure. Its weight is greatly increased, sometimes even doubled. "Professor Rokitansky states, as the result of many microscopic examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the enlargement of those already existing, but by an increase in the intermediate granular matter." 1 According to Sims and Rilliet and Barthez, the hypertrophy and induration may be limited to the corpora striata or optic thalami, or to one lobe of the brain, which, of course, will condense the parts in its neighborhood more or less. The membranes of the brain are sometimes pale, sometimes injected, and distended so tightly by the brain that when an incision is made the brain protrudes. M. Mauthner has remarked a frequent coincidence of enlargement of the thymus gland, the left side of the heart, and the liver, thus affording some support to Munchmayer's theory of the connection of thymic asthma with hypertrophy of the brain. 256. Causes. — Hypertrophy of the brain, or at least a condition of that organ strongly predisposing it to undue and more or less rapid augmentation of bulk, is very frequently congenital. All causes which give rise to cerebral congestion may, according to Hufeland, determine hypertrophy of the brain. Laennec, Papavoine, Rilliet and Barthez, mention an extraordinary and inexplicable effect of the preparations of lead in producing this disease ; but I do not find it mentioned by other authors. 2 Dr. Lee regards the disease as " dependent upon or connected with struma." 257. Diagnosis. — It is not very difficult in most cases to distinguish hypertrophy from acute hydrocephalus ; not because the symptoms of the former are so very clear, but because those of the latter are gene- rally sufficiently marked. Their acute inflammatory character, the high fever, quick pulse, and the sequence of symptoms, are very unlike hypertrophy. Chronic hydrocephalus has more resemblance to it, and especially in 1 West's Lectures, Medical Gazette, August 27, 1847, p. 354. 2 Mai. des Enfans, vol. i. p. 665. 182 HYPERTROPHY AND INDURATION OP THE BRAIN. the most obvious characteristic, enlargement of the head. Mauthner has thus marked the points of difference : " In hypertrophy, the poste- rior part of the skull first presents an unnatural prominence. In chronic hydrocephalus, the forehead is the first part to present unnatural pro- minence. The altered direction of the eyes, and the very great width of the sutures and fontanelles, are likewise characteristic. In hyper- trophy, children lie horizontally, or throw the head back. In chronic hydrocephalus, children lie on the belly, with the head lower than the rest of the body, burying the face in the pillow. In hypertrophy, the face is puffy, the eyes inexpressive and staring, mouth half open. In chronic hydrocephalus, the countenance is withered, having the expres- sion of premature old age. In hypertrophy, functional disturbance comes on very gradually, not before the period of dentition or weaning, and consists at first in an affection of the respiratory apparatus, difficulty of breathing, and attacks of apncea. In chronic hydrocephalus, func- tional disturbance occurs early, and involves the cerebrum from the very beginning. In hypertrophy, the patient is fat and leucophlegmatic. In chronic hydrocephalus, the patient is ill nourished, subject to rickets and tabes mesenterica." 1 Add to these, the projection of the parietal protuberance, observed by Drs. Miinchmayer and Lee, which is not observed in chronic hydro- cephalus. 258. Prognosis. — The prognosis is in all cases serious, not so much from the dangerous character of the disease as from the effect pro- duced upon the brain by other causes, and its increased susceptibility to disease. There is more hope when it occurs before the sutures are ossified, and when the cranium yields readily to the increasing mass of the brain. When the skull is resisting, the result of compression may be fatal. At the same time, as Dr. Lee has observed, in the majority of cases, the post-mortem appearances do not throw much light upon the cause of death. 259. Treatment. — When the disease is fully confirmed, there appears to be no means capable of reducing the volume of the brain ; and our principal efforts must be directed to guard against any attacks of con- gestion or inflammation, by means of leeches, cold lotions, purgatives, and counter-irritants. But, when the disease is commencing, we ought to prohibit everything which tends to produce excitement or determination to the brain. Quiet, rest, and tranquillity of temper should be observed, cold sponging of the scalp, and occasional purgatives. The hair should be cut short, and the head kept uncovered in the house. I do not know that iodine, either internally or externally, has been administered ; but it appears to me well worth a trial, in connection with other counter-irritants ; or the scalp might be painted with tincture of iodine at the same time that hydriodate of potash is given internally. The appetite, which is generally too good, should be restrained as to the quantity of food, and that not too nutritious in quality. The 1 British and Foreign Medical Review, No. 42, p. 389. RAMOLLISSEMENT OF THE BRAIN. 183 moment the gums become irritable they should be lanced, and the child should take plenty of exercise in the open air. Education must be carried on at a moderate rate, so as not to stimu- late the intellect too highly ; and it may be necessary to suspend it entirely at times. When the affection results from saturnine poisons, we are recom- mended to employ bloodletting, opium in large doses, cold applications, and evacuants, &c. II. RAMOLLISSEMENT, OR SOFTENING. 260. There can be no doubt that encephalitis frequently terminates in softening, 1 even if we admit that the latter may occur independently of the former, as in some cases of hydrocephalus already noticed, and in other cases of old standing disease of the brain (tubercles, for instance), when the neighboring tissue is softened and pulpy. These are instances of secondary ramollissement. 261. It does not appear that there is any symptom which positively indicates the occurrence of this lesion. Some French writers have regarded tonic contraction of one or more limbs as pathognomonic, and no doubt it frequently occurs ; but it is frequently absent, and it is also met with in other affections of the brain. In most cases, we have con- vulsions, paralysis, and coma as the principal symptoms ; sometimes a single convulsion, followed by coma ; in other cases, the convulsion is repeated. Occasionally, the loss of power is the most remarkable symp- tom succeeding the evidences of encephalitis just noticed ; sometimes the rigid contraction already mentioned, followed by relaxation and paraly- sis. Or there may be convulsion of one side of the body and paralysis of the other. In a case of M. Deslande's, quoted by Barthez and Rilliet, the child exhibited a slight but continual stupor, was very easily disturbed, and died without an additional symptom. In other cases, the coma is deep and permanent until death. In a few examples, not remarkable for any evidences of disease, the child has died suddenly during the night. We generally find complete loss of intelligence, as of voluntary motion ; the pulse is sometimes nearly natural, in other cases quick or irregular, and there is occasional vomiting. In one case, already quoted, the speech was impeded from the begin- ning, and ultimately rendered impossible — a fact which Dr. Abercrombie has noticed in adults. In some cases, there is squinting and retraction of the head. It is probable that softening of particular portions of the brain is attended by appropriate symptoms ; but it is excessively difficult to determine this point. I have seen a case of ramollissement of the cerebellum, the effect of inflammation caused by a fall, and which gave rise to very few symp- 1 Abercrombie on Diseases of the Brain, p. 128. 184 ABSCESS OP THE BRAIN.' toms, and those not characteristic. Frequent paroxysms of headache, vomiting, and loss of appetite ; but neither impaired intellect nor mus- cular power, and no affection of the bladder or genital organs. The pulse was quiet, the tongue clean, and there was no convulsion. 1 262. Pathology. — Ramollissement, as Dr. Abercrombie observes, " consists in a part of the brain being broken down into a soft pulpy mass, retaining the natural color of the part, without any appearance of suppuration, and without fetor. This condition we often find as the only morbid appearance; but we frequently find it combined with the former (evidences of inflammation), one portion of the diseased mass presenting the deep red color, while another is in the state of ramollissement." 2 The color of the softened mass is sometimes yellow. All such cases, Rilliet and Barthez think, are the result of secondary inflammation or softening. The consistence and extent of the softened portion vary much. It may be reduced to a kind of jelly or pulp, but without destroying the form of that part of the brain ; or it may be utterly disorganized, and fluid, or semi-fluid, like cream. So we may find it of small extent, limited to a portion of the brain, or occupying the greater portion of an hemisphere. Mauthner has observed that the white substance is almost always the seat of the disease in children, the gray matter being seldom affected. The disease is almost uniformly fatal, and of very short duration. 263. The diagnosis is necessarily obscure. We may know that inflam- mation of the brain exists, and we may suspect that softening is taking place ; but that is nearly the only conclusion to which we can attain. The sudden paralysis, especially when combined with convulsion, the loss of the power of articulation, or the complete resolution of muscular force, appear to be more characteristic than any other symptoms. 264. The fact that we cannot recognize with any certainty the dis- ease during life, that all the cases on record died, will at once explain our ignorance of any efficient mode of treatment. I have laid down the best mode of management for encephalitis; but I have no additional information to give as to any change of remedies required by this ter- mination. If the leeching, counter-irritation, and mercury have not secured the patient against this consequence of inflammation, we know not how to afford relief. III. ABSCESS OF THE BRAIN. 265. In this affection, we find, according to Dr. Abercrombie, " a well-defined regular cavity, filled with purulent matter, generally lined by a soft cyst, and surrounded by cerebral matter in a healthy state." 3 So few cases are on record that it is impossible to give a general description of the disease without calling in the aid of the imagination. I think it better, therefore, to quote two cases from Dr. Abercrombie's excellent work than to attempt any more formal statement. 1 Dublin Journal, July, 1853. 2 Diseases of the Brain, p. 72. 3 Ibid. ABSCESS OF THE BRAIN. 185 The first occurred in a girl set. 5, and the case is described by Dr. Bateman. 1 "An abscess was found in the posterior part of the right hemisphere, inclosed in a fine vascular sac, and containing four ounces of pus. She was first affected with convulsion of the whole body, which continued for nearly two days ; during this time the left side was in a state of rigid extension, and the right was in constant motion ; and when the attack subsided the left side remained paralytic. She then had headache, squinting, blindness, and repeated convulsions ; and died after an illness of eleven weeks, having been comatose for only one day before her death. In some cases of this kind paralysis has occurred without convulsion, and in others convulsion without paralysis ; but one or other of these affections appears to be a common attendant on the encysted abscess." 2 266. The next case I shall quote is that of a " girl set. 11, thin and delicate, who, after having complained for some days of headache, was seized on the 11th of January, 1817, with convulsion, which continued for about half an hour. I saw her on the twelfth, and found her affected with severe headache and paralysis of the right arm, which had taken place immediately after the convulsion. The pulse was 100, the tongue foul, the face rather pale, and the eyes languid. Being bled from the arm and purged, she was much relieved. On the 13th the pulse was natural, the headache was much abated, and she had reco- vered considerable motion of the arm. On the 15th, the headache being increased, and the arm more paralytic, she was bled again ; and on the 16th and 17th she was much relieved, the pulse natural, and the motion of the arm much improved. On the 18th, after being affected with increase of headache and some vomiting, she became convulsed, the convulsion being confined entirely to the head and the right arm. The head was drawn towards the right side, with a rolling motion of the eyes ; the arm was in constant and violent motion ; she was sensible, and complained of headache ; pulse 100. Being bled to oviij, the convulsion ceased instantly, and the headache was relieved, but the right arm continued in a state of complete paralysis. 19th and 20th, the arm had recovered a little motion ; some headache continued, with occasional vomiting ; pulse 60. On the three following days the con- vulsive attacks returned several times ; they did not now affect the head or face, but were entirely confined to the right arm, which after the 23d was left in a state of permanent paralysis. Hitherto no other part of the body had been affected by the convulsion, but on the 24th it attacked the right thigh and leg, and left them in a state of paralysis ; pulse 60. The former remedies were again employed with activity, without any effect in arresting the progress of the disease. The thigh and leg now went 'through a course precisely similar to that described in regard to the arm, and on the 29th remained in a state of perma- nent paralysis. When the convulsion first began to affect the leg, the arm was affected at the same time; but afterwards it was confined to the thigh and leg, the arm remaining motionless. February 4. — Com- 1 Edinburgh Medical and Surgical JourDal, vol. i. p. 150. 2 Abercrombie on Diseases of the Brain, p. 111. 186 TUMORS OR TUBERCLES OF THE plete paralysis of the whole right side ; no return of convulsion ; she continued quite sensible, and made little complaint : pulse from 50 to 60. She now continued for several days without any change, and, except the palsy of the right side, every function was natural. She was quite sensible, appetite good, pulse and vision natural, and she made little complaint of any uneasiness. She was, however, inclined to lie without being disturbed, and gradually became more oppressed. On the 11th this had increased to perfect coma, in which she continued for three days, and died on the 14th. " Inspection. — In the upper part of the left hemisphere of the brain there were two distinct, defined abscesses, containing together from six to eight ounces of very fetid pus. They were lined by a firm white membrane, and a thin septum of firm white matter separated them from each other ; the one was in the anterior part of the hemisphere, very near the surface, and the other immediately behind it. They had no communication with each other, or with the ventricle. In the pos- terior part of the right hemisphere there was a small abscess containing about half an ounce of pus. There was no serous effusion in any part of the brain, and no other morbid appearance." 1 CHAPTER IX. TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. 267. Besides the tubercular disease of the membranes of the brain already described (182), we find larger and more isolated deposits of the same matter, or tumors of a different kind, growing from the mem- branes or imbedded in the substance of the cerebrum, cerebellum, and spinal marrow, attended by symptoms which indicate their presence but very obscurely, and having almost always a fatal termination. This form of disease is not very common, though more frequent than was suspected, until the more accurate researches of late years by Green, Barrier, Rilliet and Barthez, West, &c. It occurs too at an earlier age, for of thirty-four cases mentioned by Barrier, sixteen were under five years ; thirteen from five to ten ; and five only from ten to fifteen years. Of Dr. Green's thirty cases, in thirteen it occurred be- tween two and four years ; and in seventy-five cases he states that it occurred most frequently in children from three to seven years. Of Rilliet and Barthez's twelve cases, six were from three to five years ; four from six to ten and a half; and two from eleven to fifteen years ; and eight were boys. Dr. Condie considers it very rare before the first year. Dr. Mauthner found, in seventeen out of thirty-two, that the age did not exceed six years, which was the case in seven out of eight cases observed by Dr. West. On the other hand, it is very rare in adults, according to Cruveilhier, Louis, and Lugol. 1 Abercrombie on Diseases of the Brain, p. 93. BRAIN AND SPINAL MARROW. 187 The sex of the child does not appear to have any influence in the production of the disease ; the majority of Dr. Green's cases were fe- males ; the majority of Rilliet and Barthez's cases males. 268. Symptoms. — Dr. Abercrombie has observed, with great truth, that " the symptoms accompanying tubercular disease of the brain in its early stages, are often exceedingly obscure and variable ; perhaps little more than a tendency to headache, which assumes no formidable character, or sometimes assumes the appearance of what has been called the periodical headache, or the sick headache. The symptoms may go on for a long time in this manner without exciting any alarm, until the disease suddenly assumes a more active character, and is lily fatal." 1 In five of Dr. Green's thirty cases, there was no symptom at all of cerebral disorder ; in three, headache was the only symptom ; in one, deafness ; and in one, a purulent discharge from the ear. Moreover, we find it extremely difficult to draw the line between the symptoms which arise from the tumor simply, and those which are the result of the morbid action which it provokes in the neighboring tissues. Headache is, perhaps, the most universal symptom ; it may be either general or local, but in the latter case it does not necessarily mark the seat of the disease. In general it is also an early symptom, and corre- sponds with the remissions and accessions of the constitutional disturb- ance ; it may continue even until death. In more cases it is absent at the commencement, and is noticed only at an advanced period of the disease. 269. The organs of sense are generally more or less affected ; the touch the least so, however. Occasionally, at first, it seems more acute, but subsequently less sensitive, especially when the tumors are seated in the cerebellum, or near the sensitive nerves. M. Barrier mentions a case in which there was paralysis of the trifacial nerve of the right side, in consequence of the tumor pressing upon the fifth pair of nerves. 2 The eye and ear will be similarly affected by the pressure of the tumor in the neighborhood of their spinal nerves, and more or less by the general disturbance of the nervous system, from cerebral tumors. Amaurosis and deafness are not uncommon ; and it is, perhaps, Worth noting, that in a certain number of cases there is a discharge from the ear, or an abscess of that organ, 3 but whether connected, as cause or effect, with the tubercles, it is not easy to say, but as yet I am inclined to think not. 270. During the early stage of the disease, and so long as it is un- complicated, there is rarely much disorder of the intelligence. In some cases, it is true, the temper becomes irritable, especially if the headache is severe ; or perhaps the child may lose its natural vivacity, and be- come apathetic and dull, weary of play, and wishing to be alone. At a more advanced period of the disease, even when uncomplicated, 1 On Diseases of the Brain and Spinal Marrow, p. 167. 2 Mai. de l'Enfance, vol. ii. p. 630. 3 Dr. Green, Med. Cliir. Trans., vol. xxv. p. 193. Abercrombie on Diseases of the Brain, &c, p. 171. 188 TUMORS OR TUBERCLES OF THE , so far as we can ascertain, there gradually steals over the countenance an expression of mental feebleness and vacuity ; the child is indisposed to intellectual exertion, even if not actually incapacitated. In propor- tion as morbid actions (meningitis, encephalitis) are excited by the tumors, we find the mind exhibit the same disturbance as is usual in these disorders. 271. Convulsions are by no means uncommon, though not universal ; they pretty constantly occur in those cases where the tubercles occupy the central portion of the brain, or are disseminated extensively through- out. Rigidity or contraction of one or more of the extremities is more common ; it generally affects the leg and arm of the same side, some- times only one limb, and very rarely both upper or both the lower limbs. It is not easy to determine whether it be referable directly to the pres- sure of the tumors, or whether it be the result of the inflammation and induration, or softening of the surrounding cerebral substance (261). Or perhaps we may observe a weakness of certain muscles, as in a case of Dr. Green's, where the eyeball was convulsively jerked inwards, or in other cases, in which strabismus occurs. In the majority of cases, paralysis occurs at some period of the dis- ease ; at the commencement in a few, and at a more advanced period in most instances. It may be partial, the result of local pressure, or affecting generally the sensation and motion of one side. It is remark- able that although the child may recover partially and for a time from the affection of the eyes and ears, from the rigidity and deficient sensi- bility ; the paralysis is permanent in almost every case in which it occurs, and continues without mitigation. 272. The stomach and bowels generally sympathize with the cerebral irritation, and, coincident with the headache, stupor, or coma, we find vomiting to occur; and constipation, sometimes easily overcome, but in other cases very obstinate. The circulation is generally affected, but in an uncertain manner ; the pulse is sometimes slow, sometimes quick ; in other cases very un- equal. My friend Dr. Chas. Johnson attaches great value, as a pathog- nomonic sign, to irregularity of the pulse, occurring at an early period of the disease, and without apparent cause. So far the symptoms may be considered the result of the tubercles alone, and they do not differ, whether the seat of the tumor be the cerebrum or cerebellum ; and they may persist, with intermissions or remissions of varying duration, for a considerable time, and then the child gradually sinks into stupor and coma, and at length dies. Or, which is more frequently the case, a secondary affection, meningitis or encephalitis, may be excited, giving rise to the symptoms formerly described, and masking the proper cha- racteristics of the present affection, and proving certainly fatal. Some cases have terminated in chronic hydrocephalus when the tumor has been so situated as to press upon the large veins or sinuses, or to offer considerable mechanical interruption to the circulation. Nine of Dr. Green's cases died with symptoms of acute hydrocephalus, and a few with those of softening of the brain. In many cases there are tubercular or scrofulous affections of other organs, which are of value in forming a diagnosis. BRAIN AND SPINAL MARROW. 189 273. The duration of the disease is very difficult to be determined ; the tumors may be latent for a long time ; the early symptoms are slight and undefined, and even when marked, they are common to other diseases, or occur frequently without any diseases at all. Dr. Green remarks that in his cases the chronic stage varied from six weeks to two years. Rilliet and Barthez state that of twenty-five cases of tubercles with or without chronic hydrocephalus, the disease lasted in 3 cases from 3 to 4 months. 10 " 5 to 7 3 " 7 months to 1 year. 2 " 1 year to 2 years. 3 cases for several years. And the termination is uncertain, generally occasioned by a secondary complication, and more quickly than would have happened from the simple disease. I have already spoken of the complications, but as they are of great importance I may as well enumerate them again. 1. Meningitis, either the simple acute or the tubercular form, not unfrequently the latter, and not unnaturally owing to the tubercular cachexia. 2. Inflamma- tion of the substance of the brain, with (probably), first, some degree of induration, and thenramollissement. 2. Effusion of fluid into the ventri- cles, distending them, and compressing the brain, and constituting a simple form of chronic hydrocephalus. 4. Scrofulous or tubercular disease of the chest or abdomen, becoming active, and in its effects superseding the disease of the brain or cerebellum. 274. Pathology. — Tumors of the brain and cerebellum are of different kinds. Dr. Monro mentions a hard tumor of a dirty yellow color growing from the innersurf ace of the dura mater, 1 and occasionally imbedded in the brain ; scrofulous, adipose, scirrhous, and ■ encysted tumors, but they are very rare in children, with the exception of the scrofulous or tubercular. Constant found that in four years, at the Hopital des Enfans, he met with but three kinds of tumors of the brain — tubercles, cancer, and acephalocysts, and that the frequency of the first, compared with the latter, was as 40 to I. 2 Dr. Abercrombie described a tumor compressing the brain, which was formed of a "mass of pellucid albuminous matter," lodged under the arachnoid; "it resembled much the albumen of an egg, but was much firmer, so that pieces of it could be separated from the mass, and lifted up. Parts of the mass, being thrown into boiling water, became imme- diately opaque and coagulated." 3 275. But by far the most common kind of tumor of the brain in children consists of deposits of tubercular masses, varying in size from a pea to a hen's egg, and in number from one to fifty. 4 The character of these masses is that of the ordinary tubercular matter ; we often find 1 On the Morbid Anatomy of the Brain, p. 45. 2 Gazette Medicale, 1836, p. 487. 3 Diseases of the Brain, &c., p. 178. 4 Dr. Green, Med. Chir. Trans., vol. xxv. p. 199. 190 TUMORS OR TUBERCLES OF THE them in a crude state, or perhaps softened in the centre, 1 generally very firm, yellowish or greenish in color, less friable than tubercles in the lungs or lymphatic glands, and in appearance like Gruyere cheese. Their form is generally globular, with irregular surfaces; oc- casionally, however, the shape is modified by pressure, or by the junc- tion of several smaller masses. It has been a matter of dispute whether they possess a regular cyst, but the general opinion seems now to be that they do not, but that the appearance of cellular membrane between them and the central substance is either the remains of the pia mater, or irregular unconnected shreds of cellular membrane. Barrier remarks that whenever a well-marked cyst exists, it always surrounds an ancient tumor suppurated in the centre. The tumors are generally situated in the cellulo-vascular tissue of the pia mater, and as they increase they depress the substance of the brain or cerebellum, and, as it were, bury themselves in it, except at one point, where they are adherent to the membranes. In other cases, but by no means frequently, they are formed actually in the cerebral substance, unconnected with the membranes. The tubercles may occupy either hemisphere of the brain, or both, the cerebellum or the pons Varolii, or we may find them in more than one place in the same case. Dr. Green observes: "In the thirty cases contained in my table, the tubercular deposit existed eleven times in the hemisphere of the cerebrum, nine times in the cerebellum, seven times in the cerebrum and cerebellum together, and twice in the cerebellum and pons Varolii together. I have, however, notes of two cases in which the tubercle was confined to the pons Varolii. 276. So much for the tumors themselves ; but as a careful analysis shows that the more marked symptoms, especially in the more advanced stage of the disease, arise rather from morbid conditions of the sur- rounding brain or membranes than from the mechanical pressure and irritation of the tumor, it is of great consequence to notice these condi- tions. In some rare cases no change could be detected in the mem- branes of the brain, but in the majority there are decisive evidences of inflammatory action. The membranes may be thickened or injected, and adherent to the cortical substance, and simple or puriform fluid effused. The surrounding cerebral structure may be injected and soft- ened, but superficially, or the softening may be extensive and deep, with evidences of inflammation 2 or without. In some rare cases the surround- ing substance is fuller and more firm than usual, as if slightly indurated ; in others it appears hypertrophied. Lastly, the ventricles are some- times largely distended with fluid, as in chronic hydrocephalus, the con- sequence, most probably, of mechanical obstruction to the circulation, occasioned by the pressure of the tubercles. 277. Causes. — No doubt the deposit of tubercle in the brain depends upon the same state of constitution which occasions its presence in the lungs or any other organ, and beyond this we know little or nothing. There must be some peculiar cause, certainly, for its greater frequency in children than in adults; for whilst Cruveilhier, Louis, Lugol, and 1 Monro, Morbid Anatomy of the Brain, p. 51. 2 Moncrieff's case in Monro on Morbid Anatomy of Brain, p. 51. BRAIN AND SPINAL MARROW. 191 Abercrombie afford testimony to its rarity in adults, Dr. Green found it once in every fifty-one cases out of 1824 admitted into the Children's Hospital ; and the testimony of Barrier, Constant, Rilliet and Barthez, &c, confirms this fact. Scrofulous diathesis, hereditary predisposition, and age, therefore, all appear to aid in determining the deposits of tubercular matter in the brain, and this is really all our positive know- ledge of the subject. 278. Diagnosis. — After the description I have given, I need hardly say that the diagnosis of tubercles, or tumors of the brain, in children, is extremely difficult, not only from the absence of any very character- istic symptom, but from the irregularity and distance of the symptoms which do arise. In general we can only arrive at a presumption by carefully collating all the symptoms, their sequence and relation, with the history, habits, and constitution of the patient. My friend, Dr. Charles Johnson, relies much upon the occurrence of irregularity of the pulse at an early period, when other symptoms which might explain it are absent. The most common and best marked symptom is the headache, which is either persistent or in paroxysms, and often circumscribed, to- gether with emaciation, without apparent organic disease. But it may be months before any other decided evidence of cerebral disease is de- veloped. Dr. Adams mentions scrofulous habit, paroxysmal headaches, vomiting, convulsions, muscular tremors and weakness of the limbs, with variations in the pulse, as the principal diagnostic symptoms. "When, however, a child has suffered for some time from severe headache, when the headache is followed by convulsive movements, some paralytic affec- tion, amaurosis, contraction of muscles, occasional vomiting, accesses of fever, and the train of symptoms already mentioned, and when these symptoms succeed each other at various intervals of weeks or months, we have very great reason to believe that the child has tubercle of the brain." 1 M. Rilliet founds his diagnosis of cerebral tubercle upon the follow- ing general considerations: 1. The age of the child, the disease being much more frequent after than before the age of three years. 2. The circumstances which preceded the attack, and particularly the causes under the influence of which the disease was developed. 3. The state of health at the period of invasion. 4. The primary symptoms, as con- vulsions, lancinating headache (continued or intermitting), paralysis, amaurosis, and much more rarely, rigidity. 5. Lesions of the cranial parietes, exophthalmia, nasal or auricular discharge coinciding with cere- bral symptoms, or having been preceded by continued vomiting. 6. The chronic progress of the symptoms, for time alone will sometimes discover the nature of the disease. Chronic symptoms with reference to motility are more to be depended on than disorders of the intellect. 7. It is necessary to keep in remembrance the great frequency of tuber- cular disease in childhood and the infrequency of other kinds of chronic cerebral disease. 279. Still more difficult is it to determine the locality of the tumor; certainly the pain is often limited and fixed in one spot, as, for example, 1 Dr. Green, Med. Chir. Trans , vol. xxv. p 207. 192 TUMORS OR TUBERCLES OF THE at the occiput when the tumor is in the cerebellum, and in some cases it has suffered for a direct diagnosis; but it is by no means certain; the pain is often too general, and when localized it has been found not to correspond with the seat of the tumor. The pressure of the tumor upon some spinal nerves, or origins of nerves, may give rise to symptoms which explain their source, but these cases are very rare. In like manner the symptoms which arise when the tumor is seated in the spinal cord possess more peculiarity, as we shall see presently. As to our distinguishing between different kinds of tumors, all we can effect is a calculation of probabilities. We have the evidence of M. Constant, already quoted, that tubercles are forty times as frequent as any other tumor of the brain in children ; and if, in addition, we can ascertain the presence of scrofulous diathesis, the presumption will be altogether in favor of tubercle. 280. The prognosis is, in all cases, unfavorable. Almost all die, either of the wasting and suffering caused by the tubercle, or of some cerebral disease excited by it. Yet neither can we say that tubercles are absolutely incurable, for there is evidence that they may be arrested, absorbed, or transformed at an early period. In a case of M. Leguil- lon's, quoted by M. Barrier, the child showed symptoms of tubercles four years before its death, and after death they were found to have become calcareous. 281. Treatment. — In so hopeless a disease little is to be expected from treatment, and on that account, perhaps, too little effort has been made to afford relief. So long as we have to deal with the effects of the tumors simply, our chief remedy is counter-irritation employed pretty freely. Gendrin thinks that it is used too timidly, and has failed in consequence. 1 He advises large moxas to the temples, to the neck, behind the ears, &c. I really think that a succession of blisters to the head, and a seton or issue in the neck or arm, will be found as useful and far less painful. The general treatment of tubercles must also be adopted; and it may be worth while, at an early period, to give iodine a fair trial. 282. But when secondary affections arise, such as acute meningitis, chronic hydrocephalus, &c, the treatment will require modification, and it may be necessary to adopt more active measures. The treat- ment I have already laid down for these diseases will be proper, in a minor degree however, under these circumstances, proportioning it to the violence of the disease, the strength and constitution of the child, &h. The diet should be light and nourishing, but not stimulant ; and the child should, at an early period, be much in the open air. 283. I have mentioned that tubercles are occasionally developed in the spinal cord or its membranes. Ollivier has recorded a considerable number of cases, 2 and he remarks that although there are cases on record where the tumor occupied the lower portions of the spinal mar- 1 Translation of Abercrombie, p. 262. 2 TraitS de la Moelle Epiniere, &c, vol. ii. p. 272. BRAIN AND SPINAL MARROW. 193 row, yet that they are much more common in its superior portion. The symptoms in many cases are as few and obscure as in tubercle of the brain ; in others we find convulsive movements, contraction, epilepsy, feebleness of limbs, loss of sensibility, retention of urine, constipation, &c. &c. A certain amount of disturbance is due, doubtless, to the mechanical pressure of the tubercle, but still more to the congestion, inflammation, and softening of the surrounding tissues, which are observed in the spinal cord, just as we found them in the brain. 284. My friend, Dr. Geoghegan, of this city, has recently published 1 a very interesting case of a scrofulous tumor in the lower portion of the spinal column, some of the details of which I am tempted to extract, in the absence of any systematic statement of this disease. "A boy, set. 7, of tolerably healthy appearance, was admitted into the city of Dublin Hospital in September, 1847, laboring under well- marked paraplegia, and who presented the following conditions : Com- plete paralysis of sensation of the lower part of the body, commencing at a point a little above the upper margin of the pelvis ; severe pinch- ing, or the introduction of a needle, not eliciting the slightest indication of pain. Complete loss of voluntary motion of the same parts, except of the muscles concerned in the adduction and rotation inwards of the thighs, which retain a very slight degree of power. The muscular con- tractions depending on excito-motory power in the paralyzed parts are extremely well marked ; pinching of the integuments of the legs, thighs, scrotum, penis, and lower part of the abdomen, producing abrupt mo- tion, chiefly in the flexion of the leg. These effects are most intense when the stimulus is applied to the integument of the penis or scrotum. When the soles of the feet are tickled, the legs are retracted. Marked motion of the lower extremities is also produced on pressing on the sacrum. The feet are cold, and the legs and thighs somewhat flexed and rigid, conditions which increased as the case progressed. There is incontinence of urine and feces, the former of which, it is stated, did not immediately follow the paralysis of the limbs. The sphincter ani, when in repose, is closed, and grasps the finger moderately when intro- duced within it. Irritation of the integument covering the sphincter produces abrupt contraction of the muscle. There is stillicidium of urine, which is converted for a few moments into a stream, when the boy is placed on his face. On one occasion the catheter having been introduced after the patient had been lying on his back, two or three ounces of turbid, faintly acid urine, admixed with pus globules, were withdrawn, the operation producing partial erection of the penis. The fluid removed became putrid and ammoniacal in three hours afterwards." A little precaution prevented the recurrence of this condition of the urine. " On examination of the spinal column, with a view to the detection of the cause of the preceding phenomena, no deviation from its natural figure was discernible. From about the fifth to the eighth spinous process of the dorsal vertebrse, tenderness is evinced oa percussion, 1 Med. Press, March 8, 1848. 13 194 TUBERCLES OF THE BRAIN AND SPINAL MARROW. but not on firm pressure. The functions of the brain are perfectly natural ; the child, however, seeming more lively than is usual at his a S e '" " It appeared that since last April this patient had suffered from un- easiness in the back, in the situation of the tenderness, although, from his silent habit, he did not complain of pain ; he used frequently, how- ever, to place his hand on the affected part. About the latter end of September his legs were observed to drag in walking, and pains in his lower limbs were experienced. While out airing he suddenly stopped and fell, but is reported to have walked home with little assistance, and also to have gone to bed without help. Next morning it was discovered that he was perfectly paralyzed in his lower limbs." Dr. Geoghegan came to the conclusion that either a tumor existed in the spinal cord, or that the investing membranes were considerably thickened. Issues were reintroduced, and iodide of potassium given, with a generous diet, and attention to the bowels. For some time the symptoms continued the same, with emaciation ; but " about the early part of January symptoms of cerebral disturbance manifested them- selves ; frontal headache, stiffness of neck, and retraction of head ; slight dilatation of pupils, which were contractile, but oscillating under the appearance of a fixed current of light ; slowness and irregularity of pulse ; incapacity to answer questions ; although volition, in its minor grades, is still capable of being roused, either through the intervention of common or spinal sensation : in a word, symptoms of effusion within the head were manifest. Notwithstanding suitable treatment, he sank about the middle of the month." On dissection there was observed moderate venous congestion of the brain, with some effusion ; the upper part of the spinal cord, as well as the brain, was free from disease ; but " at a point corresponding to the tenth dorsal vertebrae, before the theca was divided, a very perceptible enlargement of the spinal cord was discovered." " On dissection of the diseased portion, it was observed to be of a light, sulphur-yellow color, having much the aspect of matter often found in scrofulous glands, containing a few minute cavities, and having embedded in its lower parts a distinct reddish-gray mass, about the size of a pea. The tumor, generally examined by a lens, possessed a coarsely granular texture, and throughout the greatest part of its length had completely supplanted the natural texture of the cord ; but, from its oblong oval figure, its upper extremity and the superior part of its lateral surfaces were invested with a thin coating of nearly healthy medullary texture. The mesenteric glands were enlarged, internally of a reddish-gray color, and gray externally. The lungs contained a considerable quan- tity of crude tubercles. The rectum was natural, and the urinary blad- der contracted and empty ; its mucous surface not thickened or ulcer- ated, and presenting livid patches of venous submucous congestion. The total thickness of its eoats, a quarter of an inch." 285. It is more than probable that any treatment will fail in relieving this form of disease ; but as it is our duty to make a trial, there appears more hope from counter-irritation, iodine, and due attention to the stomach and bowels, than from any other plan. CONGESTION AND APOPLEXY OF THE BRAIN. 195 CHAPTER X. CONGESTION AND APOPLEXY OF THE BRAIN. 286. I have already alluded to an effusion of blood which takes place between the cranium and dura mater during parturition, under the term "subcranial cephalsematoma" (103), and the effects of which are manifested shortly after birth, and which generally terminates fa- tally. Of eight cases collected by Dr. West, two were stillborn, one died on the fifth day, two on the ninth, and two on the twenty-first. I have now to direct the reader's attention to effusions occurring after birth, from the age of one or two days up to the period of puberty; and I may remark that, whilst the disease is more frequent than has been imagined among children, it appears more common at an early age than subsequently. Dr. Evans Kennedy and Dr. Doherty have related several cases in which it occurred a few days after birth. 1 Dr. Condie mentions that during the thirty-eight years preceding 1845, there occurred in Philadelphia sixty-nine deaths from apoplexy in children under ten years of age, viz : in those under one year, twenty-seven cases ; between one and two years, sixteen ; between two and five, fourteen ; and between five and ten, twelve. 2 Rilliet and Barthez give thirty-eight cases: four under two years ; ten between two and three ; six between three and five ; six from five to seven ; three from nine to ten ; and seven from ten to fourteen years of age. It occurs both in children apparently healthy, and in those of de- ilitated constitutions. 3 287. As in adults, we find different degrees of morbid action giving rise to nearly the same symptoms and similar results. I. We find that a child may die of apoplexy apparently, and on making a post-mortem examination we may discover nothing but ex- cessive vascularity of the brain or membranes resulting from con- gestion. II. If the congestion of the membranes be carried to a very great extent, the blood escapes drop by drop, or exudes into the cavity of the arachnoid, or into the ventricles, giving rise to the variety called by M. Serres apoplexie meningienne, and which comes next in fre- quency to the congestive apoplexy, and occurs chiefly between one and five years of age. in. When the vessels which supply or permeate the texture of the 1 Dublin Journal, vol. x. p. 421 ; vol. xxv. p. 49. 2 Diseases of Children, p. 888. 3 Cases by Quain, Lond. Journ. of Med., No. 1, p. 27. 196 CONGESTION AND APOPLEXY OF THE BRAIN. brain are subjected to great pressure by the accumulation of blood, their tunics may give way, and the blood escapes into the substance of the brain, constituting the ordinary apoplexy of advanced life. This variety is more rare than the others, and is generally observed a few years later. 288. Let us first consider the congestive apoplexy of young infants. It cannot be a matter of surprise that the vascular action of the brain in infants should be liable to violent and extreme disturbances, nor that these irregularities should act powerfully upon that organ ; the diffi- culty is to explain why mischief does not more frequently result. The attack is generally sudden, but in some instances we find it preceded for a few days by a disorder of the stomach and bowels ; or it may occur in the course of some other disease, as ramollissement of the brain, hooping-cough, &c, or after convulsions. Barrier mentions its occurrence in a case of general oedema. The symptoms are, more or less complete stupor, lividity of the face, which appears tumid, contraction and insensibility of the pupils, labo- rious respiration, hemiplegia, or occasionally rigidity of the neck and lower extremities, and sometimes convulsions. If not relieved, those symptoms increase in intensity, and the child dies comatose. M. Constant relates the case of a girl who died thirty hours after admission into the hospital, apparantly from hemorrhage into the brain. There was loss of power in all the limbs, insensibility, loss of intelli- gence, and stertorous breathing. On dissection, nothing but extreme congestion of the brain was discovered. 1 289. When the congestion is confined to the spinal marrow, the symp- toms are nearly the same ; convulsions are more frequent, there is great drowsiness or stupor, the corners of the mouth are drawn downwards, and sometimes the arms are pressed close against the side, or paralysis may occur. 290. Meningeal apoplexy, which constitutes one-third of the causes of death in stillborn infants, according to Cruveilhier, 2 occurs also after birth, during the first few hours or days of life, as well as subsequently. It is not easy to explain why it should occur previous to birth in many cases, for in them there has been neither undue pressure in the use of instruments nor undue delay in the expulsion of the body after the transit of the head ; but in other cases it sometimes occurs that after the head is born the uterine contractions cease for a time, and then the veins of the neck are compressed by the external orifice, and the cord by the body of the child against the walls of the pelvis ; the face becomes livid, purple, almost black, and if the infant be not quickly extracted it may die of apoplexy. The same result may occur in breech, footling, or funis presentations. 291. The symptoms which are developed in young infants some time after birth are very like those of inflammation, and may easily be mis- taken for them. M. Legendre, who has carefully investigated that subject, remarks : "After two or three vomitings, or even without 1 Ga2. Med., 1835, p. 572. 2 Anat. Path., livr. xv. p. 1. CONGESTION AND APOPLEXY OF THE BRAIN. 197 previous vomiting, the infants were attacked with fever and some con- vulsive movement, most frequently of the globe of the eye, and having some degree of strabismus ; the appetite was lost, thirst great, the evacuations natural or easily excited. Soon after, there was permanent contraction of the feet and hands, followed by tonic or clonic convul- sions. During the convulsions, sense and sensibility were abolished, and the face, ordinarily congested, became of a deeper color. During the intervals there was drowsiness and stupor, which, slight at first, increased as the disease made progress ; the fever continued, and became more intense as they approached the fatal termination. Lastly, the convulsions, at first more or less distant, became more and more frequent, and, during the last period,, almost constant." 1 In other cases, the incursion is more sudden and marked ; the child becomes suddenly drowsy, stupor and coma come on, convulsions or paralysis, and death follow rapidly. The difference of symptoms and their intensity will depend very much upon the amount of effusion. In some cases convulsions are almost the only symptom observed, as is stated by Dr. Schleifer to have been the case in the Foundling Hospital at Prague. Paralysis is much less frequent. M. Legendre met with it once in nine cases, and Rilliet and Barthez once in seventeen. 292. The course of the disease depends a good deal upon the amount of effusion. When it is great, and has been quickly effused, speedy death is the result. And, no doubt, the great majority of all cases die; but, whilst very few indeed recover, the disease changes its character in some cases, and becomes chronic. In young infants, before the skull is completely ossified, a proportionate amount of distension may take place, and the brain, relieved of some of the pressure, to a certain extent becomes accustomed to and tolerant of the remainder, the effused blood separates into its two portions, the more solid is partially, at least, absorbed, the fluid rather increased, a sort of cyst is formed around it, and the child exhibits the symptoms, not of apoplexy, but of chronic hydrocephalus (226), except that the head is more unequally enlarged, running the same course, and ultimately proving fatal. Both the acute and chronic forms of the disease, however, are very often shortened by secondary attacks of thoracic or abdominal inflam- mation. This was the case with most of M. Legendre's cases. 293. Cerebral apoplexy, or effusion of blood into the substance of the brain, is much more rarely observed. Guersent states that he saw but two cases in twenty years' practice. Becquerel mentions that in three years, and among four hundred autopsies, he has not met a single case of simple hemorrhage into the cerebral substance. Some cases, however, have been recorded. M. Rochoux, in 1833, has collected eight cases, one by a physician at Breslau, and one by M. Guibert (93t. 14) ; one by M. Payen (set. 12); one, of a child ex- posed to the sun, by M. Andral (get. 12) ; another of a child who, after being exposed to the sun, died suddenly (in a fit of anger) from hemor- rhage into the cerebellum ; one by Tonnelle" (set. 2) ; one by Burnet (set. 1) ; and one by M. Serres (set. three months). Since then, Lalle- 1 Bouchut, Mai. des Nouv. Nes, p. 468. 198 CONGESTION AND APOPLEXY OF THE BRAIN. mand has related the history of one case (set. 3) in his third letter, and M. Constant of another (get. II). 1 MM. Sestie' 2 and Cazalis have re- corded three, M. Valleix three cases, 3 M. Billard one, and Dr. West one case. 4 But hemorrhage into the brain may be the result of, or at least con- nected with ramollissement, and these cases are by no means so rare ; for instance, Becquerel met with four such. 294. It appears that this form of the disease is not limited to any peculiar age ; it has occurred as early as three months, but it seems more frequent in children after three years. The symptoms do not differ very widely from those observed in adults laboring under the disease. There may be previous headache, heaviness, and drowsiness, or the attack may be sudden, and marked by stupor, coma, convulsions, or paralysis. The symptoms are more obscure in delicate children, as Valleix has remarked ; the stupor and loss of power being present in all. Nor does there appear to be any special symptoms indicating whether the effusion is into the substance of the brain or the arachnoid. Of course, in cases of tubercles or ramollissement, the symptoms of these diseases will be present, and those of apoplexy merely an addi- tion to them. 295. Pathology. — When a child dies of apoplexy from excessive con- gestion merely, we find, on examining the head, that the scalp is un- usually vascular, the sinuses of the dura mater filled with blood, and the vessels on the superficies of the brain engorged. Very commonly the meningeal vessels participate in the general congestion. I have seen the former the size of small leeches, with the blood partly fluid and partly coagulated. On slicing the brain, innumerable red spots appear, indicating that the vessels which permeate the substance of the brain are equally the seat of unusual distension, and even so much so as to give a reddish color to the brain. 296. In meningeal apoplexy, the effusion is into the cavity of the arachnoid ; most frequently, according to Cruveilhier, limited to the cerebellum, sometimes surrounding the posterior lobes of the cerebrum, and occasionally both the cerebrum and cerebellum are covered with a layer of blood. Rilliet and Barthez state that it is more frequent on the convex surface of the brain. It is very rare that the hemorrhage takes place into the ventricles ; however, Cruveilhier met with three examples of it ; M. Valleix with one ; and M. Walther has recorded another. 5 Still more rare is it for the blood to be effused external to the arachnoid, either on the side of the pia mater or the dura mater, although I have already (103) mentioned the occurrence of the latter ; and I may add that in very young infants who die of apoplexy, it is by no means uncommon to find cephalhematoma, or even patches of blood effused under the scalp or pericranium, quite independent of local pressure. 1 Gaz. des Hopit. des Enfans, Ap. 1842. 2 Bull, de la Soc. Anat., 1832. Bull., xlii. p. 331. 3 Clinique des Mai. des Enfans, p. 575. 4 Lectures. Med. Gnz.. June 18, 1F47, p. 1062. 5 Banking's Abstract, vol. iii. p. 159. CONGESTION AND APOPLEXY OF THE BRAIN. 199 <* 297. The blood effused into the serous cavity presents different as- pects, and undergoes different changes, according to the period which may elapse after its escape. At first it is, of course, fluid, but about the fourth or fifth day it coagulates, the serum is absorbed and gra- dually disappears, and the clot becomes adherent to the parietal serous membrane, and undergoes an important transformation. A new mem- brane is formed, and covers both its surfaces, but the layer on the upper surface gradually becomes thinner, until it is closely adherent to the serous membrane ; the inferior layer assumes all the character of a serous membrane, and is united to the arachnoid at the circumference of the clot, giving to the latter the appearance of subserous effusion. That this is not the case has been demonstrated by M. Baillarger, who has proved that the true serous membrane can be traced behind the clot. 1 The clot increases in firmness and diminishes in volume by the gra- dual absorption of its serum. At first of the usual red color, it be- comes paler by degrees, more slowly internally than externally, and at length is little more than a thin fibrinous lamella of a fibrous character, resembling in appearance false membrane, which has led to its being attributed to inflammation. In other cases to which I have already alluded the membranes form around the clot, and the more solid portion is absorbed, leaving in the species of cyst so formed nothing but reddish serum, thus constituting a kind of chronic hydrocephalus. 2 Notwithstanding the large amount of blood thus effused, it is gene- rally quite impossible to detect any opening in the vessels from which it could have escaped ; we merely find unusual congestion of the arach- noid, pia mater, and brain in most cases. M. Piedagnel mentions three sources : 1. Fracture and rupture of the vessels ; 2. Exhalation ; and 3. A morbid alteration of the arach- noid. Although in some few cases the arachnoid in connection with the clot is softened, it appears to have occurred subsequently to this effusion, and is even more rare than rupture of a vessel. Other organs participate in the hemorrhage diathesis also; it is not very rare to find ecchymosis, or effusion into the lungs, spleen, intes- tines, &c. We do not find the brain either hypertrophic or the con- volutions flattened. If the child be young, and the effusion great, the cranium expands in proportion ; if it be older, and the effusion great death results immediately. 298. Cerebral apoplexy may present either of two pathological condi- tions, first, in the form of innumerable bloody points, the size of pins' heads, in the gray and white substance of the brain. These are, in truth, small clots, and can be enucleated quite easily ; the brain around them may be quite healthy, or it may be softened, and of a white, yellow, or red color. The apoplexy may be limited, or it may be diffused through- out the hemisphere, giving to it a peculiar spotted appearance. 3 Rilliet and Barthez found this capillary apoplexy limited in five cases and dif- fused in three. 1 Bouchut, Mai. des Nouveaux N£s, 466. 2 Rilliet and Barthez, Mai. des Enfans, vi. ii. p. 39. 3 Valleix, Clioique des Mai. des Enfans, p. 594. 200 CONGESTION AND APOPLEXY OF THE BRAIN. Or, secondly, the blood may be effused into the substance of the brain, and form a coagulum, and this occurs about as frequently as the" former kind, and sometimes in combination with it. These apoplectic foci are found in various parts of the brain, as in the optic thalami, cor- pora striata, and either hemisphere, but in the left oftener than in the right, and in the cerebellum not less frequently than in the brain. If the case be recent, the blood will be found in a fluid state; but if of longer standing, it becomes coagulated, and is imbedded in, but distinct from the cerebral substance. When it is connected with ramollissement, however, it has the appearance of being mixed with the softened brain, and does not, generally, form a distinct clot. Billet and Bavthez relate a case of very extensive effusion, which, in some degree, illustrates the observation ; and Billard another, of a child who died on the third day after its birth, of hemorrhage into the left hemisphere. He found a certain degree of softening around the clot, but it would seem to have been rather the consequence of the effusion. 1 299. Causes. — Rilliet and Barthez thus enumerate the causes of apo- plexy: "1. The untimely cure of diseases of the scalp; 2. Diseases of the sinus of the dura mater ; 3. Compression of the vena cava superior by the bronchial glands; 4. Vascular compression, owing to hypertro- phy of the abdominal organs ; 5. Cachexia, or general debility, origin- ally connected with tubercularization ; 6. Sometimes the hemorrhage is primitive, and unconnected with any anterior disease. 2 In one of M. Valleix's cases, he attributes the apoplexy to the ob- struction offered by coagula to the return of the blood. In new-born infants, apoplexy may, perhaps, result from some injury connected with labor, although we are not able to appreciate it at the time, and at a later period to diseases which obstruct the return of the blood from the head, as hooping-cough and perhaps disease of the valves of the heart. 300. Diagnosis. — There is so much uncertainty in the symptoms of apoplexy in infants and children, sometimes one and sometimes another predominating, and most of those which are present occur in other cere- bral diseases, that the differential diagnosis is, in many cases, extremely difficult. For example : — I. Congestive apoplexy may very closely resemble primary convulsions, and, in fact, may be no more than an exaggerated form of the same disease; but in general we find that the functions of the brain are re- stored more completely between the fits in the latter case. In apoplexy, on the contrary, the child is drowsy and heavy, or lies in a state of stupor or coma. II. Meningeal apoplexy may resemble acute meningitis when the effu- sion is moderate, or chronic hydrocephalus when considerable, and espe- cially when the cyst of serum is formed, as I have mentioned. In acute meningitis, the symptoms exhibit more of the character of inflamma- tion ; in apoplexy, of compression ; and the incursion of the latter is generally more sudden, and the destruction of voluntary power more complete; the pulse, too, is less affected, and there is little or no fever. 1 Mai. des Enfans, p. 600. 2 Mai. des Enfans, vol. ii. p. 63, CONGESTION AND APOPLEXY OF THE BEAIN. 201 Chronic hydrocephalus is of slower development, a series of symp- toms generally preceding the enlargement of the head, or those evi- dences of compression which present themselves when the sutures are ossified; in meningeal apoplexy, on the contrary, symptoms of effusion generally precede all others, although some time may elapse before the head is perceptibly enlarged. in. Cerebral apoplexy, if slight, may be mistaken for an attack of convulsions, or of epilepsy, but it will generally be found that the con- vulsion is less violent, shorter, and that the patient does not recover from it so completely. The stupor, coma, insensibility, and paralysis which follow a larger effusion, and the rapidly fatal progress of the disease, are quite characteristic, and are in no clanger of being mistaken for any other disease, unless, perhaps, the water-stroke. When there is simple hemiplegia, we can have but little doubt of the case being one of apoplexy, but when convulsions occur, they tend much to confuse the diagnosis. We should, however, always bear in mind that the diseases with which apoplexy may be confounded are much more frequent than the latter ; that the causes of the former are generally more patent, and the series of symptoms, the whole aspect and physiognomy of the case, are widely different to an experienced eye. 301. Prognosis. — Nothing can be more serious than the prognosis in apoplexy. From the congestive form of the disease, no doubt, persons who are promptly treated have a tolerable chance of recovery, but me- ningeal and cerebral apoplexy almost always prove fatal. There is scarcely a case of cure on record, either of primary, secondary, or chronic apoplexy, in which any reliance can be placed ; not from defi- cient veracity on the part of the writers, but from doubtful diagnosis. 302. Treatment. — When the case is recent, and, above all, if we have reason to believe it one of congestive apoplexy, we should have recourse to bloodletting immediately, either from the arm or jugular vein, or by leeches. The effect of this proceeding will probably determine the cor- rectness of our diagnosis, for if the symptoms have been the effect of congestion merely, they will at once be mitigated, and the more alarm- ing ones disappear. Judging from the result, we may find it advisable to repeat the leeches, and to have recourse to cold applications to the head, purgative enemata, small doses of calomel and James's powder, if the patient can swallow, and, after a short time, to successive blisters to the head or nape of the neck. Should we see any disposition to a return of the congestion, in addition to a repetition of these remedies, it will be necessary to establish some permanent counter-irritation, either a seton or issue, or a perpetual blister on one arm. 303. If effusion have already occurred, it may be very right to try the above remedies, although we shall probably find but little amend- ment follow them ; the disease will run its course, nearly unmodified by our efforts, and terminate, in the great majority of cases, fatally. But should the case be one of meningeal apoplexy, and take on a chronic character, distending the cranium, as in the cases described by M. Legendre, we shall have an opportunity of trying how much (or rather how little) treatment can effect for the patient. For this pur- 202 PARALYSIS. pose we have four remedies of great value, calomel, cold lotions, coun- ter-irritation, and purgatives. The calomel should be given in small doses, guarded, so as not to affect the bowels too quickly, and should be continued until the constitution is affected, as will be evidenced by mercurial diarrhoea or soreness of the gums. Mercurial inunction may be used, or the blisters dressed with mer- curial ointment, for the purpose of more rapidly affecting the system, or in case the calomel should excite irritation. The hair should be removed, and an evaporating lotion constantly applied. I have always found that a succession of small blisters acted more beneficially than one or two large ones, besides being less liable to ul- ceration. I would recommend, then, that we should begin by applying a blister to the forehead, then, in a day or two, another to the temple, followed by a third on the opposite side, and so on. The bowels should at all times be kept free, but after we remit the mercury we may try the effect of a brisk purgative occasionally. I mentioned before, that, if there should be any sign of teething, the gums should be scarified deeply, and all round. The diet in all cases should be mild and unstimulating, but in some cases a better diet will be necessary, as well as the use of tonics. This will depend upon the state of the constitution. 304. In these latter cases of which I have been speaking, i. e. where a large quantity of blood has been effused and separated into its com- ponent parts, without an immediately fatal result, Rilliet and Barthez recommended that the serum should be removed by puncture, as in chronic hydrocephalus. They oppose the practice in the latter disease, because the effusion may be connected with tubercular deposits, but in meningeal apoplexy they conceive that " nothing but good can result from it." 1 CHAPTER XI. PARALYSIS. 305. 1. Paralytic affections, general, partial or local, particularly the latter, though not very frequent, are by no means rare in children. That they have not been more distinctly noticed by writers may have arisen from their classing them under their various causes, instead of regarding them as examples of a special disease. The attack presents great varieties as to extent and the accompa- nying symptoms : In some cases the upper and lower extremities of one side are affected, constituting hemiplegia ; in others both the lower extremities, paraplegia : but I am not aware that both the upper ex- tremities alone are ever paralyzed. Again, the seizure may be partial, * Mai. des Enfans, vol. ii. p. 66. PARALYSIS. 203 loss of power to a great extent, with perhaps a diminution of sensation, but not absolute paralysis : or it may be local, affecting a portion of one extremity, certain muscles of the face, of the eyeballs, eyelids, or of the organs of deglutition, &c. Lastly, in any of these cases, the sensibility may be impaired or destroyed, or, as we occasionally find, unaltered or even increased. In seven out of eighteen cases given by Dr. West, " the leg only was af- fected, and in two of these the power over both legs was lost ; in five both the leg and the arm were palsied, while in six instances facial para- lysis existed. In four of these six cases the paralysis of the portio dura was not associated with impaired power over any of the limbs ; once it was combined with palsy of the leg and once with general impairment of the power of walking." 1 2. There does not appear to be any age exempt from these attacks ; infants at the breast or children of fourteen or fifteen years of age may be the subjects of them, but they are perhaps more common from the period of the first dentition up to the tenth year. There is some reason to believe that in some cases the paralysis is congenital, whether from disease in utero, or from pressure during the transit of the infant through the pelvis, it is difficult to determine. Professor Robert Smith, of this city, brought before the Surgical Society several cases where one extremity was not fully developed, and in which there was a de- ficiency of cerebral substance in the opposite hemisphere of the brain, but whether they ought to be considered as fair examples of paralysis, or merely of arrest of development, may be a question. Dr. Evory Kennedy, whose experience in the Lying-in Hospital was very great, states that " paralysis in the new-born infant is not a very unfrequent disease ; it may occur as the effect of injury to the nerve in the part paralyzed, or in its course after its transmission through the cranial or spinal aperture. Examples of this we have in injuries to the portio dura, as in face presentations, or when the head has been long pressed against the projecting ischiatic spines. Several cases of this kind have occurred to me, in which the disease Avas quite local, the paralysis being removed on the subsidence of tumefaction produced by the protracted pressure." 2 Inmost cases, however, Dr. Kennedy men- tions that the paralysis is connected with cerebral or spinal derange- ment ; in some preceded by apoplexy, in others by convulsions, or convulsions of the opposite side may co-exist with paralysis. Some- times the affected limb was convulsed: in other cases, there was a more or less complete paralysis of one side, with a partial paralysis of the other. Cases illustrating these varieties are related by the author. Leeches, stimulating frictions to the spine, and calomel, appear to have been very successfully employed. More recently, Dr. Landowzy has published a paper showing that facial paralysis may be the result of pressure by the forceps during delivery, even though the instrument may have left no marks upon the infant ; and he considers that the same result may follow when the 1 Diseases of Infancy and Childhood, p. 137. 2 On Apoplexy and Paralysis in New-born Infants, Dublin Journal, vol. x. p. 430. 204 PARALYSIS. pressure is from pelvic tumors or deformity ; and he states that during quiescence the face is quite natural, but that when the child cries the paralysis becomes evident. He found the disease to cease spontaneously after an interval of from a few hours to two months. 1 Dr. Doherty, in an excellent paper, 2 gives two cases which were delivered by the forceps, and in which facial paralysis was observed immediately afterwards ; and two other cases, in one of which paralysis of the arm and in the other of the muscles of the neck occurred shortly after birth. The former was cured by the use of mercurial alteratives, continued purges, the douche, and chalybeate tonics. There can be no doubt, then, that facial paralysis may be congenital, and as little, I think, that more extensive paralytic affections are so occasionally. Dr. Henry Kennedy has given two cases which he thinks were con- genital. One of them he relates as follows : " A child, set. six, was brought to me on account of his walking lame. The mother said that from the time the child began to walk it had limped ; several medical men had seen it, but that it was no better. On examination, the right lower extremity was wasted, and its temperature was evidently lower than the other. Nothing could be detected wrong with any of the joints except that they could literally be twisted in every direction." 3 Dr. "West also mentions cases, which one can scarcely doubt were congenital. In all these cases, the growth has evidently been checked and retarded; the affected limb has not kept pace in volume or length with the sound one, and its power is much inferior. I have a case under my care at present somewhat resembling these, but with less loss of power. The child, aet. eight, had an attack of endocarditis about five or six years ago, from which he recovered, but with injured valor. About two years ago, he showed symptoms of lameness, and since that time his leg has evidently been checked in its growth, and is now less in volume than the other ; but he manages to use it pretty well. 306. 3. Causes and Symptoms. — Paralysis in infants and children may arise either from organic disease of the nervous system ; from pressure upon some part of the nervous centres or upon individual nerves ; or, lastly, it may be a reflex irritation from some distant part. Let us examine the principal varieties shortly. (1). No doubt that paralysis in children, as in adults, may result from a partial effusion of blood pressing upon certain parts of the nervous centres, less in amount than in cases of apoplexy, but sufficient to occasion loss of motive power and sensibility in one-half of the body. Morgagni, for example, mentions a case of spinal apoplexy which was attended with pain and paralysis, 4 and other cases might be adduced. They are, however, rare in children. (2). When speaking of tumors of the brain and spinal marrow, I mentioned that paralysis generally occurs at some period of the disease ; at its commencement in a few cases, but generally at a more advanced 1 British and Foreign Med. Review, vol. x. p. 269. 2 Dublin Journal, vol. xxv. pp. 82-87. s Med. Press, vol. vi. p. 202. 4 Epistola 10, Sect. 13. PARALYSIS. 205 stage. It may be partial, the effect of local pressure, or affecting gene- rally the motion and sensibility of one side. It is remarkable that although the child may recover to a certain extent from the other accidents of this disease, the paralysis is in almost every case permanent and without mitigation. 1 In Dr. Geoghegan's case there was complete paraplegia ; but in Dr. Green's case, certain muscles of the eyeballs alone were affected. (3). Encephalitis is not unfrequently accompanied with partial or general hemiplegia, and this paralysis may be combined with involuntary movements of these limbs, or with rigidity. When the inflammation ends in softening, we also find hemiplegia among its effects, alone or with convulsive movements of the other half of the body. In these cases, however, the concomitant symptoms are pretty plain, and we shall generally be able to trace the palsy to its true proximate cause. (4). In abscess of the brain we almost always find paralysis, as in the cases I have related in a former chapter from Drs. Bateman and Aber- crombie. Such cases, however, are both rare and obscure. (5). Chronic softening of the spinal marrow is characterized by par- tial or general hemiplegia. There is great general weakness of the lower limbs, which the patient can scarcely move. "Sometimes one limb," McCalsy observes, " or a portion of it only, is paralyzed. In this case, the extremity, or the diseased portion of the spinal medulla, when it is only partially affected, is in a state of atrophy, the muscles being much softer and smaller than those of the opposite extremity. In some cases, when the muscles have continued long in a state of paralysis, the antagonist muscles, acting with uncontrolled force, produce a per- manent contraction." " On examining the spinal marrow after death, we find it in different states of softening, from that almost resembling a fluid to that which permits the finger to be pressed upon it, and only presents a kind of indentation." 2 (6). Acute tubercular meningitis, which often commences by a convul- sion, not unfrequently exhibits paralysis towards its termination. The arm or leg, or both of them, lose power and sensibility, and occasionally we see convulsive movements of the opposite extremity. From this disease, and especially from the stage at which paralysis takes place, patients rarely recover, and therefore the paralysis possesses less prac- tical interest for us. In some cases of meningitis, when recovery does take place, we find remaining a kind of partial paralysis ; for example, one leg will be more feeble than the other; the child rather drags it, and complains perhaps of its being weak. I have repeatedly observed that children recovering from this disease are less able to walk, less sure footed, and more apt to trip and stumble over slight obstacles than previous to their illness, indi- cations probably of both loss of power and sensibility. Squinting, also, which so often remains after this disease, is clearly a partial paralysis of the muscles of the eyeball. I have also known paralysis of the portio dura remain after an attack of meningitis, presenting all its peculiarities, the face natural in repose, 1 See Dr. J. McCcrmac's paper, May 27, 1843. 2 On Diseases of Children, p. 430. 206 PARALYSIS. but distorted when speaking or excited, mastication natural, &c. This case has now remained in the same condition for several years. (7). I have already mentioned the paralysis of chronic hydrocephalus. In slighter cases we find a diminution of power, but rarely of sensi- bility of the lower limbs ; the child may be able to move them, but can with difficulty, if at all, stand or walk. In other cases the paralysis is observed at an early period, or even from the beginning, and as Dr. Bright remarks, the patients lie in bed with their legs bent under them, or, as in Dr. Ryan's and Battersby's cases, the child may be nearly de- prived of the functions of vision, hearing, taste, smell, and touch, and entirely of voluntary motion. In some cases, one leg only is affected; in others, the lower half of the body, and occasionally, but rarely, the ex- tremities. The same thing is observed in spina bifida, which is an analogous disease ; the limbs may be of the natural size, but they are deficient in power. Generally speaking, the sensibility is preserved, and occasionally increased, but I have seen cases in which it was decidedly diminished. (8). After convulsions we not unfrequently find a partial weakening of the motor power of certain muscles of the limbs or eyeball ; but if the child recover promptly from the principal disease, this symptom gra- dually disappears. (9). When treating of chorea, I observed that in some cases it ter- minates in palsy, either in consequence of inflammation or from pressure upon some portion of the brain, spinal cord or nerves, which is not un- common in that disease. Dr. H. Kennedy has noticed some symptoms of chorea in two of the cases of paralysis which he has reported. (10). So far the paralysis may be distinctly traced to some pathological condition of the brain and its membranes, or of the spinal marrow, of which it appears to be the direct result. In most of these cases the intel- lect of the child is weakened or totally obscured, and the expression of the face corresponds very accurately ; we see either compression, stu- pidity, or a fatuous semi-idiotic expression. But by far the most numerous class of cases of paralysis in children are of quite another kind ; originating in causes which act through the excito-motory system of nerves, they present admirable examples of reflex irritation. They generally occur in children between the ages of one and six years, though sometimes earlier. 2 Of Dr. West's eighteen cases, thirteen occurred between eight months and three years of age. (11). From the age alone at which the attack occurs, we might at once conclude that dentition must be one main cause, and we have evidence to prove that it is so in the fact that in many cases the most careful in- quiry shows us no other exciting cause, that the gums are much swollen and irritated, and that scarifying the gums is often followed by a case of the palsy. The attack may arise during either the first or second dentition, but is much more frequent with the second, or perhaps it may be, as Dr. Heiss has suggested, that the origin is overlooked in young infants from their not using their lower limbs 3 1 Dublin Journal, vol. ix. p. 91, N. S. 2 Underwood, Diseases of Children, p. 2G9. 3 London Journal of Medicine, Jan. 1850. PARALYSIS. 207 One great peculiarity of these attacks is their suddenness. The child may go to bed perfectly well, and during sleep perhaps become uneasy, restless, grinding its teeth, or groaning and screaming out suddenly. Towards morning, it may be rather feverish, and its head hotter than usual. The next day, we find it unable to raise its arm or leg, or perhaps an arm and leg, or more rarely both arms or an arm and both legs. The affected arm hangs down helplessly, and, from the gravita- tion of the blood, the hand and fingers become bluish and swollen, but the temperature of the limb is not diminished. The sensibility is generally more obtuse than usual, and sometimes entirely lost. No pain is felt, but occasionally a sensation of dragging about the shoulder- joint. The leg when affected is equally powerless and insensible, and now and then the palsy seems to extend itself from the upper to the lower extremity. Some variation as to the mode of invasion is observed ; the prelimi- nary symptoms may be more prolonged, and occasionally the attack is ushered in by a convulsion. The duration of this form of paralysis is very uncertain. Some cases recover after a few days or a week or two, others continue for months or years; some appear easily cured, others resist all treatment, and in the course of time exhibit symptoms of more serious disease of the spinal cord or brain, as dyspnoea, twitching of the muscles, squint- ing, perhaps convulsions, or the child falls into a comatose state and dies. But there is another class of cases, where the disease is not cured, or only partially, but the patient does not die. The limb remains par- tially or wholly paralyzed, its growth is retarded, and its muscles become atrophied, 1 while the rest of the body is fully developed. In cases of the upper extremity, the shoulder-joint may be injured. Dr. West saw two cases of dislocation, evidently from relaxation of the ligaments and the constant weight of the paralyzed arm. Dr. Underwood mentions that he has known the sound side to become paralyzed, the side previously affected recovering its power. As a general rule, the intellect is not enfeebled unless organic disease of the brain should be superinduced ; but in some few cases the expression of the face would rather denote a feeble state of the mind. It is not easy to pronounce upon the exact pathological cause of all these attacks. In the majority of cases, no lesion of the nervous sys- tem is discoverable, the attack being a reflex irritation simply. And even when we find some disease of the brain or spinal marrow, it is not always easy to say whether that may be the primary lesion or one that has supervened. Dr. Heiss is disposed to attribute the paralysis to pressure upon the roots of the brachial nerves from excessive congestion ; and he has given a case in which this state of the nerves was found in a child who suffered from paralysis and was killed by an accident. 2 Dr. West states that of his eighteen cases there were but two in which the paralysis appeared to be connected with permanent disease 1 Simpson, Ed. Monthly Journal, Jan. 1851. 2 London Journal of Med., Jan. 1850. 2C8 PARALYSIS. of the brain ; and in eight out of eighteen cases no indications of cere- bral disturbance occurred before the paralysis, or came on afterwards. Dr. Coley, whilst regarding the disease as a reflex irritation, observes that he has always found " organic mischief either near the pons Varolii or in the intestinal or laryngeal mucous membrane as the pri- mary cause of the morbid action of the motor nerves." 1 In two cases mentioned by Rilliet and Barthez, where death was oc- casioned by an attack of pneumonia, there was no alteration whatever in the brain or spinal marrow. 2 5. Another more limited and local form of paralysis to which I have already alluded, also occurs during dentition. I mean the facial para- lysis, or paralysis of the portio dura, and which has also been termed Bell's paralysis in consequence of that celebrated physiologist being one of the first, if not the very first, to give the true explanation of it. It may arise during dentition, with or without any other symptom of nervous disturbance, and its peculiarities are so marked that we can have no difficulty in recognizing it at once. During repose, the countenance has its natural calm and equal aspect, both sides being alike and natural ; but if any emotion be excited, or the child attempt to speak, the face becomes instantly distorted; the muscles of the affected side are passive, whilst those of the unaffected side draw the mouth, cheek, and sometimes the eyelid outwards. The child can masticate its food as well as other children, but if it should get into the pouch of the cheek, he will generally be obliged to remove it with his finger, because the buccinator muscle is paralyzed, although the temporal and masseter muscles are not. The tongue is not para- lyzed, although if the child be desired to put out his tongue, it is pro- truded crookedly, yet this is on account of the distortion of the mouth. If the angle of the mouth on the paralyzed side be drawn a little out- wards by the finger, then the tongue will project straight. The eyelids appear weakened and unable to close promptly and com- pletely, so that in some cases they seem permanently half open. Dr. Watson has drawn the following graphic picture of a patient affected with this disease. " The appearance presented by patients affected by facial palsy is peculiar and very striking. From one-half of the countenance all expression is gone, the features are blank, still, and unmeaning. The other half retains its natural cast, except that in some cases, the angle of the mouth on that side seems drawn a little awry. This is apt to be mistaken for proof of a spasmodic condition of that part ; but it is owing simply, as I stated before, to the want of the usual balance or counterpoise from the corresponding muscular fibres of the palsied side. The patient cannot laugh, or weep, or frown, or express any feeling or emotion with one side of his face, while the features of the other may be in full play. One-half of the aspect is that of a sleeping or of a dead person ; or stares at you solemnly ; the other half is alive and merry. The incongruity would be ludicrously droll, were it not also so pitiable and distressing." 3 1 British Record of Obstetric Med., June 1, 1848, p. 189. 2 Mai dos Eni'ans, vol. ii. p. 336. 3 Practice of Physic, yoI. i. p. 548. PARALYSIS. 209 This power of paralysis often proves but temporary, the child gradu- ally recovering the use of the affected muscles, but in other cases the paralysis remains permanently, and it is important to bear in mind that it may result from more serious organic mischief. Dr. Graves mentions that he has seen it the result of an apoplectic seizure, and he relates a case in which it was caused by an abscess of the internal ear, with destruction of the tympanum, ossicula, the portio dura, and a part of the petrous portion of the temporal bone. 1 It may occur alone or in combination with palsy of the limbs. During dentition, also, we find not unfrequently a partial paralysis of the muscles of the eyeball, giving rise to squinting, and in some cases a peculiar drooping of the eyelid, so that the child cannot expose the entire eye, as in ptosis. As to the curability of paralysis connected with dentition, Dr. West informs us that in six only of his eighteen cases was a cure effected ; in two of them the portio dura alone was affected ; in two others the paralysis of both leg and arm was incomplete and associated with a state of general debility, and in two the loss of power in one leg had come on after the child had been sitting for some hours on a stone door-step. The facial paralysis, when it exists alone, is by far the most easily cured, and it is a disease involving no clanger. (12). Cold may directly cause paralysis. I have just mentioned that in two of Dr. West's cases it resulted from sitting on a cold stone step, and such cases are by no means uncommon. Paralysis of one arm has come on from lying too long in the grass, and of the portio dura from driving in an open vehicle in the teeth of a cold wind. (13). From the delicacy of the mucous membranes and the suscep- tibility of the nervous system in young children, we cannot be surprised that paralysis, as well as convulsions, may be caused by a disordered state of the alimentary canal, proceeding from indigestible food, ivorms, constipation, §c. Drs. Underwood, 2 H. Kennedy, 3 Doherty, 4 Graves and others attribute it to this cause, and Dr. H. Kennedy especially where it complicates remittent fever. (14). Remittent fever is occasionally followed by paralysis, most fre- quently of one of the extremities, of which Dr. Doherty has given a case. Whether it is a pure reflex irritation, or proceeds from some or- ganic mischief, it is very difficult to decide. Dr. H. Kennedy has given three cases, and remarks, that he found them very uncertain as to re- covery, some requiring months and others remaining incurable. Sir Walter Scott is an illustrous example of the power of the disease. (15). In like manner, paralysis may follow scarlatina; when the patient becomes convalescent, he is found to have lost the use of an arm or a leg. Dr. Kennedy has published a case of this kind, in which there existed a bruit de soufflet and slight symptoms of chorea. He has also kindly furnished me with another which occurred in the practice of Dr. Jabuteau of Portarlington. The child on recovering from scar- latina was exposed to cold, and was attacked by anasarca, for which diuretics and calomel were exhibited. Very unexpectedly salivation oc- 1 Chir. Med., vol. i. p. 569. 2 Diseases of Children, p. 269. 3 Dublin Journal, vol. ix. p. 88, N. S. 4 Dublin Journal, vol. sxv. p. 78. 14 210 PAKALYSIS. curred, and it was whilst thus relieved from the anasarca, but under the ptyalism, that paralysis of the right side occurred. Dr. Simpson also mentions similar cases. 1 (16). But other and some apparently unlikely causes may bring on an attack. Sir Charles Bell knew facial paralysis to accompany mumps. Dr. Watson mentioned a case in which it arose from a scrofulous tumor behind the ear, which was followed by caries of the bone. 2 My friend Dr. Stokes informs me that he has seen it connected with a carious tooth, with a miL the internal ear. 6. Pathology. — I have incidentally stated nearly all that is to be said upon the pathology of this affection. Certain cases, although by no means frequent, evidently result from disease of the brain and spinal marrow, and the appearances after death will exhibit either hemorrhage, inflammation and its consequences, or tumors, as I have described in their respective chapters. Dr. McCormac attributes it in some cases to spinal concussion or temporary injury of the sciatic nerves ; but he does not give any evi- dence in support of this opinion. In other cases, where an opportunity of making an examination has been afforded, no morbid change whatever has been detected, or perhaps, as in Dr. Heiss's case, some congestion about the roots of the nerves. But our information about the disease is very scanty, as it very rarely proves fatal. 7. Diagnosis. — As a general rule, there will be little difficulty in forming a correct diagnosis if we make a careful examination. But a superficial inquiry may mislead, and we may attribute the loss of power to the injury of a joint, to a blow, or to pressure, instead of regarding it as a serious disease. But the absence of pain on moving the limb, or examining it, the loss of voluntary power, and the diminished sensibility generally, are sufficiently characteristic. Another very important question is how to distinguish those cases where the palsy results from organic disease of the nervous system from those which are reflex irritation merely ? As a general rule, those cases where an evident exciting cause exists, such as dentition, cold, &c, may be set down as reflex irritation, and this will include a large class ; but of the doubtful cases which remain, what are we to say ? I should place great value as a guide upon the presence or absence of other symptoms, such as startings, wakefulness, partial convulsions, stupor, beat of head, quick pulse, &c, provided that no other irritation existed which might give rise to them. Facial paralysis is almost always a reflex irritation, but I have men- tioned an exception which occurred in my own practice. Upon the whole, I am inclined to agree with Dr. West, who observes that " in many cases the history of the patient will of itself be sufficient to guard you from error ; for if paralysis occur suddenly, affecting both limbs on one side, and be neither preceded nor attended by any cerebral symptom, it is almost certain that it does not depend on serious organic 1 Ed. Monthly Journ., Jan. 1851. 2 Pract. of Phys., vol. i. p. 555. PARALYSIS. 211 disease of the brain. Our decision will be more difficult if the loss of power have been gradual, especially if only one limb be affected ; but if the brain be diseased, you will rarely find a mere weakening of the motor power ; for connected with it there will usually be occasional in- voluntary tremor or twitchings of the limbs, or contraction of the fingers or toes. When the paralysis succeeds to convulsions, the case will be still more obscure. In most cases of simple paralysis, however, the palsy comes on after a single fit; while if it depend on some local mischief in the brain, it is generally preceded by several convulsive seizures, during each of which the limb that afterwards becomes palsied is in a state of perpetual movement, or is sometimes the only part where convulsive movements occur." 1 8. Prognosis. — When the attack originates in organic diseases of the brain, the prognosis will depend upon the nature of that disease, and upon the general condition of the patient, the paralysis being rather an aggravation of the prognosis. Upon these subjects I have entered fully in the respective chapters. This paralysis, which is the result of reflex irritation, is rarely fatal, but it may impair the usefulness of the limb for a long time, and entail its comparative inferiority to its fellow for life. Facial paralysis involves no danger of itself, though it often proves tedious and sometimes incurable. Dr. West thus sums up the results in his eighteen cases : " in only six of the eighteen did a cure of the palsy take place;" "in four of these cases the treatment was commenced within two or three days after the occur- rence of the paralysis, and continued uninterruptedly until the patient's recovery. In one the treatment was begun after the lapse of three weeks ; and in another, though begun immediately, it was discontinued for some weeks. In four instances partial improvement took place, and there seems reason for anticipating that in one, this improvement Avill go on to complete recovery. In two the improvement was but slight ; in both these cases, however, there was more serious cerebral disease than in any others. The treatment of another was continued out for a week, and though the child gradually recovered power over the arm, yet the leg remained quite useless. In the other three cases, treatment was begun within a few days, and was continued without interruption. In eight cases, in which no treatment was adopted, or not till after the lapse of a period of six months, no improvement took place in the patients' condition." 9. Treatment. — I shall not now allude to the treatment of those cases which depend upon organic disease of the brain, but refer my readers to the different chapters upon these diseases. The facial paralysis which results from the use of instruments, or from pressure, requires but little treatment ; it subsides spontaneously in many cases ; and in others its disappearance may be assisted by fomentations to the part upon which pressure has been made. In facial paralysis at a later period, after removing every possible cause, scarifying the gums thoroughly, clearing out the bowels, &c, 1 Diseases of Infancy and Childhood, p. 140. 212 PARALYSIS. it is advisable in many cases to apply a leech or two to the neighbor- hood of the portio dura, near where it emerges from the skull. Small blisters are also of use, and I think benefit will be derived from painting the part with tincture of iodine, or rubbing in the ointment of the hydriodate of potash. Dr. Watson advises that mercury should be given so as just to touch the gums, and for a valid reason: "I always take the latter precaution, lest any effusion of lymph should cause abiding pressure on the nerve." He, however, is rather speaking of adults, and we must not forget that this effect is not so easily produced in children, and we may, I think, rest satisfied with giving a certain amount of mercury, especially if mercu- rial diarrhoea be produced, even though the gums be unaffected. The constitution must also be carefully attended to, the bowels regu- lated, a purgative given occasionally and tonics if necessary. I agree with Dr. West, that preparations of iron answer better than other tonics. When the paralysis affects the limbs, the treatment should be directed to the spine, or near to the place whence the nerves affected issue from the spinal canal. Frictions to the limbs, stimulating applications, &c, which are so commonly employed, are of little use, as they do not go near to the root of the evil ; they may quicken the circulation and pre- serve the heat of the limb, and when the disease is subsiding, may per- haps assist in restoring muscular tone, but no more. Cupping or leeches near the spine, especially if we have reason to believe that there is any congestion ; l or where the disease is more chronic, blisters or irritating liniments seem to afford the best chance of relief, but they not unfre- quently fail. Purgatives, not severe ones, and tonics seem to be of more use than anything else. Dr. H. Kennedy speaks favorably of turpentine in doses of a few drops three or four times a day. Electricity has been tried, but the results have not been equal. Dr. West has found it rather uncertain. Dr. Simpson has known it to fail. Dr. Stokes is strongly impressed with the value of electro-galvanism, and he has found electro-puncturation very successful, but the latter could hardly be used with young children. In chronic cases, strychnine may be cautiously tried in very minute doses, say from ^ to g 1 ^ part of a grain three times a day to a child of three years old, very gradually increasing the dose, but it will require great watchfulness, and an immediate suspension of the medicine if twitching and starting of the muscles be produced. In one case in which Dr. West gave it and at the same time applied a blister, the child seemed much benefited. Dr. Coley quotes two cases in which it was remarkably useful; he recommends the thirtieth part of a grain every eight hours to an infant six or eight months old, and about the twentieth part of a grain to a child two or three years of age ; the dose to be gradually in- creased if convulsive twitchings are not observed after a few days. He recommends a purgative in most cases before commencing the strychnine. The list of remedies we see is not extensive, nor is their successful action at all certain, but the chances of success are greater when we see the child shortly after the attack. 1 Heiss, Loncl. Jouru. of Med., Jan. 1850. SECTION II. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. I. INTRA-UTERINE DISEASES. — II. CORYZA. — III. EPISTAXIS. 307. Considering that the respiratory apparatus is not used during foetal life, we might naturally expect that it would escape disease ; but it is not so. Billard and Cruveilhier observe that in the bronchial tubes we find concretions, polypous masses, and evidences of inflamma- tion ; and the latter mentions a case of death immediately after birth, in which the bronehi were filled with a thick mucus, apparently the result of chronic catarrh. Examples of lobular pneumonia are recorded by Cruveilhier ; of san- guineous effusion, by Mende, Wrisberg, Joerg ; of abscess in the lung, by Koelpin, Mende, and Cruveilhier ; of pleurisy, by Veron, Billard, Orfila, and Cruveilhier ; of tubercles, by Husson, Chaussier, Cruveil- hier, Lobstein, and Billard; of scirrhus, by Wrisberg; of oedema of the lungs, by Zierhold ; and of hydro-pneumonia. 1 II. CORYZA. 308. Nasal catarrh, or, as it is commonly called, "snuffles," is a very common affection among infants, and very troublesome so long as the infant is at the breast, because the nose is obstructed, and of course, when sucking, the child is not able to breathe through the mouth. The attack commences by frequent sneezing, with a snuffling sound in breathing through the nose. We are not, however, to suppose that because a very young infant sneezes often it has necessarily taken cold; the impression of light upon the branches of the fifth pair of nerves distributed to the eye, naturally gives rise to sneezing. At first there is but little discharge from the nostrils, in a short time a secretion of a thin mucus takes place, sometimes acrid and irri- tating; and ultimately of an abundant, thick, muco-puriform fluid. The mucous membrane is unusually vascular, and peculiarly irritable and tender, and after the first stage the sense of smell is lost for a time. The voice, too, is changed to that tone which is popularly expressed by 1 Graetzer Die Krankheiten des Fotus, pp. 1G3, 169. 214 CORYZA. " speaking through the nose." The eyes are in general suffused and ■watery, sensitive to light, and there is more thirst than usual. Some degree of feverishness is present, the infant is uncomfortable, heavy, and cross, the skin is hotter than usual, and perhaps, but not necessarily, the pulse maybe quicker. If the child be old enough, it will complain of heat and soreness of the nose, of some headache in the region of the forehead, and probably uneasiness in the back and limbs, if it be very feverish. The attack is at its height about the third or fourth day, after which the feverishness disappears, the discharge diminishes, becoming more viscid and yellow, and the difficulty of breathing through the nose ceases. It is very liable, however, to be reproduced by any exposure to cold. 309. This is the simple and ordinary form of catarrh of the nasal mucous membrane. Drs. Denman and Underwood, however, describe a much more serious variety, which presented itself to their notice for the first time in the summer of the year 1790. It was characterized by a thick, puriform discharge, great, but not constant difficulty of breathing through the nose, at times requiring an attendant to watch the child and to keep its mouth open. A curious purple streak was observed at the verge of the eyelids, which Denman considered pathog- nomonic, and in most cases a fulness about the throat and neck exter- nally. After the symptoms had continued for some days, the infant became feeble and languid, and upon looking into the throat " the ton- sils were found tumefied and of a dark red color, with ash-colored specks upon them, and in some there were extensive ulcerations." The patients " gradually declined in strength, and had a peculiar catch in respiration, as if the velum pendulum palati were elongated. They were unable to suck, though not universally ; swallowed with difficulty whatever was given in a spoon ; and died in convulsions, or with all the marks of great debility, though not on any particular day of the dis- ease." 1 Dr. Denman met with eight cases in eight months, six of whom died. One of them was examined, but no internal organic disease was dis- covered ; and the affection seems to have been an intense inflammation of the entire Schneiderian membrane, with great constitutional debility, and accompanied with disorder of the stomach and bowels, as the stools were thick and pasty, and of a green or blue color. Billard also speaks of a severe form of coryza, accompanied with exudation of lymph, and proving fatal. I shall notice the syphilitic coryza by and by ; it seldom constitutes the sole symptom, and its true character will be determined generally by the concomitant symptoms. 310. Causes. — In very young infants it is owing to cold taken in washing, or by undue exposure — the great transition from the warm temperature of uterine life to the severe and changeable atmosphere of extra-uterine existence rendering the infant peculiarly susceptible. It also accompanies certain other diseases, as the exanthemata, and in 1 Underwood on Diseases of Children, p. 175. EPISTAXIS. 215 these countries prevails epidemically during winter and spring, but affecting chiefly infants of more advanced age. 311. Treatment. — When it exists simply, and is not a symptom of a more general affection of the mucous membrane, but little treatment will be necessary. A dose of purgative medicine, with warm baths at bedtime for a few nights, will relieve the feverish symptoms and head- ache ; and a gentle diaphoretic mixture may be given at intervals through the day. It is very necessary to do something for the relief of the local com- plaint, on account of the distress of the infant, and I have found the best thing to be fomentations, by means of a hollow sponge dipped in hot water, and squeezed nearly dry, and then laid on the nose and forehead. The vapor of the water is thus applied both internally and externally, and is very soothing. After this we may adopt the popular remedy of greasing the nose externally, which I know by experience to be very useful, although I am quite unable to explain why. [Dr. Chas. D. Meigs recommends the application of a flannel cap to the infant's head, and to be worn until the affection yields. In children subject to this annoying disease, I have succeeded in obviating a constant recur- rence of attacks by adopting Dr. Meigs's mode of treatment.] These measures will apply equally to infants and children : but with the former, if the nose be quite obstructed, it will be better to sub- stitute food for nursing two or three times in the day; and with the latter, if there be much fever, low diet for a few days will be advisa- ble. When the coryza forms but a portion of a more general attack, the proper remedies for the more serious disease will be beneficial, and, in addition, we need only use the fomentations. In the more serious variety described by Dr. Denman, he found great benefit from repeated purgation by castor oil, and some cordial, as Dalby's carminative, with the exhibition of the decoction of oak bark, if the discharge continue long. Blisters are inadmissible, for in some cases in which they had been applied, he found the surface ulcerated and sphacelated. III. EPISTAXIS. 812. Bleeding from the nose is by no means uncommon with children of all ages, but it is generally very moderate, and, when primary, never to such an extent as to endanger life. M. Valleix, who has analyzed a great number of reported cases, has not found a single example of pri- mary nasal hemorrhage to this extent, and the researches of MM. Rilliet and Barthez confirm his conclusion. 1 Secondary epistaxis is not unfrequent in children, and is more serious in its effects. It occurs in purpura hemorrhagica, in the course of eruptive fevers, intermittent typhoid fevers, in hooping-cough, &c. &c. M. Latour relates an example occurring during the access of quartan 1 Mai. des Enfans, vol. ii. p. 28. 216 SPASM OF THE GLOTTIS. ague, and which compromised the life of the child. Rilliet and Bar- thez mention a case of very considerable hemorrhage which occurred in an infant, attacked with anasarca consequent upon nephritis, and many other cases are upon record. We have all, probably, witnessed cases of epistaxis occurring during hooping-cough, and during an attack of purpura,' the hemorrhage is oc- casionally sufficient to destroy life. 313. In general there can be no difficulty in the diagnosis of the dis- ease. The escape of the blood externally marks its source ; but it some- times happens that it may proceed from some vessel situated high up the nostril, and after it has ceased to flow externally it may gradually dribble into the back part of the nasal fossa and pharynx, and then, being swallowed and rejected by vomiting, it may be supposed to have its origin in the stomach. The only way of deciding this question is by carefully examining the pharynx, to ascertain if any blood be still escaping, and if so, we can no longer doubt the source of the blood vomited. 314. Treatment. — When the amount of this discharge is neither too great nor too often repeated, the effort may be salutary rather than in- jurious, and in such cases we shall not need to interfere. Should direct treatment be necessary, the best local applications are cold lotions to the forehead and nose, counter-stimulants to the extremi- ties, astringent injections (such as decoction of matico or oak bark, &c), and, as a last resource, the plug. In many cases of secondary epistaxis, however, there is some morbid alteration of the blood, and the disease which has given rise to this will claim our predominant attention ; that being relieved, the epistaxis, like the other symptoms, will disappear. It may, however, for present re- lief, be proper to have recourse to some of the local applications just named. CHAPTER II. SPASM OP THE GLOTTIS. — THYMIC ASTHMA. — LARYNGISMUS STRIDULUS. 315. Much confusion has arisen concerning this disease, from the use of names, which, to say the least, are inaccurate, and some of which convey altogether false ideas of its nature. Thus it has been called "Millar's asthma," "Kopp's asthma," "thymic asthma," "suffocative catarrh," " false croup," " spasmodic croup ;" " cerebral croup ;" whereas it has no affinity at all either to asthma, catarrh, or croup. The complaint which is characterized by crowing inspirations, occur- ring at intervals, and repeated irregularly but frequently, appears, at first sight, to be a simply local affection, but upon close investigation will be found to have a deeper origin and a more important character. It is not unfrequent in Great Britain and Germany, but very rare in France, as Barrier, Rilliet and Barthez, are mainly indebted for their SPASM OF THE GLOTTIS. 217 descriptions to British or German physicians. Drs. Stewart and Con- die speak of it as common in America. It occurs in infants of from a few months or even days to three or four years old. Dr. Copland limits it to between three and four years of age. Dr. James Reid to the period of dentition. However, Dr. H. Ley saw one case at four or five years old, and another between six and seven, and Mr. Porter one at nearly six years of age. Dr. Jas. Reid saw a case of this disease in an infant two days old, and heard of another in an infant a few hours after birth ; Sir H. Marsh mentions one three days, and Dr. Underwood one fourteen days after birth. M. Blache found it most frequent from four months to a year, and Guersent from one year to six ; but in these countries it is uncommon at the latter age. Most of the German writers state that it is most common between the age of three weeks and eighteen months, but especially between the fourth and tenth month. 316. The first record we have of the disease, I believe, was in 1761, by Dr. Simpson, who termed it " the spasmodic asthma of infants." A few years afterwards Dr. John Millar described it (in 1769), and from him it was called Millar's asthma. Dr., Rush, of Philadelphia, followed him in 1770 (in the Philadelphia Gazette), and both he and Dr. War- burton, in 1809, and Dr. Hamilton in 1813, give a fair account of it. But by far the most complete description of it is given by Dr. John Clarke, in 1815, under the title, "A peculiar species of convulsion in infant children." "The child," he says, "is suddenly seized with a spasmodic inspiration, consisting of distinct attempts to fill the chest, between each of which a squeaking noise is often made. The eyes stare, and the child is evidently in great distress ; the face and the ex- tremities, if the paroxysm continue long, become purple ; the head is thrown backward, and the spine is often bent as in opisthotonos ; at length a strong expiration takes place, a fit of crying generally suc- ceeds, and the child, evidently much exhausted, generally falls asleep." 1 There appears to be a considerable resemblance between this disease and the very rapid form of hydrocephalus described by Dr. Munro, which I have formerly noticed. Dr. Golis also alludes to this affection, and includes it among the predisposing causes of hydrocephalus. He speaks of it as " a peculiar disorder of respiration, in which infants, after a sudden waking out of sleep, or from terror or anger, often, without any cause, are suddenly seized with a deep, shrill respiration, which for many seconds, sometimes even for minutes, threatens suffocation. The whole body becomes stiff; the face, hands, feet, and particularly the fingers and toe nails, black or blue ; and the little patients lose their breath and consciousness ; at length, however, with a cry of alarm, they again recover both.'' Dr. Underwood evidently embraces spasm of the glottis in that mys- terious term, "inward fits," which, he says, is occasionally accompanied "with a peculiar sound of the voice, somewhat like the croup," with a quick breathing at intervals. 2 1 Commentaries on the Diseases of Children, p. 87. 2 Diseases of Children, p. 181. 218 BPASM OF THE GLOTTIS. Dr. Chcync thus describes the disease in his work on hydrocephalus : "It begins with crowing inspiration, like that which takes place at the Commencement of a paroxysm of pertussis. At first there are long in- tervals between the spasmodic inspirations (several days, perhaps), as they appear to be connected with a disordered stomach and the absence of bile in the bowels — to arise from sudden exertion or fits of passion ; and as the child often continues to thrive notwithstanding, the disease is not much attended to." Very valuable monographs on this affection have since appeared by Dr. II. Davies, Mr. Pretty (cerebral croup), M. Roberton, Dr. Mont- gomery (thymic asthma), Mr. Hood, Sir Henry Marsh (spasm of tho glottis), Dr. Jas. llcid, Dr. Ley (laryngismus stridulus), (infantile laryngismus), MM. Tilache, Gucrsent, Kopp, Ilirsch, Kyll, Caspar, Fricke, Oppenheim, &c, and it is noticed in almost all the systematic treatises. 817. Symptoms. — The disease appears, then, to consist essentially in a, spasmodic closure of the rima glottidis and larynx, terminating by a forced inspiration, rather than in a spasmodic inspiration, as Dr. Clarke supposed. In the milder cases there are no premonitory symptoms ; the attack occurs quito suddenly, perhaps on first awaking out of sleep, sometimes even during sleep ; after a full meal, or whilst at play, or in a fit of passion. In other cases the attack has been preceded for some days by slight wheezing respiration, and an occasional cough, then suddenly the spasm occurs. Lastly, I have seen spasm of the glottis superadded to general con- vulsions, commencing subsequently, and continuing after they had subsided. 318. Whether there be preliminary symptoms or not, the muscles of the glottis and larynx are first affected ; tho child is suddenly startled by finding that it cannot breathe ; it struggles violently, becomes red or even purple in tho face, tho eyes are injected and suffused, tho eyeballs protruding, the hands clinched, the head thrown back, and tho wholo body agitated with distress and fright, presenting tho aspect of one in imminent danger of suffocation. This state lasts generally for a minuto or two, and at length, after many fruitless attempts, by a vigorous effort, or owing to relaxation of the spasm, inspiration is effected with a loud crowing sound, resembling the whoop of pertussis. A good fit of crying generally succeeds, and then tho child, exhausted by tho fright and struggles, falls asleep. In some rare cases the countcnanco remains pallid, though not less ex- pressive of anguish and fear. M. Kopp has remarked that in many cases tho tongue is protruded during the paroxysm, and that even during tho intervals there is a similar tendency. M. Ilirsch mentions that tho urine and feces arc often discharged involuntarily during a paroxysm. I have mentioned that tho hands arc clinched during the paroxysm, as a portion of the general muscular effort ; but if wo observe carefully, wo shall find that tho remarkable spasm of the thumbs and great toes, described by Dr. Kcllic, is present ; tho thumbs are spasmodically con- SPASM OF THE GLOTTIS. 219 tracted, and thrown across the palm of the hand ; the toes are bent towards the solo of the foot, and both wrists and feet are rigidly bent downwards and somewhat inwards. The backs of the hands, wrists, and feet appear swollen. This local spasm may continue in a slighter degree after the spasm of the glottis has subsided, the duration of each attack of difficult inspiration is generally about half a minute or a minute ; but Dr. Condie mentions their lasting fifteen or thirty. 1 Dr. Jas. Reid has described four forms of the disease which differ merely in intensity, from the slight catching of the breath, the decided spasmodic breathlessness with carpo-pedal spasm of the second up to the general convulsions of the third, and the complete asphyxia of the fourth form. 319. At the commencement of the disease, especially in the milder cases, the spasms occur at distant intervals, perhaps once in the day, or with some days' intermission, increasing in frequency and in severity, unless checked. In severe cases, the paroxysm may occur many times in the day. I have known it repeated thirty or forty times ; and in such cases, although the spasm is at first confined to the muscles of the glottis and larynx, yet, if the disease be neglected or mismanaged, the spasmodic action is extended to the extremities, and may terminate in a general convulsion, as Sir II. Marsh has observed. 2 During the intervals the child appears pretty well, but pale, exhaust- ed, and irritable, if the fits are frequent. There is no fever, the pulse is quiet, the tongue clean, the appetite pretty good, and in many cases the bowels are regular. In others, as Dr. Cheyne remarks, there is evidence of biliary and gastric derangement. The respiration is much as usual between the paroxysms, provided they are not very frequent. In the worst cases I have seen it was very hurried. When the disease is complicated with dentition, intestinal disorder, or general convulsions, of course the constitutional symptoms will be more marked ; there will be a quick pulse, loaded tongue, pale flabby skin, hurried respiration, and unhealthy evacuations. The spasm may return at very uncertain and unequal intervals, as I have said, and without any apparent cause, or the very slightest. Trivial irritation or annoyance, contradiction, sudden noises, are quite sufficient to provoke a return. Sir II. Marsh mentions that the smell of new paint always reproduced it in one of his patients. 320. Dr. II. Davis states that, in all the cases he had lately exam- ined, the tonsils were enlarged, the fauces puffy and swollen, and the uvula elongated ; but as these symptoms have not been observed by other writers, it is possible that the cases may have been complicated with this affection. He mentions also that in one case there was obsti- nate constipation, with dysuria, and that every attempt to evacuate the bladder brought on the spasm. 3 To another symptom which has been occasionally observed consider- able importance has been attached, from its correspondence with a pathological condition to which the disease has been attributed. I al- 1 Diseases of Children, p. 347. 2 Dublin Hosp. Reports, vol. v. p. G18. 3 Underwood ou Diseases of Children, p. 187. 220 SPASM OF THE GLOTTIS. lude to a swelling of the thyroid and thymus glands. Dr. Montgomery mentions a case in which he observed this enlargement, and by direct- ing his treatment to this point the child was cured. 1 In four cases, Dr. Ley observed a swelling extending from the jaw to the sternum, and laterally parallel to the clavicles. Just in proportion to the reduction effected in this enlargement, was the diminution of the spasm of the glottis and the other symptoms. This enlargement, which would be a most important symptom if gen- eral, has not been very commonly observed. One cannot doubt the accuracy of those who have mentioned it; but, to have the significance they have attributed to it, it should have been far more frequently noticed. 821. The duration of the disease, as well as its termination, is very uncertain. It may continue a few weeks, and then cease spontaneously, or in consequence of suitable treatment ; or it may persist longer, and subside after the cutting of some teeth, or from long-continued treat- ment. A considerable number of cases run either of these courses, and terminate favorably. Others, however, prove more serious and end fatally, either suddenly, during the first attack, or during a fit subsequently ; or they die after a longer illness, in convulsions, or worn out by continual distress. It has been suggested that fatal spasm of the glottis may be the cause of the sudden deaths, without any apparent cause, that are met with among children. Such cases are recorded by Maunsell and Evanson, Montgomery, Jas. Reid, and very many writers. The infant may be perfectly well, or perhaps only slightly indisposed, when in a moment it falls back dead, as happened to the infant of a friend of mine. I confess that I am inclined to believe that many of the deaths at- tributed to the nurse or mother overlaying the child, are, in truth, cases of sudden death from spasm of the glottis. 322. Pathology. — As one might expect in a disorder which is but a symptom, the appearances on dissection present great variety, according to the other diseases with which it may happen to be complicated. For instance, in many cases, no appearance of disease whatever, in any organ, could be detected. 2 In others, the cranium is large and imperfectly ossified, the mass of the brain large and rather soft, 3 or there have been found tumors in the brain, congestion, and effusion of serum, effusion of blood into the cranium, partial closure of the rima glottidis, open foramen ovale, congestion of the lung, congestion of the glands at the root of the lung, enlargement of the bronchial glands, of the thymus gland, of the mesenteric glands, and disease of the intes- tines, but no one morbid change is found in the majority of cases. This has given rise to an equal variety of opinions, but the very absence of morbid phenomena is a sufficient answer to some of them ; as, for ex- ample, it is thus proved not to be of the nature of croup, as supposed by Underwood, Ferrier, Hecker, Albers, &c, or of asthma, as stated by 1 Dublin Journal, vol. ix. p. 439. 2 Sir H. Marsh, Dublin Hospital Rep., vol. v. p. 616. 3 Dr. Shoepf-Merci, Edin Journal, Not. 1850. SPASM OF THE GLOTTIS. 221 Millar and others, because none of the post-mortem appearances of either are ever found. Dr. John Clarke regards it as a convulsive affection, depending upon diseased action of the brain, and induced by over-feeding, the sudden cure of ophthalmia, suppression of cutaneous eruptions, &c. ; and he found congestion of the vessels of the brain, water in the ventricles, and mesenteric disease. 1 Dr. Cheyne has no doubt that the brain is really the seat of the dis- ease, although the precise morbid condition has not been ascertained. He had seen twenty cases, of which one-third were fatal, and he has given descriptions of these cases : in the first there were two scrofulous tumors imbedded in the brain ; in the second, the convolutions were obliterated, and the substance of the brain unusually firm (hypertrophy and induration) ; in the third, congestion and serous effusion. Dr. Merriman could detect no cerebral disease in two children who died during the paroxysm. He found a collection of enlarged glands of the neck pressing upon the par vagum. Gardien regards the disease as a spasm of the diaphragm, and of the muscles of the chest and larynx. The name "cerebral croup," given to it by Mr. Pretty, sufficiently expresses his view of its nature. Kyll attributes it to inflammation of the cervical portion of the medulla spinalis, or to enlargement of the cervical and thoracic glands compressing the pneumogastric nerve. 323. As early as 1723 it was attributed to enlargement of the thymus gland by Richa, and in 1726 by Verduis. This view has been revived in late years by Kopp, who published a work on the subject in 1830. He found the trachea and larynx healthy, the tongue large and thick at the root, and the body generally exhibiting marks of suffocation ; but the most remarkable post-mortem appearance was the state of the thymus gland : " In one case it might have been mistaken for the lung, it was so thick and hypertrophied ; it extended from the thyroid gland to the diaphragm, was two inches wide, weighing more than an ounce, and pressing strongly against the trachea ; on cutting into it there flowed out of its whole tissue a quantity of milky fluid. In another post- mortem the thymus was found occupying the whole of the anterior part of the chest, and forming, with the superior part of the thorax, adhe- sions that could be removed only by the scalpel ; it was united to the thyroid gland by thick cellular tissue. By the thymus covering the whole heart, the sounds of that organ had been intercepted during life. The lobes of the gland were elevated and enlarged : its parenchyma presented no trace either of suppuration or tubercles, or any other de- generation ; on pressure being applied, there came away an abundant milky humor, like the spermatic liquor in consistence." 2 Dr. Hirsch published five cases ; three proved fatal, and in two there was a post-mortem examination : "The thymus of the first of these occu- pied all the anterior mediastinum, and was composed of two large lobes besides several smaller ones. An appendix of the gland arose about its 1 Commentaries on Diseases of Children, p. 90. 2 Dublin Journal, vol. ix., p. 514. 222 SPASM OF THE GLOTTIS. middle, and surrounded the common jugular vein ; the glandular paren- chyma was firm, and weighed nine drachms and a half. The thymus of the second child was not so thick nor of so close a texture ; it ex- tended from the thyroid gland beyond the pericardium, which it covered ; it had contracted adhesions with the arteria innominata and right caro- tid, and its weight was six drachms six grains." 1 It may be as well to mention here that the thymus gland, in its normal state, weighs about half an ounce, or six drachms, and extends from the thyroid gland into the upper part of the thorax, lying over the pericardium, lungs, and roots of the great vessels. Dr. Kornmaul mentions a thymus gland weighing fourteen drachms ; Dr. Hirsch one weighing nine and a half drachms ; and Dr.' Van Velsen one weighing nine drachms. Dr. Montgomery mentions that in two cases the gland was enlarged, one of which, he feels assured, weighed two ounces. 2 On the other hand, the researches of Caspari, Pagenstecker, Rosch, Fricke, Oppenheim, &c, led to the conclusion that the disease did not depend upon enlargement of the thymus. The latter physician found the plexus choroides full of blood, effusion into the chest, glottis erect, and the rima open ; no swelling in the neck, thymus gland much as usual, perhaps rather heavier, but not corresponding to the description of Kopp and Hirsch, and neither pressure nor displacement of the par vagum nor recurrent. Dr. Roberts mentions five cases of enlarged thymus gland, and the editor of the New York Medical Journal two, in which the accompa- nying symptoms were not those of spasm of the glottis, but of pneu- monia. Sir H. Marsh seems to think that the seat of the irritation may be at the origin of the pneumogastric nerve. In one post-mortem exami- nation which he mentions there was found effusion into the ventricles, but no other trace of the disease ; in another, contraction of the rima glottidis, engorgement of the right lung and erosion of the mucous mem- brane of the stomach ; but in neither is any enlargement of the thymus mentioned, and the author is far too acute and careful an observer to have overlooked it had it been present. 3 M. Trousseau refers the disease to a spasmodic condition, with a want of harmony in the action of the respiratory muscles ; and he states that, during the six years he has been at the head of his hospital, he has never met with a single case of thymus sufficiently enlarged to occasion the slightest inconvenience. Dr. Hugh Ley attributes the disease to a suspended or impeded state of the functions of that portion of the eighth pair, which is distributed to the larynx, caused by enlarged cervical or thoracic absorbent glands, but not from enlarged thymus. 4 324. I have thus given a cursory glance at the chief of the 'post- mortem observations, upon which the different views of the pathology of the disease have been founded. These views may be divided into, 1, 1 Dublin Journal, vol. ix. p. 517. 2 Ibid., p. 433. 3 Dublin Hosp. Rep., vol. v. p. 515. 4 On Laryngismus Stridulus, p. 113. SPASM OF THE GLOTTIS. 223 those which adduce the evidence of irritation in the central nervous system ; 2, those which attribute the affection to pressure upon some particular nerves ; and 3, those which look to the enlargement of the thymus gland as the "fons et origo mali." Let us examine the two latter views a little more closely. The advocates of the last-named hypothesis generally consider that the enlargement of the thymus, from engorgement, acts mechanically, by pressing upon the larynx and trachea, and obstructing respiration ; that relief is afforded, and a ces- sation of the paroxysm effected by the diminution of the congestion ; and the cure completed by the reduction of the gland to its normal size. Dr. Montgomery mentions three ways in which enlargement of the gland may occur : 1, either as simple hypertrophy ; 2, comparative hypertrophy, when there is a disproportion between the size of the gland and the capacity of the upper part of the chest ; or 3, as the result of disease ; and he thus explains its modus operandi in producing spasm of the glottis : " Supposing any cause to occur capable of producing agitation or strong mental excitement in the child, and that the gland has been previously enlarged and capable of great distension, a number of circumstances will occur which combine in rendering that distension still greater, and increasing the size of the gland in such a manner as to affect materially the condition of the surrounding parts. Any cause producing agitation on the part of the child excites the heart's action, the enlarged gland becomes distended and increased in size, presses on the vena innominata, and prevents the return of blood from the head. The same pressure prevents the venous blood of the thymus itself from getting into the innominata, and thus becomes a fresh source of dis- tension. The combined result of this is great and dangerous pres- sure exercised on the great vessels, preventing the return of blood from the head, and thereby suddenly producing cerebral congestion ; on the trachea, by which respiration is impeded ; and on the important nerves in that situation, especially the sympathetic, the par vagum, and its recurrent branches, any interference with which has been found, by the experiments of Dr. Alcock, of this city, most powerfully to influence respiration, &c.' n No doubt these views are stamped with high authority, and with a considerable array of learning and research; but there are two important facts which meet one at the outset, and which have very great weight, so far as the mechanical production of the disease is concerned: — 1. That in a great majority of cases of spasm of the glottis there is no universal hypertrophy of the thymus perceptible during life, or dis- covered after death. It is impossible to suppose that such observers as Clarke, Cheyne, Hall, Ley, Marsh, Schoepf-Merei, &c, could overlook such enlargement ; and yet we have their positive testimony that in many cases no morbid changes whatever could be detected, and in others the disease existing was not enlargement of the thymus gland ; and, 2. That many cases of enlarged thymus are on record in which the symptoms of spasm of the glottis never occurred ; nay, that no affec- 1 Dublin Med. Journal, vol. ix. p. 437. 224 SPASM OF THE GLOTTIS. tion of the glottis or trachea was observed, although at the same time the lungs were seriously affected. Dr. Condie remarks : " There has not been adduced a single well- established fact to show that an hypertrophied condition of the thymus is capable, under any circumstances, of exerting upon the nerves in its vicinity such a degree of pressure or irritation as would produce the phenomena of the disease under consideration." 1 I may add that the enlargement of the thymus gland, when it does occur, has been regarded as the effect, and not the cause of the spasm of the glottis, by Dr. Marshall Hall, and more recently by M. Suiron. 2 As to the mechanical pressure upon the trachea of the enlarged gland producing the disease, it appears more than doubtful, when we consider the structure of the trachea, and that the peculiarity of the disease is not difficult or impeded respiration, but complete arrest of inspiration; expiration, when effected, being quite easy. I doubt whether pressure from an enlarged thymus would affect respiration at all; and, if it did, I believe it would affect inspiration and expiration equally; that the dyspnoea would be less in amount than in the present affection, and not so temporary. 325. With regard to the agency of pressure upon the nerves in caus- ing this disease, whether exercised by enlarged thymus or absorbent glands of the neck or thorax, according to Dr. Ley, I prefer quoting the observations of my friend, Dr. Marshall Hall. "In the first place," he remarks, " as far as my memory and judgment serve me, the cases adduced to support this view are not cases in point, but in reality cases of other diseases. Secondly, supposing pressure upon the par vagum to exist, it would induce totally different phenomena from those actually observed in this disease ; and it would not explain the series of pheno- nema which actually occurs in it ; for, " 1. Such pressure would induce simple paralysis. This would, in the first place, affect the recurrent nerve and the dilator muscles of the larynx; it would not induce a partial but constant closure of that orifice — a permanent state of dyspnoea, such as occurred in the experiments of Legallois, or such as is observed to be excited in horses affected with the '•cornagej or roaring. Secondly, it would induce paralysis of the infe- rior portion of the pneumogastric, with congestion in the lung or lungs, and the well-known effects upon the stomach of a division of this nerve. " 2. The disease in question is obviously a part of a more general spasmodic affection, and frequently — indeed, most frequently — comes on in the midst of the first sleep, in the most sudden manner, receding equally suddenly, to return, perhaps, as before, after various intervals of days, weeks, or even months — very unlike paralysis from any cause. " 3. It not unfrequently involves, or accompanies, as I have said, other affections, indisputably spasmodic, as distortion of the face, stra- bismus, contraction of the thumbs to the palms of the hands; of the wrists, feet and toes; general convulsions ! sudden dissolution! a series of phenomena totally unallied to paralysis. "4. Indeed, the larynx is sometimes absolutely closed, an effect which paralysis of the recurrent nerve and of its dilator muscles cannot effect. 1 Diseases of Children, p. 318. 2 Banking's Abstract, vol. i. p. 246. SPASM OF THE GLOTTIS. 225 " 5. Paralysis from pressure of diseased glands would be a far less curable, a far less variable disease, a far less suddenly fatal disease, than the complete convulsion. " Thirdly. Almost all recent cases are at once relieved by attention to three or four things, viz: 1, the state of the teeth; 2, of the diet; 3, of the bowels; and 4, of change of air. They are as obviously pro- duced by the agency of errors in one or more of them. " Fourthly. In fact, the complete convulsion is a spasmodic disease, excited by causes situated in the nervous centres, or eccentrically from them. In a case of spina bifida, a croupy and convulsive inspiration was induced by gentle pressure on the spinal tumor. In cases from teething, the attack has been induced and removed many times by freely lancing the gums; and, when it has arisen from crudities, it has been relieved by emetics and purgatives, and by change of air, &c. "Fifthly. There is a series of facts which prove the connection of this disease with the other forms of convulsions in children, and with epilepsy in the adult subject. " Sixthly. In protracted cases, congestion and effusion within the head occur as effects of this disease. "Lastly. Innumerable cases of undoubted croup-like convulsions have occurred, in which no enlarged glands could be detected in any part of the course of the pneumogastric nerve." 1 826. These reasons appear to me as conclusive against the supposi- tion of the disease being caused by the pressure of enlarged thymus or bronchial glands upon the nerves, as the former facts were against the supposed efforts of mechanical pressure upon the trachea by the hyper- trophied thymus : and we have now remaining only those cases in which a post-mortem examination records no morbid change or some lesion of the brain or its membranes, i. e., as Dr. M. Hall has observed, those cases where death has anticipated organic change, and those where time has allowed the organs, at first functionally, to be afterwards organically disordered. Irritation is excited in the nervous system, already perhaps more irritable than usual, 2 from some distant point, and is again projected, as it were, to another. I know of no case of disease so illustrative of Dr. Marshall Hall's physiological discoveries. "It is an excitation," he observes, " of the true spinal or excito-motory system. It originates in, " 1. a. The trifacial, in teething. b. The pneumogastric, in overfed or improperly fed infants. c. The spinal nerves in constipation, intestinal disorder, or ca- tharsis. These act through the medium of, " 2. The spinal marrow, and, " o. a. The inferior or recurrent laryngeal, the constrictor of the pharynx. b. The intercostals and diaphragmatic, the motors of respira- tion." 3 15 1 Underwood on Diseases of Children, p. 184. 2 Reid on Infantile Laryngismus, p. 71. 3 Diseases and Derangements of the Nervous System, p. 71. 226 SPASM OF THE GLOTTIS. 327. Causes. — Among the predisposing causes has been mentioned the peculiar condition of the larynx in infants, scrofulous constitution, hereditary peculiarities, and climate. It certainly is often observed in several children of the same family successively, 1 and is undoubtedly more prevalent in moist and damp situations. In dry, pure air in the country it is almost unknown, whilst it is sufficiently frequent in towns. The exciting causes may be stated to include any species of irrita- tion capable of exciting the nervous system into irregular but not ex- cessive action. Dentition is, perhaps, the most common of such causes; next, indigestible food, or overfeeding, constipation, or disorder of the bowels, suppressed eruptions. Mr. Coley mentions a curious kind of constipation giving rise to it, in which there was an accumulation of feces in the colon, with a secretion of viscid mucus, like white paint, in the duodenum, and until this was evacuated no relief was obtained. 2 After what I have just said, I can hardly admit tumors pressing upon nerves as exciting causes, except in a different sense to that proposed by Dr. Ley. It is quite conceivable that irritation in or from a tumor may act in producing the disease in the same way as dentition, though not from pressure. 328. Diagnosis. — The pathognomonic sign of this disease, as Dr. Cheyne has well observed, is " a crowing inspiration, with purple com- plexion, not folloived by cough." The suddenness of the attack, the temporary character of each paroxysm, its facility of reproduction, the absence of the normal symptoms of inflammation of the larynx or tra- chea, or of much constitutional suffering, are sufficiently characteristic, and render the differential diagnosis tolerably easy. 1. It has been considered as a variety of croup, and has been mis- taken in practice for a variety of that disease, or of laryngitis ; but in these affections the dyspnoea is permanent, and affects expiration as well as inspiration, though not to the same degree, and, notwithstand- ing, respiration is steadily performed ; but in spasm of the glottis, it is the inspiratory effort which is arrested, and for the time, inspiration is absolutely stopped. The rough, metallic sound of croupy breathing is quite different from the clear, ringing crowing of the present disease ; and moreover, it is evident in expiration, and is accompanied and aggravated by a severe cough. In spasm of the glottis there is no cough, and in the intervals between the spasms the respiration is natural. Lastly, in the present complaint, there is generally little or no disturbance of the circulation, and no fever ; but, as the disease in- creases, there is a disposition to general convulsions; whilst in croup we have high fever, quick pulse, thirst, heat of skin, and no convulsions, except at the termination. 2. The milder forms of the disease are distinguished from convulsions by the purely local nature of the spasm, and the absence of constitu- tional irritation ; but as the more severe cases may merge into general convulsions, the distinction will cease. 3. From hooping-cough it is easily distinguished, although there is a great resemblance between the sound of the hoop and the crowing 1 Ley on Laryngismus Stridulus, p. 53. 8 Diseases of children, p. 290. SPASM OF THE GLOTTIS. 227 inspiration, owing to both resulting from the same mechanical condition of the larynx, viz : more or less perfect closure, terminating in a forci- ble inspiration. But in spasm of the glottis there is very rarely any accompanying cough, and the spasm occurs quite independently. There is no kink, no expectoration, nor vomiting, nor any catarrhal sounds in the lungs. ' 329. Prognosis. — In all cases the prognosis is grave, and in the severe case very serious, because of the implication of the brain, and the tendency to terminate in convulsions or in sudden death. One- third of Dr. Cheyne's cases died ; Dr. John Clarke says that the patient rarely recovers ; Dr. Gooch states, that it proves fatal to one third of those attacked. Of Sir H. Marsh's cases, five recovered and two died. In Dr. Hirsch's cases, three out of five died. And it appears to be more fatal with males than females. Gervino and Gardien think it almost always fatal if remedies be not employed in the early stage ; and this seems to be the general opinion ; but, on the other hand, if the complaint be recognized, and the treatment early and prompt, the symp- toms will, in many cases, yield to the remedies employed. The change which indicates a favorable termination is a diminution in the frequency and duration of the paroxysms, and freedom from any complications. The unfavorable symptoms are an increase of the spasms, spasmodic affections of the limbs, or general convulsions. 330. Treatment. — Fortunately, however different opinions may be as to the nature of the disease, all are unanimous as to its treatment. The first thing to be attended to is to remove all exciting causes, and according to them will be the treatment. If the child be teething, " the augmented arterial action within the gums and alveolar processes must be subdued by deep, diffused, and repeated scarification of the gums, conducted with every precaution to avoid excitement of a mental kind." 1 If we suspect overfeeding, or that indigestible food has been taken, the stomach must be emptied by an emetic, or by tickling the fauces with a feather; and the effect of accumulation, or disorder of the bowels, may be removed by one or two brisk purgatives of calomel and jalap, or rhubarb, or by large enemata of warm water. If the air of the room in which the child has been confined be close and impure, it must be removed to a larger apartment, or fresh pure air admitted. 331. During the paroxysm, the child should be placed in an upright position, with the head leaning a little forward, and exposed to a current of pure fresh air, whilst cold water is sprinkled on the face. If this fail, the child may be placed in a warm bath, and cold water sprinkled in its face; in short, whatever is calculated to induce a more forcible effort at inspiration. Dr. Condie mentions that the application of ammonia to the nostrils is useful, or tickling the fauces with a feather, so as to induce vomiting. 2 If these means fail, an attempt must be made at artificial respiration. In extreme cases, it has been a question whether tracheotomy ought 1 Lancet, July 12, 1847. 2 Diseases of Children, p. 358. 228 SPASM OF THE GLOTTIS. not to be performed; and certainly, in prospect of instant death, it may be right to try some extreme measures ; but the advantage to be derived from this operation is by no means certain, and as yet we want facts to warrant our recommending it. Mr. W. J. Cox has used chloroform during a paroxysm with great success. " In a few seconds, the muscles will be relaxed, the spasms will be over, and the little patient will breathe freely." 1 A few drops of the fluid should be sprinkled on a handkerchief, or poured into the hand and held before the mouth. Generally speaking, the paroxysm terminates too quickly to allow of much interference. 332. During the intervals, our object should be to diminish the fre- quency of the spasm, and to improve the general health. In very few cases is bleeding either necessary or useful ; in many, it would do mischief by weakening the vital powers. When the child is robust, florid, and plethoric, a few leeches may, perhaps, be beneficial; but when there is any threatening of general convulsions, or any other evidence that the brain is more than usually involved, then prompt bloodletting will form a necessary and important part of the treatment. Purgatives are universally recommended, not powerful doses, but moderate ones, repeated three or four times a week, so as to clear out the bowels and act as a derivative. Dr. M. Hall strongly recommends the antacid aperients. Antispasmodics have been found useful. Millar gave assafoetida in large doses ; the proper dose, however, for a child of two years is from one to two grains, and four to six grains for a child from five to ten years. Dr. John Clarke used ether and ammonia; Dr. Underwood assafoetida, oleum succini, tinct. fuliginis, of the old pharmacopoeia, musk, cicuta, &c. Musk may be given in doses of two to five grains, every six or eight hours, to a child of three years old and upwards. Sir H. Marsh tried the tincture fuliginis with benefit, and, in one case, an infusion of tobacco leaves (gr. v to ovj) as an enema. Dr. Stewart speaks highly of a poultice sprinkled over with Scotch snuff. Drs. Ley and Davis gave henbane with relief; or, if the child be restless, a little Dover's powder may tranquillize it ; and Dr. Chas. D. Meigs recom- mends the application of ice to the epigastrium. In cases where dysuria w T as present, Dr. Davis derived great benefit from a combination of hyoscyamus, spirits of nitrous ether, and almond milk. When the fauces are swollen, they may be washed over with a solution of the nitrate of silver, with a cameUs-hair pencil, or of a mixture of dilute sulphuric acid and syrup. 333. It will be advisable in most cases to apply some form of counter- irritation, either some irritating liniment, or a blister, or, what I have found far better, a small seton in the arm. In one case under my care, the moment the seton discharged fairly, the spasms ceased, and when- ever it w T as left out they returned. 334. With almost all children who have the disease for some time, but especially with those of a delicate constitution, tonics will be found 1 Lancet, Sept. 1, 1849. PERTUSSIS. 229 beneficial. Sulphate of quinine, infusion of cascarilla, or of hops, as advised by Dr. Ley, or some of the preparations of iron, may be given in doses suitable to the age of the child. Dr. Davis recommends the vinum ferri, combined with the carbonate of ammonia and hyoscyamus, if the child be languid and irritable ; Mr. Cox the citrate of iron, with small doses of hydrocyanic acid to allay irritation (a quarter of a minim three times a day to a child three years old). Dr. Schoepf-Merei states that no remedy is equal to the cod-liver oil, in doses of two to four teaspoonfuls a day to a child of three or four months old, increasing according to the age. Attention to the diet of the child is of great importance. We may succeed in removing the disease, and improper food will instantly repro- duce it. The food should all be of a bland nutritious character, and moderate in quantity. If there be any danger of over-indulgence, or of imprudence, it will be better to adopt Dr. M. Hall's plan, and fix upon one kind of food to the exclusion of all other. Dr. Montgomery very wisely cautions us against laying infants on their back when feed- ing, if they are liable to this disease, and against hasty feeding. In the case of infants at the breast, it will be prudent in many cases to change the nurse. Lastly, I have already alluded to the necessity of a pure atmosphere within the room in which the child lives. I must add that the tempera- ture ought to be carefully regulated, so that it shall neither be too hot nor too cold; and also that the clothing of the child should be sufficient, according to the season, without being oppressive. But very special benefit, as Sir H. Marsh and Mr. Roberton have shown, is derived from change of air. After we have removed all the causes within our reach, prescribed antispasmodics and tonics, we shall often find more imme- diate benefit from a removal to the pure mild air of the country than from all our medical treatment in town. This should be done as early in the disease as possible, in order to check its progress. Should the disease increase in spite of all our efforts, and issue in general convulsions, then the treatment must be adopted which I have recommended for that disease. CHAPTER III. PERTUSSIS — HOOPING-COUGH. 335. I have placed hooping-cough next in order to spasm of the glottis because of the similarity between them, the former constituting a transition from purely spasmodic to inflammatory affections, being a mixture of both. Dr. Cullen has given a brief but accurate description of this disease : " Morbus contagiosus, tussis convulsiva, strangulans, cum inspiratione sonora, iterata, ssepe vomitus." Dr. Copland's definition is an expan- 230 PERTUSSIS. sion of this, with more details. He says that it is " a convulsive and suffocative cough, accompanied with a reiterated hoop, or consisting of many successive short expirations, followed by one deep and loud inspi- ration, and these alternating for several times ; occurring in paroxysms, ending with the expectoration of tough phlegm, and frequently with vomiting ; infectious, and often epidemic, appearing but once during life." It has obtained various popular and learned names: chin-cough, kink- cough, and hooping-cough, in England ; kinkhoast, in Scotland ; coque- luche, in France; and, in Germany, keichhusten, stickhusten, eselshus- ten, &c. By Willis, it was called tussis convulsiva ; by Hoffman, tussis ferina ; and by Sydenham, pertussis. 336. It is very doubtful whether it was known to the ancients. No accurate description is to be found in the Greek or Arabian -writers; and the disease is so peculiar that they could hardly have omitted to notice it had it been familiar to them. It has, therefore, been supposed by Rosen that it came from the East Indies and Africa into Europe. The earliest record of it we find is by Mezeray, as it occurred in France in 1414 ; but Dr. Copland considers that there is nothing cha- racteristic about his description, or the subsequent ones of De Thou and Pasquier, but the name " coqueluche." The first accurate account is by Willis, 1 who was followed by Millar, 2 Sydenham, 3 Alberti, 4 Brendel, 5 Butler, 6 Danz, 7 Paldam, 8 Perrada, 9 Watt, 10 Marcus, 11 &c. ; and more recently by Guibert, 12 Desruelles, 13 Blaud de Beaucaire, 14 Blache, 15 Roe, 16 C. Johnson, 17 Duges, 18 Copland, 19 &c. ; besides excellent notices in the systematic works of Dewees, Eberle, Stewart, Condie, Maunsell and Evanson, Coley, Barrier, Bar- thez and Rilliet, Bouchut, &c. 337. Hooping-cough has this peculiarity in common with some erup- tive diseases, that it occurs once, and in general but once in a lifetime; and consequently almost always in infancy or childhood, i. e. the first time the child is exposed to the peculiar exciting cause, whether that be epidemic miasma, or contagion. Thus we find the most common age is between two and ten years. Dr. Watt has given the following table of the ages at which death from hooping-cough occurred in Glasgow during thirty years: — 1 Opera Omnia, Amst. 1682, vol. ii. p. 169. De Morbus Convulsiva Puerorum, &c. 2 Obs. on Asthma and Hooping-cough, 1769. 3 Opera Universa, 1726, p. 311. 4 De Tussi Infant. Epidemica, 1728. 5 Prog, de Tussi Convuls., 1747. 6 A Treatise on Kink-Cough, 1773. 7 Versuch einer Allgem. Gesch. des Keichhustens, 1791. 8 Der Stickhusten, 1805. 9 Memoria, &c. Verona, 1815. 10 Treatise on the History and Treatment of Chin-Cough, 1813. 11 De Keichhusten, 1816. 12 Recherches sur la Croup, et la Coqueluche, 1824. 13 Traite de la Coqueluche, 1824. 14 Revue Med., 1831. - 15 Archives Gen., vol. iii. 1833. 16 Treatise on the Nature and Treatment of Hooping-cough, 1838. 17 Cyclopaedia of Practical Med., vol. ii. p. 428. 18 Diet, de Med. et de Chir. Pratiques, vol. v. p. 487. )9 Diet, of Medicine, part. v. p. 236. PERTUSSIS. Under 6 months in 135 cases Abcrv e6 " and under 1 year, " 357 " " 1 year " 2 years, " 596 " " 2 years 3 " " 333 " " 3 " 4 " "186 " «' 4 " 5 " " 109 « « 5 " 6 " " 37 " " 6 '• 7 " " 34 " << 7 " 8 " " 12 " " 8 " 9 " " 10 •' " 9 " 10 " " 5 " " 10 years, . 3 » 231 1817 The author states, that this may be considered about half of the deaths in Glasgow from this cause. Out of 130 cases collected by M. Blache, 106 were from one year old to seven, and twenty-four from seven to fourteen years. Of twenty- nine cases observed by Rilliet and Barthez, three were from one to two years old; five, three years; seven, four years; six, five years; two, six years; three, seven years; one, eight years ; one, nine years; and one twelve years old. 1 Dr. Hood mentions having seen a child of a fort- night old, 2 and Dr. C. Johnson one of three weeks old, attacked by the disease. On the other hand, it has undoubtedly occurred more than once in the same individual, some say even three times ; and cases are on record of persons who had escaped until a very advanced period of life. Eberle mentions two cases occurring after fifty years ; and Heberden one in a woman of seventy, and another in a man of eighty. Boys and girls are of course equally exposed to the attack, and yet, according to the researches of Blache and Constant, a greater number of boys arrive at maturity without having had the disease. Blache proved the proportion of such cases to be seven boys to six girls, and Constant, three boys to two girls. 3 338. Symptoms. — The disease has been divided generally into two or three stages. Desruelles and Lombard have a period of invasion, a period of increase, and a period of decline ; Blache and Williams divide it into the inflammatory, congestive, and nervous stage ; others into the catarrhal and spasmodic stages, which is at any rate the simplest and most natural division. The period of decline is simply the termina- tion of the second or spasmodic stage. The first stage commences with the usual symptoms of catarrh. The child appears to have caught cold ; it is languid, restless, feverish, and irritable without cause. There is loss of appetite, sneezing, coughing, and an extra secretion of mucus from the membrane lining the nose and bronchial tubes after the first day or two. This is by far the most general mode of invasion, a well-marked but not very severe catarrh ; but occasionally we find the patient suffering much more, the fever intense, great thirst, the pulse quick, the oppres- sion and general distress considerable, the cough very frequent and 1 Mai. des Enfans, vol. v. ii. p. 230. 2 On the Fatal Diseases of Children, p. 103. 3 Barrier, Mai. de l'Enfance, vol. i. p. 370. 282 PERTUSSIS. painful, dry at first, but with profuse expectoration afterwards. The bowels, according to Dr. Watt, are generally constipated, and require large doses of medicine for their relief; but this, I think, is not gene- rally the case. In some few cases there is no evidence of the existence of this first stage ; the child is at once seized with the characteristic cough, without any irritation of the mucous membrane. M. Blache mentions that the child of his colleague, Dr. Tavernier, set. two years, was brought home from the country in perfect health, and without the slightest cold. The day after she was playing with two children who had hooping-cough. In the evening of the second day she had an attack of shrill, spasmodic cough, which proved to be hooping-cough, and continued for two months without any complication. 1 On the other hand, Dr. Watt observes that the disease, throughout its course, may present this character only. 2 "I have had instances of a disease," says Dr. Cullen, "which, though evidently arising from the chin-cough contagion, never put on any other form than that of a com- mon catarrh." 3 And Dr. Burns observes that, "in young children, even death may take place, although the disease never fully forms ;" and his observation is confirmed by M. Duges. I think, however, that in such cases there must ever remain a doubt as to the true nature of the disease. 389. These catarrhal symptoms continue for twelve or fourteen days, but gradually subside, the fever and coryza diminish, the pulse becomes quiet, and the appetite returns. The cough, indeed, persists, or even appears aggravated, but it exhibits a change of character. Instead of being a simple cough, with few suc- cessions, we find it prolonged by a succession of expiratory efforts, and at its termination we occasionally hear a forcible inspiration, accompa- nied by a loud ringing sound. The prolonged paroxysm of coughing, or kink, and the hoop, mark the commencement of the second stage, as the subsidence of the catarrh does the termination of the first. The cough is very peculiar ; when fully established we find "a number of expirations made with such violence, and repeated in such quick suc- cession, that the patient seems to be almost in danger of suffocation. The face and neck are swollen and livid, the eyes protruded and full of tears ; at length one or two inspirations are made with similar violence, and by them the peculiar hooping sound is produced ; a little rest pro- bably follows, and is succeeded by another fit of coughing, and another hoop ; until, after a succession of these actions, the paroxysm is ter- minated by vomiting, or a discharge of mucus from the lungs, or perhaps by both." 4 The child is perfectly conscious of the approach of the cough; he feels a sensation of rattling in the chest, and tickling in the larynx, which he endeavors to suppress, and the struggle continues until his resistance is overpowered by the irritation. The paroxysms, or a rapid succession of them, may last from one to fifteen minutes, and in proportion to the violence and length will be the 1 Diet. Ge"n. des Sciences M6d., art. Coqueluche, p. 24. 2 On the Chin-cough, p. 37. 3 First Lines of the Practice of Physic, sect. 1400. 4 Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. -128. PERTUSSIS. 233 breathlessness and fright of tho child, and its efforts to inspire. If lying down, it will suddenly jump up, and seize hold of whatever is nearest, so as to make a fulcrum, as it were, for the whole muscular force of the body, which is employed in overcoming the spasm. The paroxysm most generally terminates in vomiting, but if it be very violent, some small vessels may be ruptured, and blood escape from the nose or mouth, or it maybe effused beneath the conjunctiva, or be mixed with the expectoration. After the fit of coughing is over, the child appears exhausted, and requires a short rest to recover itself; but then, and during the interval until the next cough, it appears tolerably easy and cheerful, occupied with its usual plays, and not averse to food. If the attack be severe, it will be pale, thin, and languid. 840. The length of the intervals, and the frequency of the parox} r sms vary a great deal. At first, and for some time, they are very frequent when the disease is severe. I have known them occur every half-hour during the day and night ; but in other cases they return every five or ten minutes during the day, and less frequently at night, though the paroxysms are rather more severe. 1 The principal cause of their return is the accumulation of mucus if the secretion is profuse. Frequent efforts will be made to get rid of it, and if it be easily expelled, in sufficient quantity, the fit will be light, and the interval easy. If it be scanty and tenacious, the paroxysm will be violent, the efforts great, and the cough renewed almost imme- diately, or it will occur in double paroxysms. A full meal, a fit of anger, crying, fright, or laughter, will generally bring on the cough ; nay, even the force of sympathy will have a similar effect, for it is mentioned that, in the case of two children who had hooping-cough, when one had a fit of coughing, the other immediately began also. In some rare cases, towards the decline of the disease, the paroxysms have assumed a periodic character, returning at a given hour. A case of this kind is mentioned by Dr. Good; 2 it occurred daily at a certain hour, continued obstinately for several months, and returned at the same season for two years. 341. The expectoration which, during the first stage, was a frothy mucus, assumes, in the second stage, a very tenacious character ; it may be clear and transparent, or yellow, and even puriform, but still thick, tenacious, and ropy, so that it may be drawn out of the infant's mouth with the fingers. If we make a stethoscopic examination of the chest during the first stage, we shall find the mucous or sibilant rhonchi, characteristic of the catarrh; and the respiratory murmur somewhat weaker than usual. The chest is clear and sonorous on percussion. During the second stage, when the hooping-cough is fully developed, Laennec observes that, "during an interval, we find but the ordinary symptoms of catarrh, i. e. the respiratory murmur more feeble than usual, or altogether absent in some parts, otherwise resonant; puerile in others, 1 Marley on Diseases of Children, p. 157. 2 Study of Medicine, vol. ii. p. 393. 234 PERTUSSIS. with mucous or sibilant rales. During the paroxysms we perceive only the vibration of the trunk, from the shock of the cough, and we only hear a slight rhonchus or the respiratory murmur in the short intervals between the successions. The hooping inspiration, so characteristic, seems limited to the larynx and trachea. Neither pulmonary nor bronchial respiration is heard, even in those parts where puerile respi- ration had been audible a few minutes before." 1 Similar testimony is borne by Dr. Williams ; he says : "On applying the ear to the chest during a fit of hooping-cough, one is surprised, with such violent external motions, to hear so little sound of respiration within the chest ; and, during the sonorous back-draught, there is scarcely any sound of air entering the lungs. This is to be ascribed to the continued contraction of the glottis and large bronchial tubes, pre- venting the air from entering the pulmonary texture with sufficient force to produce the ordinary respiratory murmur." 2 All writers agree pretty much with this description when the disease is uncomplicated ; and, so far as the positive part is concerned, I have no doubt it is true, but I think more can be heard during the intervals in well-marked cases than is here mentioned. I have examined a great many children at intervals, from one paroxysm to another, and I have in a great many cases found that, after the chest had been cleared by the last cough and vomiting, the respiratory murmur or inspiration was louder, and more rough than usual, nay, in some cases, that it had a rather loud, brazen sound, something resembling a loud sonorous rale, as if the air was passing through tubes much narrower than usual. It is perceptible, also, in expiration, though more feeble. This sound may continue until the mucus begins again to accumulate, and then it will be exchanged for the large, mucous, bubbling sound, which increases until the next cough, and is almost universal. In milder cases the rough dry sound is more feeble, though gene- rally audible, and I think this loud, rough murmur of inspiration and expiration quite peculiar to pertussis. The chest is clear on percussion throughout this stage in simple cases. The explanation given of the cough and the hoop by Dr. Roe is, I think, satisfactory: "Any one who will make the experiment will perceive that by the exercise of the voluntary muscles of respiration, he cannot either continue coughing loudly for so long a time, or empty the lungs so completely of air, as a person does in a paroxysm of hoop- ing cough ; it must, therefore, be inferred that the involuntary muscles, namely, those pointed out by Reisseissen, as connecting the extremities of the cartilaginous rings of the trachea and bronchise, powerfully assist in accomplishing both these objects. They seem, by acting spas- modically, to expel the air from the lungs, and to excite, by sympathy the voluntary muscles of inspiration ; the combined action of both sets of muscles appears to produce this peculiar cough." I think it ex- tremely probable that the spasmodic action involves the smaller bron- chial tubes as well as the larger. "The hoop takes place in the larynx 1 Del' Auscultation Mediate, vol. i. p. 188, 2d ed. 2 Pathology aud Diagnosis of Diseases of the Chest, p. 89. PERTUSSIS. 235 and trachea, and appears to be caused by a rush of air through a con- tracted passage, for no sudden or violent inspiration could produce this sound in the natural healthy state of the air-tubes. The lungs are so completely emptied of air, by long-continued expirations, that a most distressing sense of suffocation is produced, to relieve which, a full inspiration is instinctively made, and at the same moment the rima glot- tidis is contracted, and the air passing quickly through a very narrow opening, causes the hoop." 1 The action of the heart is excessively quick and strong, and it is a little time before it subsides to the natural standard during an interval. 342. The second or spasmodic stage persists a considerable time, generally six weeks or two months, but often three, four, or six months: if we make a third stage, one month may be allotted to the spasmodic stage, and the remainder to the stage of decline. The effects upon the child will be pretty much in proportion to the violence and duration of the disease, and the susceptibility and delicacy of the constitution. They are seldom of serious importance, however, if the pertussis be uncomplicated. The appetite is generally diminished, and the digestion disturbed by the frequent vomiting ; nutrition is not very effective, and the child loses flesh. The sleep is interrupted, the circulation deranged by the excitement of the cough, the surface is moist, with profuse sweating sometimes ; the flesh is generally flabby, and the skin is of a darker hue, especially underneath the eyes ; the spirits are unequal, often depressed. As the disease declines, the paroxysms become less frequent, though, perhaps, equal in violence. They now occur but four or five times during the day, and rarely at night ; ultimately, towards evening only, and under special excitement, and then are reproduced at distant in- tervals only, and with much less violence, until they cease altogether. Meanwhile, if not too much exhausted, the constitution begins to re- cover its healthy condition ; tranquil sleep restores the nervous system ; the absence of vomiting allows the food to be digested, and the child recovers flesh and spirits ; the circulation returns to its normal condi- tion, and the surface assumes its natural aspect. 343. Thus we may find that in simple pertussis the first stage is cha- racterized by the symptoms of common catarrh, which, however, are occasionally absent, and the second stage by the peculiar prolongation of the cough in inspiration, i. e. the kink and the forcible inspiration or hoop. In some very rare cases the kink is but little remarked, but it is always present in a greater or less degree, and is, so far, more cha- racteristic than the hoop, which is not unfrequently absent. The presence of either will prove the nature of the disease, but the absence of both would, of course, deprive us of the power of diagnosis. The entire duration of the disease is from two to four months. Ac- cording to popular belief it is six weeks coming to its height, and six weeks going off; but it maybe almost indefinitely prolonged, as, for some time afterwards, the hoop returns when the child catches cold. Marley mentions a case in which the symptoms did not disappear for 1 On Hooping-cough, p. 44. 236 PERTUSSIS. two years : x and Dewecs and others mention its continuance for twelve months. According to Barrier, 2 the child may die in simple hooping-cough, from the intensity of the kinks : it may, in short, be suffocated. The disease may also prove fatal from exhaustion, and the child die, utterly worn out, according to Hamilton, 3 Barrier, and others; or, what is more common, it may lay the foundation of other diseases, such as dilatation of the bronchial tubes, phthisis, epilepsy, struma, ophthalmia, &c. "In scrofulous habits," says Dr. Watt, "the disease is not so apt to prove suddenly fatal ; but if it be severe and protracted, it generally ends in some affection of the glandular system, laying the foundation for tabes mesenterica, rickets, or pulmonary consumption." 4 344. Complications. — So far I have spoken only of simple hooping- cough, but we find that a very large proportion of the cases during some part, at least, of their course, are complicated with other secondary affections, and a careful inquiry will establish the fact, that it is to these' complications that almost all the mortality is owing. Simple hooping- cough is rarely fatal, and yet the mortality in hooping-cough is very great, arising from the liability of other organs to take on morbid ac- tion, and from the circumstance that in three out of the four most fre- quent complications the hooping-cough causes and reproduces them. I shall notice complication with, 1. Bronchitis or pneumonia. 2. Infantile remittent. 3. Congestion of the brain, convulsions, or hydrocephalus. 4. Sanguineous apoplexy. Other minor or more rare complications are mentioned occasionally by authors, but I shall content myself by noticing, briefly, the foregoing. 345. I. Pertussis complicated with Bronchitis and Pneumonia. — ■ This will be found in these countries the most frequent, and one of the most fatal of all the secondary diseases. Of Barrier's cases, seven out of ten died of lobular pneumonia. Of twenty-seven fatal cases under Dr. West's care, thirteen died from bronchitis or pneumonia. 5 Dr. Copland attributes the frequency of this complication during the winter to the variable climate of these countries, and the prevalence of easterly winds. The attack, as we have seen, commences with some degree of bron- chitis ; this maybe very intense, and it may continue on during the second stage instead of subsiding, or it may occur at any subsequent period, either from the stress thrown upon the lungs, from a strong pre- disposition, or from cold. The same may be said of pneumonia, except that the latter is more common during the second stage than the first, and in children of a full habit of body. The age has little to do with these complications. They are met with in children of all ages, and very often creep on very insidiously, so as to deceive the physician as well as the nurse, unless he adopt the proper precaution of auscultating the chest very frequently. I would strongly 1 Diseases of Children, p. 159. z Mai. cle l'Enfance, vol. i. p. 378. 3 Diseases of Infants, p. 169. 4 On the Chin-Cough, p. 75. 6 Medical Gazette, Feb. 25, 1848, p. 311. PERTUSSIS. 237 recommend that this should be done at each visit, as a matter of duty, in all cases of hooping-cough, and minutely and thoroughly whenever we suspect the existence of more than the simple affection. The presence of bronchitis or pneumonia during the first stage may be suspected by the greater amount of constitutional disturbance, the quick pulse, high fever, loss of appetite, dyspnoea, and incessant cough, with a diminution or cessation of the hoop, and we may certainly as- certain the fact by percussion and auscultation. 346. During the second stage, after the subsidence of the catarrhal fever, the occurrence of bronchitis or pneumonia will generally be marked by the return of the fever, loss of appetite, the increase of the cough, and the addition of difficult or hurried respiration during the intervals, as well as by constitutional disturbance in proportion to the intensity of the disease. We need, however, to be very watchful, for in some cases the inroad of the disease is very gradual, and marked by few symptoms, until the little patient is beyond aid. It is not necessary that I should here detail minutely the symptoms and course of either complication ; they will be found in the proper place ; it will be sufficient to notice, that the child will generally be found to be very feverish, restless, sleeping uneasily, with a quicker pulse, greater thirst, hotter skin than usual, and a red flush on one or both cheeks. The respiration is considerably affected, quick, hurried, and difficult, the chest heaves, the alse nasi expand, and the muscles of the chest and abdomen are in vigorous action, even during the intervals of coughing. We may sometimes count thirty, fifty, eighty, or a hun- dred respirations per minute, and the pulse will be, in proportion, fre- quent, and in general hard. " The cough is generally aggravated in frequency, and more distress- ing, but in severe cases it may altogether lose the spasmodic character, and exhibit that of the cough in bronchitis or pneumonia. If the cough had already declined, it may return, as during the early part of this stage. The expectoration is" more difficult, the sputa being less profuse and tenacious, and of a puriform appearance. As the disease advances, the cough may diminish, but the wheezing and dyspnoea increase, the fever continues, the respiration is more fre- quent, hurried, and labored, the pulse very rapid, small, and feeble, the cheeks and lips purple, the surface cold and clammy, and death soon closes the scene. 347. If the child be attacked by bronchitis, we shall find the chest generally clear on percussion; in some parts there may be a degree of dulness, but it is never either extensive or absolute. By the stethoscope, sonorous, sibilant, and mucous rales will be heard over a portion or the whole of one or both lungs. 1 think I have more frequently seen both lungs affected than one alone, and it will be ob- served that these rhonchi are as audible immediately after a fit of cough- ing, and during the interval, as just before the cough comes on, therein differing widely from simple hooping-cough. The respiratory murmur will be feebler than usual, and more or less mask*ed by the bronchitic rales. 238 PERTUSSIS. In cases of secondary pneumonia, the chest is dull on percussion over the diseased portion of the lung, but resonant in other parts. The stethoscope will detect a crepitating rale in the early period of inflammation, with puerile respiration in the surrounding lung, or, if the entire lung be involved, the respiration will be puerile in the other. At a more advanced stage, we may find a portion of the lung solidi- fied, absolutely dull, without respiration or rhonchus, but in which bronchophony will be audible. If the child live until suppuration be established, which is very sel- dom the case, there may be heard a large mucous bubble, or a large crepitus, with, perhaps, cavernous respiration, and the dulness, on per- cussion, may diminish. So, in the progress of recovery, the lung which was solified, and im- permeable to air, will now yield at first a mucous or crepitating rale, and then gradually more and more respiratory murmur, with increasing resonance on percussion ; and along with this local amelioration, we shall have a diminution of the dyspnoea and rapid breathing, a return of the natural cough, a quieter pulse, calmer sleep, and restoration of appetite. 348. II. Pertussis complicated tvith Infantile Remittent. — I have already mentioned that the condition of the stomach and bowels is variable in hooping-cough ; they may be pretty regular, or they may be much disordered ; and in our anxiety about the principal affection, they are liable to be neglected. During the first stage, the effect upon the concurrent disease, and upon the infant may be comparatively slight, but in the second stage, when the constitution is somewhat shaken, it may prove more serious, and require great attention and prompt treat- ment to prevent it running on into infantile remittent and its con- sequences. This disordered condition of the bowels will be marked by a foul, loaded tongue, loss of appetite, tympanitic abdomen, and un- healthy discharges. These may continue for some time, and then, if not relieved, symptoms of infantile remittent will arise. " After the symptoms just enumerated have continued for a longer or shorter time, the fever makes its appearance, sometimes commencing with a rigor ; more frequently, however, it comes on so gradually that we do not know precisely when to date its commencement. The paroxysms of coughing become more frequent, and the breathing is quickened and oppressed ; but still it may be, with a little care, distinguished from the attack of bronchial inflammation. The stethoscope affords us useful, though negative evidence. The usual symptoms of bronchial inflamma- tion are absent. The frequency and force of the respiration are found increased, but this increase is not accompanied by any rale indicative of bronchial inflammation ; while the daily remissions, the loaded tongue, the nature of the alvine discharges, the aspect of the child, constantly picking its nose and lips, all serve to determine the true character of the disease." 1 There is a marked difference between the inspiration in this and the last complication; in the former it was quick, hurried, and difficult; 1 Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. 430. PERTUSSIS. 239 in the present it is quick, hurried, and somewhat unequal, but not diffi- cult. The fever, also, unlike that which accompanies hydrocephalus, has distinct remissions in the morning, and increases towards evening ; ■whereas, in the majority of cases of meningitis, it is nearly equal, and certainly without distinct remissions. It must not be forgotten, how- ever, that infantile remittent may terminate in hydrocephalus, if not relieved. This complication is neither so frequent nor so formidable as the last, but quite sufficient to render the disease very intractable, and often fatal. 349. in. Pertussis complicated with Congestion of the Brain, Con- vulsions, or Hydrocephalus. — We might anticipate the occurrence of these complications, even before experience had proved the fact. If we watch a child during a paroxysm of hooping-cough, and notice the great congestion of the vessels, of the head, face, and neck during the fit, and observe how often this is repeated during the day for weeks together, and remember the delicate condition of the brain in young children, and especially in infants, our wonder will be, not that these cerebral affections occur at all, but that they are not more frequent. These attacks may occur in children of any age, but I think are more common in young infants, or about the period of the first denti- tion, and they are highly dangerous, if not generally fatal. Dr. West mentions that fourteen of his twenty-seven fatal cases died from conges- tion, convulsions, or hydrocephalus ; and all who have had much ex- perience will admit the rarity of cure, and the rapidity with which they run on to a fatal termination. These complications may accompany the disease at its commence- ment, or may arise at any period of its course. Dr. West remarks very truly, " The nervous system sometimes suffers so severely from the very first, that death takes place almost before the disease has had time to assume its usual character. At other times, hooping-cough comes on naturally ; its two elements, the bronchitic and the nervous, if I may be allowed the expression, increase daily in intensity, till, all at once, the symptoms of the former recede, and are almost lost in those of the latter, which, in a day or two, bring on the fatal termination of the case. Or, lastly, no symptoms referable to the nervous system call for our solicitude until after the hooping-cough has continued many weeks; but then the long continuance of the disease seems to excite mischief in the brain, and death overtakes the patient when we had already begun to hope that nothing more than time was needed to perfect his cure." 1 350. We may fear the occurrence of one of these complications when we find the cough increase in severity, without either of the former complications ; the face become livid, and remain so longer than usual ; the existence of the carpo-pedal spasm, the previous occurrence of nerv- ous affections, any hereditary taint, or the occurrence of convulsions or hydrocephalus in other members of the family. 1 Lectures in Medical Gazette, Feb. 25, 1848, p. 312. 240 PERTUSSIS. Probably the earliest symptoms will be an unusual sleepiness and heaviness after the fits of coughing, with an uncertain look of the eyes, or stare, or spasmodic twitchings of the face or extremities, carpo-pedal spasm, sometimes an attack resembling spasm of the glottis ; and any of these may be followed by an attack of convulsions and coma, or coma without marked convulsion. Or perhaps the first evidence of the brain being seriously affected may be a fit of convulsions, fatal in some cases, but from which the patient generally recovers, to be again attacked when the congestion from coughing reaches a certain point. The convulsion, when repeated, does not return with every fit of coughing, but generally as the result of a very severe paroxysm. This constitutes our great difficulty in the treat- ment; we may relieve the head temporarily, but just as we fancy our- selves successful, a cough of unusual violence destroys all the effects of our previous exertions. Meningitis, or hydrocephalus, may set in in the same manner, or it may creep on more insidiously, until at length it be manifested by the usual symptoms, as heretofore described. Dr. West has given a striking example of the insidious manner in which tubercular meningitis may come on during hooping-cough, and prove fatal, without affording us an opportunity of suitable treatment. 351. These diseases will generally run the course I described when treating of them, modified partly by the presence of the cough, as a permanent exciting cause, partly by the influence they in turn exercise upon the cough, and partly by the state of health of the child. Thus they are even more unmanageable than in their ordinary form, in con- sequence of the repeated cerebral congestions ; they may either partially suspend the cough, i. e. diminish its frequency, but not its violence, or, by adding force to the spasm, death by suffocation may be the result of the sudden closure of the larynx ; or, lastly, if the child have been harassed and broken down by hooping-cough for some time previously, the constitution will offer but little resistance to the secondary attack. With regard to the distinction between convulsions and hydrocepha- lus, occurring as secondary affections, it does not appear easy, nor do I deem it very important, and therefore I have grouped them together. It is almost certain that if the convulsions continue for any length of time without proving fatal, they will terminate in hydrocephalus. My experienced friend, Dr. Johnson, observes, in his excellent essay, " It is said that in hydrocephalus one side of the body is more affected than the other ; but in convulsions, which are independent of organic disease of the brain, that both sides are equally affected. If the convulsions are confined to one side of the body, there is every reason to fear the existence of hydrocephalus; but it certainly does not follow, because the convulsions are general that the brain is unaffected. In the latter case we must wait till the convulsions subside before we can discover their cause, and then we must form our opinion from the general state of the child, and the history of the case, rather than from any peculi- arity in the convulsion itself." 1 1 Cyclop, of Pract. Med., vol. ii. p. 431. PERTUSSIS. 241 852. IV. Pertussis complicated with Apoplexy. — We have already seen that fatal apoplexy may occur from excessive congestion of the brain : it cannot, therefore, surprise us to find, in a disease involving such frequent congestion of the vessels of the head, that occasionally cases occur in -which the vascular fulness produces not merely convul- sions, but a true apoplectic attack. The same result may take place from a higher degree of pressure, under which the texture of the vessels gives way, and effusion of blood takes place between the membranes, or into the cerebral substance. Although this appears a natural result of the pressure exercised upon the brain by the repeated force of the cough, it does not seem to be a frequent complication, unless we suppose that the sudden deaths on record are really such cases. It is mentioned by Marley 1 and others : and I shall quote a case from Barrier, as illustrating the mode of attack, and in some degree countenancing the suggestion I have just made, that some at least of the sudden deaths may have been owing to sanguineous apoplexy : — "Claude Charmillon, set. 17, had suffered six weeks from hooping- cough, when admitted into the Hopital des Enfans, May 5, 1848. The first stage had lasted about fifteen days, and for a month past the cough had been accompanied with hoop, and followed by vomiting of glairy matters, more frequent during the night than the day, free from com- plications, and the condition good during the intervals. ''During the first few days he was under M. Barrier's observation, the cough was forcible and frequent, sometimes followed by epistaxis. Auscultation gave evidence of fluid in the bronchial tubes. May 9. The patient, being feverish, was bled. May 10. Considerable catarrh. May 11. Slight eruption of scarlatina. After this the eruption con- tinued quite as usual, but the bronchitis increased, and the bleeding was repeated with benefit. But the patient became emaciated, and phlebitis set in where the vein had been punctured, and two abscesses formed in the fold of the arm. The hooping-cough had necessarily diminished, when, in the night of the 31st May, the patient died suddenly, after a severe fit of coughing. On making a post-mortem examination, the lungs were healthy, the bronchial mucous membrane inflamed. The bronchial and thymus glands, the head, and abdominal viscera, were healthy ; but on opening the cranium, a great effusion of blood was found in the cavity of the arachnoid, covering the convexity, and also at the base of the right hemisphere of the brain and cerebellum, with some blood infiltrated between the pia mater and arachnoid of the same side." 2 The symptoms, then, which ought to excite alarm, are a continuance of the congestion about the head and face, unusual drowsiness, &c. ; and we find that the attack may either occur suddenly, proving instantly fatal, or the drowsiness may degenerate into stupor and coma, equally fatal, but less rapidly so. Though not a frequent complication, it is in all cases a most serious one. 353. Pathology. — We have very rarely any opportunity of examining the condition of the organs engaged in simple hooping-cough, on account 1 Diseases of Children p. 159. 2 Mai. de l'Enfance, vol. i. p. 381. lb' 242 PERTUSSIS. of its rarely proving fatal, unless complicated, and then there is danger of mistaking, as many have done, the effects of the latter for the former. It is only when the child dies from some other disease, or from some distant complication, that we can ascertain the real condition of the lungs. In such cases, there is most frequently no trace at all of disease in the larynx, trachea, or lungs ; in other cases there is slight vascularity of the mucous membrane of the glottis and larynx, and sometimes sub- mucous oedema of these parts. When the cough has been violent, we may occasionally discover some interlobular emphysema, owing to the rupture of some of the air-cells, and, though rarely, this emphysema has extended to the surface. Ulceration of the glottis and in the larynx and trachea have been mentioned by Astruc, Mackintosh, and Alcock. The bronchial tubes are found more or less filled by mucus, and occasionally by muco-purulent fluid. My friend Dr. Hess informs me, that in several cases of hooping- cough, which proved fatal from lobular pneumonia, and which he ex- amined with Mr. Friedleben, they found an enlargement of the bronchial glands, so that pressure on the nervus vagus and the recurrens seemed not unlikely. 354. In fatal cases from any of the complications, the usual post- mortem appearances are discovered. In bronchitis or pneumonia there is vascularity of the lining membrane of the air passages, muco-purulent secretion, congestion, and hepatization of the lung. Simple convulsions generally leave no trace, or merely an unusual degree of vascularity. When the child has been attacked by hydrocephalus, the usual evi dences have been found : extreme vascularity of the membranes, congestion of the vessels of the cerebrum and cerebellum, effusion of serum, tubercular deposition, &c. And in cases complicated by apoplexy, extreme congestion and vas- cularity of the substance of the brain, or sanguineous effusion, as in M. Barrier's case. Thus the rarity of opportunities for examining cases of simple hoop- ing cough after death, and the fact that, in those which have been exa- mined, some of the appearances I have enumerated have been found, has misled many observers as to the essential nature of the disease, and given rise to very various and contradictory views on the subjects. 355. Linnaeus maintained that it arose from inhaling, in respiration, the minute eggs of a peculiar species of insect ; ! and his view, somewhat modified, was advocated by Riverius, Dessault, Rosenstein, &c. Hoffmann attributed it to an acrid serum in the blood ; Sydenham to some irritating effluvia cast off from the blood into the lungs, in conse- quence of suppressed transpiration. Huxham thought it was owing to a morbid condition of the intestinal canal ; Butter that it depended upon derangement of the liver ; Waldschmidt and Stoll that it was caused by crude and bilious matter in the stomach. 1 Diss. Exanth. viva in Amcenit. Acad., vol. v. p. 82. PERTUSSIS. 243 Dr. Watt, judging from the results of his post-mortem examinations, attributes it in all cases to inflammation of the bronchial tubes, either so mild as to cause no inconvenience, or so severe as to cause death. Mr. Dawson limits the inflammation to the mucous membrane of the glottis and larynx. Dr. E. Watson considers the pharynx and larynx to be involved with peculiar irritability of the glottis. 1 MM. Marcus, 2 Broussais, Boisseau, Guersent, Rostan and Duges, regard it as a spe- cific inflammation of the bronchi. M. Danz places the seat of the disease in the lungs, and Strong, Cul- len, Astruc, Lettsom, and Darcy, mention having found evidences of inflammation of the mucous membrane of the larynx and trachea. Dr. Webster considers the hooping-cough as essentially a cerebral disease ; he found, on examination, the hemispheres of the brain very vascular, the convolutions almost obliterated, serous effusion, &c. 3 M. Lobenstein Lobel met with a case in which a considerable portion of the diaphragm was covered with pustules. Dr. Alcock states that he found the larynx invariably inflamed, and sometimes so much so as to close the glottis mechanically, that the mucous membranes of the trachaea and bronchi were very vascular, and that the cavities of the latter were filled with fluid mixed with air. 4 M. Alph. le Roi agrees with Dr. Webster that hooping-cough should be classed among diseases of the membranes of the brain. M. Gilbert considers the disease as essentially nervous or spasmodic, the cough being caused by a spasmodic affection of the glottis and diaphragm. Inflammation of the pneumogastric nerves has also been regarded as the essential cause of hooping-cough. It has been observed twice by MM. Breschet and Autenrieth, and fifteen times by Kilian ; but not- withstanding the most careful dissection, MM. Jadelot, Guersent, Baron, and Billard, could discover none. M. Albers, of Bonn, out of forty-seven cases, found that in forty-three the nerve was healthy : in one it was reddish on the left side, and in three on the right side. 5 The late Dr. Sanders, of Edinburgh, considered congestion at the origin of the pneumogastric and other respiratory nerves to be the essen- tial pathology of hooping-cough, and Dr. S. Piddock adopts this opinion and bases his treatment of this disease upon it. 6 Laennec admits that the suspension of inspiration may be owing either to congestion of the mucous membrane or to spasm, and that the larynx and bronchige are affected. Dr. Alderson makes the disease to consist in inflammation of the lungs. 7 Dillon, Hufeland, Lobel, Breschet, Albers, and Eberle, s regard it as a nervous disease, perhaps of the brain, or perhaps of the pneumogas- tric nerve. Desruelles says that "hooping-cough is nothing more than bronchitis 1 Dub. Med. Press, Feb. 1850. 2 Traite de la Coqueluche, 1816 ; trad. par. M. Jacques, p. 67. 3 London Med. and Phys. Journal, vol. xlviii. 4 Lectures on Surgery, p. 132. 6 Roe on Hooping-cough, p. 57. 6 Lancet, June 16, 1849. 7 Med. Chir. Trans., vol. xvi. part 1. s Diseases of Children, p. 479. 244 PERTUSSIS. complicated with irritation of the brain ; and that the inflammation of the bronchise is always primitive, the irritation of the brain consecutive. So long as the bronchitis is simple, the cough is without any peculi- arity ; but when the diaphragm, muscles of expiration, and of the glottis, larynx, and posterior membrane of the bronchise and the air cells of the lungs, come into action, and are simultaneously affected with spasm, under the influence of the cerebral irritation, the cough changes its character, and becomes convulsive ; and every time that an afflux of blood takes place into the brain, the cough returns, and appears in paroxysms." 1 M. Blache is of opinion " that hooping-cough is a nervous affection, having its seat both in the mucous membrane of the bronchige, and in the pneumogastric nerves : an affection very frequently complicated with bronchitis and pneumonia, but which may exist without them ; and, like all other diseases of the same kind, having no appreciable anatomi- cal character." 2 In this opinion Dr. Roe, MM. Barrier, 3 Rilliet and Barthez, 4 and many of the more recent writers, coincide. Dr. Copland considers the "medulla oblongata, or its membranes, to be early implicated in this disease; evidences of inflammatory irritation of these parts having been very generally observed in the post-mortem inspections I have made. I conceive that the morbid impression or irri- tation occasioned by the exciting cause in the upper parts of the respi- ratory surfaces, particularly the glottis and its vicinity, affects the res- piratory nerves, especially the pneumogastric; and that the irritation is extended to the origin of the nerves, when it aggravates and perpetu- ates the primary affection." 5 Dr. James Duncan has recently proposed to class hooping-cough with exanthematous diseases, a view which was formerly broached by Volz, the resemblance having been already noticed by Jos. Frank. The es- sence of the disease, according to Dr. Duncan, consists in turgescence of the bronchial glands, coinciding with or arising from a peculiar fever, and the result of a specific poison ; and acting upon the pneumogastric nerve, in the way Dr. Ley supposed in the case of spasm of the glottis. 6 Dr. Fyfe, in a late paper, looks upon the disease as a neurosis alto- gether distinct from bronchitis, and he affirms that the two diseases can- not co-exist. 7 356. It would have been very easy to have multiplied conflicting opinions; for most writers, having pre-conceived opinions of the school in which they had been educated, were prepared to view the disease in a certain light. Thus the humoral pathologist saw in it some peculiar acrid quality of the fluids, and the morbid anatomist mistook the results of a post-mortem examination for the active pathology of the affection, and both were undoubtedly in error. The different views of the nature of the disease may be thus summed up: — 1 Traite de la Coquelucke, p. 77. 2 De la Coqueluche. Archiv. Gen. de Med., 1833, vol. ill. , second series. B Mai. de l'Enfance, vol. i. p. 39. 4 Mai. des Enfans, vol. ii. p. 228. 5 Diet, of Med., Part v. p. 242. 6 Dublin Quarterly Journal of Medical Science, &c, Aug., 1847. 7 Prov. Med. and Surg. Journ., June 16, 1847. PERTUSSIS. 245 1. That it consists simply in inflammation of the mucous membrane lining the air-passages, the glottis, larynx, trachea, bronchial tubes, and air-cells. 2. That this inflammation is of a specific character. 3. That it is an affection either of the pneumogastric nerves, spinal nerves, medulla spinalis, the brain, or the nervous system generally; either of a nervous or inflammatory character, or a reflex irritation. 4. That it is a compound affection : in the beginning an inflammation of the air-tubes, and subsequently a spasmodic or nervous affection. 5. That it is a nervous affection, having its seat in the bronchial mu- cous membrane, and in the pneumogastric or other nerves. 357. Now, if we are to decide the question by the results of post- mortem investigations, we must necessarily conclude that none of these theories can be the true one, because the facts upon which they are based are by no means sufficiently general ; some indeed are so rare that it is evident they are additions to the primitive disease, and others so very uncommon that one must conclude that they have nothing at all to do with it. Again, if we analyze minutely the history of the disease, and com- pare many cases together, we must arrive at the conclusion that they are divisible into two great classes, the simple and the complicated, and these differ, not merely in degree, but in kind ; that the former present, upon the whole, a very uniform appearance, with similar stages, symp- toms, and course; but that the latter possess additional symptoms, of different kinds, by which their history is altogether modified; they are, in short, hooping-cough, plus the peculiar complication of each. This is so evident that the best modern authorities have based their descrip- tion of the disease upon it. On this ground we must reject those post-mortem evidences of exten- sive bronchitis, pneumonia, arachnitis, congestion of the brain and spinal marrow, redness and swelling of the pneumogastric nerves, &c, as being foreign to cases of simple hooping-cough ; and if we then proceed to the consideration of the question of the nature of the disease, we find very little assistance to be obtained from morbid anatomy, for in the majority of cases of death from other affections during hooping-cough, the air-passages exhibited little or no trace of disease. If we turn to the history of the disorder, we find that it generally commences by a catarrhal affection of the mucous membrane of the eyes, nose, and air-passages, amounting, in some cases, to actual bron- chitis; but it may be doubted how far this must be considered essential to the disease, inasmuch as many cases occur in which it is altogether absent. And as this affection subsides, in its place we have a peculiar spasmodic cough, consisting of a series of forcible succussions during expiration, with an impossibility for a time of making a complete inspi- ration. This impediment to inspiration evidently arises from spasmodic action of the muscles of the larynx, trachea, and bronchial tubes, extending probably to the smallest, as it comes on quite suddenly and subsides as suddenly. And although the cough is excited by the pre- sence of mucus, and has for its object its removal, yet its character is peculiarly spasmodic and unlike any ordinary cough. 246 PERTUSSIS. Now, without attributing it to organic disease of the brain or spinal marrow, we cannot but refer the peculiarity of this cough and hoop to a state of the nervous system analogous (shall I say) to that which gives rise to spasm of the glottis — in other words, that hooping-cough is also a case of reflex irritation of the nervous system, excited, no doubt, by other and different causes, but exhibiting a similar transfer- ence of effects. We are at present, I believe, quite ignorant of the nature of the peculiar exciting cause. We know that it exists, and that when it is applied the primary irritation of the mucous membrane arises, followed by the reflected nervous irritation which gives rise to the peculiar phe- nomena of the disease. 358. Causes. — I have already mentioned that this disease is most common in infants and children, though not absolutely confined to them ; and although, doubtless, the chief cause of this is, as Dr. Watts observes, "that few individuals can pass many years of their lives with- out being so much exposed to the contagion as to bring on the disease," yet there does appear to be something in the constitution of children which renders them peculiarly susceptible to its influence. Dr. Butter observes that " the nervous system bears a much larger proportion to the other solid parts in children than in adults ; the solid parts are likewise of a much softer texture and of a much quicker growth; the human body is then endued with much more irritability than at any other period of its existence," and consequently more easily affected. "One can hardly doubt," says M. Gendrin, "that, owing to the development and extreme activity of the circulation, and the permea- bility of their tissues, that infants are in the most favorable state for the absorption of miasmata." On these grounds, it has been attempted to explain the fact that more girls have the disease than boys. Climate has much influence upon the mortality in the disease, though little, if any, upon its presence and extension. It is very prevalent and very fatal in northern regions ; less frequent and much less severe in the south, as a general rule, to which, however, there are exceptions, as in the fatal epidemic of 1808 in Madeira. In these countries, it appears more frequent in winter and spring ; and, according to Dr. Watts's tables, March was the most fatal month, and July, August, and September the least. The agency of a cold and moist atmosphere in the production of the disease is much insisted upon by Richter, Marcus, Desruelles, &c. It appears also to be in some way connected with other epidemics, often appearing just before, during, or immediately after an epidemic of measles or influenza. 359. Now and then we meet with single cases of hooping-cough ; but such are comparatively rare, for the disease almost invariably spreads through a town or village, either by epidemic influence or by contagion. No one questions the occurrence of the disease as an epidemic ; it has repeatedly spread thus over extensive districts, and proved most fatal. PERTUSSIS. 247 De Thou, Sermert, Sauvages, Riverius, &c, notice epidemics as occurring in 1510, 1557, 1580, 1757, 1767, and 1769, and many of them spreading over a great part of Europe. According to M. Desruelles, 1 Pasquier mentions an epidemic of this kind in 1411, in Paris, which attacked more than one hundred thousand people. De Thou and Sennert mention another in the same city in 1510 ; Riverius one that spread almost over Europe in 1557 ; Baillou one in 1578. In Sweden, Rosen has noticed their prevalence from 1749 to 1764, during which 43,398 deaths occurred. Geller one in 1757, in the duchy of Magdeburgh ; Arand one that occurred in Mayence, in 1769 ; Aaskou one that happened at Copenhagen, in 1775. Dr. Willey mentions that in 1805 it was introduced into Block Island, and prevailed epidemically. 2 Dr. Tretis that it was epidemic in Madeira in 1808, 3 and proved very fatal. In 1817, it is said by Marcus to have been epidemic in Milan and at Bamberg. Since then, partial epidemics, with which we are all familiar, have occurred, limited generally to a city or town, but occasionally spread over a tract of country more or less extensive. No doubt the characters of these epidemics, and especially of the complications of hooping-cough, differed very much. Thus sometimes the patients were attacked by epistaxis, sometimes by convulsions : in other cases by eruptive fever, or by some visceral inflammation, as is recorded by Ozanam. 4 360. It must always be extremely difficult, if not impossible, abso- lutely to prove the contagiousness of an epidemic disease, inasmuch as proximity or contact involves also exposure to the same atmospheric influence. Nevertheless, there are diseases which prevail epidemically (smallpox and measles, for instance) which are admitted by all to be contagious, and among them we must class hooping-cough. No doubt its great extension is as an epidemic ; but yet we see now and then cases which appear to be fairly communicated from one person to another, as, for example, in the case related by Barrier, of children who caught the disorder at a day-school, and, being confined at home by it, communi- cated it to their father and mother, 5 and those related by Duges. 6 The weight of opinion is certainly in favor of its being propagated by contagion. On this side we have the authority of Cullen, Sims, Hillary, Watt, Hamilton, Underwood, Dewees, Eberle, Stewart, John- son, Roe, Barrier, Dug&s, &c. Laennec, Desruelles, and others, have expressed a doubt of this being the case, and others have altogether denied it ; but to my mind the evidence is conclusive. 361. Diagnosis. — We must always take into consideration the posi- tive and negative evidence in forming our judgment. The most strik- ing characteristics of the disease are the subsidence of the catarrhal 1 Traite de la Coqneluche, p. 100. 2 American Med. Repos., toI. x. p. 95. 3 Med. and Phys. Journ., vol. xxiii. p. 100. 4 Barrier, Mai. de l'Enfance, vol. i. p. 372. 5 Ibid., vol. i. p. 373. 6 Diet, de Med. et de Chir. Prat., vol. v. p. 488. 248 PERTUSSIS. and setting In of the spasmodic stage, with the remarkable kink and hoop. It is not very easy to mistake either; but I must recall to my readers ■what I have mentioned before, that the hoop is not always present, and also that in very young infants a common cough is often accompanied by an occasional hoop, if they are at all alarmed by the cough. The kink, however, is almost never absent (both cannot be absent together, of course, or the case would not be hooping-cough) ; and the series of forcible and rapid succussions, without intervening inspiration, is observed in no disease that I know of, to the same extent, except asthma, which is not an affection of childhood. No doubt, in some forms of bronchitis there is a paroxysmal charac- ter of cough, kinks of coughing,"in fact, though different from those of hooping-cough. Rilliet and Barthez have laid down the differences very distinctly. In pertussis we have the catarrhal stage generally preceding the kink ; in bronchitis the paroxysm of coughing is coinci- dent with the commencement of the disease. In pertussis we have the hoop, the glairy tenacious expectoration and almost always vomiting ; in bronchitis the kinks are shorter and less intense, no hoop, but little expectoration, and no vomiting. In simple pertussis there is little fever, no hurry of respiration during the intervals, and the respiratory murmur pure ; in bronchitis the fever is intense, the respiration hurried and increasing in frequency, rales sibilant and mucous, afterwards sub- crepitant. In pertussis the kinks continue for a time, then decrease until the cough becomes simple, and the child convalescent; in bron- chitis the smallness of the pulse, the extreme dyspnoea, paleness of face persist or increase, and the disease almost always terminates fatally. 1 362. Prognosis. — In simple hooping-cough there is comparatively little danger, the principal risk being from exhaustion, or from the set- ting in of some of the diseases already mentioned as following upon hooping-cough in delicate, broken down children. Young infants, even, who are carefully nursed, go through the disease very well. But in epidemics, because of the complications, and in single cases which are complicated, the danger is very great, and the mortality very high. In the epidemic of 1580, 9000 children are said to have died at Home. In Sweden, from 1749 to 1764, Rosen states that 43,393 deaths oc- curred from this disease, and of these, 5832 occurred in the year 1755. Dr. Armstrong mentions that from 1769 to 1777, 732 cases oc- curred at the dispensary for the infant poor, and that twenty-five died. 2 Dr. Watt mentions that on the whole the deaths from hooping-cough, in Glasgow, amount to five or five and a half per cent, of the entire. deaths in the city ; and that in 1809 they amounted to 259, or more than eleven and a half per cent. 3 In Prussian Pomerania the deaths were as 1 to 25J of the entire mortality; in Denmark, as 1 to 21J; in Brandenburg, as 1 to 29J ; in Sweden and Finland, 1 to 13 J ; in Strasburg, 1 to 94 ; in Boston, 1 to 1 Mai. des Enfans, vol. ii. p. 223. 2 An Account of the Diseases most incident to Children, p. 142. 3 On the Chin-Cough, p. 24. PERTUSSIS. 249 82 ; in Charleston, 1 to 46.6 ; in Baltimore, 1 to 95.38 ; in New York, 1 to 64.7 ; and in Philadelphia, 1 to 63. 1. 1 In the admirable Report upon the Population Census of Ireland, Mr. Wilde states the mortality from hooping-cough to have been 36,298 in ten years, in the proportion of 100 males to 115.43 females. " It has proved most fatal in the rural districts, being there in proportion to all other diseases as 1 in 30.48, and to those of the epidemic class as 1 to 9.09 ; while in the civic districts it is 1 in 36.76 of the deaths from all other causes, and 1 in 14.04 of those denominated epidemic or contagious. Its general mortality, in comparison with all other af- fections, for the entire kingdom, is 1 in 32.71, and of the total epi- demic diseases, 1 in 10.5. In the metropolis, this affection was to the total epidemics, 1 in 17.47 ; in the province of Leinster, 1 in 12.24 ; in Munster, 1 in 11.24 ; in Ulster, 1 in 9.4; and in Connaught, 1 in 9.1." 2 363. With such evidence of the fatal results of the disease, it will become us to inform ourselves most carefully as to the age, constitution, previous health, and the actual state, not merely of the lungs, but of every organ of the body, before giving our prognosis ; and even then it will be wise to be very guarded, and to watch well for the first symptoms threatening any of the complications. The symptoms which justify a favorable prognosis are the paroxysms being distant, with intervals of complete relief and quiet respiration, the rest at night not much disturbed, the appetite good, no local complica- tions, and the absence of fever. The unfavorable symptoms are, fre- quent and violent cough, hurried respiration, dyspnoea, fever, loss of sleep and appetite, and any indication of local complication. 364. Treatment. — As it is generally admitted that hooping-cough will run its course notwithstanding all our efforts, it is pretty clear that but little treatment, and that palliative, is necessary in the milder cases. During the first stage, a gentle antimonial emetic may be given, followed by an expectorant every four or six hours, with a dose of aperient medi- cine, and a repetition of the emetic occasionally, a warm bath at bed- time, and confinement to a warm, equable temperature. I would also remark that in different epidemics different remedies seem to succeed. Some formerly successful, seeming to lose their power, and when this is the case it is right to suspend their use and have recourse to others. Burton, Millar, Lieutaud, and others, deprecate blood letting, and certainly, unless the disease be complicated, or the first stage set in with considerable violence, it is quite unnecessary ; but in the latter case, loss of blood will lower the fever, relieve the catarrhal oppression, and render the second stage milder ; but the amount should be carefully regulated, and be rather under than over the mark. Willis, Sydenham, Lettsom, Dewees, Duges, &c, recommend the abstraction of blood under these conditions. Dr. Pidduck, in accordance with his views of the pa- thology of the disease, advises leeches directly over the junction of the occiput and the atlas vertebra, followed by a blister between the shoul- ders, and he speaks most strongly of their good effects if the disease be uncomplicated. 1 Condie on Diseases of Children, p. 3G7. 2 Report upon the Tables of Deaths, p. 15. 250 PERTUSSIS. The use of emetics of tartarized antimony was first recommended by Dr. Armstrong, who had employed them "for eighteen years with very good success," 1 and they have since been advised by the highest authori- ties. They may be given, as I have said, at the commencement, and repeated occasionally. A mixture with ipecacuanha wine, syrup of squills, a little syrup of white poppies, and almond milk, or mucilage and water, will answer very well as an expectorant ; or we may give Coxe's hive syrup, as recom- mended by Dewees, which is made by boiling half a pound of senega root and dried squills, in eight pounds of water, over a slow fire, until half is consumed, and then adding to the strained liquor four pints of strained honey, and again boiling down to six pounds, and adding a grain of tartar emetic to each ounce. The dose must be regulated ac- cording to the age of the child, from six to eight drops or upwards, every hour or two. 2 Probably the best aperient medicine is castor oil or rhubarb, magnesia and ginger ; and the frequency of its administration must be regulated by the state of the bowels, which should be well evacuated. The diet should be bland, and, if there be much fever, confined to milk and vegetables ; if otherwise, a little chicken broth may be allowed. 365. During the second stage, marked by the peculiar cough and hoop, the tenacious mucus, and the absence of fever, we shall find it beneficial to continue the emetics occasionally, and also the expectorant medicine ; but in addition it will be necessary to employ some antispas- modic remedy for the relief of the paroxysm. Probably the most common is opium in some form. A few drops of laudanum may be added to the expectorant mixture, or we may adopt Mr. Pearson's 3 plan, who, after an emetic, prescribed one drop of lauda- num, five drops of ipecacuanha wine, and two grains of carbonate of soda, every fourth hour. As the cough subsided, he diminished the opiate, and substituted gum myrrh for the ipecacuanha wine. Dr. Dewees recommends a combination of paregoric, antimonial wine, liquorice, gum Arabic, and water, as a mixture, and I can add my testi- mony, if it be necessary, to its value. Lombard recommends the syrup of white poppies, Condie the watery extract of opium, and others Dover's powder. There is no reason, however, for believing that opium will cure the disease, but it renders the paroxysms less severe and composes the patient. Hemlock is highly recommended by the older writers. Dr. Butter, in 1772, praised it as a specific. Dr. Armstrong tried it in 357 cases, of whom seventeen died, but nine of these, he says, were unfavorable cases. 4 The formula he employed was this : — R. — Extr. cicutse gr. x. Aq. purse, Aq. nienth. pip., aa ^iv. Sacch. alb. ad grat. sapor, q. s. — M. 1 On the Diseases most incident to Children, p. 50. 2 On Diseases of Children, 437. 3 Med. Chir. Trans., vol. i. p. 25. 4 On Diseases of Children, p. 142. PERTUSSIS. 251 A dessertspoonful was given to an infant six months old, every four hours ; three teaspoonfuls to a child of a year ; and a tablespoonful to one of two years of age. Dr. Gurnprecht speaks most highly of the extract of the lactuea virosa in the second stage. He advises half a grain, with sugar, three times a day, for children of two years of age. 1 Acetate of lead has been highly praised by Dr. Reece. 2 He pre- scribed the following mixture : Four grains of the acetate of lead, two drachms of syrup of violets, and two ounces of water ; of which he gave to a child four years old a teaspoonful every six hours, increasing the dose to two teaspoonfuls the following day. But perhaps the most influential narcotic and sedative we possess is the belladonna ; it has been very extensively employed, and the evidence in its favor is very strong. Hufeland, Jackson, Guersent, Blache, Stewart, Condie, &c, speak highly of it. As it is very powerful, and somewhat uncertain, we should begin with small doses, and watch it very closely. From one-quarter of a grain to one grain of the powdered root, and from one-eighth to one- half a grain of the extract, may be given two or three times a day. Dr. Jackson advises that one-sixth of a grain should be given to a child of three months old, every three hours; to a child of two years old, one grain; and to a child of four years, a grain and a half in each dose. 3 Jackson, Guersent, and Blache recommended its continuance until the effect upon the pupil is evident ; it may then be discontinued. 4 Kahleiss gave it in combination with Dover's powder, and between each dose a mixture containing prussic acid. M. Trousseau combines it with opium and valerian. M. Guersent recommends equal parts of henbane, belladonna, and oxide of zinc; of the latter he gives one grain every hour to a child of six months old. M. Caron du Villard derived great benefit from laurel water, in doses of six drops every two hours. Dr. Krimer, of Halle, and Dr. Brofferio, recommend the inhalation of its vapor. Hydrocyanic acid was first used, I believe, in hooping-cough, by Fontaniottes and by Coullon, in 1808, and since by Heineken, Behr, Kahleiss, Muhrbeck, &c. It was introduced into this country as a remedy in this disease, by Dr. Granville, in 1819 ; and has been tried successfully in America, by Drs. Edwin Atlee, Stewart, Condie, and others. Dr. Roe has found it most valuable in checking and cutting short the spasmodic stage. I have tried both the laurel water and the acid repeatedly, and the latter certainly with great benefit, though it failed in many cases to shorten the disease. " The dose of hydrocyanic acid," says Dr. Roe, " for an infant, is about three-quarters of a minim, of Scheele's strength, gradually in- creased to a minim, which may be given every fourth hour ; for a child of three years of age, about one minim, gradually increased, if neces- 1 Med.-Chir. Trans., vol. vi. p. 608. ~ 2 Med.-Chir. Rev., vol. xv. p. 37. 3 American Journal of Med. Science, Aug. 1834. 4 Barrier, Mai. de l'Enfance, vol. i. p. 392. 252 PERTUSSIS. sary, to a minim and a half every fourth hour ; for children of ten or twelve years of age, a minim and a half, increased to two minims every fourth hour. It is safer to give this medicine in small doses, at very short intervals, than to run any risk of producing too great a depression by a large dose. The frequency of its exhibition must depend upon the strength of the patient and the severity of the attack. The dose should be repeated when the effects begin to subside, which in mild cases gen- erally happens in three or four hours ; but when much fever is present, its influence is felt but a very short time : under such circumstances, a larger quantity may be given, and at shorter intervals, without any apprehension of danger, so long as the fever lasts. In some very severe cases, when the pulse was up to 120, with a good deal of fever, and a very hot skin, I have given to a girl of ten years of age a minim and a half of this medicine every quarter of an hour for twelve hours ; at the end of twenty-four hours she was free from fever, and her strength was not in the least reduced by the effects of the remedy. As some catarrhal symptoms are generally present, a few drops of ipecacuanha or antimo- nial wine may be advantageously combined with the hydrocyanic acid ; but the latter alone possesses the power of curing this formidable com- plaint." 1 I would suggest that this medicine should always be given in draughts, and not in a mixture, because then only can we be quite sure that the child will not get an overdose. I have found almond milk an excellent vehicle. Other narcotics have been recommended, but I need hardly occupy the reader's time with them ; I will only add a general observation or two ; and first, that as narcotics have the effect of diminishing secretion, that effect should be corrected by some expectorant, or the original te- nacity of the mucus of the second stage will be increased, and its expec- toration rendered more difficult ; secondly, that (with the exception of the prussic acid) narcotics are of less efficacy in proportion to the amount of fever, and it is when that has subsided that they possess so much power over the spasm ; and, lastly, as they also constipate the bowels more or less, we must counteract this effect by an occasional pur- gative. Among the antispasmodic remedies we find also assafoetida, castor, musk, valerian, sal ammoniac, &c, highly recommended, and which may, perhaps, in some cases be useful, but which are evidently inferior to the narcotics. • 366. Variations in the mode of administering narcotics and anti- spasmodics have been adopted. Mr. Warren recommends liquid lauda- num to be rubbed on the abdomen and pit of the stomach daily. Mor- phia, applied to a blistered surface, has been useful, according to Brendt and Meyer, of Minden, who state that five cases were so much relieved by it in eight days as to require no further treatment. Embrocations consisting in part of laudanum, have been very long employed with benefit. Another mode is by inhalation. Marley mentions that he has known 1 On Hooping-Cough, p. 89. PERTUSSIS. 253 "inhaling the steam of a decoction of the fresh leaves of hemlock, alone or with ether, to be of use." 1 Dr. Stewart mentions that fumigation with the vapor of benzoin was accidentally discovered, a few years since, to allay, with remarkable quickness, the paroxysms of hooping-cough. 2 Dr. Watt and Mr. Waddington 3 have used the vapor of tar with success ; and it is said that relief has been afforded by the fumes of warm spirits of turpentine. M. Paterson made some experiments with the nitrous ether, but I do not know that they were very successful. Soon after the discovery of the anesthetic effects of sulphuric ether, it struck me that it would be likely to modify or suspend the spasm in hooping-cough ; and, having a case under my care, I directed that a little (I suppose about half a drachm) should be spilled upon the nurse's hand and held before the child's nose and mouth at the commencement of a fit of coughing. I preferred this simple mode of administration (and do still) because of the impossibility of thereby giving an overdose. The effect surpassed my expectation. Most generally, the paroxysm was shortened more than one-half, often stopped immediately, and the duration of the disease unquestionably considerably diminished. Since then, I have tried the ether in twelve or fourteen cases, and chloroform in six. In one or two cases, no benefit accrued ; in others, great mitiga- tion of the spasm ; and in three or four almost complete relief when the ether was applied at the beginning of a fit of coughing. Decidedly, also, in two-thirds of the cases, the course of the disease was much shortened, so that I look upon this as a valuable addition to our reme- dies. In no instance was insensibility or the least inconvenience occa- sioned. There are two obstacles to its fair administration to young children ; 1, they do not give notice of the approach of the cough, so that by the time the chloroform is ready the paroxysm has commenced, and, as that consists of expirations mainly, the chloroform will have evaporated before its full effect is produced ; 2, young children resist any apparent impediment to free respiration, as a hand placed before their mouth. I have, however, had an opportunity of trying it in four cases of young persons above sixteen years of age. In two (girls), in whom the hoop was fully developed, it arrested it at once; and, after using it for two days, the hoop entirely disappeared, a trifling cough only continuing for some time. In a third (girl), it was used from the commencement. It immediately stopped or prevented the hoop, and always relieved the tickling preceding the cough ; and, after using it three or four times a day for three weeks, the disease disappeared. She never lost appetite or sleep, vomited only once or twice, and was never distressed by the cough. Her brother, who had the disease most severely, also took chloroform, and it reduced the paroxysms more than one-half in number during the twenty-four hours, without diminishing their intensity ; but, as it seemed to make him stupid, it was suspended, and prussic acid given, under which treatment the disease was cured in a month. 1 Diseases of Children, p. 163. 2 Diseases of Children, p. 109. Lancet, June 21, 1845. 254 PERTUSSIS. In 1797, Mr. W. Simmonds, of Manchester, recorded his experience of the great value of arsenic in the form of Fowler's solution — in small doses even with infants. He says that it seldom failed to put a stop to the disease in about a fortnight, and that with proper precautions no ill effects were produced. 367. When the disease is pretty well advanced, and especially when the constitution has suffered, if there be neither complication nor fever,, great benefit will be derived from tonics ; and of these, perhaps, cin- chona has the most advocates. Dr. Burton, Mr. Sutliff, Dr. Lettsom, and Dr. Armstrong recommend it very highly in combination with tincture of cantharides and paregoric, as in the following formula for a child of three years old : — R. — Decoct, cort. Peruv. gvj. Elixir sudorif. (paregoric) giij. Tinct. cantharid. gj. — M. Capiat semi-unciam ter in die. Dr. Hamilton speaks highly of the Peruvian bark. We have the evidence of Dr. Beatty as to the value of Mr. Sutliff's compound of bark, paregoric, and tincture of flies; and, on his recom- mendation, Dr. Graves was induced to try it, and found it very suc- cessful. 1 Dr. Golding Bird speaks most highly of alum in the second stage, after all inflammatory symptoms have subsided and the mucus is tena- cious and expectorated with difficulty. He gives from two to six grains of alum every four or six hours, to children from one to ten years of age. The following is his formula for a child of two or three years : — R. — Aluminis gr. xxv. Extr. conii gr. xij. Syr. rhoeados sjij. Aqu£e anethi ^iij. — M. Capiat cochl. med. 6ta quaque bora. Dr. Davies, in his edition of Underwood, " attaches more value to alum than to any other form of tonic or antispasmodic." Tannin, in doses of from half a grain to gr. iij, every second, third, or fourth hour, has been recommended by some high German autho- rities. Dr. Durr speaks highly of tannin and benzoin in the latter stages of hooping-cough. He gives from two to five centigrammes of each with fifty centigrammes of sugar every two hours. 2 Dr. E. Watson applied Dr. Horace Green's plan of cauterizing the glottis and larynx with a solution of nitrate of silver, and in several cases with apparent' success. The strength of the solution was gr. xv to the ounce, and applied by whalebone tipped with sponge, at first to the pharynx only. Oxide of zinc has been praised by Guersent and Lombard ; the 1 Graves's Clinical Med., p. 762. 2 ProY. Med. and Surg. Journ., Ap. 3, 1850. PERTUSSIS. 255 lobelia inflata by Eberle ; the rhus vernix, garlic, and electricity by others ; arsenic by Dr. Ternan and Mr. Simmons ; sulphuret of potash by Dr. Bland ; the sesquioxide of iron by Drs. Steymann and Lom- bard, &c. y liquor ammoniae by Dr. Peyroton, &c. In fact, there is no end to the list of remedies which have been recommended in hooping- cough ; and probably my readers may thank me for not extending mine further. I think I have included the most important ; and I shall only notice, in conclusion, the use of external counter-irritants and change of atmosphere. That external rubefacients are of use there is no doubt, especially when combined with a narcotic, as already mentioned ; but that they will cure or cut short the disease I do not believe. Roche's embrocation is a popular liniment, or we may order one of compound camphor lini- ment and laudanum, two ounces of the former to two drachms of the latter. The chest and back should be rubbed alternately morning and evening. Dr. Hamilton seems to approve of garlic to the soles of the feet ; and a popular use of it is to steep it in brandy and rub the spine. The celebrated " pommade d'Autenrieth" is simply tartar-emetic oint- ment, which is most strongly recommended by many writers of high authority. Vaccination has been recommended as a remedy. I am not aware of its having been tried in this country ; but Dr. Hess informs me that some continental experience is rather favorable to it. [I have employed vaccination in several cases, and have every reason to be satisfied with the result, having found it to modify both the severity and length of the affection.] 868. Great stress has been laid upon change of air, and no doubt, at a certain period, the removal from a town to the country, if the air be mild and the weather fine and warm, does promote convalescence ; but, on the other hand, much mischief may result from indiscreet changes and undue exposure. Dr. Merriman remarks, most judiciously, " I am not acquainted with many, if with any, instances in which the force of the disease has been abated by change of air. I should not recommend it for this purpose; but I have often witnessed its usefulness in short- ening the stay of the distemper after its force was abated. I believe that change of air is seldom advisable (unless the patient be placed in a house particularly close and unventilated) during the active stage of hooping-cough ; but when the violence of the complaint is subdued it is highly beneficial, particularly if the change be from a cold situation to one of a warm temperature, or when the coldness of winter and the bleak east winds of March are changed to the more genial warmth of spring and the mild western breezes of April and May. But even then much discretion is required to regulate the time and mode of exposure to the open air, otherwise ill consequences are likely to ensue." 1 Dr. Mackintosh remarked, in a severe epidemic, that all the children that were removed for change of air had the disease the longest. Dr. Beatty made it a rule to confine his patients to their bedroom until the cure was completed ; and Dr. Graves seems to approve of his plan. Of the two extremes, doubtless it is the best. 1 Underwood on Diseases of Children, p. 428. Note. 256 PERTUSSIS. During the catarrhal stage, I have always confined the child to the house, and during the commencement of the second stage, unless the weather was very mild and dry. After this the child will benefit by an occasional walk or drive on fine days and during the warm parts of the day ; then, when the cough is fairly on the decline, a change from town to the country will accelerate the convalescence. Great care should be taken that the rooms in which the child passes the day and night should be well ventilated and of a comfortable tem- perature. This will be particularly necessary in very severe cases, or in winter, because the child must then be confined altogether to the house. The diet at fir,st should be rather restricted : all stimulating food should be withheld, and cooling drinks allowed freely. As the second stage advances, the diet must be improved, broth or meat allowed according to the age of the child and its condition, and perhaps a little wine and water. 369. Treatment of the Complications. — A considerable deviation from, or addition to, the treatment already indicated, will be necessary when either of the complications I have described, exist. It will not, how- ever, be necessary to enter at length into the subject at present, as the reader will find all the details in the chapter on bronchitis, pneumonia, convulsions, &c. I shall mention so much of it only as will indicate the line to be pursued and the modifications required. Whenever we detect the evidences of bronchial or pneumonic inflam- mation, it will be necessary, notwithstanding the hooping-cough, to adopt prompt and energetic treatment. Unless the child be greatly exhausted, we must have recourse to bloodletting, either by a free use of the lancet or by an equivalent number of leeches, arresting the bleeding when the leeches fall off, or by cupping, if the child be old enough. Dr. Mackintosh states that he found great benefit from leeches applied over the larynx. After relief from bleeding, and as scjpn as the fever has somewhat subsided, a blister may be applied to the chest ; and here let me repeat that I have found a succession of small blisters much more effectual with children than one large one, and also that we must be cautious not to leave them on too long, especially with infants, as the surface, when much inflamed, is apt to ulcerate. Two or three hours are sufficient for children up to five or six years of age ; and although there may be no vesication when we remove it, it will take place after- wards. Let me add, that it is better not to cut the blister, unless its prominence makes the child uncomfortable, and that the best dressing, if the surface be not broken, is French wadding or cotton wool. Internally, we must increase the quantity of ipecacuanha wine in case of bronchitis ; but in pneumonia we must have recourse to tartar emetic in small doses, from its well-known power over that disease. Either remedy may be added to the expectorant mixtures formerly advised, and continued, so as to keep up a slight nausea, unless the bowels become affected. In such a case, we may try small doses of calomel and Dover's powder, or some other antiphlogistic remedy. If the child be much weakened, the addition of ammonia to the expectorant mixture or its alternation with it, will be advisable. I have also seen great PERTUSSIS. 257 benefit from spirits of turpentine given alternately with the ipecacuanha or tartar emetic. The bowels must be carefully regulated. Brisk purgation rather does mischief than good, but a gentle purgative now and then may be necessary. If there be diarrhoea, chalk mixture with aromatic confec- tion and a very small quantity of laudanum, will be of use. 370. If the child be attentively watched, the second complication, disordered bowels and remittent fever, may, in most cases, be prevented. At each visit an accurate account of the state of the stomach and bowels should be obtained, and the treatment judiciously adapted to avoid these inconveniences. If the bowels be constipated, a brisk purgative may be given, followed by an enema, if the medicine be ineffectual. When the congestion about the head is considerable, it is often accompanied by obstinate constipation, which does not yield until the cerebral condition has been relieved by bleeding. If the bowels be not constipated, but the discharges are unhealthy in colour or smell, which is by no means uncommon, mild laxatives, with small doses of hydr. c. creta or calomel, will probably excite bene- ficial action upon the mucous membrane, and restore the natural secre- tions. When diarrhoea is present and considerable, we must have recourse to some astringent medicine — chalk mixture, compound powder of chalk, powder of chalk and opium, &c. I generally order the following simple mixture for a child of a year old : — U. — Mist, cretse gj. Confect. arom. gr. v. Syr. zingib. gij. Tincturse opii gtt. ij. — M. Cap. cochl. i. parv. ter quaterve in die. Increasing the quantity of laudanum if the child be older, and adding a little tincture of kino or catechu if the purging be obstinate. Gentle frictions of the abdomen with compound camphor liniment and laudanum, or fomentations, are very useful. A small starch enema, with a few drops of laudanum, will often arrest the discharge after other measures have failed. I have also derived great benefit from hydrocyanic acid in this complication ; it decidedly diminished the irritability of the bowels at the same time that it acted beneficially upon the cough. The diet must be carefully guarded, nutritious but not too stimu- lating, and rather of solid food than fluid, if the child be old enough. For the management of remittent fever I must refer to the chapter on that subject, as the only result of its being a complication will depend upon the constitution of the child. 371. With regard to the treatment of convulsions occurring in hoop- ing-cough, the first thing is to remove the ordinary exciting causes, if they exist; the gums should be freely divided, the bowels freed, and a warm bath administered. Notwithstanding, the convulsions will con- stantly recur, and in these cases there are two plans strongly recom- mended by Dr. Johnson : " One is a total alteration of the child's diet, 17 258 PERTUSSIS. and the other is change of air. When the child affected is at the breast, de- fectiveness in quantity or quality will usually be detected in the nurse's milk. Often it will be found that she has menstruated, or, as sometimes happens, without the discharge actuall} 7 occurring, she has experienced sensations similar to those which attend the accession of the catamenia. In such cases the milk almost uniformly disagrees, and hence it is a good rule, whenever the convulsive attacks withstand ordinary treatment, to inquire into the state of the nurse, and, if there be any ground of sus- picion, to have a young and healthy one procured. Change of air often in the most remarkable manner puts a stop to the recurrence of convul- sions, and will be found particularly beneficial in those cases of spasm of the glottis to which we have alluded." More active treatment than this will, of course, be necessary; leeches to the forehead or behind the ears, cold lotions, and probably a blister to the nape of the neck, with a purgative, should immediately follow an attack of convulsions. If we succeed in mitigating their severity, it will be well to establish a permanent drain by a seton of two or three threads in the arm. as heretofore recommended. But in the majority of cases, all our treatment will be in vain, unless we can contrive to lessen the frequency and violence of the cough; the reiterated arrest of the circulation will shortly reproduce the convulsion. For this purpose T have found the hydrocyanic acid of great value; if anything will check the cough, it will he either that or the belladonna. I should think it probable that the same effects would follow the chlo- roform or ether, but as yet I have had no opportunity of trying either. I am not prepared to say whether the convulsion ought to prohibit their use, but 1 rather think not. 372. These observations will apply as well to hydrocephalus^ with the addition that, as the disease is more hopeless and more serious, our treatment must be more active, limited only by the state of the child's constitution, and by the recollection that, in the event of recovery from the complication, it has still a, long and exhausting disorder to encounter. In addition to the leeching, cold applications, blisters, and purgatives, we must give a fair trial to mercury in whatever mode it is heat borne by the child; and if we are successful in controlling the secondary affec- tion, a more liberal use of tonics, and a more generous diet, will be ne- cessary at an earlier period than usual. 378. When the symptoms of cerebral congestion or apoplexy make their appearance, no time is to be lost in abstracting a. sufficient quan- tity of blood, and the effect of this first bloodletting will guide us as to the necessity for its repetition. If the stupor diminishes, the intelli- gence returns, and the child appears more conscious of what is passing, we may either repeat the bleeding after an interval, or have recourse to counter-irritation, cold lotions, and purgatives. If there be no return of sensibility, or diminution of the stupor or Coma, the case is one of apoplexy from effusion, and with so powerful an exciting cause continuing as hooping-cough, it is not likely that any treatment will he of use. We may, as a matter of duty, try the reme- dies I have recommended for apoplexy, but it, is most likely that they will altogether fail. croup. 259 CHAPTER IV. CROUP. — CYNANCHE TRACHEALIS. 874. The disease which is the subject of the present chapter consists, essentially, in inflammation of the larynx and trachea primarily, but which may occupy a greater extent of the respiratory organs; accom- panied by a peculiar pellicular secretion, with a certain amount of spas- modic action, modifying the respiratory and vocal functions. By the ancients it seems to have been confounded with other diseases of the air-passages. According to Cheyne, Michaelis, &c, Baillou, of Paris, in 1576, was the first to indicate the anatomical characters of croup. Etmiiller described a disease strongly resembling it, and after him Molloi, 1743; Malouin, 1746; Ghisi of Cremona, in 1747, who called it angina strepitosa; Starz, in 1749 (morbus strangulatorius) ; Middleton, 1752; Bergius, 1755; Rudberg, 1755; Berghen, 1759; Wahlbom, 1761; and Wilcke, 1764. It was first noticed by its present name by Dr. Blair, of Cupar Angus, in 1718. In 1765, Dr. Home, of Edinburgh, published his essay, in which the disease was first accurately described, and from original observations. He was succeeded by several writers, among whom I may mention Eller, 1766; Engstroem, 1767; Rosen, 1771; Rush, 1769; Bard, 1771 ; Callisen, 1776; Buchan, 1776; Turnbull, 1776; Mahon, 1777; Middleton, 1780. Since this period numerous monographs of greater value have appeared, by Jurine, Albers, Vieussieux, Valentin, Cheyne, Blaud, Bretonneau, Guersent, Trousseau, Desruelles, &c. ; and it has formed a very important chapter in the sys- tematic works on diseases of children, besides being more or less de- scribed by writers on diseases of the respiratory organs. It has been described under various names, but I prefer the ordinary name "croup," as being generally intelligible, and as involving no pa- thological opinion. 375. It is one of the most alarming and fatal diseases to which chil- dren are liable; sudden in its attack, alarming in its symptoms, and rapid in its results, it sweeps over a family, leaving behind it distress a,nd desolation. Generally speaking, it attacks children between the ages of one and twelve years, and most frequently those under five years. Marley men- tions having seen it in an infant at the breast; 1 Hamilton in one of six qr eight mouths; 2 Cheyne in one of three months; 3 Bouchut in one of 1 Diseases of Children, p. 13^. 2 Disc; 863 of Infants, p. 142. 3 Pathology of the Larynx and Bronchia, p. 15. 260 croup. eight days old. 1 M. Andral gives the following table of ages in 332 cases. It occurred During the 1 st month in 1 case. 3d » " 1 " 5th " " 1 " From 5 to 12 months " 18 cases. " 1 to 2 years " 61 " " 2 to 3 " " 45 " « 3t0 4 « 54 " " 4 to 5 " " 42 " " 5 to 6 " " 29 " " 6 to 7 " 29 " " 7 to 8 " 3 " " 8 to 11 " 6 " " 11 to 15 " 7 " " 15 to 30 " " 13 " « 30 to 50 " 10 " « 50 to 70 " 12 " In thirty cases observed by M. Trousseau, thirteen were from eleven months to three years of age, eleven from three to five years, and six from five to twenty-six. 2 " In Philadelphia, during the ten years preceding 1845, 475 deaths are reported from croup, in infants between two and five years; 238 in those between one and two years; 319 in those under one year; 112 in those between five and ten years; and six in children over ten years." 3 MM. Rilliet and Barthez state that primary croup is most frequent between the ages of two and seven years; and of eleven cases of se- condary croup, six were from two to five years, and five beyond that age. 4 Dr. Vauthier states that, of thirty-seven cases, twenty-five occurred at or under two years of age. 5 Mr. Wilde observes, in his Report upon the Irish Census of 1841 : "This fourth most fatal epidemic affection carried off 42,705, in the pro- portion of 100 males, to 82.89 females. The registries of this disease afford returns of death up to the adult age, even so high as 30, and one at 40." From the fifth to the tenth year, the deaths amounted to 1316 males, and 1292 females. " Compared with other infantile dis- eases, the deaths during the first year are 100 to 48.29 of measles ; 100 to 6.82 of scarlatina ; 100 to 92.62 of hooping-cough; 100 to 4.98 of thrush; and 100 to 60.1 of pemphigus." 6 From these details, it will be seen that it is not altogether confined to infants or children, but that adults, and even old people, are occasionally attacked, upon which M. Louis has published a valuable paper. 7 There is another fact concerning croup, in direct opposition to what occurs in hooping-cough, alluded to in Mr. Wilde's report, viz : that it is more frequent among males than females, and which is confirmed by general experience. Of M. Trousseau's thirty cases, twenty-two were males and eight females; and of M. Jansecowich's twenty-five cases, there were seventeen boys and five girls. 1 Mai. des Nouv. Ne"s, p. 265. z Barrier, Mai. de FEnfance, vol. i. p. 414-5. 3 Condie, Diseases of Children, p. 332. 4 Mai. des Enfans, vol. i. p. 351. 6 Arch. Ge"n. de MeU, May, 1848, p. 10. « Wilde's Report, p. 16. 7 Recherches Anat. Path., p. 203. Sur le Croup cousidere chez l'Adulte. croup. 261 376. Different classifications have been made of the varieties of croup, according to the predominance of peculiar symptoms. Thus we have the catarrhal, the spasmodic, and the inflammatory croup of some authors ; the acute and spurious of Ferrier ; the three varieties of M. Blaud, dependent mainly on the intensity of the attack ; the three species of M. Porter, 1 the spasmodic, the inflammatory, and a third, in which the lining membrane has become thickened and altered, so as to spoil the appearance of the organ and interfere with its functions. The com- mencement is insidious, its progress slow, and its termination fatal. Dr. Stokes divides croup into primary and secondary ; the latter being an extension of the disease from the neighboring parts, or a complica- tion with other diseases. 2 It appears to me, however, that most of these distinctions are only differences in degree, or in the predominances of certain characters over others; the only invariable one, if the disease be allowed to run on, being the inflammation and the false membrane. Experiments made by Schwilgue, Schmidt, Chaussier, and others, have proved that the same causes, applied to animals of the same class, have given rise to each variety, according to the peculiar constitution and age of the animal. The plan I propose, therefore, is to describe inflammatory or primary croup, as it ordinarily occurs ; then to speak of the modifications arising from the predominance of some one characteristic, as the spasm ; of its complications ; and lastly, of the secondary form of the disease, either owing to its extension, or to its complicating other diseases. 377. Symptoms. — The course of the disease has been divided into four stages by Golis — the invading or catarrhal, the inflammatory, the albuminous, and the suffocative stage. Dr. Cheyne makes two stages — the incomplete or inflammatory, and the complete or purulent ; Dr. Dewees into three — the forming, the completely formed, and the con- gestive stage ; M. Guibert into three — the stage of irritation, that of albuminous secretion, and that of suffocation. I prefer adopting that of Dr. Copland, 3 nearly the same as Dr. Stokes's, and shall speak, first, of the precursory stage ; second, of the stage of development ; and third, of the stage of collapse, or threatened suffo- cation. I. The Precursory Stage. — As a general rule, some catarrhal symp- toms precede an attack of croup. The child is cross and feverish, the skin hot, the pulse quick, the thirst increased ; there may be sneezing, lachrymation, and cough. There is always a change in the voice, a degree of hoarseness, to which, as the surest sign of an approaching attack of croup, Dewees and others attach great importance. It is not, however, like the subsequent hoarseness, but rather an unusual huski- ness, as though the throat needed clearing. If we examine the pharynx, we shall discover no trace of disease ; the tongue is generally loaded but moist; there is evident uneasiness in 1 Surgical Pathology of the Larynx and Trachea, p. 29. 2 Diseases of the Chest, p. 205. 3 Let me here, once for all, acknowledge my obligations to the learned and accurate work of Dr. Copland ; to it and to the works of MM. Barrier, Rilliet and Barthez, I am more indebted than to any others. My deep sense of their value must be my apology for the free use I have made of them. 262 croup. the windpipe, and the cough is short and generally dry. The chest is resonant, and it is rarely that we can detect any morbid sounds with the stethoscope, and then only some slight bronchial rales. The rapid- ity of breathing will be in accordance with the amount of the fever, quickness of pulse, &c. In some cases it is greatly hurried, in others pretty quiet. Vieussieux lays great stress upon the catarrhal symptoms and changes in the voice ; but although the latter is very characteristic when present, many cases occur in which there is neither the premonitory catarrh nor hoarseness, but where the disease first appears fully formed. The duration of the precursory stage is very uncertain, varying from a few hours to a day or two ; as a general rule, it does not extend beyond eighteen or twenty-four hours. 378. ii. Stage of Development. — After the symptoms I have men- tioned have characterized the first stage, increasing towards evening, or without any warning in cases where the first stage is absent, the child is suddenly awoke out of sleep by a sensation of suffocation, with a hoarse ringing cough, hurried and hissing respiration, and a rough hoarse voice, with great alarm, agitation, and distress. Ferrier, 1 Cheyne, 2 and indeed most writers, have noticed, as a pecu- liarity, the first occurrence of the croupy cough at night, without giving any explanation of it. It seems probable that it may be another exam- ple of the disposition there is in nervous or convulsive attacks to occur in the night. After mentioning the setting in of this stage with "in- crease of fever, anxiety, and distress, and by indications of mechanical obstruction in the larynx itself" Dr. Stokes remarks : "Indeed, one of the most remarkable circumstances connected with the disease is the rapidity with which this latter symptom shall occur, a fact strongly confirmatory of the opinion that the mere effusion of lymph is not the principal cause of the obstruction, but that it is owing to the inflamma- tory spasm of the part." 3 I have no doubt that thus early the dyspnoea and peculiarity of the cough are chiefly owing to spasm of the larynx, and, like similar nervous affections, they are peculiarly apt to occur in the night. " The child's illness," says Dr. Cheyne, " does not prevent him from going to sleep at the usual time ; but he awakes with an unusual cough, suffocative, acute, and ringing. His breathing is difficult ; often the inspirations, particularly those which follow the cough, are crowing. His face is swelled and flushed, and his eye is watery and bloodshot, and he seems in danger of suffocation ; his skin is hot, and he has some thirst. He labors in breathing, and still the difficult and perhaps crow- ing inspiration continues, and the distinctive cough. He tries to relieve himself by sitting up or coming out of bed. No change of position gives him relief. Generally, his sufferings are thus protracted until morning, when, perhaps, there is a slight remission." 4 The cough, then, with the rough breathing (bruit serratique) and the 1 Med. Histories and Reflexions, vol. iii. p. 134. a Pathology of the Larynx and Bronchia, p. 16. 3 Diseases of the Chest, p. 208. 4 Pathology of the Larynx and Bronchia, p. 15. croup. 263 hoarse voice, are the distinctive characteristics of this stage. The sound of the cough is so peculiar that, once heard, it is never forgotten. It resembles slightly the crowing of a cock or the bark of a dog, but still more succussions of air through a brazen tube ; it has a ringing metallic tone in it. The breathing is evidently changed by the air being forced through a narrower orifice than usual, and the voice has a rough hoarse- ness even when quiet, but very marked when the child is crying. The paroxysms of coughing become more frequent and spasmodic, during which the inspiration is almost suspended and the heart's action accelerated. The difficulty of respiration and the consequent efforts on the part of the child are very great ; the countenance is flushed, sometimes almost livid, and covered with sweat; the hands are clinched, the arms thrown about, all covering rejected, and whatever might im- pede the access of air is hastily removed. The body is sometimes erect, sometimes recumbent, and occasionally with the head rigidly bent back- wards. 1 The eyes project, and are injected and suffused. The carotid arteries beat strongly, the pulse is quick and hard, the skin burning, and the thirst great. The little patient refers the seat of distress to the larynx, to which the hand is frequently carried, as if to remove some obstruction, and where, as Dr. Ferrier has remarked, a degree of tumefaction is sometimes observed. As yet, there is scarcely any expectoration. 379. In a simple case of croup, the stethoscopic signs are chiefly of a negative character; the chest sounds clear on percussion; the respi- ratory murmur is hurried and unequal ; the croupy sound and sibilant breathing are heard over the larynx. But occasionally the information is more positive. Dr. Stokes observes : " The active physical signs referable to the lungs, which I have had an opportunity of detecting, have been as follows: First, a diffuse sonorous rale, not so intense as to extinguish the vesicular murmur ; secondly, the same rale, but with more intensity, indicative of disease in the more minute tubes; thirdly, a combination of the sonorous and mucous rales, causing a loud sound, and a feeling of vibration when the hand is applied to the chest ; fourthly, the crepitating rale of pneumonia in one or both lungs ; in some cases, with distinct dulness of sound on percussion. I have not heard the bronchial respiration of hepatization, or the frottement of pleurisy; but there can be no doubt that if these conditions existed before the laryngeal disease had obtained its maximum, these signs would be distinctly audible." 2 Several of these signs are referable to the complication of croup, as we shall see by and by. Dr. Williams notices a "weak respiratory murmur in the chest, which yet sounds well on percussion," and "a concave state of the intercostal spaces at each inspiration." He further states that ' v the sonorous inspiration of croup is audible through the stethoscope applied to the throat or upper part of the chest before it can be heard by the ear unapplied." 3 In addition, 1 This peculiar symptom is observed in several different diseases, and, among others, spinal arachnitis, pleuritis, pericarditis, &c; and I have in vain striven to make out its exact import. In croup, however, it appears to be a mechanical arrangement to facilitate the passage of air by straightening the primary air- tubes. 2 Diseases of the Chest, p. 214. 3 Diseases of the Chest, p. 84. 264 croup. M. Bartliez remarks that at a certain period of the disease, when the stethoscope is applied to the larynx, we may perceive a peculiar vibra- tion, as of something flapping, which always indicates the existence of loose false membrane ; and if this be confined to the larynx, it is so far a favorable sign that it announces the concretions to be slightly adherent, and capable of being removed by expectoration. If, on the other hand, this vibration be prolonged into the trachea and bronchial tubes, it is unfavorable, from the evidence it affords of the great extent of the disease. 1 Thus, the physical examination of the chest may yield either positive or negative results of great practical value in' the treatment of the dis- ease, and at each visit we should make ourselves acquainted with its exact condition. 380. The symptoms already mentioned, the cough, dyspnoea, and hoarseness, first appear and afterwards increase during the evening and night, along with the fever, and diminish in the morning, when we find the fever less, the cough not so frequent, perhaps less characteristic, and the inspiration less labored. This intermission may continue during the greater part of the day; but the exacerbation reappears towards evening, probably after a sleep, with greater severity than before. The cough, dyspnoea, anxiet} r , and fever are increased ; the hand is con- stantly applied to the throat to remove the obstruction ; and the larynx, when pressed, is sometimes painful. The countenance is swollen, puffy, and flushed or livid; the eyes prominent and suffused ; the expression that of agony. The pulse is quick, hard, and small ; the skin is hot and dry, except the face and head, which generally perspire profusely during the fits of coughing. The child is restless, and constantly changing its position in the hope of obtaining relief. The respiration increases in difficulty, and the voice in hoarseness ; the cough is sudden, convulsive, and ringing, terminating often in a crowing inspiration. There is little or no expectoration. 381. Arrived at this period, the progress of the disease becomes very rapid, and its advance is marked at every step by an aggravation of the symptoms., The remissions are less perceptible, the cough more diffi- cult, suppressed, and strangulating; suffocation more imminent; and the paroxysms are occasionally followed by vomiting, and the expulsion of a glairy mucus, sometimes, but rarely, mixed with flocculent or mem- branous shreds, which affords temporary relief. The croupal respira- tion is permanent and increases, and if the lungs be unaffected, the ribs are drawn somewhat inwards, and towards the mesial line (as in atelec- tasis) instead of being protruded by the distended lungs ; the voice be- comes broken, whispering, and suppressed, partly from the pain it ex- cites, and partly from its bringing on the cough. Deglutition is occa- sionally difficult, and gives rise to fits of coughing and strangulation. The bowels are generally constipated, and the urine sometimes clear, pale, and abundant ; in other cases scanty, thick, and high colored, and occasionally whitish and turbid, particularly towards the close of the second stage. 2 1 Archives Gen. de M6d., July, 1838. 2 Valentin, sur le Croup, p. 219. croup. 265 382. It is during this second stage or period of development that the pathological peculiarity of the disease, the secretion of false mem- brane, occurs, but at what period, or by what symptoms it is indicated, it is difficult to determine. M. Blaud states that he has found the larynx and trachea lined with false membrane, in cases whose whole course did not occupy more than twenty hours, whilst in others several days elapsed before it was formed. The evidence derived from auscultation on this point is not always certain or precise. The vibration spoken of by M. Barthez is, I should think, pretty conclusive, but it is by no means common, and it is not easy to say whether the sonorous laryngeal inspiration is at the moment we examine, due to inflammatory spasm, to the mechanical obstruction of the false membranes, or to both combined. M. Trousseau states that when the cough, having been clear, loud, and ringing, becomes less frequent, and at length almost without sound and suffocating, we may be certain that exudation has taken place. 1 Occasionally the expectoration will throw some light upon the matter. Early in the disease the child expectorates nothing, or a little frothy mucus; but in some more advanced cases shreds of lymph are thrown off, and on this account we should never omit to examine the sputa carefully. Dr. Hegewisch 2 recommends their being put into hot water to render them more apparent : they should always be placed in water for examination. No doubt this is a symptom of considerable impor- tance, but, as Rilliet and Barthez have observed, it is far from being frequent, and rarely occurs before an advanced period of the disease, perhaps the day before death. In one of their cases it occurred on the fourth day. It does not appear, then, that we can lay down any symptom which will prove that lymphatic exudation has actually occurred, nor have we any evidence to show that this occurs at any regular period of the attack. It cannot be doubted that it does take place during the second stage, but the exact time seems to vary in different cases. 383. in. Period of Collapse. — This stage may set in from the third to the seventh day after the invasion, according to the intensity of the inflammation or the peculiar constitution of the child. It is charac- terized by the absence of any remission, by the aggravation of all the symptoms, especially the pulse and respiration, which are greatly accel- erated, and with diminished power. The pulse is not only quick and weak, but often unequal and intermitting ; the cough is less frequent, less sonorous, suppressed, and suffocative. The voice is low, whisper- ing, or perhaps entirely abolished ; the speech quipk, imperfect, or lost. The respiration is extremely difficult, and accompanied with a loud hiss- ing noise. All the muscles of inspiration are called into powerful ac- tion ; thus the alge nasi, the muscles of the neck, chest, diaphragm, and abdomen, all act with great force, and the movements of the larynx are extensive and incessant. The head is constantly thrown back, the forehead is covered with cold perspiration, the eyes are sunken and dull, and the complexion is livid, or of a leaden color. The surface gene- 1 Journal de Connois. Med. Chir., 1884, p. 3. 2 Rust's Magazine, vol. xxxii. p. 2. 266 croup. rally is pallid, and the veins are very visible, especially those of the neck, which seem unusually distended. The tongue is dark-colored and loaded, the lips sometimes purple, in other cases of a livid paleness ; the thirst is often intense, but can only be gratified at the risk of suffoca- tion. The bowels are rather confined ; the motions are dark and fetid. There is generally some little expectoration, and it may be that, by great efforts, some shreds of the lymph mayjbe thrown off from the larynx, with manifest relief for the time, but followed by a return of the distressing suffocation. The whole expression of the child's face, figure, and posture, is one of unmitigated distress, of the agony of oppressed breathing, of the horrible dread of suffocation. It turns on every side for relief and finds none ; it changes its position, lying down or sitting up, restless and anxious as those who strive for the breath of life, and despairing as those whose efforts are in vain. Awake or asleep, the distress con- tinues ; it finds no relief in the arms of its mother, no comfort in her caresses. From this condition the child rarely recovers; there may be occa- sional remissions, as I have mentioned, after the expectoration of mucus and lymph, but this is only temporary, and as the disease extends itself downwards, along the bronchial tubes, all chance is excluded. The local and general distress increases ; the efforts at respiration partake of a convulsive character ; the passage of air through the larynx be- comes more and more difficult; and after a short time, seldom above twenty hours, death terminates the painful scene. The child may either expire with signs of convulsive suffocation, or it may fall into a state of stupor from exhaustion of the vital powers, and die lethargic. The younger the child, the more liable it is to have the disease terminate by convulsions. Occasionally, the disease terminates more suddenly than I have de- scribed ; the child has appeared to be instantly suffocated just when the symptoms had become somewhat more favorable ; and, in some of these cases it has been owing to the partial detachment of the false membrane, and the formation of a valve whose closure proved fatal. 384. Such is the course of the severe form of croup, when uncom- plicated and unchecked by treatment. It may, however, run a different and- less fatal course. The fever may be slight, and the laryngeal affection much milder. Still there will be the sibilant and impeded respiration, the croupy cough, and the hoarseness, never to be mis- taken when once they have been heard. These will be troublesome during the night, and perhaps there may be more or less complete remission during the day. No matter how slight the attack may be, the most vigilant care is requisite, as the disease very often acquires great intensity in a very sudden manner, and a very few hours lost can never be regained. Or, if the treatment be early, active, and judicious, the disease may be checked in either the first or second stages, and we shall then find that the character of the cough will be changed ; it becomes softer and more moist ; the respiration, although for a time rough, is much easier croup. 267 and less hurried, and the voice acquires some tone ; the case assumes the aspect of common catarrh, with hoarseness. I have seen this change take place in my own children in two hours, when the disease was attacked in the very commencement. In more severe cases, the fever, with evening exacerbations, may continue for some time after the voice, cough, and breathing have lost all croupy character, as in a case at pre- sent under my care. We must never forget the great liability of the disease to relapse, nor cease our watchful care until the patient has perfectly recovered. It is also very apt to recur in the same individual. According to Jurine and Albers, it has been known to recur seven and nine times. I have seen it occur two, three, or four times. Nor can we be sure that every attack will be equally mild ; a child may recover from two or three attacks, and be destroyed by the next. Much of the chance of recovery depends upon our seeing the disease at its commencement, for even the milder cases, if neglected, may assume greater intensity, and destroy the patient. 385. The duration of the disease depends partly upon the severity of the inflammation, and partly upon the vital energy of the child. It may prove fatal in twenty-four or thirty-six hours, as Dr. Hamilton mentions, or it may last nine or ten days. Dr. Cheyne states that it generally proves fatal on the third, fourth, or fifth day. Probably from three to six days will be found to include the greater number of cases. 386. Pathology. — The morbid phenomena exhibited on dissection, by the structures chiefly occupied by this disease, are the following: — I. The mucous membranes of the larynx and trachea, in the majority of cases, show evidences of inflammation ; they are of a bright red, vas- cular, and thickened, so that they can be peeled off easily. Occasionally the redness is partial, with patches of ecchymosis around the follicular orifices ; and in some rare cases, as has been noticed b}^ Albers and Ju- rine, Rilliet, and Barthez, the mucous membrane is pale, and apparently perfectly healthy, underneath the false membrane. This Albers ex- plains by supposing that the inflammation subsides after the peculiar secretion is accomplished. The orifices of the mucous follicles are often in a state of dilatation. Jurine remarks that they give the mucous membranes a dotted ap- pearance, and that they are larger on the membranous portion .of the trachea, in the direction of its longitudinal fibres, and in their in- tervals. 387. II. But the characteristic morbid appearance is the false mem- brane which lines the air-passages, lying upon the mucous membrane. We find a layer of lymph of considerable consistence, of varying thickness, and of a whitish or yellowish color, lining the larynx and trachea, and sometimes extending into the bronchi. This extension to the bronchial tubes occurred in forty-two cases of 120, according to M. Guersent, or in about one-third. In some cases it is of small extent, resembling grains or patches, between which we see the mucous membrane, and occupying different parts of the larynx and 268 croup. trachea ; in others it forms demi-cylinders, or more rarely, entire cylinders, or tubes of different length — casts, in fact, of the tubes in which it is moulded. It is thinner and more fragile in the larynx than in the trachea, and its consistency is least in the bronchial tubes. The less the consistence, the greater the probability of its being ex- pectorated. The free surface of the false membrane is generally smooth, and often covered by a layer of muco-puriform matter. The other surface adheres more or less strongly to the mucous membrane. In some cases it is partially separated by puriform matter ; in others an attempt to remove the false membrane brings away the mucous coat. When the secretion is extensive and general, it is generally less adherent ; and when removed, the surface, which had been in contact with the mucous membrane is generally smooth, and of a whitish yellow color, with longitudinal strise, owing, probably, to the impression of the muscular fibres of the trachea. In this adherent surface, also, we may sometimes see a number of small red points, which, according to M. Hache, correspond to the little ecchymoses of the mucous membrane which I have already noticed ; and it has been doubted whether this may not be the com- mencement of organization in the false membrane. 1 Soemmering, Royer, Collard, Guersent, Blache, and others, believe in the possibility, and have discovered vascular striae which penetrate the substance. Portal, Valentin, and others, have denied the development of vessels. Rilliet and Barthez, without deciding positively, admit the possibility, but very sensibly remark, that such cases must be extremely rare on account of the rapidity of theVlisease. As to the chemical properties of the false membrane, I cannot do better than quote the following passages from M. Bretonneau's valuable work: "I have endeavored," he observes, "by means of different chemical reagents, to establish the differential characters of the croupal concretions, the albuminous concretions which are the consequence of inflammation of the serous membranes, and the fibrin of the blood, and I have not been able to discover any." " Sulphuric, nitric, and hydro- chloric acids coagulate all ; acetic acid, liquid ammonia, and alkaline solutions, dissolve all, and convert them into a diffluent and transparent mucus, exactly at the same temperature, and in the same vessel." 2 It consists, therefore, of albumen ; and, according to Lelut, it is the mucus, enriched with fibrin, in consequence of the inflamed condition of the part. Dr. Hosack attributes the membrane to the rapid passage of the air. Dr. Seitz has recorded a microscopic examination of this membrane ; it was about half a line thick, and of a slight consistence ; it was seen to be composed almost entirely of pus globules, mixed with inflammation corpuscles, and a species of cell double the size of the pus globule, but otherwise similar to it. 3 Instead of this plastic lymph, we occasionally find the air-passages in- 1 Mai. des Enfans, vol. i. p. 319. 2 Traite de la Diphtherite, p 293. 8 Ranking' s Abstract, vol. iv. p. 334. croup. 269 flamed, and to a greater or less extent lined with a layer of viscid puri- form or muco-puriform matter, offering, of course, an impediment to respiration, but more easily expectorated. 1 388. It may be as well to notice here certain other morbid conditions, although they result from the complications of croup, which I shall notice by and by. The pharynx occasionally participates in plastic exudation, and on examination we find it either disposed in patches, or continuous and extending into the larynx. In almost all cases the oesophagus ia healthy ; in two cases related by Bretonneau, however, the false mem- brane lined the whole extent of the tube to a little beyond the cardiac orifice of the stomach. In one case, by Ferrand, it extended to the commencement of the oesophagus ; and in another, reported by M. Lespine, it occupied the inferior third. It is rare to find any morbid appearances in the stomach or bowels. Rilliet andBarthez met with minute ecchymoses of the mucous membrane of the stomach, and a considerable development of the isolated follicles of the small intestines, but nothing more. The bronchial tubes are often found inflamed, even when there are no false membranes ; in some cases the mucous membrane is simply vas- cular ; in others red and softened. Moreover, they contain a quantity of mucous or puriform fluid. In a large proportion of cases — five-sixths, according to Rilliet and Barthez — lobular pneumonia exists, and occasionally it is general and and extensive ; nor does it depend upon the extension of false membranes to the bronchi, for it is present in many instances when they are absent. An emphysematous condition of the lungs exists in a large proportion of cases in consequence of the asphyxia ; it is generally vesicular, in children. Dr. Cheyne mentions that serous effusion and evidences of inflam- mation are occasionally found in the cavities of the pleura and peri- cardium in severe and protracted cases, and that the cavities of the heart are sometimes full of blood. The sub-maxillary and bronchial glands are generally swollen and soft, and in one case Dr. Cheyne found a quantity of glutinous matter surrounding the thyroid gland, and passing from behind it round the trachea. 389. Now, from the morbid appearances I have mentioned, there cannot be much doubt of the pathology of the disease : that it consists of inflammation of the mucous membrane, giving rise to a peculiar secretion, and exciting spasmodic action ; and the result is a great im- pediment to the ingress of air, to its access to the minute bloodvessels, and a less perfect aeration of the blood. Dr. Copland has given an admirable series of inferences from the post-mortem appearances, which I shall make no apology for quoting : — " 1. That the mucous membrane itself is the seat of inflammation of croup ; and that its vessels exude the albuminous or characteristic discharge, which, from its plasticity, and the effects of temperature, 1 Dr. Francis, New York Med. and Pbys. Journal, vol. iii. p. 56. 270 croup- and the continued passage of air over it, becomes concreted into a falso membrane. " 2. That the occasional appearance of bloodvessels in it arises from the presence of red globules in the fluid when first exuded from the inflamed vessels, as may be ascertained by the exhibition, upon the approach of the symptoms, of a powerful emetic, which will bring away this fluid before it has concreted into a membrane ; these globules generally attracting each other, and appearing like bloodvessels, as the albuminous matter coagulates on the inflamed surface. " 3. That the membranous substance is detached in the advanced stages of the disease, by the secretion from the excited mucous follicles of a more fluid and less coagulable matter, which is poured out between it and the mucous coat ; and as this secretion of the mucous cryptge becomes more and more copious, the albuminous membrane is the more fully separated, and ultimately excreted, if the vital powers of the res- piratory organs and of the system are sufficient to accomplish it. " 4. That subacute or inflammatory action may be inferred as having existed, in connection with an increased proportion of fibro-albuminous matter in the blood, whenever we find the croupal productions in the air-passages ; but that these are not the only morbid conditions consti- tuting the disease. " 5. That, in conjunction with the foregoing — sometimes only with the former of them in a slight degree — there is always present, chiefly in the developed and advanced stages, much spasmodic action of the muscles of the larynx, and of the transverse fibres of the membranous part of the trachea, which, whilst it tends to loosen the attachment of the false membrane, diminishes, or momentarily shuts the canal (of the lar3 r n\) through which the air passes into the lungs. "6. That inflammatory action may exist in the trachea, and the ex- udation of albuminous matter may be going on for a considerable time before they are suspected, the accession of the spasmodic symptoms being often the first intimation of the disease ; and these, with the effects of the previous inflammation, give rise to the phenomena characterizing the sudden seizure. "7. That the modifications of croup may be referred to the varying degree and activity of the inflammatory action, the quantity, the fluidity, or plasticity of the exuded matter, the severity of spasmodic action, and to the predominance of either of these over the other, in particular cases, owing to the habit of body, temperament, and treatment of the pa- tient, &c. " 8. That the muco purulent secretion, which often accompanies or follows the detachment and discharge of the concrete or membranous matters, is the product of the consecutively excited and slightly in- flamed state of the mucous follicles, the secretion of which acts so bene- ficially in detaching the false membrane. "9. That a fatal issue is not caused merely by the quantity of the croupal productions accumulated in the larynx and trachea, but by the spasm, and the necessary results of uninterrupted respiration and cir- culation through the lungs. " 10. That the partial detachment of fragments of membrane, par- croup. 271 ticularly when they become entangled in the larynx, may excite severe, dangerous, or even fatal spasm of this part, according to its intensity, relatively to the vital powers of the patient ; and that this occurrence is most to be apprehended in the complicated states of the malady, where the inflammatory action, with its characteristic exudation, spreads from the fauces and pharynx to the larynx and trachea ; the larynx being often chiefly affected in such cases, and, from its irritability and conformation, giving rise to a more spasmodic and dangerous form of the disease. "11. That the danger attending the complication of croup is to be ascribed not only to this circumstance, but also to the depression of vital powers, and the characteristic state of fever accompanying most of them, particularly in the more advanced stages. " 12. That irritation from partially detached membranous exudations in the pharynx, or in the vicinity of the larynx or epiglottis, may pro- duce croupal symptoms in weak, exhausted, and nervous children, with- out the larynx or trachea being materially diseased; and that even the sympathetic irritation of teething may occasion the spasmodic form of croup, without much inflammatory irritation of the air-passages, parti- cularly when the prima via is disordered, and the membranes about the base of the brain are in an excited state. " 13. That the predominance in particular cases of some one of the pathological states noticed above (5) as constituting the disease, and giving rise to the various modifications it presents, from the most in- flammatory to the most spasmodic, may be manifested in the same case, at different stages of the malady, particularly in its simple forms, and in the relapses which may subsequently take place ; the inflammatory character predominating in the early stages, and either the mucous or the spasmodic, or an association of both, in the subsequent periods. " 14. That the relapses which so frequently occur, after intervals of various duration, and which sometimes amount to seven or eight, or are even still more numerous, may each present different states or forms of the disease from the others; the first attack being generally the most inflammatory and severe, and the relapses of a slighter and more spas- modic kind ; but in some cases this order is not observed, the second or third, or some subsequent seizure, being more severe than the rest, or even fatal, either from the inflammation and extent of exudation, or from the intensity and persistence of the spasmodic symptoms, most frequently from the latter circumstance." We find, then, that the cause of the peculiar sound of the cough and sibilant breathing is not simply that the lining membrane is inflamed and coated with lymph, but also because the larynx and trachea are spasmodically affected, and it is most important to bear this in mind. 1 Dr. Stewart remarks, that " the cough, or the peculiar sound so re- markable in expiration in croup, is observed to exhibit two kinds of sound : the first acute, from the active spasmodic contraction of the muscles of the larynx, excited at first by the column of expired air; the grave, which succeeds it, from the forced enlargement of the glottis, by 1 Desruelles, Traits du Croup, p. 170. 272 croup. the shock of the same column of air overcoming the contraction of the muscles." 1 Dr. Stokes considers the "cause of obstruction in this dis- ease to be more spasm than effusion of lymph," and adduces in proof the temporary suppression of the sibilant breathing which follows vom- iting. 3§0. It is not very easy to explain satisfactorily why children are so much more liable to the disease than adults. Dr. Cheyne considers that in the latter " the constitution is, in a great measure, secured from croup by the increase and vigor which the larynx and trachea acquire at puberty." This might explain their immunity from spasm, but surely not from inflammation and the exudation of plastic lymph. Dr. Stokes suggests that it may be owing to the preponderance of white tissues in children, and to these tissues possessing the greatest reproductive power. "In the child, too, there may be a greater relation between the physiological, and consequently the pathological states of the mucous membrane of the larynx and trachea, and their subjacent (white) tissues, than in the adult ; and the same condition which deter- mines the progressive development of the larynx up to the period of puberty, may also predispose the mucous surface to the plastic or forma- tive irritations." 2 I confess I do not think the explanation altogether satisfactory, nor have I any better to offer. I may add the fact that the disease attacks animals : dogs, cats, lambs, horses, and cows, accord- ing to Duval, Rush, Valentin, Youatt, &c, especially the young ; and a similar disease is said by Duval, Jurine, Albers, Porter, &c, to have been induced by the injection of stimulating fluids into the trachea. 3 391. Causes. — The principal causes appear to be constitutional apti- tude, exposure to a cold, damp, changeable atmosphere, insufficient clothing, and epidemic miasma. No doubt that children of an irritable, nervous habit, and great sus- ceptibility, are the most liable to its attacks. Contrary to M. Barrier's statement, children are very liable to a return of the disease, and dif- ferent children in the same family sometimes share the liability. One of my own children has had three or four attacks, and another two ; the predisposition has ceased, however, with advance in age. There does not appear to be any ground for attributing it to hereditary influence. It prevails much in countries or localities exposed to great vicissi- tudes of weather : Savoy, Switzerland, the east of England, northwest of Europe generally, the middle and south of France, the north of Italy, &c, are countries in which it is very prevalent. In towns, too, it is more frequent than in the country ; it is common in London, Edinburgh, Leith, Dublin, &c; and more so in the low, damp parts of towns. I am informed that it is rare in the north of Ireland ; but Underwood mentions that it infests Mullingar. It is more common during winter than summer, owing, probably, to the frequent changes of weather, and the prevalence of east and north- east winds. I have no hesitation in saying that the fashion of clothing children 1 Diseases of Children, p. 75. 2 Diseases of the Chest, p. 211, note. 3 Valentin, Sur le Croup, p. 464. croup. 273 lightly, exposing their legs, arms, and necks, under the foolish notion of hardening them, is extremely favorable to the production of croup. Dr. Eberle has given a striking illustration of this in the case of a German settlement in America, "who are in the habit of clothing their children in such a manner as to leave no part of the breast and lower portion of the neck exposed. During a practice of six years among this class of people, I recollect having met but a single case of this affection, and this case had occurred in a family who had adopted the present universal mode of suffering the neck and superior portions of the breast to remain uncovered." 1 The suppression of cutaneous eruptions, the breathing of noxious gases, swallowing boiling water, &c, are all occasional causes of the disease. It may attack children in perfect health, or those whose constitution has been weakened by previous disease ; and it not unfrequently occurs during an epidemic of influenza or scarlatina, primary in the first, secondary in the latter, or as an extension from the neighboring parts. Lastly, it has prevailed epidemically at different times to a consid- erable and fatal extent. The principal epidemics of which we have authentic account are those of Paris in 1556 (Baillou); Cremona, in 1747 (Ghisi); Cornwall, in 1748 (Starr); Upsal, in 1762 (Rosenstein); Frankfort, in 1764 (Van Bergen); Sweden, in 1768-72 (Wahlbom and Baeck) ; Wertheim, in 1772 (Zobel) ; in Gallicia, in 1778 (Hirschfeld); Clausthal, in 1783 (Boehmer) ; United States, in 1805 (Barker) ; Stutt- gard, in 1807 (Autenrieth) ; Saxony, in 1807-8 (Albers) ; and in 1811 (Schundtmann) ; 2 at Vienna, in 1807-8 (Golis); and in Maryland, in 1807 (Chatard). Several partial or local epidemics have since occurred, but none so general as the above, that I am aware of. Dr. Vauthier has published an account of the epidemic which prevailed in the Hopital des Enfans at Paris in 1846-7. 3 Several authors, as Wichman, Boehmer, Field, and others, maintain the contagiousness of croup ; but this is denied by the majority of writers, at all events in the case of primary croup. Certain forms of diphtheritic inflammation of the fauces and pharynx are undoubtedly contagious ; and as the inflammation and exudation sometimes spread to the larynx, constituting secondary croup, it may be so far regarded as sharing in the same mode of propagation. 392. Modifications and Complications. — I shall now proceed to con- sider the modifications of croup, i. e. croup with certain of its symptoms predominating sufficiently to give a peculiar character to the attack. I. Croup, with Predominance of Inflammatory Symptoms — the acutely inflammatory croup of some authors. — This is nearly the severest form of the disease, attacking plethoric children of a sanguine temperament, and perhaps at a more advanced age. It is preceded by chilliness, horripilation, and rigors, and characterized by a more con- 1 Diseases of Children, p. 347. 2 Albers, de Trackseitide, p. 70. Valentin, Sur le Croup, p. 402. 3 Archiv. Ge"n. de M6d., May and June, 1848. 18 274 croup. tinuous and unremitting severity of symptoms, by strength and rapidity of pulse, heat of skin, difficult and forcible respiration, redness or lividity of cheeks and lips, and the inflammatory appearance of the blood taken from the child. "When limited, as it may be, to the larynx, it has been called by Guersent and others laryngeal croup, and the symptoms connected with the respiration, voice, and cough, are peculiarly severe ; the pain and swelling of the larynx are remarkable, and convulsions occasionally occur. The attack may terminate fatally in twelve hours, or be pro- longed to four or five days, but rarely longer. On the other hand, the disease may be confined to the trachea, con- stituting the tracheal croup of continental writers, and having a less rapid and less fatal progress, with some variation in the symptoms. For instance, although the cough and breathing are sonorous, they have not the brazen sound of ordinary croup, and the voice is far less affected ; the sense of suffocation is not so oppressive. Pain, or a burning sensation, is felt along the trachea; the croupy sound of breathing will be heard if the stethoscope be applied over the trachea, and there is severe inflammatory fever present. The attack may be prolonged to twelve or fifteen days ; and in some cases it has subsided into a chronic form, or, passing downwards, has terminated in bronchitis. ir. Croup, iviih a Predominance of Nervous or Spasmodic Symptoms. — The attack may come on like ordinary croup, with feverishness, cough, &c. ; or, as I have more frequently found, the child may go to bed perfectly well, and in the course of an hour or two may awake with perfectly formed croup, hoarse voice, ringing cough, dyspnoea, and threatened suffocation, which, if not relieved by treatment, will continue during the night, and have a remission during the clay. There is, on the whole, less fever, but not less distress ; and if the attack be neg- lected, it will run a course similar to ordinary croup, characterized by greater dyspnoea, louder cough, and more sibilant respiration, and prove fatal, as in the other forms. 1 Fortunately, if taken early, it is far more manageable ; the spasmodic irritation may be relieved before there has been time for false mem- branes to form, and with the relief of the spasm the inflammation may either disappear or be modified. Thus, with my own children, I have repeatedly subdued the croupal affection in the course of two hours, and there remained only catarrh with hoarseness. 393. Now let us notice the diseases with which croup may be com- plicated, or, in other words, its secondary affections. These are not numerous, but they add much to the severity and danger of the disease. I. Bronchitis. — I have already mentioned that morbid appearances indicating inflammation of the bronchial tubes are found even in cases where the croupy exudation does not extend below the trachea ; and, in practice, we find that this complication is not very uncommon. It seems more frequent in young and delicate children, and is marked by the predominance of catarrhal symptoms from the beginning generally. 1 Blaud, Reclierches sur le Croup, p. 312. croup. 275 "We find the croup, dyspnoea, and hoarseness much as in an ordinary case ; but there is more wheezing in the chest, and more expectoration. There is generally less fever, the skin is cooler, and the throat and larynx seem less permanently the seat of the mischief. After three or four days, the cough is softer, the paroxysms shorter, and the expecto- ration increased. If the croupy sound be not very loud, we shall be able to hear bronchial rales in one or both lungs. The chest is resonant on percussion. In the progress of the attack, either affection, the croup or the bron- chitis, may predominate, and give to it its peculiar character, i. e., it may merge into a case of marked croup, such as I have described, with some bronchitic symptoms, or it may degenerate rather into a bronchitic affection, with very little of croup. The latter is much safer, for in the former we have the danger from the croup augmented by the disease of the air-tubes. 394. II. Pneumonia. — This disease complicated five-sixths of the cases collected by MM. Hache and Rilliet and Barthez; and, according to the observations of Blache, Guersent, Trousseau, and others, it is the most frequent complication of croup ; and I need not say how fearfully it increases the danger of the primary disease. It seldom occurs at the commencement of the disease, or during the precursory stage, but makes its inroad in the course of the second, or towards its termination. The pneumonia may be either general or lobular, and this, together with the loud croupy sound, renders its detection often extremely diffi- cult. We ought to examine the chest daily, to seize upon a moment of comparative quiet ; and, if we can avail ourselves of the temporary sus- pension which follows vomiting, as suggested by Dr. Stokes, we may be able to detect the crepitant rale in the portion of the lung occupied by the inflammation. The only symptoms which will indicate the deeper mischief will probably be an increase of fever, and a more rapid sinking of the vital powers. The cough is sometimes less ringing ; but the sibilant breathing, the hoarseness, and the fever are as well marked as in the other cases. The disease thus complicated runs a very rapid and almost universally fatal course, without remission or mitigation. 395. in. Other complications have been noticed, but they occur much less frequently ; thus, Cheyne, Condie, and others, mention the occur- rence of pleuritis ; several authors speak of emphysema ; others of partial rupture of the trachea ; and Martin 1 of a case in which vomit- ing of blood occurred. 396. Secondary Croup. — So much for the complications of croup ; but we must not forget that croup may complicate other diseases, and be to them a secondary affection. 2 Thus, for example, in some cases of diphtherite, cynanche maligna, scarlatina maligna, cynanche tonsillaris, or cynanche pharyngea, the inflammation, which, in those parts, gives 1 Rec. Period, de la Soc. de Med. de Paris, April, 1810. 2 Albers, Comment, de Trachseatide, p. 69. 276 croup. rise to the ash-colored or whitish membranous exudation, may extend itself to the larynx and trachea, giving rise to croup, and adding a for- midable complication to the primary affection. Again, croup, though rarely, supervenes upon thrush ; in this case it takes its character from the state of the constitution induced by the primary disease, and, generally speaking, the pharynx and larynx are more severely implicated than the trachea. The accompanying fever is of an ataxic or adynamic type. 1 It also occurs in the course of several of the exanthemata ; during the first or eruptive stage of measles, miliary eruption, scarlatina, as I have mentioned, smallpox, &c, according to the testimony of many authors. In the latter case it comes on most frequently during the suppurative stage of confluent smallpox, and, as in diphtherite, the inflammation extends from the pharynx to the larynx. Some cases of erysipelas of the fauces, in which the extension of the inflammation gave rise to croup, are related by Forester, Latour, Ste- venson, and Gibson. Dr. Vauthier relates eight cases of secondary croup out of thirty- seven. Three complicated measles ; two, pneumonia and typhoid fever; one, scarlatina ; and one, hooping-cough. 397. The morbid changes discoverable after death in secondary croup are of the same character as in the primary affection, but less marked ; there is less redness ; the softening or thickening of the mucous mem- brane is less extensive ; the false membranes are yellowish, and of smaller extent, thinner, less adherent, and softer than in the disease just described. They seldom occupy the entire larynx, but often the interior portion of the epiglottis, and the superior part of the larynx, as far as the chordos vocales, or the ventricles of the larynx. In one case out of eleven only did Rilliet and Barthez detect them at the infe- rior portion of the trachea, and in another in the bronchial tubes. 398. The symptoms of the secondary croup are a good deal mo- dified, and resemble more some of the forms of laryngitis. Thus, the cough is sometimes dry, sometimes moist, easy, or painful and hoarse, but it has less of the metallic ringing sound ; the respiration is difficult and hissing, but without the loud sibilant sound of primary croup ; the voice is less changed. Rilliet and Barthez mention that in five of these cases it was unaltered ; in two others it was nasal, embarrassed, but not extinguished ; in three it was muffled, and in one it was extinct ; with- out any peculiarity in the situation of the false membrane to explain the difference. The expectoration varies ; there may be some mucous or muco-puriform matter thrown off, but there is rarely or never any shreds of lymph. On inspecting the fauces, however, in these cases, we shall find there the primary affection in the form of inflammation (and perhaps ulcera- tion) of the tonsils, uvula, and palate, with a gray or yellowish exuda- tion of lymph ; the parts are swollen, and of a dark red color, and there is considerable difficulty in swallowing. 1 Med. Obs. and Inq. by Dr. Rush, vol. ii. p. 376. Ferrier, Med. Hist, and Reflec- tions, vol. iii. p. 205. croup. 277 Dr. Stokes has given a comparative view of the symptoms of primary and secondary croup, which I shall take the liberty of extracting : — " 1. In primary croup the air-passages are primarily engaged ; in secondary croup the laryngeal affection is secondary to disease of the pharynx and mouth. " 2. In the former the fever is symptomatic of the local disease ; in the latter the local disease arises in the course of another affection, which is generally accompanied by fever. " 3. In the former che fever is inflammatory ; in the latter typhoid. " 4. In the former there is necessity for antiphlogistic treatment, and the frequent success of such treatment ; in the latter, incapability of bearing antiphlogistic treatment, necessity for the tonic, revulsive, and stimulating modes. " 5. The former is spasmodic, and in certain situations endemic, but never contagious ; the latter, constantly epidemic and contagious. " 6. The former is a disease principally of childhood ; by the latter adults are commonly affected. " 7. In the former the exudation of lymph spreads to the glottis from below upwards ; in the latter from above downwards. " 8. In the former the pharynx is healthy ; in the latter it is dis- eased. " 9. In the former dysphagia is either absent or very slight ; in the latter it is constant and severe. " 10. In the former, the catarrhal symptoms are often precursory to the laryngeal ; in the latter, the laryngeal symptoms supervene, without the pre-existence of catarrh. " 11. In the former, the complication with acute pulmonary inflam- mation is common ; in the latter, rare. " 12. In the former, the absence of any characteristic odor of the breath; in the latter, the breath is often characteristically fetid." 1 399. Diagnosis. — The pathognomonic symptoms of croup are the hoarse voice, the sibilant breathing, and the rough metallic ringing cough ; which, in the third stage, become the whispering voice, wheez- ing, hissing respiration, and husky, choking cough. I. It may be distinguished from spasm of the glottis by the catarrhal stage, by the hoarse voice, by the sibilant respiration, and by the ring- ing cough; in spasm of the glottis there is no catarrh, inspiration only is difficult ; the crowing sound is quite different from the expiratory noise in croup ; there is no cough, and the voice is unaltered. 2 ir. In simple laryngitis the cough and voice are rough and hoarse, but very unlike the ringing, metallic cough of croup ; the respiration is sometimes difficult, but rarely, if ever, sibilant; there is fever, expecto- ration, and no such paroxysms of suffocation as in croup. in. Primary croup differs from secondary croup in the absence of sore throat, inflamed fauces covered with false membrane, the peculiar characters of the original disease, and in the greater intensity of the 1 Diseases of the Chest, p. 206. 2 Albers, Comment, de Trachseatide, &c, p. 50. 278 croup. symptoms, fever, dyspnoea, and cough. 1 I have already given Dr. Stokes's parallel between the two affections. IV. In pertussis there is hurry of respiration, but neither the diffi- culty nor the sibilant sound; the cough, though loud, has not the pecu- liar metallic sound, and in the intervals there is complete relief, neither hoarseness nor dyspnoea. v. If the previous history were obscure, it might be possible to mis- take the symptoms resulting from foreign bodies in the trachea for croup, but a careful inquiry will generally remove the difficulty, and, in addition, the suddenness of the attack, the absence of false membrane and of inflammatory fever, with the results of auscultation, will leave but little doubt. VI. It is, perhaps, impossible to draw the line between croup and the laryngitis resulting from swallowing boiling Avater, as in the latter case there is an exudation of lymph firmly adherent to the membrane of the larynx ; it never, however, extends to the trachea ; and although the swollen membrane impedes respiration, still the spasmodic paroxysm is wanting. Our best guide will be the previous history of the case. 400. Terminations and Prognosis. — I. Croup may terminate favor- ably in resolution, the fever diminishes, the croup becomes softer, loses its croupy sound, and resembles the cough in a slight attack of laryn- gitis ; the respiration gradually becomes easier, and expectoration takes place. "Most commonly," says Dr. Cheyne, "after the disease has arrived at its height, the decline is, as it were, a retrogression of the attack ; the skin is moist, the fever abates ; the cough becomes loose, the breathing easy, and the voice gradually recovers its natural tone." Sometimes the crisis is marked by the expectoration of false membrane, but this is not always a proof that the disease will subside. II. The inflammation may subside in the larynx, but extend itself downwards to the large or small bronchial tubes, and the croup will then merge in bronchitis or pneumonia. III. In the majority of cases, croup ends fatally with the symptoms I have already detailed. Marley says that two-thirds die. Vieussieux, in 1775, states that, in his early practice, ten cases out of twenty died ; Jurine, that one in ten die ; Michaelis and Bard, two out of three. In Philadelphia, during the ten years preceding 1845, there occurred 1150 deaths from croup, or 150 per annum. In Paris, in 1838, the deaths were 187 ; in 1839, 286 ; and in 1840, 326. In London, in 1840, the deaths from croup amounted to 391; and in all England to 4336. Sudden deaths, as I have already stated, may occur from the partial detachment of a valve of false membrane, but ordinarily the cause of death is a deficiency of air, and consequently the patient dies of as- phyxia. 401. The prognosis, therefore, in all cases of croup, is very serious ; the probabilities are against recovery, but in estimating those probabili- ties we must take into careful consideration the period of the disease at which the child comes under treatment, the intensity of the symptoms, 1 Pathology of Larynx and Bronchia, p. 16. croup. 279 the degree of fever, the complications, and the extent of the disease, and the strength of the constitution. If the disease be attacked at the very commencement, it is by no means an unmanageable or fatal disease, but will in most cases yield to appropriate treatment ; nay, if it be further advanced before we see it, yet if it be a mild case, the symptoms marked but not violent, the in- flammation limited, the fever moderate, and no complication, the child may recover under proper care. But if the attack be rapid and severe, the cough violent, the dyspnoea intense, and the fever high, and especially if the lungs be affected, and time has been lost, there will be but little hope from treatment at any period; none if the case have been overlooked for twenty-four hours. I cannot quite agree with Rilliet and Barthez that we ought never to despair of the life of the patient in croup, nor do I anticipate as much benefit from tracheotomy, even as a last resource, as those ex- cellent practitioners ; but certainly there are some cases of recovery recorded when all hope seemed extinguished, and they appear to have been mainly owing to the strength of the patient's constitution. 402. Treatment. — The indications of cure are : 1. If we are called early, to arrest or subdue the inflammatory action, and to prevent the formation of false membranes, or the albuminous secretion and accumu- lation in the air-passages ; 2. When the time for doing this has passed, to procure the discharge of these matters ; 3. To mitigate the spas- modic symptoms ; and 4. To support the powers of life in the latter stages, so as to enable the system to throw off the matter exuded in the trachea. 403. Our success in the first of these indications depends, I think, upon seeing the child early ; if we are present at the very beginning, we may almost always cut short the disease. My own children, for exam- ple have been attacked five or six times. I always give immediately an emetic of tartarized antimony, and afterwards smaller doses to keep up the nausea for an hour or two. In no instance has bleeding been neces- sary after this, and the attack has never lasted more than two or three hours. We should, in the first stage, commence by an emetic of ipecacuanha or tartar emetic, and keep up a nausea for some time by smaller doses. "Emetics," says Dr. Cheyne, "appear peculiarly fitted to answer the indications of cure in the first stage of croup. They increase the secre- tion from the mucous membrane of the bronchia, while, at the same time, they lessen the general tone of the arterial system. Hence they are the only true expectorants." 1 M. Valleix states that of 31 cases in which emetics formed the basis of treatment, 15 recovered, while of 22 in which they were rarely given, but one recovered. By most practitioners the tartar emetic is preferred, and I think with reason, because of its peculiar antiphlogistic power ; it may be given in doses of a quarter or half a grain every quarter of an hour, until vomit- ing is excited, and then continued in doses of an eighth or a twelfth 1 Pathology of the Larynx and Bronchia, p. 51. 280 croup. of a grain every hour or two. Some German physicians, as Droste, Kerting, and Steinmetz, prefer the sulphate of copper ; and Smith, Farre, and Francis, recommend the sulphate of zinc. Dr. Meigs uses the alum, and speaks most highly of it in doses of a teaspoonful of the powder in honey or syrup, and repeated in a quarter of an hour, if it do not excite full vomiting. 1 Dr. Hubbard prefers the turbith mineral (subsulphate of mercury) for this purpose. 404. In the severer cases, or when the emetic fails in changing the character of the disease in an hour or two, we must have recourse to bloodletting. There is no difference of opinion as to the propriety of this practice, but merely as to the mode. Some advise bleeding from the arm or jugular vein, as Marley, Cheyne, Porter ; others, as Dr. Merriman, cupping ; whilst by the majority leeches are employed. Whatever method we adopt, the essential point is to take as much blood as will make a decided impression on the disease, and to repeat the bleeding if necessary. I prefer leeches applied to the upper part of the sternum, where the bleeding can be readily arrested by pressure ; and I repeat that it ought to be arrested when the leeches fall off. I quite agree with Dr. Condie that " there is certainly no disease in which bleeding, when Avell timed, and carried to a sufficient extent, is calcu- lated to produce more beneficial effects than in croup. The practitioner who, in violent cases, neglects this important measures, and places his hopes in any other remedy, or combination of remedies, will have but little reason to flatter himself upon his success in the management of the disease." 2 The quantity of blood taken must vary according to the intensity of the disease, the strength of the child, and the effects produced. It is not desirable to carry it to excess in any stage, but in the first stage it is less mischievous to take too much than too little. In the eighth volume of the Dublin Medical Journal, and more re- cently in his Clinical Medicine, my friend Dr. Graves has called atten- tion to the treatment proposed by Dr. Lehman, of Torgau. It consists in the immediate application of hot water in the following manner : " A sponge, about the size of a large fist, dipped in water as hot as the hand can bear, must be gently squeezed half dry, and instantly applied beneath the little sufferer's chin, over the larynx and windpipe ; when the sponge has been thus held for a few minutes in contact with the skin, its temperature begins to sink, and it requires to be dipped again in hot water." This is to be continued from ten to twenty minutes, and will produce a vivid redness, as if a sinapism had been applied, accompanied with a general perspiration, and followed by immediate relief of the cough, hoarseness, and dyspnoea. ; ' Since then," Dr. Graves observes, " I have repeatedly treated the disease on this plan, and with the most uniform success. It is, however, only applicable to those cases which are seen at the very onset of the disease ; and you must remember, also, that I do not propose it to the total exclusion of 1 American Journ. of Med. Sciences, Ap. 1847, p. 290. 2 Diseases of children, p. 305. ceoup. 281 bleeding and tartar emetic, which must be used in the more aggravated cases, or in those which are not seen until the disease is somewhat ad- vanced." 1 405. The bleeding may be preceded or followed by a warm bath, which, for a time, relieves the oppression, and certainly gives greater effect to the other remedies ; and it is peculiarly beneficial when the disease is yielding to the treatment. Dr. Horace Green, of New York, has proposed the local application of nitrate of silver in croup, as well* as in other laryngeal affections. Ordinarily he uses a solution of from two scruples to a drachm of the crystals of nitrate of silver in an ounce of water, and he applies it at first to the fauces and glottis, and afterwards within the larynx, by means of a small piece of sponge fastened on a curved rod of whale- bone. " The instrument being prepared by suitably saturating the sponge with the solution to be applied, and the head of the child being firmly held by an assistant, and the base of the tongue depressed by a spoon or any other suitable instrument, the operator carries the wet sponge quickly over the top of the epiglottis, and on the laryngeal sur- face of this cartilage ; then pressing it suddenly downwards and for- wards, passes it through the opening of the glottis into the laryngeal cavity." 2 This Dr. Green says does not produce the amount of irrita- tion we should expect, and he considers it suitable to every stage either of simple or complicated croup. He has given several cases, in which this treatment succeded. Dr. Blakeman of New York has recorded two cases in which it succeeded ; the first requiring three, and the second two applications of the solution. 3 Dr. Clarke has related six cases thus treated, of which four recovered, and two died. 4 Dr. Latour has used the solid nitrate of silver to all the parts within reach, and afterwards contrived to squeeze some of the solution into the larynx. The child recovered. 5 Dr. J. F. Meigs, of Philadelphia, used a solution of nitrate of silver (gr. x to oj) to the fauces, applied with a camel's-hair brush. He does not, however, seem to attribute much of his success to this application. 6 Dr. Townsend proved it of great use in one case. 7 These are the principal means at our command during the first stage, and it is necessary to use them promptly and vigorously, for, as Dr. Ferrier observes, the course of genuine croup is very short. If the alarming symptoms I have described, are not mitigated during the first six hours, the disease will generally prove fatal. It has happened several times that I have been called early in the day to patients who had become seriously ill only on the preceding evening ; and in such cases I have only succeeded once. The proper time for administering 1 Clinical Med., Lecture xxxix., vol. ii. p. 4. Second edition. 2 Observations on the Pathology of Croup, p. 83. 3 New York Med. and Surg. Reporter, &c, Oct. 1847. 4 American Journ. of Med. Sciences, Ap. 1850, p. 360. 5 Gazette Med., Aug and Oct. 1846. 6 American Journ. of the Med. Sciences, Ap. 1847, p. 290. 7 Ibid., July, 1851, p. 85. 282 croup. relief is when the cough, dyspnoea, and palpitation increase towards ten or eleven o'clock in the evening. 1 406. In the second stage it will be well to have recourse to an emetic, and certainly to bleeding, if it has not been practised before. Dr. Cheync recommends the employment of tartar emetic in quarter or half grain doses every hour, so as to excite vomiting occasionally. In this practice Dr. Stokes agrees ; he dissolves a grain of the salt in an ounce of distilled water, and gives a dessertspoonful " every quarter of an hour, or every half-hour, as the case may be." 2 Mr. Porter rather prefers nauseating doses of this remedy to those which occasion repeated vomiting, and I am inclined to think that after the emetic effect has been at first excited, and kept up for an hour or two, as much good will be derived from the smaller doses. On the other hand, we must not forget that with some children tartar emetic produces a very depressing effect. Dr. Stewart mentions that he has known "utter and irrevocable prostration and death quickly ensuing from its use in young children," and in such cases it may be combined with oxymel of squills, or ipecacuanha may be substituted for it without danger of similar effects. 407. Drs. Rush, Hosack, Bard, and other practitioners, have attached great value to calomel, alone, or in combination with Dover's powder. Dr. Cheyne does not think it of much use ; during two seasons, in which he had used it freely during the second stage, all the cases terminated fatally. Dr. Stokes observes, that the mercurial treatment of croup is insufficient and unnecessary. " The uncertainty of the action of calo- mel, the difficulty of producing ptyalism in violent acute inflammation, the shortness of the period for the exhibition of the remedy, and the various injurious effects of mercurial action on the system at large, are sufficient reasons against the employment of this treatment in the croup of children ; and when we have so valuable a remedy as the tartar emetic, it seems scarcely justifiable to tamper with the case by the attempt to produce mercurial action." 3 Certainly, as a substitute for tartar emetic, it would be of feeble and doubtful value ; but I have seen much benefit from it after the vomiting or nausea had been kept up for some time, or when the depressing effects of the latter had been too decided to permit its prolonged use. MM. Bretonneau and Guersent have repeatedly succeeded by the mercurial treatment carried to ptyalism ; but the latter author cautions us against its use in weak or debilitated constitutions. Mr. Porter speaks well of it "in long-protracted and chronic cases, when there is a tendency in the mucous membrane to become thickened and changed in structure." 4 I have generally given it in combination with James's powder and a minute portion of Dover's powder, say half a grain of each of the former, with a third of a grain of the latter, every three or four hours. Eberle prefers the combination of calomel with tartar emetic, in the proportion of four or six grains of the former with a fourth of a grain 1 Mod. Hist, and Reflections, vol. Hi. p. 139. 2 Diseases of the Chest, p. 217. 3 Diseases of the Chest, p. 218. 4 Surgical Pathology of the Larynx and Trachea, p. 45. croup. 283 of the latter, every fifteen minutes, until vomiting is excited, in the case of children from two to five years old. He further states that he " administered the lobelia inflata, with a view to its emetic operation, with the happiest effects." 1 With the same object, decoction of senega, sulphate of zinc or copper, have each its advocates. 408. Counter-irritation is certainly of great use, but some difference of opinion exists as to the best course. Some prefer strong liniments to the throat and chest. Dewees recommends turpentine, hartshorn, or the mustard and vinegar poultice. Others, as Drs. Ferrier, Underwood, &c, recommend the application of a blister ; but Mr. Porter objects to these, on account of the time required to produce their effects, and on account of the danger of applying them in the immediate neighborhood of inflammation, but he admits their value when the lungs are congest- ed. 2 Rilliet and Barthez, and Bouchut, disapprove of them as rarely useful, and they mention that the denuded surface is sometimes covered with an exudation resembling that in the larynx. 3 During the first stage, and the early part of the second, I conceive that blisters are quite inadmissible ; but after the employment of bleed- ing and tartar emetic, and the lowering of the system by these means, especially if there be any tendency towards bronchial complication, I have certainly seen benefit from the mustard poultices and blisters. 409. The action of purgatives upon the system generally, and upon the local disease, is beneficial, and should, therefore, never be neglected ; but we cannot depend upon them as a main part of the treatment. If neither the tartar emetic nor calomel act upon the bowels, some brisk warm cathartic should be given; but, on the other hand, should diar- rhoea result from the above treatment, it must be controlled by some astringent and cordial medicines. 410. Now if, under this treatment, the disease give way, and the cough become softer, the breathing easier, and the fever less, we may diminish the frequency of the doses and their amount, or we may simply confine ourselves to expectorant remedies, decoction of senega, squills, ammo- nia, and small doses of ipecacuanha, &c, with an occasional warm bath, and a little James's powder two or three times a day, so long as the fever lasts, with due attention to the stomach and bowels, and a careful regulation of the diet. 411. But suppose the symptoms continue unmitigated, and there is evidence that they are not entirely spasmodic, we shall have but too much reason to fear that the pseudo-membranous exudation has taken place, and some modification of the treatment will be necessary. It will be of little use to continue the depletion further, as the result will be rather loss of strength than benefit ; but we may continue the calomel and the expectorants I have already mentioned. If the fits of coughing be severe and suffocative, an occasional emetic will be of service in loosening and perhaps expelling the lymphy exuda- tion. The continued use of tartar emetic must depend upon the circum- 1 Diseases of Children, p. 359. 2 Surgical Pathology of Larynx and Trachea, p. 45. 3 Mai. de l'Enfance, p. 269. 284 croup. stances of the case. The inhalation of aqueous or medicated vapors has been recommended by high authority, that of Hume, Pearson, Rosen, Pinel, Golis, &c. ; they ought to be merely emollient in the first stage and early part of the second, but afterwards slightly stimulant. It may be useful, also, in the spasmodic form of the disease, but must not impede the employment of antispasmodics by the mouth or in ene- mata. Dr. Budd, of Bristol, recommends converting the bed of the patient into a vapor bath, and giving an emetic every four hours. 1 A warm bath will also be found useful occasionally, but in some cases it seems to aggravate the dyspnoea. 412. The use of narcotics in this stage requires great care ; they should be given in small doses, and only those should be employed upon whose action we can reckon most certainly, and in the form the most uniform in its operation ; for this reason they had better not be given in clysters. Dover's powder may be combined with the calomel or with camphor, or camphor with James's powder and hyoscyamus ; or a drop or two of laudanum added to the expectorant mixture will probably answer the purpose best. Dr. Purefoy has related a case of croup in which much benefit was derived from the iodide of potassium, after bloodletting, emetics, and blisters. He gave one grain, combined with a grain of hyd. c. creta, every two hours. 2 Mr. Hird speaks highly of the effects of alkalis in allaying spasm, and promoting the absorption of the exudation ; he gives ten or fifteen minims of the liq. potassse every four hours. 3 Dr. Condie recommends a tobacco poultice to the throat, " composed of the moistened leaves of tobacco, mixed with the crumbs of stale bread or ground flaxseed. The patient must be carefully watched, lest the depressing effects be excessive." The hydro-sulphuret of ammonia is said by Chamerlat and Condie to be beneficial in this and the next stage. Dr. John Archer, of Maryland, strongly recommends senega root as an almost infallible remedy in cases of croup, and almost all American writers speak favorably of it. I can bear witness to its value, but it is rather as an expectorant, after the first violence of the inflammation has been subdued. It may be advantageously combined with antimo- nials, or ipecacuanha, or squills, as in the following formula: — R. — Decoct, senegse ^ij. Oxymel scillse ^ij. Vini ipecac. 3J, or Liq. antimon. 311J. — M. Cap. cochl. i. parv. 2ndis vel 3tiis horis. Drs. Maclean and M. Constance speak very highly of tincture of digitalis ; the former gentleman tried it in one case, and the latter in two, and all recovered. It may be a useful adjunct in the first, and 1 Med. Times and Gazette, June 19, 1852, p. 611. 2 Dublin Journal, May, 1846. 3 Lancet, December 5, 1846. croup. 285 early part of the second stage, but it would, I think, be unwise to depend upon it to the exclusion of other remedies. Should the active measures hitherto recommended cause much depres- sion, it may be necessary to make a cautious use of stimulants or tonics. 413. In the third stage, the three latter indications of cure are to be kept in view. The expectorants must be continued, and occasionally vomiting should be excited. It is advantageous at this period to combine them with antispasmodics or stimulants, such, for instance, as camphor, musk, assafcetida, &c. ; or the latter may be given in the form of enema. Inhalation of the vapor of ammonia, camphor, or ether, with aqueous vapor, has often been found useful, and occasionally the fumes of vinegar alone, or mixed with camphor. Tepid baths may be used occasionally, and if there be much collapse, a little flour of mustard should be added to them. If we have any evidence of the expectoration of lymph, it may be promoted by emetics ; and for the same purpose Sentin and Thilenius recommended sternutatories. Blisters may be applied to the neck or sternum, and during this stage they act as stimulants as well as counter-irritants ; or strong rube- facients to the throat, chest, or between the shoulders, may be employed. Stimulants will certainly be necessary as the disease advances, and probably the best we can employ will be camphor, ammonia, or musk. Harden, Schmidt, and Copland, speak well of cold affusion to the head by way of relieving the congestion of that organ which results from impeded respiration, and so diminishing the chance of convulsions. The bowels should, of course, be kept free throughout each stage. The persistence of the more active part of the treatment during the third stage is generally undesirable ; it must depend upon the character of the symptoms and the strength of the patient. If the bowels be not too much affected, the calomel may be continued, and an occasional emetic exhibited ; but in general we have to act more indirectly, and through the medium of the constitution, aided by counter-irritants. 414. Thus we see the means at our disposal which offer a probability of success are not very numerous. Early vomiting, continued nausea, bloodletting, warm baths, counter-irritants, expectorants, tartar emetic, calomel, some few antispasmodics and stimulants, compose the whole list ; but these, used judiciously, promptly, and vigorously at first, and more cautiously afterwards, afford a reasonable hope of success if we are summoned sufficiently early. 415. The modifications of croup will require nearly the same treat- ment. When the attack exhibits more of a spasmodic character, the remedies need not be quite so severe ; emetics at the beginning are equally necessary ; but in many cases we may dispense with blood- letting, not, however, if any of the croupy character remains. Next to emetics, counter-irritants, expectorants, antispasmodics, and cathartics will afford the greatest relief. Dr. Copland recommends the administration of bark, and, no doubt, in the more advanced stage, when there is much sinking, it is calculated to be of use. 416. When croup is complicated with bronchitis, pneumonia, or pleu- risy, the same principles of treatment will apply ; but in addition, local 286 croup. remedies will be necessary. Fortunately, tartar emetic, calomel, counter- irritants, &c, are as effectual in these diseases as in croup. I do not think that children so affected bear depletion to any great extent; but, with regard to this and the rest of the treatment, we must be guided by the intensity of the attack and the strength of the constitution. 417. Secondary croup requires a more skilful modification of treat- ment ; it is seldom that very active means can be employed. In addi- tion to the remedies for the primary disease (to be hereafter mentioned), we must have recourse to an occasional emetic, to small doses of tartar emetic, expectorants, counter-irritants, stimulants, topical applications, &c. I shall have an opportunity of alluding to this part of my subject in another part of this volume, when speaking of diphtherite, &c. 418. But we have seen that a portion, at least, of the disease con- sists in the mechanical impediment to the passage of air into the lungs, that this obstacle is chiefly in the larynx, and that the fatality of the disease is partly owing to the inefficient aeration of the blood in conse- quence. Now, it is a very natural and plausible question whether this difficulty might not be avoided by an operation ; in other words, whe- ther the operation of tracheotomy, by admitting air freely to the lungs, might not, even in the third stage, prolong life and increase the chances of cure. Accordingly, the question has occupied the attention of most writers, and led to different conclusions. It appears to have been first proposed by Home and Michaelis; and it has been practised in Spain, Denmark, Germany, America, and in Geneva, Brest, Lyons, Paris, London, Dub- lin, &c. I shall mention the opinions of some of the principal authorities. Dr. Cheyne is opposed to it because he thinks it would be useless unless the membrane could be removed, which, in most cases, would be impossible, and in others superfluous, on account of its rapid reproduction. He condemns, also, the danger of the operation in young children. 1 Dr. Dewee's saw the operation performed twice by Dr. Physic, under favorable circumstances, but without success; and he objects to it as being uncalled for in the earlier stages, and unavailing in the later. 2 Dr. S. Merriman seems more favorable to it. He mentions that, " in a case which he attended along with Mr. Lightfoot, this operation was proposed as a last and only remedy; and it was performed by the late Mr. Chevalier, and was perfectly successful." 3 A successful case is also mentioned in the third volume of the Medico- CMrurgical Transactions. Mr. Porter has investigated the matter with his usual ability, as to the necessity of the operation, the symptoms requiring it, the period at which it ought to be performed, and the amount of success which has attended it; and, having had extensive experience of the disease, and moreover having performed the operation as a last resource himself, he has arrived at the conclusion that " the operation does not afford suffi- cient prospect of benefit to admit of our having recourse to it." 4 1 Pathology of Larynx and Bronchia, p. 41. 2 Diseases of Children, p. 480. 3 Underwood on Diseases of Children, p. 451. 4 Surgical Pathology of Larynx and Trachea, p. 57, el seq. croup. 287 Mr. Carmichael lias recorded a case in which he performed the opera- tion with success, and a second which was unsuccessful. 1 Dr. Stokes expresses his decided dissent from the performance of tracheotomy : " Experience has shown that the operation has failed in the great majority of cases ; and it is obvious that, with our present knowledge of the nature of the disease, we can scarcely hope for good from its performance. 2 Dr. Stewart is evidently unfavorably disposed to the operation. 3 Dr. Condie admits that in severe cases, when timely performed, it may save the life of the patient ; and he mentions Drs. Hosack and Farre among those favorable to it. 4 Dr. J. F. Meigs has seen the operation performed three times, and in two of the cases the children recovered.* But he mentions that it had been performed in Philadelphia in eight cases prior to 1848, and in four cases during that year (exclusive of his three cases), and in all un- successfully. Dr. Bigger has recently recorded a successful case in the Dublin Medical Press. 6 Dr. Coley relates a case in which he performed the operation, and the patient died. 7 Mr. W. Craig has published a case in which he operated successfully. 8 The child was set. 7, and the false membrane had extended below the incision, but was removed through it. • 419. On the Continent, however, the operation has found some ad- vocates, and apparently met with somewhat greater success. Caron Marigault, Senn, Maslhieurat, Berard, Petit, Rilliet and Barthez, Bar- rier, Guersent, Bouchut, Thore, R. Latour, &c, are in favor of it ; but it has also powerful opponents in Vieussieux, Double, Albers, Jurine, Royer Collard, Bricheteau, Becquerel, Bondet, &c. In the cases in which tracheotomy was performed by Guersent and the "internes," in the Hopital des Enfans at Paris, in 1841, the opera- tion, while it was of no advantage whatever when the pseudo-membra- nous exudation extended to the bronchi, appeared in many cases to accelerate the fatal termination by inducing severe bronchitis, or an exces- sive secretion of mucus in the bronchi, pneumonia, or convulsions; while in many cases the patient died immediately after the operation, without any local lesion existing to which the fatal termination could be referred. 9 M. Guersent states that he has performed the operation one hundred and fifty times since 1834 ; the later operations having been much more successful than the earlier ones. In 1850 he operated upon forty chil- dren in private practice, and eleven recovered ; of twenty operated upon in the hospital, seven recovered. During 1851, of thirty-one ope- rations at the hospital, thirteen were successful. 10 1 Transactions of Association of Physicians of Ireland, vol. iii. p. 170. 2 Diseases of the Chest, p. 219. 3 Diseases of Children, p. 85. 4 Diseases of Children, p. 309. 5 American Journal of Med. Sciences, April, 1849, p. 307. « Jan. 6, 1847. 7 Brit. Record of Obst. Science, Feb. 1, 1848, p. 60. 8 Med. Times and Gazette, May 21, 1853, p. 522. 9 Condie, Diseases of Children, p. 309. 10 M£m. de la Societe, de Chir. de Paris, vol. iii. 1852-3. Brit, and For. Rev., Ap. 1854, p. 466. 288 croup. The researches of M. Bretonneau revived the operation in France, and gave hopes of its being more successful. Out of fifty-five cases of different ages, he found the exudation reaching to the bronchial ramifi- cations in six or seven ; in one-third of the whole number it reached as far as the bifurcation, and in thirty or thirty-one, it terminated at dif- ferent parts of the trachea, so that it was inferred that it was possible to perform the operation below the seat of the disease, and that to these cases the most formidable of the objections would not apply. M. Fourquet mentions five successful operations out of seventeen, by M. Bretonneau, and strongly advocates the operation. It was performed on the child of Dr. Scoutetten, aged three weeks, on the third day of the disease, and under very unfavorable circumstances, and it recovered. M. Valleix found that out of a number of cases treated by medicine, about one-third recovered, and as many when the operation had been performed, and certainly, as he remarks, even one recovery ia a life saved, inasmuch as the operation is generally performed under most dis- couraging circumstances, and as a dernier ressort. Dr. Karl Weber has recently recorded two cases, one of which suc- ceeded. 1 More recently, M. Trousseau has reported the result of the operation in 150 cases, of which thirty-nine recovered, and 111 died. He is, of course, favorable to the operation, which he advises as soon as we are sure that false membranes exist in the larynx. He prefers tracheotomy to laryngo-tracheotomy, for although the latter is the more simple and the more easily performed, by the former we get more probably below the disease, and the canula is more easily tolerated ; it occasions less irritation ; and, after all, he concludes that there is little danger from tracheotomy, as he has performed it 121 times, with only one mis- chance as far as the operation was concerned. He gives the following summary of the success of croup treated by tracheotomy. M. Bre- tonneau saved six out of twenty ; M. Trousseau saved twenty-seven out of 112 ; M. Leclerc, of Tours, succeeded in two cases ; M. Velpeau suc- ceeded in two out of ten ; M. Petit in three out of six. He mentions that there are also living in Paris about fifteen children saved in croup by tracheotomy, performed by Gerdy, Robert, Guersent, Jun., Boni- face, Depres, Blandin ; &c, but he is unable to communicate particu- lars. 2 420. From the slight sketch I have given, the reader will perceive that the weight of authority, especially in Great Britain and America, is against the operation in croup, and also that the results of the cases in which it has been performed exhibit no very encouraging success. As an argument, this is not worth much, however, to those who regard the operation as a " dernier ressort," to be adopted in no case where there is hope from the ordinary method of treatment. The objections to the operation are principally these : — I. That the larynx is not mechanically closed by false membrane ; that in all cases, as Dr. Cheyne has remarked, there is sufficient space 1 Henle's Zeitschrift, vol. iii. pt. 2, p. 8. 2 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 379. croup. 289 for the access of air ; that if the larynx be closed, it must be by spasm in addition to the exudation ; and that, therefore, to attempt relief by a mechanical operation would be superfluous, to say the least of it. II. That it is extremely difficult to say that exudation has taken place, and still more to fix the limits of it, and pronounce in any case that it has not extended below the larynx ; and yet upon this depends the utility of the operation, for, in. If the false membranes have extended below our incision, the operation, being purely mechanical, can afford no relief, but may seri- ously add to the clanger. iv. Bronchitis or pneumonia may exist at the time of the operation, or may very likely arise very soon after, and render it altogether useless. v. The operation itself is not without danger, nor quite so easy as has been stated, especially with young infants. In addition to hemor- rhage and escape of blood into the trachea, the patient may be attacked by prolonged syncope, asphyxia, or convulsions, as occurred in M. Trousseau's practice, and occasionally either of them may prove fatal. vi. That the risk of inflammation and other accidents after the ope- ration is very considerable, and materially diminishes its value. vn. That the results of the operation hitherto, although successful to a considerable extent, are not sufficient to justify our having recourse to it under ordinary circumstances. " If," says Mr. Porter, " it were possible to place a host of those cases in which bronchotomy had not proved serviceable, in array against those wherein it had seemed to be useful, it would scarcely be necessary to advance any further argument in proof of its uncertainty." 1 421. Still Mr. Porter admits, very justly, that he cannot say that there are no cases of croup in which tracheotomy would be useful and proper ; the great difficulty is how to recognize them with sufficient ac- curacy. If it were possible to ascertain that false membranes had formed in the larynx without extending beyond it, that the lungs were free from disease, the constitution good, and no cerebral symptoms present, then, the dyspnoea being relieved, and the threatened asphyxia postponed, we might hope to gain time for the operation of other reme- dies ; for, as Trousseau remarks, tracheotomy is not a cure, but a means of gaining time for a cure. Mr. Porter has himself mentioned a case in which it might be employed: "But if the infant is, to all appearance, dead, and if the practitioner is called to him within any reasonable time, he should then, with the least possible delay, endeavor to inflate the lungs and restore animation by whatever means shall appear to be the speediest, and of these, perhaps the most preferable will be laryngo- tomy " 422. This being the case, I shall mention a few of the peculiarities in the mode of performing the operation suggested by MM. Bretonneau and Trousseau. The trachea should be laid open freely, and as quickly as possible ; if we can avoid cutting through the veins it is desirable, but if we cannot, it is unnecessary to apply a ligature, as the bleeding will stop the moment the canula is introduced. Much time is thus saved, 1 Surgical Pathology of the Larynx and Trachea, p. 64. 19 290 croup. and we escape the chances of phlebitis. When the trachea is opened, a dilator is to be introduced into the wound, the child placed upright, and time allowed for the establishment of respiration and the arrest of the hemorrhage; or a portion of one or two of the rings of the trachea may be removed which will render a canula unnecessary according to Mr. Lawrence's suggestion, or we may use the instrument recently invented, which saves time and the necessity for cutting the cartilages. If the child is in a state of asphyxia or syncope, cold water should be dashed in its face, and a feather introduced into the trachea, so as to excite in- spiratory action. In case of orthopnoea, a few drops of water may be thrown into the trachea, and that tube cleared of blood and false mem- brane by means of a small sponge fixed upon a slender stem of whale- bone. Generally speaking, the child will itself reject the blood or loose fluid matters which may be in the trachea, but it will require several light spongings to ged rid of the false membranes; and when this is done, if the respiration be fairly established, and the child be vigorous, we are advised to inject fifteen or twenty drops of a weak solution of nitrate of silver ; or if the larynx alone be affected with the disease, to apply a stronger solution to it by means of the sponge. M. Trousseau prefers the large curved canula of M. Bretonneau, or the bivalve canula of M. Gendrin. It is necessary to have it sufficiently long to allow for the subsequent swelling of the parts, and wide enough to allow for the expulsion of mucus. The canula should be withdrawn and cleansed whenever the air does not pass freely through it. At first the dilator will be necessary for its introduction, afterwards the wound remains open, and the replacement is easy. After the fourth or fifth day, if the case be going on favorably, we may allow the at- tempt to breathe through the larynx, as " an essential principle of tra- cheotomy is to withdraw the canula as soon as possible ;" and when the patient has been gradually accustomed to natural respiration, and it is performed with facility, the canula may be altogether withdrawn, and the wound closed. But the operation is only a part of the treatment, merely for the relief of the asphyxia, and will probably fail unless topical remedies be applied. Those recommended by Trousseau and Bretonneau are a strong solution of nitrate of silver applied with the sponge to the larynx, and a few drops of a much weaker solution injected into the trachea, four times the first day, three times the second and third, and once or twice the fourth day, followed by a little warm water. A few drops of water may be thrown into the trachea once or twice every hour, and if the breathing be embarrassed by mucus, the sponge must be lightly used after the injection of water. 423. I shall conclude this account of the operation from M. Trousseau by quoting his propositions relative to the prognosis : — " 1. If the commencement of the attack date several days back, if, consequently, the disease has advanced slowly, whatever may be the -extent of the false membranes in the trachea or bronchi, the child will either recover, or, at any rate, live several days. " 2. But if the disease have been rapid, even though we ascertain, croup. 291 at the moment of the operation, that the false membranes do not extend beyond the larynx, the patients die quickly. " 3. If, before the operation, the false membranes have invaded the nose, if they cover the surface of a blister, if the child be pale and somewhat puffed, -without having taken mercury or been bled, or if it have lost much blood, there is little chance of success from the opera- tion. " 4. If, before the operation, the pulse is moderately frequent, and if afterwards it is calm, we may hope. " 5. If, immediately after the operation, respiration becomes very rapid, and the child coughs but little or not at all, it is a bad sign. " 6. More boys than girls are cured. " 7. Children under two and above six years are easily cured. " 8. Caeteris paribus, the danger is in proportion to the extent of the false membranes. " 9. If the child have been subject to chronic catarrh, and if it had been suifering from cold some time before being attacked by croup, tracheotomy will be more likely to succeed. " 10. Even when the progress is favorable, very rapid respiration is a bad sign. " 11. The more rapid and more energetic the inflammation which attacks the wound, the better are the chances of cure ; a sudden sinking in of the wound is a fatal sign. " 12. There is nothing to fear so long as the respiration is noiseless, or when the sound is produced by the disturbance of the mucus ; but if the respiratory sound resembles the noise of a saw cutting a stone, death is certain. " 13. If pneumonia or pleurisy supervene, it is no ground for despair- ing of the patient. " 14. Agitation and sleeplessness are bad signs. " 15. If the wound be covered with false membranes ; if, after the removal of the canula, it remains a long time gaping ; if, when almost cicatrized, it reopens freely ; we may conclude that the child is in danger. " 16. The sooner the larynx becomes free after the operation, the sooner we can dispense with the canula, the more certain and rapid will be the cure. " 17. If croup have supervened upon measles, scarlatina, smallpox, or hooping-cough, although there is ordinarily no connection between those diseases and cynanche maligna, tracheotomy will not succeed. " 18. If, on the third day after the operation, the expectoration be- comes mucous and catarrhal, the infant will recover ; if, on the contrary, there is none, or it is serous, or like half-dried mucilage, the child will die. " 19. If the patients react violently against the injections of water or the sponging, we must not lose hope, how bad soever the other symp- toms may be. " 20. Children attacked by convulsions die, and they are the more liable to them in proportion to their youth, and to the quantity of blood 292 ATELECTASIS PULMONUM. " 21. When, after the tenth day, the drink passes from the pharynx into the larynx and trachea, even though easily rejected, the patients most frequently die. " 22. Increase of the fever after the fourth day, agitation, collapse of the wound, and dryness of the trachea, rapidity of respiration, and frequency of cough, announce the commencement of pneumonia, which, at first lobular, becomes pseudo-lobular, and must be treated by the usual means, with the exception of blisters, which are apt to be covered with the false membranes." 1 424. During the attack of croup the diet should be strictly antiphlo- gistic, but when the child shows indications of exhaustion, we may give light nourishing food, in any form of the disease. Cold water, whey, barley-water, &c, are pleasant drinks, and should be given quite cold. The temperature of the room should be moderate and agreeable, the air kept pure and fresh, and the bedclothes light yet warm. In favorable cases, when the child is convalescent, the clothing must be carefully arranged, to secure against cold. I should recommend that a light, thin flannel waistcoat be worn for some months. The child should go out only during the warm parts of the day, and carefully avoid damp or cold, and during the prevalence of east winds had better remain in the house. 425. Prophylactic Treatment. — "When croup appears among the chil- dren of a fatuity, our attention should be directed to those not attacked, in order to anticipate and prevent such a seizure ; and a patient recover- ing from the disease must be watched subsequently with more than ordinary care. All predisposing and exciting causes should be removed or neutralized, if possible. If the climate or locality are unfavorable, the children should be removed, at least for a time, and if that be im- possible, other suitable precautions must be taken. Flannel should be worn to guard against vicissitudes of temperature or cold winds. The cold or shower bath may be used, followed by smart friction, so as to insure reaction. The bowels should be kept free, and the slightest cough or cold attended to. If an attack be threatened, an emetic, followed by expectorants, warm baths, purgatives, and counter-irritation, should be instantly given. CHAPTER V. ATELECTASIS PULMONUM. I. This term has been given to a condition of the lungs, or a portion of them, which is of comparatively recent observation, and the precise pathological value of which is far from being settled as yet. 1 Rilliet and Barthez, Mai. des Enfans, toI. i. p. 380. ATELECTASIS PULMONUM. 293 We may take as the type of this condition, the lungs of a foetus who lias not breathed, although the extent varies very much, and according to the extent so do the symptoms. This state, to which the names atelectasis, atelectasia, apneumatosis, etat foetal, &c, have been given, may be observed immediately after birth, or at a later period; the former is evidently congenital, the latter acquired. I feel no doubt as to the occurrence of such an acquired dis- ease, any more than of its being also congenital, although I may not quite agree with the interpretation that has been given of it. 2. Let us first examine into the form of the disease as we see it in infants of a few days old, as it has been described by MM. Joerg, 1 Hasse, 2 &c, and thus we shall be better prepared to appreciate it in older children. I. 8. Symptoms. — We find the atelectasis of new-born infants charac- terized by a feeble and incomplete respiration, which is occasionally in- termitting. Instead of the loud hearty cry, the child wails weakly and complainingly from want of breath. It seems to have great difficulty in sucking, and if the chest be stripped so as to be observed naked, it has scarcely the usual rounded appearance, and its movements are limited, or apparently inverted, the sides of the chest being flattened rather than expanded. The surface is cold and more or less livid from the imperfect aeration of the blood ; the pulse is weak and languid. If the amount of imper- meable lung be not so great as to be inconsistent with a prolongation of life, it is sure to influence and impair the nutrition, the infant be- comes weak, delicate and emaciated. Dr. Rees mentions that such patients are obnoxious to attacks of laryngismus stridulus, by one of which the infant is frequently carried off. When the atelectasis is of moderate extent, it may terminate in par- tial or complete recovery, but when at all extensive it usually ends fatally.- In some cases when great efforts are required for respiration, Jberg states that congestion or inflammation of the lungs may be pro- duced: in this, however, Hasse differs from him, and considers that in- flammation is neither necessary nor even frequently the consequence of atelectasis, for that the part of the lung in this condition is passive to other morbid processes, especially to inflammation, as he has seen these parts remain unaltered in the midst of surrounding hepatization. From recent researches, we have reason to believe that this state of the lungs has an important relation to oedema of the cellular tissue, of which I shall speak hereafter. 4. Now the state of the lungs which gives rise to these symptoms is simply that a portion of them remains in the condition in which it was before birth, undilated and impervious to air. Medico-legal researches have shown long ago, that the entire foetal lung is not at once inflated, but the small portion thus temporarily impervious gradually diminishes, and does not interfere with the well-being of the infant. If, however, a larger portion be undilated and remain permanently so, then we have the disease in question produced. 1 Die Fcetuslunge in neuoorneD kinder. 2 Pathological Anatomy, p. 248. Sydenham Society. 294 ATELECTASIS PULMONUM. That portion of the lung in a state of atelectasia, seldom so much as an entire lobe, appears condensed; it is depressed below the level of the neighboring or surrounding parts, of a dark reel or violet color, without crepitation, and when divided by the knife, no air can be expressed. The cut surface is red and smooth, from which, when squeezed, a slightly sanguineous serum without air bubbles exudes, and the affected part sinks absolutely in water. The tissue feels rather harder than other parts, but less tenacious. " The diseased patches," says Hasse, " display a brown red, or rather a bluish red color, which is more intense if the whole lobule is uniformly unexpanded, in which case it is marked off by a sharp contour from the surrounding pale-red healthy substance. When, on the other hand, scattered cells within such a lobule become inflated, the violet color is interrupted here and there, and passes by a gradual transition, and without any distinct boundary, into the natural shade. 1 The inferior and posterior portions of either or both lungs may be affected, but most frequently those of the right lung. When atelectatic infants die a day or two after birth, it is generally possible to dilate artificially the undeveloped part. The depressed lobule is then seen to rise gradually to the level of the rest, and to assume the color, permea- bility, and the characters of sound lung, but this does not appear to be always possible when it has remained for weeks or months in a state of atelectasis. In infants dying from this disease, both Joerg and Hasse found the foramen ovale invariably open. So far then as our investigations have as yet gone, it would appear that this state of the lung in new-born infants, is not the result of in- flammation ; that it is not necessarily connected in any way with inflam- matory action in the lungs ; nay, that it is not, properly speaking, a dis- ease at all, but merely an arrest of physiological development ; there is nothing new or morbid in this part of the lung, but merely the per- sistence of the old intra-uterine condition. 5. Causes. — There is great obscurity about the causes of this affection ; in many cases we cannot account for it all ; in others, it may perhaps be owing to defective nervous energy, in consequence of compression of the head during its passage through the pelvis, inducing a degree of asphyxia. 6. Treatment. — It is not improbable that this condition may be pre- vented if we are careful to induce full inspiration when the child is born, so as to establish respiration completely before the funis is divided. The impression of cold, and the unceremonious handling, washing, &c, generally achieve this, but we ought to see that it is secured ; and if we find the respiration feeble, and the cry unusually weak, the mouth being clear of mucous, the infant should be stimulated by slight taps, sprinkling of cold water, frictions to the back, warm baths, &c, until we are satisfied with the action of the lungs, or that these remedies have failed altogether. Joerg recommends repeated enemata and emetics ; the former can do no harm, and may do good, but I should fear a frequent repetition of the former. A warm equable temperature is necessary, and the infant should not 1 Pathological Anatomy, p. 249. ATELECTASIS PULMONUM. 295 be clothed less warmly than usual, and at the time of dressing and undressing, the back and chest should be well rubbed with the warm hand. II. 7. The acquired form of atelectasis is characterized by a dry bark- . ing cough, very distressing, which may continue for a considerable time, and recur after an uncertain interval of rest ; it is generally worse at night than in the daytime. There is also a certain amount of dyspnoea varying according to the extent of the solidified portions of the lungs, and it possesses this peculiarity according to Dr. Rees, that it is shown " first in the rapidity, and secondly, in the unequal lengths of the in- spiratory and expiratory efforts, the former being much the longer ; moreover, owing to the persistence of the difficulty, it becomes habitual to the child, so that you find it cheerful, and taking notice, when the quickness of breathing is to the observer really distressing, and would be taken by any one unconversant with the nature of the case to denote active inflammation." 1 The action of the heart is naturally much increased both in frequency and force, so as after some time to indicate that enlargement has taken place, and this violent action is occasionally accompanied by hemor- rhage from the nose, rectum, &c, which appears to afford temporary re- lief. But the most striking symptom of all is the altered movement of the ribs in respiration, which resembles the peculiar motion which every one must have observed in an infant at birth before respiration is com- pletely established, viz : during inspiration the ribs laterally are drawn rather inwards and backwards towards the mesial line, protruding the sternum slightly instead of distending outwards, as in ordinary inspira- tion, the result of which is rather a diminution than an increase in the cavity of the chest. This, which can only be detected when the chest is uncovered, will serve to impress upon my junior readers the necessity of a thorough and minute examination of the chest of infants and chil- dren whenever the lungs appear to be affected. If the atelectasis be extensive, of course there will be dulness on per- cussion over the diseased portion, and a deficiency of respiratory mur- mur, with perhaps bronchial respiration. As in new-born infants in whom this state continues long, we find the power of nutrition greatly impaired, the child becomes emaciated, but not so much so as in the former class of cases according to Dr. Rees, and it is seen chiefly in the limbs, the abdomen always becoming tumefied. The skin acquires a dusky color, owing probably to the im- pediment offered to the return of the blood and its imperfect oxygena- tion. The general symptoms of inflammation of the lungs are entirely absent. Lastly, Dr. Rees has stated a result of long continued atelectasis, which appears to me to require somewhat more evidence than we have at present. He believes that in adaptation to the state of the lungs the form of the chest becomes gradually changed. " The direction of the deformity will depend upon the original constitution of the patient. 1 Atelectasis Pulmonum, p. 8. 298 ATELECTASIS PULMONUM. If a strumous diathesis be present, strumous or rickety malformation of the chest will result. The bones themselves will yield beneath the arms, where a hollow will occur, narrowing the cavity in that direction, while the front projects unnaturally forwards. The common form of rickety chest is, I believe, usually the consequence of atelectasis of the lung, and this explains a difference not readily accounted for ; namely, why in one case, with considerable rickety deformity of the extremities, there is a fully expanded and well-formed chest, while in another, with the limbs straight, the altered shape cf the chest is so considerable ; it is because in the latter case the lungs have previously become shrunken, owing to a vitiated atmosphere or other depressing cause, atelectasis of the lungs has taken place, and the walls of the chest are forced in- wards to adapt them to the state of the respiratory organs." 1 Now, without denying that this may be the case in some instances, I cannot think that it is the ordinary way in which pigeon breast is pro- duced. If a collapsed state of the lung alone involved such an adapta- tion of the ribs, we should surely see it, as Dr. Corrigan suggested to me, in pleuritis, in which the chest contracts but the deformity in ques- tion is not produced. We can understand, however, that if a rickety dis- position of the bones of the ribs exists, together with atelectasis, that the atmospheric pressure externally not being counteracted by expan- sion of the lung, the result of these two conditions may be the flatten- ing of the ribs, and protrusion of the sternum ; or, the pressure of the atmosphere alone with the ribs in this condition may, and often does, produce this deformity, as Dr. Corrigan has shown. 2 8. Pathology. — The condition of the affected portion of the lung does not differ materially from that which I have already described. It is of denser texture, of a darker color, and depressed somewhat below the level of the neighboring parts. The pleura, according to Fricdleben, is somewhat thickened, and can be peeled off the affected parts. But the most important fact is that by inflation those parts can be raised to the level and made to assume the appearance of the healthy lun s- The deformity of the chest will be apparent, if it exist, as well as the tumid abdomen, with the enlarged venous trunks both external and internal. The heart is generally hypertrophied, but chiefly the cavities of the right side, if the disease has existed for some time. 9. So much for the post-mortem appearances. There are, however, two important pathological questions, about one of which a good deal has been written latterly, but which can hardly be answered satisfac- torily at present, upon which I must say a few words. 1. Is atelectasis ever an acquired disease, or is it merely that the foetal condition of the lung has remained unchanged from birth until the age at which it is discovered ? Friedleben takes the latter view, and whatever he writes is entitled to respect. He founds his opinion upon the anatomical characters, 1 Atelectasis Pulnionuni, p. 11. 2 See Dr. Corrigan' s Lecture, Dublin Kosp. Gazette, Ap. 1, 1845, p. 47. ATELECTASIS PULMONUM. 297 which undoubtedly resemble as closely as possible the foetal lung, 1 and upon the physiological impossibility that the lung could lose its power of expansion without mechanical cause ; " but this appears to me a petitio principii," the supposition being that it does so ; and, surely, if probabilities are to have any weight, it is at least as unlikely that a portion of the lung not affected by disease or mechanical impediment, should remain for years after birth unchanged. The great authority of Dr. West is decidedly in favor of atelectasis occurring at a period subsequent to birth, "so that lungs once perme- able to air may cease to admit it, and death at length occur from apnoea, without any serious structural change having taken place in the organs of respiration." Dr. G. A. Rees, in his pamphlet, has given seven cases in which he detected it in children from two months to two years old, and he enter- tains no doubt of its being an acquired disease. If I had any doubt in my own mind, the experience and observations of Drs. Baly and Gairdner 2 would have removed it, as they have recorded a precisely similar condition, the effect of disease, in adults of various ages. 2. Is atelectasis identical with that disease which has been described as lobular pneumonia, or with the carnification which we meet with in lungs affected by pneumonia ? In the chapter on pneumonia, I have shown that this is pretty much the view taken by both Legendre and Bailey, founded mainly upon the fact that in some, but by no means in all cases, they succeeded in inflating the lobules. This opinion has been still further carried out by M. Fuchs. Dr. West conceives that most if not all the cases of so called lobular pneumonia, and especially of that stage which has been termed carni- fication, were, in truth, examples of atelectasis produced by an occlu- sion of the pulmonary vesicles. "Nothing," he says, " can show more forcibly the influence of a name than the fact that this condition of the lungs should have been described by all writers as lobular pneumonia, and that its symptoms should have been attributed to inflammation, while yet it was evident from the concurrent testimony of every one that neither in its progress nor in its results was it similar to inflamma- tion in the adult, much less identical with it." 3 An attentive consideration of the arguments and evidence adduced, whilst it has satisfied me that atelectasis has frequently been mistaken for lobular pneumonia, has not, I must confess, convinced me that the two diseases are identical. As yet, I am not prepared to deny the dis- tinct existence of lobular pneumonia any more than that of atelectasis, unless more extended observation shall afford a greater mass of evi- dence than we at present possess. This seems to be as nearly as possi- ble the opinion of M. Hasse, who thus draws the distinction between the post-moriem appearances of atelectasis and pneumonia. "In atelec- tasis, the coloring of the diseased portions of lung always approaches 1 Archiv. fur Physiolog. Heilkunde, 1847. 2 Edinburgh Monthly Journal, Nov. 1850. 3 Diseases of Infancy and Childhood, p. 159. 298 ATELECTASIS PULMONUM. more to a violet, their exterior appearing smooth and glistening, so as to contrast with the dull brown red surface of inflammation. In in- flammation, again, the diseased portions are preternaturally distended, whilst in atelectasis they are collapsed, and inferior even to the healthy texture in volume, but susceptible, provided the disease has not lasted too long, of artificial inflammation, and capable through its means of acquiring a perfectly natural appearance. In inflammation the pulmo- nary texture is softened; in atelectasis it is hard, and the cut surface is not granular, but smooth. "Where no complication exists, the anatomi- cal characters of a first or third stage of pneumonia are not discover- able in or near the diseased patch : in short, we have nothing like pneu- monia except the solid non-crepitant mass which has been confounded with the second stage of that disease, viz : with red hepatization." 1 He adds, that "unequivocal cases of infantile pneumonia, whether lo- bar or lobular, such as I have myself examined, and such as Kewisch has published, afford, on the other hand, the strongest negative grounds for establishing atelectasis as a distinct form." From the evidence adduced, I think I may draw the following con- clusions : — 1. That in certain new-born infants a portion or portions of the lung remain undilated or impermeable to air, and that these give rise to cer- tain symptoms and signs, and involve certain consequences already enu- merated. That the anatomical characteristics of these portions of the lungs are their being solid, free from air, of less proportionate bulk, capable of being inflated, and after inflation of assuming their natural character. 2. That a similar disease may be acquired during childhood present- ing analogous signs and similar anatomical characters. 3. That this condition may be, and probably has often been, mis- taken for lobular pneumonia, especially in young infants. That patho- logical condition which has been termed " carnification," has certainly a very close resemblance to the condition of the lung in atelectasis, and I should not be prepared to deny that such cases may really be exam- ples of the latter disease. 4. But I cannot at present agree with the opinion that all which has been regarded as lobular pneumonia, is really but atelectasis superin- duced by a vascular congestion, closing the air-cells, or by an obstruc- tion in the air-tubes. 5. It does not seem impossible that this disease, although distinct from pneumonia, may result from it, or from an attack of bronchitis, as Dr. Rees believes, and as Dr. Gairdner's researches have proved, in the case of adults. 10. Diagnosis. — The most important diagnostic sign of atelectasis is the altered movements of the ribs, which only occurs in one other disease, viz: occasionally in croup. In the latter disease it has been noted by Dr. Rees and Sibson, but the accompanying symptoms are too marked for any one to confound the two diseases. Dulness on percussion, with the absence of either respiratory murmur 1 Pathological Anatomy, p. 252. ATELECTASIS PULMONUM. 299 or crepitation, may perhaps enable us to distinguish it from pneumonia, but there may be doubtful cases. The progressive emaciation accompanied by the pulmonary symptoms may excite suspicions of phthisis, but a careful examination will gene- rally lead us to a correct conclusion. 11. Prognosis. — If timely measures be adopted, this disease is cura- ble, and even when they are neglected or fail, if the child survive for a time, the constitution becomes familiarized to the state of the lungs, and certain adaptations occur which allow of the child growing and thriving. In other cases, however, the secondary effects are more serious, the child becomes more and more emaciated and reduced in strength, the cough is very distressing, and he dies at length of exhaustion. 12. Treatment. — Very active treatment is evidently quite unsuitable to these cases, and so far as we yet know, the number of remedial agents is but small. The first object should be to place the child in suitable hygienic cir- cumstances — to secure a plentiful supply of pure air, warm clothing and suitable food, as to a deficiency in these requisites we may frequently trace the origin of the disease. The diet should be good, but not excessive in quantity ; meat once a day, with milk or very weak tea, but neither vegetables, fruit, nor pastry, on account of the disordered state of the digestive organs, as evidenced by the tumid belly. Emetics occasionally seem to be of use as well as stimulating expec- torants, such as the decoction of senega with ammonia. A very principal part of the treatment must be directed to the skin and kidneys. Dr. Rees prefers a combination of ipecacuanha with nitre, hyoscyamus, and sulphate of magnesia, so as to act as a gentle purgative, as well as a diuretic. A mild mercurial, the hyd. c. creta, for instance, may be given occa- sionally alone, or in combination with a purgative, as the bowels are generally confined. External irritation, by rubefacients or blisters, may be tried, and it appears to me probable, that electro-galvanism might be of use, but I am not aware of its having been tried. In accordance with his views, as to the production of deformity, Dr. G. A. Rees insists upon the patient observing a recumbent position, lying on its back on a firm unyielding surface: "The position seems to antagonize, to the small extent we are able, the altered movement, and by keeping the spine supported and extended, renders more tardy the projection of the column, thus giving the best chance for the extended lung again to expand." 300 BRONCHITIS. CHAPTER VI. BRONCHITIS. 426. Bronchitis, or bronchial catarrh, is the term applied to inflam- mation of the mucous membrane of the bronchial tubes, accompanied with increased secretion ; and those two elements, the inflammation and the secretion, not being necessarily in exact proportion to each other, has led writers to regard the disease either as a simple inflammation or as a catarrh, according to the predominance of either, and occa- sioned their estimating the disease as more simple than it is in fact. Following the example of M. Barrier, I shall use either term to ex- press the disease, without limiting my meaning to the strict pathologi- cal definition of either. In one form or other, it is undoubtedly one of the most frequent dis- eases of infancy and childhood. From the moment of birth, indeed, to extreme old age, none are altogether exempt from its attacks ; but it is at the extremes of life that it is more severely felt, and more serious in its consequences. 427. Bronchitis may be primary or secondary, simple or complicated, general or partial, acute or chronic, and these circumstances will require serious consideration in our estimate of the disease, and in determin- ing the treatment. Let us first speak of primary bronchitis, which I shall divide into acute and chronic ; and afterwards of secondary pul- monary catarrh. I. Acute Bronchitis. — The ordinary form of acute bronchitis com- mences generally with a chilliness over the whole body ; the child com- plains of cold, and objects to quit the fire ; this is followed by more or less of feverishness. There is a certain amount of cough from the commencement ; sometimes it is slight, at others severe, very rarely in paroxysms ; it may be moist or dry, but it is rarely a hoarse cough. At first the child seems to suffer pain from the cough, and, if old enough, complains of soreness on coughing, which disappears as the disease advances. In the commencement there is no secretion of mucus, which gives a hard character to the cough, but in a day or two there is a more or less profuse secretion, which, whilst it relieves the distress in one respect, may increase it in another by impeding respiration, espe- cially with young infants. The breathing is generally accelerated, but the amount varies ac- cording to the intensity of the disease. So long as the attack is con- fined to the larger bronchial tubes, and if the child be tolerably healthy, the respiration is not much hurried; it ranges from 28 to 40 per minute, nor is there much increase of respiratory effort ; but when , the smaller tubes are invaded, it is both accelerated and impeded, requiring rapid BRONCHITIS. 301 and energetic muscular effort. When the mucous secretion is estab- lished, and in proportion to its abundance, there is a wheezing and rattling in the chest very audible at some distance. In proportion to the cough and disturbance of the respiration will in general be the state of the pulse. In slight and partial attacks it may be but little quickened, but when the disease is general, and the respi- ration much embarrassed, the pulse will be found very rapid, and the fever considerable. The countenance generally expresses distress ; at the beginning it is flushed, but in a more advanced stage, and in proportion to the impedi- ment to respiration, it acquires a bluish tinge, as the consequence of the imperfect aeration of the blood. 428. The physical signs are simple and easily recognized. On per- cussion, the chest yields a clear sound, if the disease be uncomplicated ; but in severe cases we find here and there a certain amount of dulness, which is probably owing to a partial complication with pneumonia. If the ear or the stethoscope be applied to the chest, we shall find the sonorous, mucous, or sibilant rales pretty general, the former espe- cially before the mucus is freely secreted, the latter afterwards. Some- times the respiratory murmur is completely and permanently masked by them ; in other cases they are more partial and temporary, and we can still hear the rapid respiratory murmur. In a few cases there is here and there a moist sub-crepitant rale audible. When the attack is slight, the appetite will be but little impaired, digestion will take place satisfactorily, and the bowels continue regular ; but when the fever is considerable, the appetite is lost, there is occa- sionally vomiting brought on by the cough, and the bowels will be more or less disturbed. 429. Thus, as characteristic of the attack, we have cough, hurried respiration, perhaps dyspnoea, mucous secretion, and fever ; and these symptoms generally continue stationary for a few days ; then, in favora- ble cases, the fever gradually subsides, the respiration becomes more tranquil, the cough softer and less distressing, and by degrees the child becomes convalescent in the course of a week or two. This, however, must be considered a favorable case ; in many in- stances, the disease, instead of diminishing, assumes a more aggravated form ; it may either be complicated with pneumonia, or, extending to the capillary tubes, it may assume the characters of suffocative catarrh, which I shall describe immediately. In either case the cough becomes more troublesome, the respiration more hurried, the fever more intense, and the general distress and constitutional disturbance more severe. Auscultation will generally reveal the form which the disease has as- sumed, and, as we might expect, the general symptoms will also indicate the altered character of the disease. The result is much more doubtful than in the first cases ; they gene- rally recover, but when thus aggravated, if the child is much reduced already, and the attack very severe, the case may terminate unfavora- bly- 430. The other modification of acute bronchitis to which I have alluded, and which has been called suffocative catarrh, capillary Iron- 302 BRONCHITIS. c'hitis, catarrhal fever, is a more severe and more dangerous form of disease. It is not so common as the other forms of bronchitis ; Rilliet and Barthez met with but six cases of it as a primary affection, and three as a secondary. However, in certain epidemics of bronchitis it is much more frequent, as I have observed latterly in this city. As I have already mentioned, it may grow out of or be grafted upon the former slighter catarrh, or it may assume from the commencement its peculiar characteristics. In most cases, the general symptoms pre- cede the local, or at least their greater severity occasions them to oc- cupy most of our attention. The fever is intense ; the pulse rapid and full ; the skin is hot and dry, with occasional chills ; the face is flushed ; there is great thirst ; the tongue is white and coated, and there is no appetite. The respiration becomes rapid, not exactly difficult at first, but hur- ried ; it afterwards becomes difficult, with wheezing, and requiring great muscular effort. The cough, which either did not exist at first, or was too slight to attract much notice, is now developed or increased, for some time dry, and occurring in a kind of paroxysm or kink ; it causes great distress, and greatly increases the soreness or pain in the chest of which the child complains. At first there is no expectoration ; then we have a whitish or yellowish mucus, sometimes muco-puriform in its character, and, very rarely, with portions of lymph. 431. The physical signs do not differ much from those in the ordi- nary and slighter forms of disease. The chest is generally clear on percussion, with the exception, perhaps, of some spots of small extent towards the base of the lungs. The respiratory murmur is entirely masked by the sibilant and mu- cous rales, which are heard over the whole lung, mixed, in some parts, with a moist crepitus. The wheezing is audible at some distance from the patient. 432. These symptoms may all be observed very soon after the com- mencement of the disease, and every hour they seem to increase. The respiration becomes more hurried and embarrassed, and at length un- equal, irregular, and panting, with great oppression, and strong muscu- lar efforts, great heaving of the chest, and rapid action of the alas nasi. The face is pale or livid, especially after coughing, the lips purple, and the expression of the countenance that of intense anxiety and distress. The patient lies on his back, or requires to be raised into a sitting posture, according to the amount of distress in breathing. The mucous rales in the chest increase according to the abundance of the mucus secreted, which is occasionally so excessive as to threaten suffocation. The pulse becomes quicker, but smaller, weaker, and unequal, some- times, towards the end, irregular. If the disease be not quickly terminated, we may sometimes observe occasional remissions, followed by a return of all the symptoms. In unfavorable cases, the disease rapidly gains ground, the symptoms become aggravated, the cough most distressing and painful, the respira- tion amazingly rapid and difficult, the pulse very quick, irregular, and BRONCHITIS. 303 almost imperceptible, the features changed, and expressive of agony, the face livid, and covered with profuse perspiration, and at length a kind of convulsive agitation or stupor terminates in death. I have remarked that in children of three years old and upwards, the disease may terminate in pneumonia, but in young infants more frequently in profuse fluid effusions into the bronchial tubes and cells, producing asphyxia. "In some cases," Dr. Watson observes, "in young patients in whom bronchitis is idiopathic, and not engrafted on any other disease of the chest, in whom the disorder had not appeared severe, extreme difficulty of breathing will sometimes most unexpectedly arise, and rapidly termi- nate in the extinction of life. This is attributed to the permanent ob- struction or plugging up of one of the bronchi. The slightest attack of bronchitis may, in this way, be suddenly transformed into a most serious and quickly fatal malady." 433. The course of the disease is often very rapid. Rilliet and Barthez knew it terminate in three days. M. Fauvel found the dura- tion of the confirmed attack from six to eight days, although it may last much longer, even twenty or thirty days. But the attack does not always prove fatal ; under judicious treat- ment, at an early period, the disease may be checked, the fever then gradually diminishes, the dyspnoea and hurried breathing become calmer by degrees, the cough less frequent and distressing, and the child slowly recovers. 434. The description I have just given is that of ordinary suffoca- tive catarrh, but in practice we find considerable modifications. Dr. Parrish, of Philadelphia, has described one which is worth noticing i 1 " This modification of the disease commences with a cough, and the breathing soon becomes laborious and wheezing ; the face is very pale, and the whole surface cold, though generally soft and moist. The coun- tenance acquires a peculiar expression of distress and anxiety, and in some cases the cheeks become very cold, even when the other parts of the surface are of a natural temperature. The stomach and bowels are generally inactive, and the urine is small in quantity, but, so far as I have observed, of a natural and healthy color. After the disease has continued for some time, a cold perspiration breaks out on the face and neck. The cough is at first dry, attended with a wheezing sound in the chest, but towards the termination of the complaint it frequently be- comes hurried and rattling. The pulse, in violent cases, becomes very small and rapid, and the tendency to sinking is, in all instances, very obvious. There is constantly much difficulty of breathing, but at times the oppression becomes so great as to resemble a violent attack of asthma. Occasionally considerable remissions occur for a short period, during which the pulse will become fuller and slower, and the counte- nance brighter and more calm. When the disease is tending to a fatal termination, the patient becomes drowsy, insensible, and comatose, and death takes place by suffocation in a paroxysm of convulsions." 2 1 North Amer. Med. and Surg. Journ., vol. i. p. 24. 2 Eberle on Disecises of Children, p. 822. 301 BRONCHITIS. 435. Dr. Eberle lias described an epidemic which occurred in the eastern states of America in 1824, which he calls catarrhal fever, and which has very much the appearance of modified capillary bronchitis. "The disease began with a slight feeling of distress, and with a dis- tinctly formed chill. The hands and feet became cold, the whole surface of the body pale and contracted, and the patient appears languid and drowsy. This state of depression frequently continues for a whole day before the febrile action is fully developed. In many instances, how- ever, the fever supervenes in a very short time after the first feeling of indisposition. The patient complains of aching pain in the extremities and back, the pulse becomes frequent, somewhat tense, and generally full, the cheeks flushed, the eyes suffused with tears, and a thin, trans- parent fluid usually issues from the nose, attended, at the commence- ment, with frequent sneezing. The skin is dry and husky, though seldom much above the natural temperature. The bowels are torpid, and the urine scanty and high colored^ and in many instances the alvine evacuations, during the first few days, manifest a deficiency of secre- tion, and sometimes an entire absence of bile. In some cases cough, with slight hoarseness, is one of the earliest symptoms ; more frequently, however, the cough does not come on until the fever is fully developed, and often not until the disease has continued for two or three days. The breathing is not often much oppressed in the early periods of the disease, though frequently attended with a considerable rattling in the trachea. In severe cases, however, respiration is frequently difficult and wheezing, almost as soon as the fever is developed, owing to the abundant secretion of mucus into the air cells. This is most apt to be the case in infants, who, from not making any efforts to free the lungs by expectoration, suffer the bronchial secretions to accumulate in the air- passages." "In the ordinary form and course of the disease the expec- toration becomes very abundant after the fever has continued for three or four days ; and as the copious secretion of mucus keeps up a con- stant irritation of the bronchia, the cough usually becomes very fre- quent as the disease advances." 1 436. The most marked distinction between the symptoms of ordinary bronchitis and the suffocative catarrh or capillary bronchitis, consists in the greater amount of fever in the latter cases, the occurrence of de- pression, almost amounting to collapse, the hurried, wheezing, and diffi- cult respiration, the cough being more frequent, and occurring in par- oxysms or kinks, and the more imperfect aeration of the blood, evidenced by the tumid and livid features, cold, pallid surface, &c. 437. II. Chronic Bronchitis. — The chronic bronchitis of infants and children is generally the sequence of an acute attack of the ordinary disease, or of suffocative catarrh, the symptoms of which lose their acuteness, and in a great measure their severity. There is little or no fever during the day. The cough is soft, moist, and seldom occurs in kinks ; it is still distressing, however, and in some cases particularly so at night, or when lying down. The respiration is natural, with occa- sional paroxysms of dyspnoea. On applying the stethoscope, we find 1 Diseases of Children, p. 318. BRONCHITIS. 305 mucous rales mixed with a loud sound, as in dilated bronchial tubes, and the chest is clear on percussion. The pulse is quick, weak, and small, with some exacerbation in the evening, and occasional night-sweats. Considerable emaciation, also, is the result of the attack. The face is pale, and the eyes hollow ; the lips are bluish and sometimes cracked or ulcerated ; the edges of the nares are also sore, and kept so by the child picking them. The strength is very much diminished, the appetite deteriorated or lost, and in bad cases there is colliquative diarrhoea. 438. The aspect of cases so severe as these is really that of phthisis, and in fact they may run on into that disease. MM. Rilliet and Barthez observe that " chronic bronchitis, simulating phthisis, may present itself under a still more unusual form, and last longer. The disease is then accompanied with fits of suffocation, fol- lowed by the rejection, sometimes, of a large quantity of pus, sometimes of tubes apparently pseudo-membranous, with the general symptoms already mentioned. Thus, in a case communicated to us by M. Legendre, the child, who was seven years and a half old, commenced, at the age of three and a half or four years, to reject, after fits of coughing, a con- siderable quantity of matter two or three times a day. There was constantly difficulty of breathing, fever in the evening, and night sweats. There was dulness on the left side posteriorly, and in that spot cavern- ous respiration, with mucous rales. The child had all the characters of phthisis. The fever increased, and the emaciative diarrhoea came on ; then gangrene of the mouth, which, added to the other disease, ended in death. The disease lasted near four years. It was ascertained by a post-mortem examination that the child had suffered from chronic bronchitis, with considerable dilatation of the bronchial tubes." 1 The disease ordinarily lasts from thirty to forty days, and may then terminate fatally ; or, under the influence of judicious treatment, the disease may yield, the symptoms diminish, and the child regain its health gradually. 439. Pathology. — There is some difficulty in ascertaining the pre- sence of inflammation in the smaller bronchial tubes, because their mucous membrane, being very thin, shows the color of the subjacent tissue ; and because, as M. Fauvel observes, the mucous membrane has this resemblance to serous membranes, that the redness disappears immediately after death. In slight cases of acute bronchitis, limited to the trachea and large tubes, the mucous membrane will be found red and inflamed, generally or in patches, with more or less abundant secretion. If the attack involve the middle bronchial tubes, we shall find the redness and abundant secretion, with dilatation of the tubes, in propor- tion as the disease has been of long standing. In the capillary bronchitis, the extremities of the tubes are closed, partly by the swollen state of the mucous membrane and partly by the accumulation of puriform secretion, notwithstanding the considerable dilatation which takes place in a few days. Not unfrequently, in this 1 Mai. des Enfans, vol. i. p. 43. 20 306 BRONCHITIS. form of the disease, we find evidence of lobular pneumonia. Chronic bronchitis will generally be found to occupy at once the large bronchial tubes, some of the middle size, and more slightly the smaller ones. Its principal pathological characters are, the abundant secretion, the hy- pertrophy of the mucous crypts whose orifices are enlarged, hypertro- phy of the longitudinal fibrous tissue, and of the muscular fibres of the trachea and bronchi, and marked dilatation of the middle and terminal bronchial tubes. 440. A word or two upon some of these details may not be amiss. The redness of the mucous membrane, which is very commonly seen, is not always present, even in very marked cases. It is generally dif- fused, and as visible where the membrane passes over the cartilaginous rings as in the interspaces. If it appear only in the latter, we may doubt whether it be not rather due to the subjacent tissues. There can be very little doubt that the mucous membrane is thick- ened, as the result of inflammation, although it is not very easy to demonstrate it ; nor can we attribute the obstruction of the smaller tubes entirely to this cause. MM. Billiet and Barthez occasionally met cases of bronchitis in which the mucous membrane was softened, thickened, and rough, but never any in which it was ulcerated. M. Barrier found it ulcerated only in cases in which tubercles also existed. M. Fauvel detected ulceration in one case of pseudo-mem- branous bronchitis. We must be careful not to mistake the enlarge- ment of the orifice of the mucous crypts for small ulcers. 441. Bronchitis rarely continues for any length of time with infants, without causing dilatation of the bronchial tubes, as the direct conse- quence of inflammation. Sometimes it may be observed in the course of the tubes, in other cases at their extremities. In the latter case, if the lungs be incised, the surface presents a number of rounded areolae, and, if pneumonia co-exist, these are surrounded by denser tissue. Some care is necessary to demonstrate the dilatation of the branches of the bronchia), but it is not difficult to ascertain it. It is easy to understand how much this dilatation, if extensive, must increase the difficulty of breathing, by pressure upon other tubes ; and, if we remember that the quantity of secretion is excessive, Ave shall cease to be surprised at the amount of dyspnoea in capillary bronchitis. This secretion varies in character according to the extent and dura- tion of the inflammation. At the commencement there is little, if any, but in the course of a day or two we find a clear, viscid, frothy mucus expectorated, generally white, sometimes yellowish, if the attack be mild. But if it be severe, or of longer standing, the fluid is more puri- form, less aerated, and of a yellowish color. Rilliet and Barthez found occasionally shreds of false membrane mixed with the puriform matter, and in some cases false membrane alone. It is seldom that the large tubes are so far filled with it as to impede the entrance of air, but the smaller terminal ones are often completely choked up. M. Barrier has mentioned other accessory pathological phenomena, BRONCHITIS. 307 discoverable upon dissection, as redness, swelling, softening, and some- times suppuration of the lymphatic glands, near the primary division of the bronchia ; an emphysematous condition of the lungs, depending upon a dilated condition of the vesicles. 1 I may add, that the traces of lobular pneumonia are common, nor is it very rare to find tubercles, and some traces of pleuritis. Rilliet and Barthez have given the following numerical estimate of the occurrence of these morbid changes: In 174 autopsies of patients who died of bronchitis, redness of the mucous membrane existed in 143; and in thirty-four cases this was co-existent with softening and thickening. Out of the 174 cases, there was dilatation of the bronchial tubes in seventy- four ; in sixteen dilatation of the "vacuoles;" in seventeen there was vesicular bronchitis ; and in ten, false membranes were discovered in the bronchia. 2 442. Modifications and Complications. — I have already alluded to secondary bronchitis, which is the most important modification of the disease. It is very common in many other diseases, especially the erup- tive fevers. We find it very troublesome in hooping-cough, measles, scarlatina, smallpox, infantile remittent, &c. &c. In many cases it proves a serious addition to the primary malady, requiring care, vigilance, and promptitude ; in other cases, the attack being slight, it is of no great consequence. Our judgment upon this point must be formed by a careful estimate of its intensity, the effects of the primary disease, and the state of the child's constitution. The symptoms and physical signs do not differ materially from those already described, but they may be masked, or our attention diverted from them by the importance of the original affection. 443. The most frequent complication of bronchitis is lohular pneu- monia, and that kind of congestion which, if not checked, runs on into pneumonia. A careful examination in such cases may possibly detect dulness on percussing some portions of the chest, and there is a mixture of subcrepitus with the mucous and sibilant rales of bronchitis. I need not say that such a complication adds much to the danger; it renders the treatment somewhat more complicated and doubtful also. Again, the disease may give rise to emphysema, of the lungs, in con- sequence of the dilatation of the extreme ends of the bronchial tubes, or of the air-cells ; and we shall find the usual physical signs of the disease, enfeebled respiratory murmur, dry crepitus, and rather unusual reso- nance on percussion, if the tubes be not filled with muco-puriform secre- tion. Although it may add to the tediousness of the illness, I do not know that I could say that it adds to the danger. The disease may extend itself upward to the larynx and trachea, giv- ing rise not to croup, but to a modification of laryngitis, with hoarse cough and rough voice, but with no metallic sound. Lastly, it is a doubtful question how far bronchitis may be the fore- runner of tubercles. M. Fauvel says it is rare to find tubercles in these cases, and Rillet and Barthez confirm his statement, so far as the rapid, acute form is concerned, but they are not so clear that they may not 1 Mai. de l'Enfance, vol. i. p. 344. 2 Mai. des Enfans, vol. i. p. 27. 308 BRONCHITIS. complicate chronic bronchitis — whether as primary or secondary affec- tion may, of course, be doubted. Certain it is that in patients -who have died with bronchitis, tubercles, generally in a crude state, have been found. 444. Causes. — Among the predisposing causes we must include other diseases, in the course of which bronchitis occurs as a secondary affec- tion. Thus, of 115 cases of simple bronchitis, Rilliet and Barthez found that but twenty-one were primary. It may also result from the suppression of an eruption to which the constitution is accustomed. Age appears to have an evident influence upon the production of bronchitis, whether primary or secondary. Rilliet and Barthez state that the majority of their cases were before the age of six years. Dr. Condie mentions that in Philadelphia, from 1835 to 1845, 1172 deaths occurred from bronchitis, of which 643 were children under one year ; 276 were children from one to two years ; 201 from two to five years ; forty-seven from five to ten years; and five from ten to fifteen years of age.' Of twenty-three cases which occurred to Dr. Meigs, eight were under two years ; ten between two and four years ; three between four and six; and two between six and ten years of age. 2 M. Barrier explains this by the greater demand for mucous secretion in infants, to protect the membrane from contact with the air ; and this normal activity, which is extreme, is on that account easily increased beyond the bounds of health. 3 Primary bronchitis occurs most frequently in girls, and secondary in boys ; the latter owing, probably, to the greater frequency of the dis- eases in boys, in the course of which bronchitis occurs as a complica- tion. No doubt much depends upon peculiarity of constitution ; it is more common among weak and cachectic infants, or those with an hereditary disposition to catarrhal affections. It may be excited by cold, damp clothes, exposure to inclement weather, low, damp habitations, the prevalence of east or northeast winds, smoke or noxious gases, disordered liver, stomach, and bowels, or dentition. 445. Lastly, either primary or secondary bronchitis may occur as an epidemic, and generally with considerable fever, dependent, probably, upon some peculiar atmospheric influence, constituting the formidable complaint which in France has received the name of " la grippe," and in these countries the influenza. Such was the epidemic of 1557, de- scribed by Valleriola; of 1580, by Sporisch ; of 1733, by Storch ; and of 1743, by Huxham, in which great numbers of infants perished. In a paper published by M. Petugain, on the epidemic of 1837 in France and Italy, he observes : " Infancy has escaped better than other ages in Paris, at Lyons, at Geneva, at Corbeil, at La Reole, at Milan, at Padua, and at Leipsic. At Lyons, out of three hundred intern stu- dents of the College, about two hundred were attacked, and of these eighty were under fifteen years of age. During the height of the epi- 1 Diseases of Children, p. 88. * Diseases of Children, by Dr. Meigs, Jun., p. 106. 3 Mai. de l'Enfance, vol.* i. p. 317. BEONCHITIS. 309 demic, infants were most frequently attacked. Sick children as well as old people were seriously compromised by it. " The nasal mucous membrane was the seat of violent congestion, in consequence of which epistaxis was very common (one in ten, according to Brachet), which sometimes threatened danger by its abundance, in other cases afforded relief. Age exercised great influence upon the mortality. In London the disease made great ravages among old peo- ple, young children, and invalids. In Italy, as in France, it was old persons who chiefly suffered. At Geneva, more elderly people died than all other ages together. Very young infants, under two years, died in great numbers, according to M. Lombard." 446. In the winter of 1846-7, the influenza prevailed very exten- sively in Dublin, though it did not prove very fatal. I shall give the following extract from a paper I published on the subject in the Dublin Journal, as the best description I can give of the epidemic : — " The number of cases that I have seen within the last two months, and from which my remarks are drawn, exceeds sixty ; and they em- brace children of all ages, from two months old to twelve or fourteen years. I may add that, in addition to the children, in many cases, the parents or servants were similarly affected. " I think that, without exception, the younger the child the more severe the attack. " The mode of invasion varied a good deal. In some instances the whole family seemed to submit to the epidemic influence at once, and all were laid up ; in others, one or two would present the epidemic character well marked, and the others complain merely of a slight cough, accompanied in a day or two by feverish symptoms ; whilst oc- casionally each child took sick successively, allowing the one first at- tacked to recover previously. " The characteristic features of the complaint, as in previous epidemics of influenza, have been affections of the chest, invariably accompanied by smart fever. Coughs and colds, without fever, are common enough, but I exclude them, as not true cases of influenza. " The fever sometimes precedes the cough, but more frequently comes on about the second, third or fourth day. The child is heavy, dull, cross, and cold, creeping to the fire, and unwilling to exert itself, or to share in its usual amusements. The skin becomes hot, florid, and the pulse very quick, ranging from 120 to 160. There is, perhaps, rather less thirst than one would expect from the degree of fever, and the secretion from the kidneys is scanty, and sometimes high-colored. The tongue is always foul, and loaded with white fur ; sometimes, though but rarely, dry ; the appetite is lost ; and occasionally I have seen vomiting or diarrhoea, but generally both stomach and bowels are steady. In almost all cases the child has been restless and uneasy at night, sleeping little, and in a few instances slightly delirious. " As regards the local affection, I have observed three varieties, often quite distinct, but occasionally two occurring in the same child. " I. In the milder form of the disease, the primary bronchial tubes were the portion of the respiratory system affected, and this was most common among the elder children. The attack began by a frequent 310 BRONCHITIS. cough and a degree of hoarseness, indicating that the larynx and tra- chea were somewhat affected. The hoarseness often subsided, but the cough continued very troublesome, with free expectoration after the first day or two. In two case3 of young children (i. e. under four years of age), the larynx was more seriously affected, and the disease began by an attack of well-marked croup, which subsided in one case in ten or twelve hours, and in the other in two days, leaving behind it the form of influenza I am describing. " The cough gives a good deal of pain, and the elder children describe it as scraping the chest. After a day or two the fever is developed and the cough not less troublesome, and for some days the child suffers great distress ; until the fever subsides, the cough diminishes, and the expectoration becomes more abundant. " If the lungs be examined with a stethoscope, they will be found generally free from abnormal sounds, and the respiration vesicular and natural ; but the respiration through the large bronchial tubes gives a rough and slightly sonorous sound. Percussion yields a clear and per- fectly natural sound. " ii. The second form of the disease affected children of all ages, and consisted of more or less intense bronchitis of one or both lungs, with great congestion of those organ. In these cases respiration was much more rapid, and performed with some difficulty, a wheezing being au- dible at some distance. The imperfect aeration of the blood showed itself in the dusky red color of the cheeks, which, in some severe cases, were nearly livid. The cough was incessant, the mucus abun- dant ; but as little children do not expectorate, this rather added to the distress. The fever set in nearly as soon as the bronchitis, and in some cases ran very high. In some instances the attack was so severe that suffocation was imminent ; but these, with some difficulty and delay, recovered. " When the chest was examined, its movements indicated consider- able difficulty of respiration, and the respiratory murmur was lost in a variety of bronchitic rales, mucous, sibilous, and sonorous, varying ac- cording to the extent and intensity of the attack. Mixed with these is frequently heard a crepitus ; not the small, distinct crepitus of pneu- monia, but larger and more moist. Percussion yielded a pretty clear sound generally, with a diminution of tone occasionally in different parts ; mainly, I think, in those where the crepitus occurred. "In the progress towards convalescence the crepitus first disappeared; then the movements of the chest became less labored, and the respira- tions less frequent ; the distress diminished, and the fever subsided gradually. The bronchitic rales continued in a minor degree for a considerable time ; and, what was very remarkable, in a great number of cases, as the general bronchitis diminished, I found the primary tubes, and even the larynx became affected. " in. The third form which I observed the affection of the chest to assume was either simple pneumonia, or mixed with a moderate amount of bronchitis, and, I believe, this form occurred only in young children ; I do not remember any case of it in children above five years old. Its commencement in most cases was very obscure. The BRONCHITIS. 311 child labored under high fever, with very rapid breathing, but very little cough. It looked very like a case of remittent fever, and in one or two cases I believed at the first moment it was so, and examined the chest as a matter of duty, to make sure, rather than with any ex- pectation of detecting serious disease. In these cases double pneumo- nia existed. The respiration in all was, as I have said, extremely rapid, with great action of the alae nasi, but without the labored move- ments of the chest, which occurred in the last variety ; the face was flushed, with the centre of the cheek of a florid red color ; the pulse very frequent ; the thirst considerable, with great restlessness. The usual crepitant rale of pneumonia, clear, small, and distinct, was pre- sent, mixed in a few cases with mucous or sibilant rales. The part of the chest affected was dull on percussion. Under the treatment adopted, the signs of pneumonia gradually disappeared, and, in proportion, the fever subsided, the cough generally increasing for a time, the chest be- came clear, and the little patient slowly recovered. " Of course this form of disease involved the greater danger ; and of some of the patients I had but slender hopes, as they were children of weak constitution. " As to the treatment, it has been simple and successful. On the accession of fever in all the varieties of local affection, I found it most advantageous to give an emetic of ipecacuanha in the two first, and of tartar emetic in the last, and to prolong the nausea for an hour or two. In the second and third varieties I found leeches necessary when the attack was severe, the respiration hurried and difficult, the pulse quick and strong, and the child able to bear them. " In most cases, after these preliminaries, I ordered a mixture of ipecacuanha wine, paregoric elixir, and almond milk, to be given at short intervals; but when pneumonia exists, the tartar emetic mixture is better, and if it should produce great depression, this may be cor- rected by ammonia. A small quantity of ammonia, in the former mix- ture, was advised by Dr. Stokes in some of the cases, and with imme- diate benefit ; it seems to relieve the congested state of the bronchial mucous membrane as much as anything I have tried ; or if it do not answer, from two to five drops of spirits of turpentine, in mucilage and water, every three or four hours, may be given ; in several cases it was very beneficial. If these mixtures disagree with the stomach, or after they have produced their effect, or at the same time that they are exhibited, small doses of calomel, ipecacuanha, and James's powder, may be given with advantage. "As to external applications, I found it necessary, in some cases, to have recourse to blisters, but not very frequently, partly on account of the annoyance they are to young children, but principally because I found a very good substitute in poultices, which I think worthy of a more extensive use than they obtain. They are best made of linseed- meal, and should be applied directly to the surface, warm, and very moist, changing them every two hours, or oftener. If irritation be de- sired, a dessertspoonful of the flour of mustard may be mixed with the meal. " Warm baths are exceedingly useful, and may be used every night, 312 BRONCHITIS. provided the child do not cry much ; if it do, it will be better to bathe or foment the feet." 447. Diagnosis. — There is seldom much difficulty in the diagnosis: the physical signs are generally sufficiently clear; the chest is sonorous on percussion, and there are abundant mucous and sibilant rales to be heard. I. The absence of crepitating rale and of dulness will ordinarily dis- tinguish the case from lobular pneumonia; but as the two diseases may be co-existent, of course we cannot come to so decided a conclusion in every case. II. The cough in capillary bronchitis occurs in paroxysms, like the kink in pertussis, and for some little time the absence of the hoop may not be conclusive ; but if this continue, and if the physical signs of suffocative catarrh predominate, we cannot have much doubt. in. It is more easy to mistake a case of chronic bronchitis for one of phthisis, inasmuch as we find cough, emaciation, evening exacerbations, and night-sweats, in both ; but a very careful examination of the chest will show that many of the physical signs of tubercles are absent, and that those of chronic bronchitis already noticed, which are present, differ considerably from those of phthisis. 448. Prognosis. — The simple form of bronchitis is not in general very serious, unless it be secondary, and then its importance will rather be owing to the original disease. When the entire mucous membrane is affected, the case is, of course, very serious, and will often prove fatal. Suffocative catarrh is certainly the most fatal form of the disease in these countries. The increase of the dyspnoea, the severity of the cough, the feeble- ness and irregularity of the pulse, the oppression, anxiety, and rapid breathing, indicate a fatal termination to the attack ; while a gradual mitigation of the symptoms, diminished dyspnoea, a firmer, slower pulse, &c, are favorable. 449. Treatment. — There is an important distinction between catarrh in the adult and in infants. When the first stage is passed with the former, and profuse secretion takes place, the disease is essentially over- come, and the patient rapidly becomes convalescent ; but in the infant, although a certain amelioration takes place when the second stage is established, we cannot always be sure of a favorable termination ; for if the bronchial secretion be prolonged, and if it occupy the smaller tubes, there is considerable danger of lobular pneumonia, unless the treatment be continued. The indications we should have in view are : 1. To diminish the in- flammation ; 2. To remove or lessen the secretion ; 3. To support the strength ; and 4. To relieve certain symptoms when it is impossible to do more. 450. When the attack of simple bronchitis is slight, it will often be sufficient to exhibit demulcents and expectorants, with the use of a stim- ulating liniment to the chest. Almond milk, with ipecacuanha wine and syrup of squills, answers the purpose very well. Should the secretion be abundant, an emetic will be very useful ; and as the disease advances, the addition of a little paregoric will both re- lieve the cough, and, to a certain extent, control the secretion. BRONCHITIS. 313 A poultice of bread and milk, or of linseed-meal, is very soothing, and if it be desirable to excite irritation, a little flour of mustard may be added ; or the compound camphor liniment used. 451. But when the attack is more severe, it will be necessary to com- mence with more active measures. An emetic, followed by a warm bath, will generally afford some relief ; or it may be advisable to apply leeches to the chest, or to cup, regulating the amount of blood abstracted by the age and strength of the child. This will be particularly necessary when the breathing is much hurried, the pulse quick, and the skin hot, whether the affection be of the large tubes or the smaller. All authorities are agreed upon the propriety of bloodletting, and generally that it should be carried so far as to make an impression upon the disease, provided we see the child at the commencement of the at- tack. It is far less efficacious, and should be more cautiously used, at a later period. After the bleeding is stopped (which should be instantly, the leeches fall off), the child should be put into a warm bath, and then returned to a warm bed. A little calomel and James's powder may be given once or twice a day, with a purgative when necessary. The demulcent and expectorant mixture should be continued, but unless the secretion be very abundant, there is no object in repeating the vomiting. When the fever is lessened, and the pulse reduced in frequency, great benefit will be derived from counter-irritation, either by blisters or a strong liniment. Upon the whole, I think the blisters answer best ; but if we wish merely to irritate the skin, compound camphor liniment, or a linseed-meal and mustard poultice (one-third of the latter to two- thirds of the former), will be sufficient. This may be followed by an ordinary poultice, of the soothing, beneficial effects of which upon the lungs practitioners seem scarcely sufficiently aware. The best proof of this is, that the children like it, and ask for a second application. It should be applied to the surface with nothing intervening, and should be warm and moist. When it cools, it should be exchanged for a fresh one. 452. In suffocative catarrh we must have recourse to similar reme- dies, but there are others which will be necessary. The decoction of senega root has been highly extolled, and I think with reason, espe- cially when combined with ammonia and ipecacuanha wine. The two remedies I have found most efficacious in relieving the smaller bronchial tubes, are ammonia, with ipecacuanha or tartar emetic, or spirits of tur- pentine. The formulae I generally employ are the following : — R. — Mist, amy gel al. §ij. Vini ipecacuan. gj vel antim. tart. gr. j. Carbon, ammonite gr. vj or gr. x. — M. A teaspoonful may be given to a child of a year old every three or four hours, and the quantity of ammonia may be increased or diminished according to the age. Or, Mucil. acacias, Syr. simpl, aa gij. Spts. tereb. rectif. gtt. xx to gtt. xxx. Aquae carui gij. — M. A teaspoonful to be given every two, three, or four hours. 814 BRONCHITIS. From these medicines, I have found great benefit, after bleeding, warm baths, &c. In many cases, I have found the tartar emetic mix- ture act quite magically in relieving the chest ; but it is necessary to watch, lest it produce too much depression, in which case the ammonia may be increased or the tartar emetic omitted, or a little weak wine and water given. I quite agree with M. Barrier and others that active bloodletting is essential in severe cases of capillary bronchitis, and that it should be followed by other evacuants, as emetics, purgatives, &c; but in cases not so severe, and in weak delicate children, the tartar emetic supersedes the necessity for bleeding. Benefit will also be derived from small doses of Dover's powder, or the addition of a drop of laudanum to the expectorant mixture. Counter-irritation is of great value in capillary bronchitis, and cer- tainly blisters answer the purpose better than milder irritants. I have found more benefit with young children from a succession of small blis- ters than from a large one, with far less distress and exhaustion. A large poultice to the chest, without blistering, or over the dressing of the blister, has a most soothing effect. It should be changed every half hour, and continued for two or three hours. 453. In that form of the disease described by Dr. Parrish, he ordered " a warm bath, sinapisms to the feet, a large blister over the breast, and laxative injections, containing assafoetida. But the remedy on which I chiefly relied was assafoetida, rubbed up with mint water, given frequently and in large doses." However, as other remedies were em- ployed, they may have had as much influence as the assafoetida. Dr. Parrish ordered a drachm of the gum to be rubbed up with an ounce of mint water, and a teaspoonful to be given every two hours. For the catarrhal fever described by Dr. Eberle, he first freely eva- cuated the bowels, and then, if the pulse were full and quick, leeches or the lancet were freely used; after which, antimonials, calomel, and ipecacuanha, with a mixture containing small doses of tartar emetic, were employed. When the febrile action had been moderated, small doses of Dover's powder were found beneficial. He found an occa- sional emetic very useful, and an expectorant mixture, composed of equal parts of paregoric, syrup of squills, and sweet spirits of nitre, with water. 454. Chronic bronchitis will require a somewhat modified treatment. We cannot here use bloodletting very freely, nor in every case. I do not mean to say that there are no cases in which it may be necessary, but as a general rule it should be avoided. We must content ourselves with free evacuations from the bowels, an occasional emetic, repeated counter-irritation, diuretics, and expectorant mixtures, containing the stimulating balsams. Decoction of senega, with carbonate of ammonia, balsam of Tolu, Peruvian balsam, &c, will be found very useful. If, as is commonly the case, the disease be complicated, it will be of great importance to relieve the complication ; indeed, we shall scarcely overcome the chronic bronchitis without previously effecting this. In most cases, tonics will be necessary ; and of these, perhaps, some of the vegetable bitters, as quinine, infusion of cascarilla, gentian, &c, INFLAMMATION OF THE LUNGS. — PNEUMONIA. 315 will be found the best. It may also be necessary to allow a better diet than in acute cases. 455. In either form of the attack, but especially in the acute, it will be necessary that the air of the room the child inhabits should be fresh, and the temperature equable and warm. It is much better, even when the disease is slight, to confine the child to two rooms, and not to allow it to run about the house, as the frequent change of air irritates the delicate mucous membrane, and keeps up the cough. In capillar}' - bronchitis, it will be still more necessary to keep the infant in a warm temperature; and this course must be continued during convalescence. For some years past, I have been in the habit of recommending a very slight flannel waistcoat next the skin after these attacks, with the best effects. In fact, this climate is so variable that it is an excellent pre- caution to adopt at the beginning of winter, before the child takes cold; and children who can walk are so apt to stand still after heating them- selves that it is next to impossible to escape a chill without some such precaution. The diet of the child should at first be very moderate. In most cases, the appetite is lost, and no child will eat without one, so that there is no danger of overfeeding. As convalescence proceeds, we must gradually increase the quantity of the food, taking care to keep up the strength without overloading the stomach. CHAPTER VII. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 456. Inflammation of the substance of the lungs is a disease rarely or incompletely noticed by older writers, and often passed over very superficially by more modern authorities. We are more indebted to the researches of continental physicians than to those of our own countries for the information we at present possess. MM. Duges 1 and Guersent 2 ■were the first to investigate the subject, and they were followed by Leger, 3 Denis, 4 Brunet, 5 Gerhard, 6 Gumming, 7 Valleix, 8 Billard, 9 &c. ; but probably the most valuable contribution to the history of the disease is to be found in the works of Rilliet and Barthez, 10 Barrier, 11 and Dr. West, 12 of London. 1 E,echerches sur les Mai. les plus import, et les moins connues des Enf. nouveaux-nes. 2 Dictionnaire de Medecine. 3 Essai sur la Pneumonie des Enfans. 4 Recherches Anat. et Phys. sur quelques Mai. des Enfans. 5 Mem. sur la Pneumonie lobulaire. 6 American Journal of Med. Sciences, vols. xiii. xiv. 7 Trans, of Assoc, of College of Physicians in Ireland, vol. v. p. 28. 8 Clinique des Mai. des Enfans nouveaux-nes. 9 Traite de Mai des Enfans. 10 Traite Clinique et Pratique des Mai. des Enfans, vol. i. p. 80. 11 Traite pratique des Mai. de FEnfance, vol. i. p. 45. 12 Lectures on the Diseases of Infancy and Childhood, p. 175. 316 INFLAMMATION OF THE LUNGS. — PNEUMONIA. Notwithstanding that the disease has been so often slightly treated, it is sufficiently frequent in children of all ages and in different circum- stances. For example, the registered deaths in Great Britain for 1839 show that 18,151 children — 10,000 males, and 8151 females died of pneumonia ; and in Philadelphia, during the ten years preceding 1845, of 26,510 deaths, there were 1592 cases of this disease. In the appendix to the Registrar-General's Report for 1841, we find that of 1,000,000 children living in the country, 905 died of pneumonia, and 2028 out of the same number of children living in towns. M. Guersent states that three-fifths of the children dying in Paris before the completion of dentition, die of this disease. This is sufficient to prove the frequency of the disease, and to show that it deserves our most careful and minute consideration. 457. Recent researches since have established a distinction between pneumonia affecting an entire lobe of the lung, and pneumonia affecting the lobules. The former, lobar pneumonia, resembles the disease in the adult; the latter, lobular pneumonia, is peculiar to children, but some eminent authorities, Legendre, Fuchs, and I believe Dr. West, consider that the latter is not pneumonia, but atelectasis. According to Rilliet and Barthez, and Barrier, the latter is much more common than the former ; Rilliet and Barthez give the results of eighty-four cases of the former, and 203 autopsies of the latter. Of eighty-one cases of pneumonia, M. Barrier found twenty of lobar, and sixty-one of lobular pneumonia. We should bear in mind, however, that the proportion may differ, according as our observations include the children of the rich or those of the poor; those cases which we meet in private practice or in hospitals. Mr. Friedleben conceives that true lobar pneumonia is very frequent in early life, and that lobular pneumonia is for the most part confined to the first year. But, what is of more practical importance, either form may be pri- mary or secondary, although, as Barrier observes, lobular pneumonia more frequently constitutes the secondary attack. I shall endeavor to lay before the reader a short sketch of the cha- racteristic symptoms of each variety, and then notice the difference to be observed according as the disease is primary or secondary. 458. Symptoms. — I. Lobar Pneumonia. — This form of the disease, at least when primary, is rarely preceded by catarrh ; the child exhibits a degree of fever, with a hot skin, quick pulse, thirst, &c, for a few days, during which time a short cough may be observed, less strong and frequent than in adults, dry at first, and with little or no effort at expec- toration. This cough continues, and increases in frequency in most cases, but we have not the advantage of the peculiar expectoration of adults, for very young infants swallow the expectoration, if there be any, and in general up to five years of age it is not peculiar ; from five to fifteen, although the pneumonic sputa may frequently be observed, they are absent in many cases. Very often the cough is not accompanied with pain in the chest, but in some cases, when the child is old enough to complain, we find pain circumscribed to the seat of the disease ; in others, it is diffused and ob- INFLAMMATION OF THE LUNGS.— PNEUMONIA. 317 scure, sometimes at the epigastrium and radiating to the abdomen ; sometimes near the base of the lung. Dr. Gerhard observed it most frequently at the anterior edge of the axilla. The dyspnoea, Barrier remarks, is greater than in adults; " thus it is not rare to find a pneumonia occupying the lower half of one lung cause from forty to sixty respirations per minute, -whilst in the adult it would require very extensive disease to produce the same effects." 1 And from a careful register of nine patients, he finds that the frequency of the movements of the thorax, compared to those of the heart, were as 1 to 2.69. 459. The respiration, then, is short and rapid ; from 40 to 60 or 80 per minute. Nay, Dr. Cumming 2 mentions a case in which it amounted to 118 ; but although the frequency may in part be owing to the amount of disease, it appears to be partly an involuntary precaution to avoid the irritation and cough consequent on a full inspiration. Some- times this hurried respiration intermits, and for a short time the respi- ration seems natural ; but very speedily the rapid movement is resumed. This acceleration of the respiration and pulse is said to be at its height on the fourth or fifth day ; and by the seventh or ninth, if the case pro- gress favorably, the pulse diminishes in frequency, and the respiration becomes more calm and deliberate. If the disease increase, the respiration becomes more labored, not less rapid, but with greater muscular effort ; the chest heaves, the alse nasi dilate, and even the momentary interruption caused by speaking seems to add to the distress of the lungs. There is an effort now and then to fill the lungs by gaping, sighing, &c, but it appears to be in- effectual ; the congestion is so great that it impedes both the circulation in the lungs and the respiration. Rilliet and Barthez have remarked that the irregular, abrupt respi- ration occurred almost exclusively when the summit of the lung was principally affected. When the disease proves rapidly fatal, the fre- quency of respiration goes on increasing until death ; but when the dis- ease is prolonged, we may observe a diminution during the last few days, not from any amelioration, but probably from a degree of organic in- sensibility. The pulse is very quick from the beginning, seldom under 120, even in cases where the distress does not appear very great ; but it often exceeds this, and may reach 140, 160, or even 180, especially with young children. At the commencement it is generally full, strong, and regular, and in favorable cases it gradually becomes softer and slower; but in unfavorable, whilst it preserves its frequency, it becomes ex- tremely small, irregular, and ' at length insensible. The heat of skin bears a relation to the rapidity of the circulation ; during the first part of the attack, the skin is dry and very hot ; towards the end, in unfa- vorable cases, although the pulse is equally, or even more rapid, the skin becomes cooler, and moistened with clammy perspiration. The decubitus is sometimes dorsal, sometimes on one side or the other, apparently owing to the effect upon the thoracic pain or uneasi- ness. 1 Mai. del'Enfance, vol. i. p. 193. 2 Trans, of Association, vol. v. 318 INFLAMMATION OF THE LUNGS. — PNEUMONIA. The expression of the face is that of great distress, sometimes flushed, sometimes pale, or more frequently with a patch of vivid red on one or both cheeks. The alae nasi are in active operation, dilating just before or with each inspiration, and the nares are dry, for young infants rarely breathe through the mouth. Billiet and Barthez have noticed the blue circle which appears beneath the eyes, and which increases with the progress of the disease, especially when there is much emaciation. 460. The physical signs of lobar pneumonia are of great impor- tance, from the frequent absence of the characteristic sputa of pneu- monia. They, however, do not differ much from those observed in the adult, and therefore I need not dwell at length upon them. Percussion yields a distinct dulness of sound in the affected part, compared with those portions of the lungs which are free ; but we must be on our guard against making the opposite side a standard of comparison, as both lungs are frequently involved ; different portions of the lungs, as well as both sides, must be carefully percussed, and it will rarely be difficult to satisfy ourselves. The crepitant or sub-crepitant rale will be heard in those parts of the lungs still in the first stage of inflammation ; but when the respiration is very quick and short, it is less characteristic, and will require that we make the child cough, or take a deep inspiration. With infants who cannot comprehend our directions, the best way is to stop the breath for a moment ; the effort to resume it will insure a deep inspiration. The rale may occupy a small portion, or nearly the whole of the lung ; it may be heard at the superior, middle, or inferior portions. Not un- frequently, when one lung only is affected, we shall find puerile respira- tion in the other. When extensive hepatization has taken place, little or no crepitus will be audible, except around the diseased portion, but instead we may find bronchial respiration, and something resembling bronchophony, with extreme dulness. In the third stage, the stethoscopic signs are pretty nearly the same as in the second, except that the bronchial respiration is more distinct and also more extensive, occupying situations where crepitation had not previously been heard. It becomes audible in front as well as posteri- orly, and is perceived, along with dulness on percussion, in the infra- mammary, as well as in the infra-scapular region. It is generally more extensive on one side than the other, and occasionally it is audible throughout the entire back part of one side of the chest. It is never confined to the upper part of the lung, unless there have existed pre- viously tubercular disease. Dr. West observes that bronchial respiration must always be con- sidered of serious import ; in eleven out of twenty cases of pneumonia, where it existed, the disease terminated fatally. 461. The appetite is lost from the beginning in severe cases ; the tongue is white and loaded, sometimes moist, but generally dry, probably from the endeavor to breathe through the mouth ; and the thirst is con- siderable. In very young children Dr. West has noticed a peculiarity of sucking. Vomiting occurs occasionally at the commencement of the disease, INFLAMMATION OF THE LUNGS. — PNEUMONIA. 319 and more frequently than with adults ; subsequently it is generally the consequence of medicine. Diarrhoea, on the other hand, is rare, except towards the termination, or when caused by the remedies. The secretions are irregularly and variously affected ; the urine is high-colored at the beginning, and occasionally scanty, but in many cases but little altered. The liver is less affected than in adults ; never- theless, jaundice does sometimes, though rarely, occur, and in such cases, MM. Chomel and Eouillaud 1 conceive the base of the right lung to be the seat of the disease, and the jaundice to be the result of its proximity to the liver; but M. Grisolle has adduced evidence to show that this can scarcely be the reason. 2 Others have asserted that the jaundice is not the result of the peculiar condition of the liver, but of the incomplete hrematosis caused by the pneumonia, and that it is analo- gous to the jaundice determined by purulent infection. It is unnecessary to state that the strength of the patient is greatly depressed, and that in a very few days it is in every way alarmingly reduced. The nervous system does not escape ; there is generally a good deal of anxiety and agitation, especially at night. In other cases there is headache, and a degree of stupor ; in a few cases delirium or convul- sions.. In some cases, as M. Tonnelier has remarked, these nervous symp- toms may be the result of sympathetic irritation, but in others they appear to depend upon coincident meningitis. 462. Duration and Termination. — Lobar pneumonia in children, like the same disease in adults, commences, as we have seen, by rigors, heat, cough, pain in the chest, hurried respiration, dyspnoea, and quick pulse ; these symptoms continue, and perhaps increase for a time, but when the treatment is successful they gradually diminish. The pulse becomes slower, the respiration calmer and less labored, the pain dis- appears, and the cough is softer ; then the appetite returns, the tongue becomes clean, and the strength is gradually regained. Unfavorable cases, on the other hand, are marked by an increase of the symptoms, the respiration becomes more hurried and labored, the aloe nasi moving incessantly ; the cough short, frequent, and distressing ; the pulse small, weak, quick, and at length irregular or intermitting ; the face livid ; the eyes sunken ; the lips purple, and the surface cold and clammy. Upon the whole, in primary lobar pneumonia the result is favorable ; only one in twenty of M. Barrier's patients died. The duration of the disease varies somewhat : it is seldom less than from six to twelve days, generally from twelve to eighteen, and fre- quently longer. Dr. Gerhard states the mean duration to be fifteen days. Of fifteen uncomplicated cases M. Barrier mentions that the disease lasted ten days in four cases ; eleven in two ; twelve in one; thirteen in one ; fourteen in three ; and sixteen, eighteen, twenty, and twenty-five in one case each. 463. Lobular Pneumonia. — We will now enumerate the symptoms 1 Clinique, vol. ii. p. 138. 2 Traitg de la Pneumonie, p. 384. 320 INFLAMMATION OF THE LUNGS. — PNEUMONIA. of lobular pneumonia, which differ in some particulars from those just described, and which, in many cases at least, may be chiefly owing to the disease being secondary, or occurring in the course of some other malady. In almost all cases it is preceded by pulmonary catarrh ; either the latter is the primary disease, upon which pneumonia supervenes, or, being secondary to some other primary disease (as measles, for instance), it runs on into pneumonia. It occurs also more generally in infants and young children, than lobar pneumonia. Of sixty-one cases related by M. Barrier, twenty occurred from two to three years, and twenty more under five years of age, which will account also for some obscurity in those symptoms which depend upon the patient's description. For example, we have reason to believe that there is pain or uneasiness in the chest, but with young infants this can only be suspected from their crying when the cough comes on. In older children it does not appear to be acute and circum- scribed, but diffused, and principally in the region of the diaphragm, not troublesome ordinarily, but excited by coughing. The cough is an important symptom ; no doubt it exists before the pneumonia sets in in secondary attacks, but even then its increase will mark the accession of the more serious disease. It continues short and troublesome, dry or moist, until the decline of the disease ; but in fatal cases it often disappears for two or three days before death. In some rare cases of latent pneumonia, the cough is nearly absent, and these occur generally in weak, cachectic children. The cough does not occur in kinks, neither is it hoarse, unless the disease be complicated. We can derive but little assistance from the expectoration, for in many cases there is but little secreted, and by in- fants and young children it is always swallowed ; but, from some obser- vations he made, M. Barrier is of opinion that, if it occurred, the sputa, in many cases, would exhibit the pneumonic character. The dyspnoea and hurry of respiration are in proportion to the extent of the bronchitis and pneumonia, and fully as much owing to the former, when severe, as to the latter. Thus, with intense catarrh and a pneu- monia of moderate extent, the respirations will occasionally amount to fifty or sixty per minute. On the other hand, when the pneumonia is extensive, and the bron- chitis slight, the respiration will be found very rapid and short, with free motion of the alse nasi, and ultimately of the chest and abdomen. "Moreover," M. Barrier observes, "it is not merely by the number of respirations per minute that we must judge of the extent and gravity of the lesions of the lungs. We must also observe whether the respira- tion be superficial or profound, if it be easy or painful and anxious, costal or abdominal, regular or irregular. In general, the more fre- quent, deep, and anxious it is, the more serious is the attack. But we must not forget that occasionally we find the respiration increased in infants for a few minutes, without apparent cause, and that it soon sub- sides again." 464. The physical signs are of great importance, even though they may not be quite so definite and certain as in adults. Dr. Gerhard INFLAMMATION OF THE LUNGS. — PNEUMONIA. 321 lays great stress upon the dulness on percussion ; he conceives it in many cases of more use than auscultation. M. Vernois found the dul- ness very marked in twenty out of twenty-two cases, and slight in the remaining two. M. Valleix found dulness in twelve out of sixteen cases, seven times on the right side, and five times on both sides. Ril- liet and Barthez found but little deviation from the normal sound in partial or mammelonated pneumonia, but decided dulness in the gene- ralized form. M. Barrier states, that in " disseminated lobular pneumonia" the results of percussion are completely negative, and that there is no dulness unless from some complication ; but that, when the disease has gradually spread and coalesced in " generalized lobular pneumonia, the sound is dull on percussion." 1 My own experience coincides with Dr. West's, who remarks : " Per- cussion sometimes yields a very manifest dulness on the affected side ; and this dulness is usually most evident in the infra-scapular region. At other times, however, no such marked results are afforded, but the lower parts of the chest yield a somewhat duller sound than the upper, and the impression communicated to the finger is that of greater solidity below than above the scapulae. This last sign is very valuable, since it may be perceived at a time when the ear cannot clearly detect any actual dulness on percussion." In the disseminated or partial form of the disease we find the sub- crepitating and mucous rales, with an occasional mixture of the sibi- lant. Rilliet and Barthez lay great stress upon the subcrepitant rale, as being often the only sound to be heard throughout the course of the disease. It is generally audible at the back of the chest, sometimes in front, and at different points, according as the lobules affected may be distant or near. The true crepitant rale is much rarer in infants than in adults, al- though it is occasionally audible for a few moments. 2 If one lung only be affected, we shall find the subcrepitant rale on one side and puerile respiration on the other ; but if both be affected, as Dr. West remarks, we may overlook the disease, owing to the absence of contrast, unless the disease of one lung be so far advanced as to give rise to bronchial breathing, whilst in others nothing but the subcrepitus can be de- tected. At a more advanced period, or, what is much the same thing, in the " generalized lobular pneumonia," we have present more or less of the preceding phenomena, but with certain modifications. The diseased portions having coalesced, and the lung having become more generally solid, we find bronchial breathing, both in expiration and inspiration in one or both lungs posteriorly, and even bronchial rales and broncho- phony. The subcrepitant rale has changed a good deal, the bubbles are smaller, and the crackling much finer; in fact in many cases we find the pure crepitating rale of lobular pneumonia, as in the adult, especially when the disease is superficial. 1 Mai. del'Enfance, vol. i. p. 105-7. 2 Trousseau and Lasegue, Arch GCn. de Me"d., vol. xxvi. p. 130. 21 322 INFLAMMATION OF THE LUNGS. — PNEUMONIA. Occasionally these more defined phenomena of pneumonia are masked by the great amount of moist rales, but even these have a sort of me- tallic sound in this disease, which, taken along with the vocal reso- nance and the dulness on percussion, may prevent an error in our diagnosis. With regard to the vocal sounds, Dr. West observes : " In the child we lose all the evidence which in the adult is afforded by the different modifications of the voice sound ; for the shrill or querulous tone of a suffering child, and the words, often uttered in very different keys, yield, even when the child is old enough to talk well, results far too uncertain to be trustworthy." 1 465. The external appearance of the infant is not characteristic ; it will show that the chest is affected, but not the peculiar form of dis- ease. Thus, the face may be pale or colored, swollen and puffy, or red ; very often, while the rest of the face is pale, there is a bright spot of red on one or both cheeks. The alee nasi will be found in ac- tion in proportion to the hurry and difficulty of respiration, and the eyes appear sunken. The patient lies generally on his back, but is not more distressed by lying on one side than the other, which may be because the pneumonia is frequently double. The pulse varies very much, of course, but it is generally in propor- tion to the extent of the inflammation; it may range from 100 to 110, with but little heat of skin, in weak, delicate children ; to 140, 160, or 180, with high fever, in others. Towards the termination, it either gradually becomes slower and more natural ; or quicker, weaker, and irregular, according as the result is favorable or unfavorable. The usual relation between the respiration and circulation is destroyed ; in the adult suffering from pneumonia, it is as 1 to 4 ; in infants, it is as 1 to 2 or 3. The digestive system is more or less deranged ; vomiting is frequent at the commencement of the disease, but rare subsequently. Intestinal catarrh, according to M. Barrier's experience, precedes the attack of pneumonia in many cases, and in others we often have diarrhoea in the course of the disease, especially when it is secondary to measles ; and in these cases, if the pneumonia be extensive and advanced, it will be a very unfavorable addition ; but if the result of calomel or tartar emetic, it is not of so much consequence. Besides this diarrhoea, how- ever, we have no symptoms of intestinal inflammation ; there is neither pain, tenderness, nor tympanitis. As in lobar pneumonia, we may have a certain degree of sleepiness, indifference or cloudiness of intellect ; nay, even some more marked nervous affections, as anxiety, agitation, contractions or convulsions, and delirium. 466. I. Termination and Duration. — As I have described it, lobular pneumonia may continue steadily advancing, the symptoms increasing in gravity, and the constitution suffering more severely, until death. Or, the disease having arrived at its maximum of intensity, the symp- 1 Lectures on Diseases of Infancy and Childhood, p. 195. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 323 toras may gradually diminish ; and, if the termination is to be favor- able, this amelioration will affect both the general and local symptoms. In some cases, we have an improvement in some one or two symptoms for a time, and then a return. Such cases generally terminate fatally. It is more difficult to fix the duration of lobular than lobar pneumo- nia, because the former being most frequently secondary, and stealing on more or less insidiously, we cannot ascertain the exact period of invasion. Rilliet and Barthez give the following duration in eighty- three cases : in twenty, it lasted from one to five days ; in nineteen, from six to ten days; in sixteen, from eleven to fifteen days ; in twenty, from sixteen to twenty-five days ; and in eight, from twenty-six days upwards. M. Barrier remarks that those cases which are cured are of the long- est duration ; the fatal cases he has never known to last longer than from twenty-five to thirty days. The others may run on for a month or two. M. Friedleben states that in the great majority of children, the first stage lasted for twelve hours, the second for three days, the third from five to seven days, after which convalescence commenced, but that it sometimes proves fatal in from twelve to twenty hours. 467. II. Lobular pneumonia may result in abscess of the lung, as a termination ; but probably in most cases it will escape detection unless purulent matter be expectorated. This, and a large mucous rale, ap- proaching to a gurgle, may enable us to suspect the existence of an abscess when the bronchial tubes communicate with it. In other cases, it may be impossible to decide. Moreover, as these abscesses tend to the surface, and occasionally open into the pleura, the very sudden occurrence of pleurisy may lead us to suspect a perforation. 468. hi. In some rare cases, pneumonia terminates in gangrene; the symptoms are those of pneumonia, with extreme depression of strength, profound constitutional suffering, and a rapid course. It seems more apt to attack children, during exanthematous fevers, whose constitution has been much deteriorated ; and it is not uncommon to find, at the same time, gangrene of some other parts. Of eighteen cases of gan- grene mentioned by Rilliet and Barthez, three had gangrene of the mouth, one of the pharynx, two of the oesophagus, one of the larynx and pharynx, one of the bronchial glands and spleen, one of the glands, pleura, and oesophagus, and one of the pleura alone. In Dr. West's case, there was gangrene of the mouth. From all the circumstances, Dr. West infers, and, I think, with great probability, that the gangrene is due rather to some peculiar morbid alteration of the circulating fluid than to the violence of the inflammatory action. 469. Such are the characteristics of lobar and lobular pneumonia. Either may be primary or secondary; but the lobar is more frequently primary, the lobular secondary. The principal differences are in the mode in which each commences, in the greater amount of fever, the dulness on percussion, the crepitating rale, and the quicker termination of the former; the insidious approach, the greater obscurity of the physical signs, the slight dulness on per- cussion in the first stage, the diffused subcrepitant rale, the different 321 INFLAMMATION OF THE LUNGS. — PNEUMONIA. points at which it is heard, and the changes which it undergoes subse- quently, the greater duration and greater fatality, of the latter. 470. Now let us examine the different characters of primary and secondary pneumonia, whether lobar or lobular. Primary pneumonia commences by intense fever, with occasionally a slight bronchitis preceding, in very young children. The respiration is always rapid, with thoracic pain occasionally, and a short, dry cough. Auscultation reveals the existence of crepitant or subcrepitant rales on one side of the chest, and especially towards the base of the lung. Vomiting occurs at the beginning, and occasionally diarrhoea. There is anxiety, agitation, and sighing. As the disease advances, some of these symptoms disappear, and new ones appear. The fever rather increases, as does the dyspnoea and hurry of respiration ; the alse nasi are observed to move extensively, and more effort is required to breathe; the cough is very troublesome, short, and painful; expectoration makes its appearance, except in young subjects ; the pulse is very quick; the crepitating or subcrepitating rale gives place in some portions to bron- chial respiration and bronchophony, and the chest yields a dull sound on percussion. These symptoms attain their height about the fifth or sixth day; but, after the eighth or ninth day, in favorable cases, they begin to subside, the fever diminishes, the pulse and respiration become slower, the alee nasi are quiescent, the heat of the skin subsides, the large subcrepitant rale is freely heard, with bronchial breathing more rarely, and chiefly in expiration. The sound of the voice is diffused, and the dulness less marked. By degrees, the appetite returns, the spirits and strength of the child are recovered, the cough diminishes, the fever altogether dis- appears, and the patient becomes convalescent. 471. When pneumonia supervenes upon another disease, or is second- ary, it presents very different characters, and the difference is greater, according to Rilliet and Barthez, the earlier the secondary affection supervenes upon the primary disease. Secondary pneumonia (most frequently lobular) is apt to steal upon us very insidiously, the pulse, respiration, and countenance, affected by the primary disease, undergoing but little change. The cough may be troublesome, but there is little thoracic pain, and no expectoration. If no cough existed previously, we shall be induced, probably, to examine the lungs, and thus the complication will be detected. The subcrepitant rale will be heard on one or both sides posteriorly. As the disease advances, the fever will increase, the pulse become quicker, the respira- tion more hurried, the cough more constant; the strength diminishes, and the face will have a worn, anxious, and distressed expression. The chest will gradually become dull on percussion ; and, with the subcrepi- tant rales, we may also hear bronchial respiration and bronchophony, increasing in intensity and extent. The primary disease will generally be found to have undergone an unfavorable change, and with these unfavorable symptoms will at length be found others, such as feeble and irregular pulse, violet color of the face, great dyspnoea, coldness of extremities, &c, which denote the approach of death. We can readily understand that the secondary must be more fatal INFLAMMATION OF THE LUNQS. — PNEUMONIA. o^O than the primary, because the child has to combat a second most for- midable disease, at a time when his strength is reduced, and his con- stitution shaken, by a previous one. Of sixty-one cases noted by M. Barrier, forty-one died. 472. Complications. — When we recollect the anatomy of the lungs, and consider their contiguity with the tissues which line or surround them, we cannot be surprised at other affections supervening in the course of pneumonia. I. Bronchitis. — In a great majority of fatal cases, evidences of in- flammation of the bronchial mucous membrane are found after death, and in a very large number we can ascertain its existence during life, either as a primary or secondary affection. Barrier has proved that lobular pneumonia is preceded, in a very large proportion of instances, by pul- monary catarrh, and that it is, probably, an extension of this latter affec- tion. Rilliet and Barthez have drawn the following conclusions from their experience : — " 1. That the bronchitis which coincides with pneumonia is almost always an affection of the small tubes. 2. That in a great majority of cases it co-exists with lobular, mammelonated, partial, and generalized pneumonia ; more rarely with lobar pneumonia. 3. That bronchitis, with dilatation, is found almost exclusively in infants who have died of partial or generalized (lobular) pneumonia ; almost none in those who have suffered from lobar pneumonia. 4. That bronchitis exists almost always either in the centre of the part hepatized, or in the portions sur- rounding it, but that it may occur elsewhere. 5. That dilatation of the bronchi is frequent in the carnified tissue." 1 473. II. Pleuritis is a frequent complication of pneumonia, and so intense is it occasionally that the disease may well be called, as it is by some, pleuro-pneumonia. About one-fourth of Rilliet and Barthez's patients, attacked with lobular pneumonia, exhibited traces of recent pleurisy. The proportion of those suffering from lobar pneumonia, who had secondary pleurisy, was even higher ; it amounted to one-half. I do not think that the complication is so frequent in this country, or in private practice; but still it does occur, and adds much to the danger. In most cases it is extremely difficult to detect the presence of pleurisy, the symptoms, and even the physical signs, being masked by those of the existing pneumonia; but now and then we may arrive at a just con- clusion. 474. in. When we consider the extreme difficulty of the respiration in some cases, and the violent efforts made by the child, we shall not be surprised that the disease is occasionally complicated by emphysema, which is in general in proportion to the extent of the pneumonia and bronchitis, to the acuteness of the disease, and to the amount of dys- pnoea which is present. 475. IV. I have already mentioned that lobular pneumonia is occa- sionally complicated with convulsions and other cerebral affections of minor degree. Six of M. Barrier's cases were thus attacked and died. In three there were proofs of meningitis. 1 Mai. des Enfans, vol. i. p. 75. 326 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 476. But in many cases the pneumonia, whether lobar or lobular, but far more frequently the latter, is secondary, and occurs as a complica- tion in the course of other diseases. It occurs most frequently in the course of measles, but we find it com- plicating scarlatina and other febrile eruptions, hooping-cough, croup, pleurisy, bronchitis, cancrum oris, intestinal catarrh, typhoid fever, &c. 477. Morbid Anatomy. I. Lobar Pneumonia. — I need not enter at length upon the post-mortem appearances found in lobar pneumonia, as they are identical with those in the adult, and will be found laid down in all the modern books on the subject. We find in infants evidences of congestion, red and gray hepatization, extending from the base of the lung towards the summit, but very rarely terminating in abscess. Dr. West has stated the result of forty-seven cases carefully noted : in five, the first and second stages of pneumonia co-existed, and in four, the first and third ; in thirteen, the second and third ; in eleven, all three stages ; in three, the first stage only ; in six, the second stage ; and in five, the first stage only ;* and this, as he observes, agrees very closely with the results obtained by M. Grisolle in the adult. In forty cases, he found that the first and second stage co-existed in four ; the first and third in three ; the second and third in sixteen ; all these stages in two cases ; the second stage only in seven ; and the third stage only in eight. 2 It resembles the pneumonia of adults, also, in being more frequently single than double, and more common in the right lung than the left. Of 1430 cases in the adult, M. Grisolle states that 742 were on the right side, 426 on the left, and 262 double. Of eighty-four cases in children, given by Rilliet and Barthez, forty-eight were of the right lung, twenty-seven of the left, and nine double. Of M. Barrier's twenty cases, ten were of the right lung ; six of the left ; and four were double. In cases of double pneumonia, both lungs are pretty equally affected. Of seventy-five cases in which a single lung was affected, Rilliet and Barthez found forty-eight in which the base, and twenty-seven in which the summit of the lung was diseased ; and of the latter, twenty-three were of the right, and four of the left lung. M. Barrier, in twenty cases, found the entire lung affected in three cases ; the inferior lobe in twelve ; the superior in four; and the supe- rior lobe with the upper part of the inferior in one case. Observation has also proved that the posterior portion of the lung is more frequently affected than the anterior ; and even when the post- mortem examination shows both to be involved, the history of the case would lead us to the conclusion that the disease commenced posteriorly. 478. II. Lobular Pneumonia. — Considerable difference of opinion exists as to the true nature of lobular pneumonia, and the exact cha- racter of its pathology. It appears to me that its existence as an in- flammatory disease is fairly established, and without pronouncing upon the opposite views of Legendre and Bailly, Fuchs, &c, I shall first lay 1 Lectures on Diseases of Infancy and Childhood, p. 176. 2 Traite" de la Pneumonie, p. 18. INFLAMMATION OP THE LUNGS. — PNEUMONIA. 327 before the reader the ordinary appearances, and by and by refer to the different pathological views held by these ingenious observers. Anatomically speaking, lobular pneumonia is so called from its occupy- ing one or more lobules ; and it has been divided into several varieties, mammelonated, disseminated, partial, generalized, with an additional species, by M. Barrier, which he calls pseudo-lobar. "When we examine," observe Rilliet and Barthez, "the lungs of subjects who have died from this disease, we find them extremely soft and flaccid, of a grayish rose color, with patches of violet red here and there, generally circumscribed, prominent, solid under the finger, and not collapsing when the chest is opened, as the surrounding pulmonary tissue does. These patches, ordinarily circular, but sometimes elongated from above downwards, are most frequent at the posterior edge of the lung, but are to be found on other portions. Occasionally they are not visible ; but nodosities, more or less deep, can be felt in the substance of the organ." When cut, the lung presents a marbled appearance, of a grayish red color, mixed with violet red, the latter corresponding to the external red patches; and we see that these patches and the deeper nodosities are centres of congestion and hepatization, whose characters resemble those of pneumonia generally ; i. e., the surface cuts smoothly, is granu- lar when torn, easily penetrated by the finger, and sinks when placed in water. On pressure, these portions of the lung crepitate very little, or not at all, but a sanious frothy fluid escapes : from the central portion, if pressed, we obtain a red serous fluid, without air, as in lobar pneu- monia. The three degrees of pneumonia may be observed : the first with the tissue marbled, of a rose and gray color; the red portions, irregularly limited, somewhat less resisting than the neighboring parts, floating in water ; when pressed giving forth a frothy fluid, and crepitating under the finger. This is the first degree ; the second has just been de- scribed. The third degree is characterized by a gray, yellow, or yellowish gray color, owing to the infiltration of pus in the pulmonary parenchyma. The tissue is very friable, and pressure expresses a purulent fluid. When the tissue is chiefly gray, it is possible to mistake the disease, unless care be used, inasmuch as it presents a resemblance to the sur- rounding healthy tissue. The same authors have entered into more special detail, however, and have described three varieties, the mammelonated, the partial, and the generalized. 479. I. The mammelonated lobular pneumonia consists of a small nodule {noyau) of hepatization, quite distinct from the surrounding tissue ; it is an isolated point of disease, in the midst of healthy or nearly healthy tissue, with its limits clearly defined. The limits are occasionally marked by a white resisting circle or space, like a fibrous capsule ; and ordinarily we can define the extent of the diseased por- tion from its prominence, which results from the shrinking of the sur- rounding parts when cut through. The volume of these nodules varies from that of a hempseed to a 328 INFLAMMATION OF THE LUNGS. — PNEUMONIA. pigeon's egg; their shape is generally regular and spherical, or some analogous form ; varying in number from one to twenty or thirty in the same lung. They result, it is clear, from the inflammation being limit- ed to one or more lobules, without extending to the neighboring tissue ; but in some few cases they are surrounded by a portion, in the first stage of pneumonia, just as we see in the case of tubercles. 480. In these nodules of hepatization, it is not rare to find the dis- ease attain the third degree, and form an abcess. The pus primarily deposited in the pulmonary tissue is collected in the centre of the in- flamed lobule, surrounded by two concentric zones, the inner one of yellow color, the third degree of inflammation, and the outer one of a red color, inflammation of the second degree, or hepatization. By degrees the suppuration is increased, at the expense of the inner circle and of the outer, and the centre is surrounded by a layer of false mem- brane. If several lobules close to each other have been attached, the abscess may be multilocular, and each cavity separated from its neigh- bor by a thin layer of hepatized tissue : or, this being broken through, they will communicate with each other. These abscesses may be situated in any part of the lungs, but they have rather a tendency towards the surface, and we occasionally find an adhesion between the two pleurse at this point. If this adhesion do not take place, the abscess may open there, and a pneumo-thorax be the result. Rilliet and Barthez met one case in which adhesion took place between the pleura of the base of the left lung and the diaphragm, and through this adhesion the abscess opened into the peritoneal cavity. 481. M. Barrier differs from the view taken by Rilliet and Barthez of these abscesses, but as I have not entered very minutely into their description, I shall avoid the controversy altogether, and simply quote M. Barrier's conclusion : " Lobular pneumonia may terminate by sup- puration in three ways: 1. Gray hepatization, when the pus is com- bined with and infiltrated into the parenchyma, constituting the most frequent and least advanced form. 2. Purulent collection in the lobule, with direct free communication with the corresponding lobular bronchus, which is dilated but not interrupted in its continuity, and which seems to widen in order to form the purulent cavity (vacuole). This is far from being rare, and is intimately connected with capillary bronchitis. 3. Abscess, properly so called, or collections of pus, primitively iso- lated, and closed completely ; coronfcunicating at a later period with the bronchial tubes, by rupture of its walls. This form is really very rare. The number of abscesses varies very much ; sometimes there is but one, in other cases a great number. They are rarely found in both lungs, and most commonly in the left. Of twenty-six cases, Rilliet and Barthez found abscesses in seven cases, in the right lung, in fifteen cases in the left lung, and in four in both lungs. Eight of these cases occur- red in infants from one year to two and a half years old ; ten, from three to five and a half; three, from six to ten and a half; and four, from eleven to fifteen years of age. 1 Mai. de l'Enfance, vol. i. p. 60. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 329 482. II. The partial lobular pneumonia is less defined than the mam- melonated; its circumference is confounded insensibly with the sur- rounding tissue, without our being able to decide upon its limits from the color or prominence. The volume of the diseased portion is often considerable, and its form irregular. The whole may be hepatized, or the outer portion congested and the centre hepatized ; and by the exten- sion of the inflammation, many separate points of disease maybe united, so as to involve nearly the entire lobe, and so constitute the generalized partial pneumonia. When the latter passes into the third degree of inflammation, it becomes, to all purposes, lobar pneumonia, and yet there is a considerable pathological difference. The three degrees of inflammation are evident in both, but they are disposed differently ; in the latter, commencing most generally at the base, and ascending, we shall find the lower portions the most advanced, and the superior less so; whereas, in generalized lobular pneumonia, the most advanced por- tions will be those of longest standing; and as the disease begins at different points, we may find gray hepatization in any part, and conges- tion or red hepatization occupying the spaces between. Abscess may be the result of this species of pneumonia, but less fre- quently than of the former. Still more rarely is it found with the lobar pneumonia, although such cases are on record. Out of 203 autopsies of lobular pneumonia, Rilliet and Barthez met with seventy of the mammelonated, 140 of the partial, and 104 of the generalized pneumonia. Thus it seems quite possible that capillary bronchitis (443) may run on into lobular pneumonia, and lobular pneumonia, by becoming genera- lized, into lobar pneumonia ; but is far from being a necessary transi- tion. 483. Garnification. — There is another morbid condition which de- mands our attention. It has not been described by authors generally, although sufficiently frequent ; its existence was first noticed by M. Rufz, in his memoir. He states : " I have observed an alteration of the pulmonary tissue, which is certainly not hepatization, although I am quite ignorant of its symptomatic value. This condition is ordinarily found along the inferior border of the superior lobe ; it may also occupy all the middle lobe, or the circumference of the base of the inferior lobe, to the extent of from a line to half an inch in thickness. In these parts, the pulmonary tissue is collapsed, of a violet color, but with whitish patches, which circumscribe the lobules. There is no crepita- tion ; the air appears entirely expelled ; one would say that it was a portion of lung, which had not as yet been expanded by respiration. When detached it does not float ; it is firm, and when hepatization co- exists, it is not easy to perceive the difference at the first glance." 1 When cut into, we find a red, smooth, resisting tissue, on pressure furnishing a sero-sanguineous fluid, free from air ; resembling a divided muscle in appearance ; hence the name. Thus, as to situation and form, it resembles each variety of hepati- zation ; but it differs in that insufflation restores it to its natural condi- 1 Journ. des Connois. Med. Chir., 1835, 404. 330 INFLAMMATION OP THE LUNGS. — PNEUMONIA. tion just as we find in atelectasis pulmonum, which it resembles much, although produced by different causes. 1 This peculiar condition is nearly as frequent in the right as in the left lung, and more frequently single than double ; the most common situation for it is on the left side, near the heart, and on the right side, in the middle lobe. Rilliet and Barthez observed forty-two cases of carnification ; sixteen double ; seventeen on the right side only ; and nine on the left. 2 484. Grangene of the Lung. — This termination of inflammation is very rare in children. Rilliet and Barthez met with eleven cases ; Barrier does not mention the subject; and Dr. West has seen but one case. I shall quote Dr. West's description of the post-mortem appear- ances, as being as concise and accurate, and more vivid, than any I could give : " The right lung, which consisted only of two lobes, was univer- sally solid, and not crepitant, with the exception of about a fourth of the upper and inner edge of the upper lobe, which was emphysematous. The two lobes were connected together by a layer of yellow lymph. The exterior of the lung generally was of a dark reddish-gray color, with irregular patches of yellow deposit beneath the pleura, some of which were nearly half an inch in length and a quarter in breadth ; besides which, many small purulent deposits were contained within the pulmonary vesicles, as in vesicular bronchitis. The upper part of the upper lobe, and a small portion near the diaphragmatic surface of the lower lobe, felt soft and boggy to the touch. On cutting into the upper lobe, a cavity was opened as large as a hen's egg, very irregular in form, intersected in various directions by the tubes and vessels that crossed it, from which, as well as from the walls of the cavity, portions of the lung hung in shreds. The cavity contained a small quantity of dirty, grayish-yellow putrilage, which exhaled a most fetid odor. The substance of the lung in the immediate neighborhood was in a far ad- vanced stage of purulent infiltration, and other parts of the lobe were in an earlier stage of the same condition ; besides which, small collec- tions of puriform fluid, not bigger than a split pea, were found in vari- ous parts of its substance. The state of the lower lobe on the whole resembled that of the upper, but the cavity in its lower part was not larger than a marble, and contained a small quantity of yellow pus, of a less fetid character than that in the upper lobe. The bronchial glands were swollen, soft, of a homogeneous aspect, and a gray color ; but neither in them nor in either lung, nor in any organ of the body, was there the least trace of tubercular deposit." 3 485. So much for the principal lesions of the lung resulting from or connected with pneumonia. I must just notice one or two others more or less frequently observed. I. Bronchitis. — Inflammation of the mucous membrane of the bronchi may be detected in the great majority of fatal cases of pneumonia, and especially of lobular pneumonia, from the earliest slight congestion, with increased secretion, up to entire vascularity, thickening and soft- ening of the mucous membrane, and dilatation of the tubes with puru- 1 Archiv. fur Physiologische Heilkunde, 6th par. vol. iv. 2 Mai. des Etifans, vol. i. p. 74. 3 Lectures on Diseases of Infancy and Childhood, p. 209. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 331 lent or pseudo-membranous matter contained in them. Although the tubes connected with the diseased lobules are almost always affected, yet they are not invariably so, nor is the inflammation limited to these tubes. I have already given Rilliet and Barthez's conclusions from their experience. II. The pleura not unfrequently exhibits evidence of ancient or recent inflammation, more frequently the latter. Adhesions, false membranes, vascularity, and effusion, may one or all be observed in these cases of secondary pleuritis. M. Valleix met with them in twenty cases out of one hundred and twenty-three. in. The bronchial glands are often quite healthy ; in other cases, they are enlarged, softened, and red, or they may contain tubercular matter. Their alterations, however, are of no practical importance. iv. According to M. Barrier, in a small number of cases complicated with convulsions, traces of inflammation of the membranes of the brain were detected. In other similar cases, no such evidences were found. V. The intestinal canal may occasionally exhibit marks of irritation ; but although diarrhoea is a very common complication of secondary lobular pneumonia, it rarely, if ever, appears to be owing to inflamma- tion of the mucous membrane, except in cases complicated with muguet or tubercles. 1 486. These, I believe, are all the morbid phenomena to be learned by a post-mortem investigation. The inquiry still remains as to what relation they bear to each other. Whether they are in truth a chain beginning with bronchitis and terminating at gangrene, or whether there is some difference in kind? Whether bronchitis invariably pre- cedes lobular pneumonia ? Whether every form of bronchitis may originate pneumonia, or what form has this peculiar consequence ? And why, if this be the result of any species, such an effect should be con- fined to the period of infancy ? M. Barrier has entered at length into these interesting questions, and has, I think, shown that all varieties of bronchitis do not equally give rise to pneumonia, but only the vesicular or capillary bronchitis ; that lobular pneumonia is almost invariably preceded by it, and that capil- lary bronchitis is more frequent from one to six years than at any other age; and that at this period the anatomical and physiological conditions of the respiratory organs are more favorable for the extension of inflam- mation to the substance of the lungs. But I will give his conclusions in his own words : " 1. The influence of age upon the production of lobular pneumonia is circumscribed within the period of from one to six years. Before and after that age, the disease is rare. 2. The ana- tomical and physiological conditions of the lung at that age are but secondary in the production of the lobular form of pneumonia. 3. Observation proves that the disease, in its development, is intimately connected with preceding bronchitis. 4. The species of bronchitis which has most influence is that which occupies the smaller tubes, and in which the catarrhal element is the most marked — it might be called catarrh of the small bronchi. 5. Lobular pneumonia is more frequent 1 Valleix, Clinique des Mai. des Enfans, p. 70. 332 INFLAMMATION OF THE LUNGS. — PNEUMONIA. from one to six years, because this catarrh of the small tubes is most frequent during the same period, and because it calls into action those anatomical and physiological peculiarities which diminish after that age. 6. Inflammation attacks the lobules, either because it is propagated from the bronchi to the lobules by continuity of tissue, or from the stagnation of the mucus in the most dependent bronchial tubes. The obstacle resulting from this, to the penetration of air into the lobules, favors the sanguineous engorgement, as by a species of partial asphyxia. 7. MM. Rilliet and Barthez have not understood all the importance of the bronchitic affection ; the opinion of MM. Burnet and De la Berge appears better founded, but it wanted the demonstration into which we have entered. 8. To pretend that it is not demonstrated that bronchitis always precedes pneumonia, and not the contrary, is to put forth a slightly founded objection, and one easily refuted. 9. If lobar pneu- monia is rare from one to six years, it is because the causes of this form are rarely in action at this age." 1 Thus, then, it would appear that capillary bronchitis may become the first step towards pneumonia ; congestion follows, then hepatiza- tion, red and gray, abscess, and gangrene. So far the chain seems quite complete ; the disease may run through all its stages, or it may, of course, stop at any of them ; and experience shows us that the limit between capillary bronchitis and the first stage of pneumonia is very often intact. 487. But in this series of morbid phenomena, what place is held by that condition of the lung which has been termed carnification f Is it the product of inflammation, a modification of hepatization, or is it a quasi-normal condition, as if that portion of lung had been exempt from respiration ? Rilliet and Barthez seem inclined to regard it as a kind of termination of pneumonia, or as a chronic pneumonia ; and they mention the case of a child, who for a long time presented the signs of pneumonia of the right lung, yet afterwards died of pneumonia of the left lung. On making the autopsy, a considerable carnification of the right lung was found occupying the situation of the auscultatory evidences of pneumonia during life. 2 M. Barrier admits that it is not quite understood, but that it is pro- bably the consequence of acute inflammation, and " may be considered as a termination of induration." 3 Hasse, in his Pathological Anatomy, regards it as a persistence of the foetal state of the lungs after birth, and distinguishes between this condition and inflammation. MM. Legendre and Bailly have described this state, and regarding it as passive and asthenic, and not active, and not pathological — a physical modification of the organ, analogous to the condition of the foetal lungs — they have founded upon this opinion an entirely new view of the disease termed lobular pneumonia. 4 This condition of the lung they believe is not the result of inflamma- 1 . Mai. de l'Enfance, vol. i. p. 98. 2 Mai. des Enfans, vol. i. p. 74. 3 Mai. de l'Enfance, vol. i. p. 62. 4 Archives Gen. de Med., Jan., Feb., and March, 1844. INFLAMMATION OP THE LUNGS. — PNEUMONIA. 333 tion, but that the lung or portions of it collapse, owing to the congested or distended state of the capillaries, and assume this " Stat foetal," or " £tat foetal congestionnel." These portions they say differ from hepa- tized lung, inasmuch as they may be easily distended by air, and so re- stored to their primary state, whereas the hepatized lung is impermeable to air ; but in this they are opposed to the experience of M. Bouchut. According to these authors, therefore, lobular pneumonia is truly a pul- monary catarrh, answering pretty much to capillary bronchitis, with these collapsed portions of the lung reduced to a condition analogous to the foetal lung, or to that state which has been termed atelectasis. M. Friedleben differs from this view, and considers that the pneu- monia of children runs through the same course as that of adults, but that the lobar pneumonia is more frequent than has been supposed. 1 Dr. Fuchs has carried further the theory of Legendre and Bailly. He states that he has never found a condition of the pulmonary paren- chyma at all analogous to that observed in the pneumonia of adults, and that the changes are not due to inflammation, but to the cells be- coming void of air and atrophied. To this condition he applies the term apneumatosis, and he thus describes the condition of the lung : "The apneumatic lung is in its first stage of a dark color, contains air, swims and crepitates ; its compass is less than that of a collapsed lung, and hence single lobules in the apneumatic condition appear as if sunk in the normal tissue. Inflation can be performed. In the second stage, the tissue becomes firm, compact, and void of air ; it assumes a uniform character, a small compass, has an even surface on division, and no longer permits of inflation. In the third, it appears as a blue-gray colored tissue with white streaks." Dr. Fuchs distinguishes between this morbid condition established after respiration ; and the foetal con- dition of the lungs before respiration, and whilst he admits that the first stage may come on as a pulmonary catarrh in very young children, in older ones it will have more the character of a determinate inflammation. Now let me observe that in this question there are two points involved — first, what is the true nature of that state of the lung which has been called carnification — is it the result of inflammation ? is it a modifica- tion of hepatization, or is it really a collapse or atrophy of the paren- chyma, the result of changes in the neighboring parts ? and secondly, if it be non-inflammatory and only a passive apneumatosis and atrophy, is it the principal or the only change observed in lobular pneumonia, and are we to infer that that disease is truly a capillary bronchitis with the addition of (or producing) this collapsed condition of the lung? I do not feel competent to decide these questions, but it appears to me that additional observations are required before we can agree with the origi- nal views of MM. Legendre and Bailly, West and Fuchs. I am, however, inclined to believe that bronchitis may result in either lobular pneumonia or atelectasis, but that probably atelectasis is often mistaken for lobular pneumonia, and further, the condition which has been termed carnification has greater resemblance to the latter than to the former disease. 1 Arch, fur Physiologisehe Heilkunde, Part 2, 1847. 2 Der Bronchitis, der Kinder, 1849. 334 INFLAMMATION OF THE LUNGS. — PNEUMONIA. For further details on this subject I would refer my readers to Dr. Wiltshire's valuable and elaborate essay, Historic Data on Infantile Pneumonia, in which he has traced the succession of opinions and analyzed the views of the different authors with no small learning and ability. 1 488. Causes. — Among the predisposing causes, age appears to exer- cise a considerable influence. It has been said that primary pneumonia never attacks infants under five years; but Rilliet and Barthez have shown that this is not true. Out of 245 cases, fifty-eight were primary, and of these twenty-four were under five years, i. e., five from one to two years, and nineteen from three to five; and thirty-four were beyond five years. Of these fifty-eight cases, fifty-five were lobar pneumonia. M. Valleix mentions that the age of his patients were, of simple pneumonia, from seven to twelve days ; of pneumonia with cedema, from two to eight days ; and of pneumonia with muguet, from nine to twenty days. 2 M. Hache, out of 108 autopsies, found pneumonia in seventy-one between the ages of two and five, and in thirty- seven from five to fifteen years of age. 3 M. Barrier, out of twenty cases of lobar pneumonia, met with three before the age of five years, six from five to eight, seven from eight to eleven, and four from eleven to fifteen. 4 Of sixty- one cases of lobular pneumonia, forty-five were between two and five years, and sixteen from five to sixteen. In 203 cases, Rilliet and Barthez found lobular pneumonia between the ages of one and five and a half in 160, and from six to fifteen in forty-three cases. Thus, both primary and secondary, both lobar and lobular pneumo- nia, may occur from birth up to fifteen years ; both are more frequent before five than after, but especially lobular pneumonia. 489. The predominance of the male sex is more marked in lobar than in lobular, in primary than in secondary pneumonia. Of twenty-four cases of primary lobar pneumonia, referred to by Rilliet and Barthez, nineteen were males and five females; and of forty-five of secondary pneumonia (generally lobular), twenty-seven were males and eighteen females. Of sixteen cases of lobar pneumonia, related by Dr. Gerhard and M. Rufz, twelve were males and four females. Ten out of fifteen of M. Valleix's cases were males. Of M. Vernon's 114 cases, there was an equal number of males and females. Of 104 cases mentioned by Dr. Condie, sixty were boys and forty-four girls. Of 1615 deaths from pneumonia, occurring in Philadelphia during the ten years preceding 1845, 872 were in boys and 743 in girls. 5 According to M. Barrier, sex asserts but little influence upon lobular pneumonia. Temperament and constitution, doubtless, exercise great influence in the production of the disease; those of a lymphatic temperament and of an enfeebled and broken-down constitution being peculiarly liable to 1 British and Foreign Med.-Chir. Rev., Oct. 1853, p. 514. 2 Clinique des Mai. des Enfans, p. 173. 3 Mai. des Enfans, p. 478. 4 Mai. de l'Enfance, vol. i. p. 187. 5 Diseases of Children, p. 312. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 335 secondary and especially lobular pneumonia. Of 245 cases related by Rilliet and Barthez, only fifty-eight were stout and well when attacked; and in fifty-five of these fifty-eight, the form of disease was lobar pneu- monia; in a great majority of the remainder, it was lobular pneumonia. Dr. Stewart mentions an hereditary predisposition in some families to the disease. 1 M. De la Berge and M. Leger state that the disease is more frequent in spring and autumn ; Dr. Gerhard, that primary pneumonia prevails in the months of April and May ; Rilliet and Barthez mention that from April to September, 1837, only six cases of primary pneumonia were received into hospital, whereas, in the same months of 1840, twenty- two were admitted. During the six summer months of the year referred to by M. Barrier, fifty-six cases of pneumonia occurred. So that we cannot regard the summer as conferring immunity from this disease; nevertheless, I have no doubt that in this country it will be found far more frequent during the winter. In this city, I have gene- rally met with more cases from December to the end of March than at any other period of the year. This is confirmed by the opinion of Dr. Stewart and others; and Dr. Hood has quoted from Mr. Chadwick the following details : In winter there were 3326 cases of pneumonia ; in spring, 2454 ; in summer, 1827 ; and in autumn, 3600. 490. No doubt that cold is the most frequent exciting cause among children ; it can hardly affect young infants so much, but yet they are often exposed. Change of room, change of garment, exposure to draughts of air, going out in unsuitable weather, the prevalence of damp, and certain winds, all may excite the disease even in the most healthy, how much more in those already weakened by disease. By certain French writers, much stress has been laid upon the effect of a prolonged dorsal decubitus in the production of the disease among the children in the Hopital des Enfans at Paris. MM. Billard, Denis, De Commercy, Leger, Rilliet and Barthez, all attribute more or less influence to this cause ; but it seems probable that at least as much is owing to other causes acting at the same time. Pneumonia may also prevail epidemically, or, what is more frequent in this country, it may form part, as it were, of the epidemic influenza, sometimes the bronchitic, at others of the pneumonic element prevail- ing, as I noticed in the last chapter. Dr. Cheyne mentions that it prevailed epidemically every winter, about Leith — in the years 1802, 3, 4, and 8, he had seldom less than from 15 to 30 cases under his care. 2 491. Dr. West has given definite numbers for a fact which all must have experienced with regard to pneumonia, I mean the great liability of those who have once suffered from it to be again attacked. Of sev- enty-eight cases which came under Dr. West's care for inflammation of the lungs, " thirty-one were stated to have had previous attacks of the disease ; twenty-one, once ; four, twice ; two, four times ; and four were said to have had it several times, though the exact number of seizures 1 Diseases of Children, p. 50. 2 Pathology of Larynx and Bronchia, p. 187. 836 INFLAMMATION OF THE LUNGS. — PNEUMONIA. was not mentioned. Of these thirty-one, ten were under two years of age ; ten, between two and three ; and the remaining eleven, between three and six.'' 1 492. We must now examine as to what diseases predispose to pneu- monia, as a secondary affection, and I shall avail myself of a table drawn up by my friend Dr. West. It concerns 166 cases, and of these, " In sixty-five cases, the respiratory organs presented no sign of recent inflammation, the children having died of the following dis- eases : Of trismus, three ; meningeal apoplexy, two ; cerebral conges- tion, one; inflammation of the brain, one; acute hydrocephalus, twenty- five ; cerebro-spinal arachnitis, three ; chronic hydrocephalus, one ; tubercle of the brain, three; cancer of the brain, one; croup, two; laryngismus stridulus, two; phthisis, five; anasarca, one; anasarca after scarlet fever, one; diarrhoea, four ; atrophy, three; congenital syphilis, one; cancrum oris, two; lumbar abscess, one; scrofulous dis- ease of the vertebrae, one ; fungus nematodes of the liver, one ; of the kidney, one. " In fourteen cases, though there was no sign of inflammation, yet a more or less considerable portion of the lung was collapsed, but restored by inflation to its natural condition, or presented the physical charac- ters of collapsed lung in so marked a degree as to preclude the possi- bility of error. The causes of death in these fourteen cases were : — congenital atelectasis, one ; induration of the cellular tissue, one ; con- vulsions, one ; meningitis of the convexity of the brain, one ; conges- tion of the brain occurring in the course of hooping-cough, one; tubercle of the brain, one ; atrophy of one hemisphere of the cerebellum, one; atrophy, five; laryngismus stridulus, one; fungus hsematodes of the kidney, one. " In forty-seven of the above seventy-nine cases, the pulmonary tis- sue was quite free from tubercle. In twenty-two, the lungs contained crude tubercle only ; in three, some softened tubercles. "In the remaining eighty-seven cases, either the pulmonary sub- stance, the bronchi, or the pleura, showed signs of recent inflammation. " The pleura was mainly affected in twelve of these cases, its inflam- mation having been idiopathic only in four. In six of these cases the lung was inflamed ; in the other six, merely compressed. " In nineteen cases the inflammation was chiefly or entirely confined to the bronchi, and in six of these the inflammation was idiopathic. " In fifty-six cases pneumonia prevailed, which was idiopathic in sev- enteen, and secondary in forty-five instances. " In the fifty-nine cases of acute secondary inflammation of the lungs or bronchi, the patients had suffered from the following diseases Hooping-cough, sixteen; phthisis, seven; acute pleurisy, six; measles five; croup, three; scarlatina, three; diarrhoea, three; acute hydro cephalus, three; croup, consequent on measles, two; remittent fever two ; acute meningitis, two ; chronic bronchitis, one ; coryza, one ; ana sarca after scarlatina, one ; cancrum oris after remittent fever, one acute rheumatism, one ; convulsions, one. 1 Lectures cm Diseases of Children, p. 180, note. INFLAMMATION OP THE LUNGS. — PNEUMONIA. 337 " Of the whole eighty-seven cases ; in sixty-nine the pulmonary tissue was free from tubercle ; in ten, it contained tubercle unsoftened ; in five, tubercle softened; in three, tubercular cavities." 1 This valuable summary affords both negative and positive informa- tion ; negative as to the diseases of which pneumonia is not a frequent complication, and jaositive, as to those in the course of which it occurs as a secondary attack. However, as Dr. West observes, it would re- quire a large number of cases to enable us to draw any stringent con- clusions. So far as it goes, it confirms pretty exactly what I have said previously. 493. According to M. Barrier, of sixteen cases, thirteen were con- nected with acute catarrh, and three with chronic catarrh, occurring in the course of measles ; in two, with scarlatina ; in three, but obscurely, with smallpox; in ten, with bronchial catarrh ; in twelve, with bronchial and intestinal catarrh ; in nine, with hooping-cough ; in one, with typhoid fever. There can be little doubt that lobular pneumonia arises most fre- quently in the course of the eruptive fevers, bronchitis, and hooping- cough ; and knowing this, it is our duty to be constantly on the watch, that Ave may detect the earliest symptom. 494. Diagnosis. — The diagnosis of the lobar form is less difficult than of lobular pneumonia ; we have the short cough, pain in the chest, hur- ried breathing, dulness on percussion, crepitant r&le, and fever. In lobular pneumonia, the cough, dyspnoea, and fever, are much the same, the pain is less, and the dulness on percussion not so perceptible in the mammelonated form of the disease. In the generalized form we shall have less difficulty, as the dulness is marked, and the crepitant or sub- crepitant rale very evident. I. The differential diagnosis between this disease and bronchitis will depend very much upon the clearness on percussion, the presence of mucous and sibilant rales, the absence of the crepitating or sub-crepi- tating rales. In the latter disease, the face has generally a purplish tinge, the cough has more of a kink, the respiration is more labored, and perhaps less hurried. II. From 'pleurisy. In both, of course, there is dulness on percus- sion, spreading rapidly ; but in general there is less constitutional and local disturbance in pleurisy, the cough is not so frequent, the pulse not so quick, nor is there the same hurry of breathing. The pain in pleurisy, also, is more distinct, severe, and occupies a different situation. The distinguishing characteristic rales of pneumonia are, of course, alto- gether absent, and the vocal sound may be different. III. There may be great difficulty in distinguishing pneumonia from a sudden infiltration of tubercles. M. Grisolle remarks : " A child has a hot skin, violent fever, dulness, with bronchial respiration under one of the clavicles, and we have no information as to its previous his- tory. Is it certain, then, as Rilliet and Barthez ask, that the child has pneumonia ? These physicians have often seen this question answered in the affirmative, and treated accordingly, and yet the autopsy has 1 Lectures on Diseases of Infancy and Childhood, p. 181. 338 INFLAMMATION OE THE LUNGS. — PNEUMONIA. proved that these symptoms depended upon a tubercular infiltration of the lung. "In such cases," they remark, "we must observe the in- tensity of the fever, and especially the cause of the disease ; if the stethoscopic phenomena persist, notwithstanding the diminution of the general symptoms, it is probable that this persistence is the conse- quence of the tubercles. I am completely of the opinion, but this does not prove that the fever and bronchial respiration may not have been owing to a kind of pneumonia.'' 1 495. Prognosis. — Primary pneumonia, whether lobar or lobular, is much less fatal than the secondary disease. Lobar pneumonia (per- haps because more frequently primary) is less fatal than lobular, and uncomplicated much less fatal than when complicated. Secondary lobular pneumonia is, of course, frequently fatal, partly owing to the disease itself, but much more to the effects of the primary malady, and the inability of the child's constitution to resist the inroads of a new disease. Of twenty-one cases of primary pneumonia, Billiet and Barthez state that twenty-one were cured. Of twenty cases of lobar pneumonia, according to M. Barrier, but one died ; whilst, of sixty-one cases of lobular pneumonia, forty-eight died, eight were completely, and five incompletely cured. 496. Treatment. — Before entering upon the treatment of any case of pneumonia, we should carefully satisfy ourselves whether it be primary or secondary, whether simple or complicated, and of the exact state of any other existing malady, whether primary or secondary, and of the state of the patient's constitution, its strength or weakness, the injury already done to it, and the probable powers of endurance remaining. This done, we may select and apportion the remedies at our command, which, although few and simple, do yet require judgment in their ap- plication. The principal remedies are bleeding, tartar emetic, calomel, counter-irritation, and stimulants. It will be also essential to remove all existing causes of irritation, and amongst these the most influential is probably that arising from dentition. Whether it may give rise to pneumonia or not, certain it is that it will increase and perpetuate the inflammatory action. In all children, therefore, at the age of teething, the gums should be exa- mined, and if the gums be at all swollen or inflamed, they should be divided thoroughly. 497. I. Bleeding, either generally or locally, is one of our most pow- erful means for arresting inflammation of the lungs. Some of the con- tinental writers object to it, as weakening the patient, but, as Dr. West observes, this opinion, being formed from the cases of secondary pneu- monia met with in the hospitals, cannot be a guide to us in general practice. The great majority of British and American practitioners agree in recommending that at the commencement of pneumonia blood should be freely abstracted, according to the age and strength of the patient, and that, if it be necessary, owing to the severity and obstinacy of the dis- 1 Traite de la Pneumonie, p. 513. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 339 ease, it should be repeated once or twice. The blood may be taken from the arm of the child, if it be old enough, or by cupping or leeches to the chest, hand, or foot. I prefer leeches to the chest in infants, because they are more manageable, and less likely to frighten a young child than cupping ; and I think they produce greater effect when ap- plied to the chest than to more distant parts. Both lobar and lobular pneumonia may be thus treated freely when primary, but when secondary it will be necessary in all cases to modify the amount taken; and in some eases, when the child is much broken down and exhausted, it would be very imprudent to take blood at all. In such cases we must have recourse to counter-irritation, calomel, or perhaps tartar emetic. " When an abundant effusion has taken place into the bronchia," Dr. Cuming observes, in his excellent paper, " and when, as generally happens, this state is combined with more or less of collapse of the system, the abstraction of even a very trifling quantity of blood might be attended with a fatal prostration." 1 When the leeches have ceased bleeding, a large, soft, warm poultice of bread and milk or linseed-meal should be constantly applied to the part affected. I have found nothing afford such immediate comfort and relief to infants and children. It may be removed when counter-irri- tants are to be applied, and then replaced. It soothes the sensations, relieves the aching pain, quickens the action of the counter-irritants, and promotes expectoration. 498. ii. Tartar Emetic. — No physician is ignorant of the extreme value of tartarized antimony in the treatment of pneumonia in the adult. It is not less valuable with children, but it requires a little more watch- fulness and caution, as it sometimes produces very alarming depression. After bleeding, in all primary cases, it will be right to give it a fair trial, and, if it acts kindly, to continue it as long as we find necessary. The dose must be graduated according to the age of the child, the object being rather to produce nausea than vomiting. It will often be found, however, that a child will bear a larger dose than we might suppose, and that, although the first dose may cause vomiting, the subsequent ones will not. Or we may commence by producing vomiting, and then diminish the dose, so as to occasion nausea merely. Dr. West recom- mends " one-eighth of a grain every ten minutes, till vomiting is pro- duced, in the case of a child two years old, and continued every hour or two afterwards, for twenty-four or thirty-six hours." One grain of the salt to two ounces of fluid for a child under two years, and two grains for a child of four or five, will form a mixture of which a teaspoonful may be taken every two, three, or four hours. The following mixture answers the purpose, and, besides being very palata- ble, will probably check the tendency of the tartar emetic to act on the bowels: — R.— Mist, amygdal. gij. Antim. tartarizati, gr. j. vel ij. Syr. papav. alb. 31J. — M. A teaspoonful to be given every three or four hoiu*3. 1 Trans, of Association, vol. 340 INFLAMMATION OP THE LUNGS. — PNEUMONIA. But in secondary pneumonia, when the patient is much reduced espe- cially, or when the stomach and intestinal canal have been affected, we must be very cautious how we give tartar emetic. If used at all, it must be given in much smaller doses, at the same or longer intervals, or we may seriously aggravate the patient's weakness, or add to the intestinal irritation. If we cannot give it, our great reliance must then be upon calomel, counter-irritation, and stimulants. 499. III. Calomel. — It is rarely advisable or necessary to give calo- mel so long as we are employing tartar emetic ; but when a change becomes desirable, or for any reason we are afraid to give the latter medicine, we must have recourse to calomel. Of less immediate value, perhaps, than tartar emetic, it is still of great importance, and pos- sesses great control over inflammatory action. It may be given in doses varying from one-fourth or one-third of a grain to a grain, every three, four, or six hours, guarded by a little Dover's powder, or the powder of chalk with opium. In secondary pneumonia it will still be found of great use, provided there be no diarrhoea, or provided we can so guard it as to prevent it acting upon the bowels. Sometimes the hyd. c. creta is better borne than calomel, though less effective. If we cannot give it, on account of the state of the bowels, we may use mercurial inunction, which has more effect with children than adults, from the greater sensitiveness of their skin. Although salivation or ulceration of the gums are very rare in chil- dren under five years of age, yet, as they do occasionally occur, it is necessary to watch the child, and to stop the mercury on the first sign of tenderness of these parts. 500. iv. Counter-irritation. — I have always derived great benefit from blisters in pneumonia, provided they were not applied too soon. We ought not to apply them during the height of the fever, until after having recourse to bleeding and tartar emetic, except in cases in which these remedies have not been suitable. But after bleeding and tartar emetic have lowered the febrile excite- ment, even though the pulse still remains quicker than natural, a mode- rate-sized blister, applied for a few hours only over the seat of the dis- ease, will seldom fail to afford relief. It is better to apply it for a short time, and allow it to heal, and then apply another near to the former, than to cover the ehest with one at once. In cases where more active measures are inadmissible, a succession of blisters must be substituted, care being taken that they are not applied too long, so as to give rise to ulceration. Dr. West speaks highly of stimulating liniments, others of mustard plasters ; but, though useful, they are far less efficacious than blisters, and if the blister be carefully attended, I have not found any mischief result. When we do not give tartar emetic, or after we discontinue it, it will ibe necessary to give some cough mixture, and I have found one com- posed of equal parts of decoction of senega and water, with syrup of PLEURISY. — PLEURITIS. 341 smilax and a little ipecacuanha wine, of great use, to which we may add the carbonate of ammonia towards the end of the disease, as thus : — R. — Decoct, senegse, gij. Carb. aramon. Qj. to gj. Vini ipecac, gss. Syr. smilac. a?p. sjiv.— M. Aqute, gij. A teaspoonful every three or four bours. 501. v. Stimulants. — These are only required in cachectic cases, when the constitution has been broken down, or towards the termination of the disease, when the pulse has become slower, and the patient is weak. Ammonia is probably the best we can employ, and it may be given in almond milk, in doses of from half a grain to two grains every three or four hours, or it may be combined with the expectorant mix- ture. Under similar circumstances it may be necessary to give wine whey, or plain wine and water. A warm bath at the beginning of the disease, with fomentations to the feet occasionally, will be both soothing to the patient and benefi- cial. The diet in primary pneumonia must be low and spare, but towards the termination, and in all cases of secondary pneumonia, we shall find it necessary to support the strength by chicken broth, beef tea, &c. The bowels must be kept free, and it is well not to place the child always in one position in bed. 502. During convalescence, the utmost caution and care must be exercised. The child should be confined to one room, or to two of the same temperature. For some time the clothing should be warm, with a light flannel waistcoat next the skin. For the treatment of the complications, I must refer the reader to the chapter on those diseases, merely observing that, although they much increase the danger, they often diminish our poAver of active treat- ment, and in some cases (as intestinal irritation) exclude some of the most valuable remedies for pneumonia. CHAPTER VIII. PLEURISY. — PLEURITIS. 503. Inflammation of the pleura, or pleuritis, may attack children of all ages, although its comparative frequency varies a good deal. Of 4012 patients treated at the London Infirmary for Children during the year 1846, only three cases of pleurisy 1 were noted; but out of 4158 1 Eeport of the Royal Infirmary for the year 1846. 342 PLEURISY. — PLEURITIS. admitted in 1845 to the Royal Institution for Diseases of Children in the district of Wieden, Vienna, there were seventy-six cases of the dis- ease. 1 "In London, during the year 1843-44, the deaths from pleurisy in children under fifteen years of age amounted to one-sixth of the whole number of deaths from the same cause ; 2 and of twenty-five deaths afc all ages, from pleurisy, registered in the month of January, 1847, 3 eleven occurred under the age of fifteen years." 4 M. Billard 5 states that he has found it more common than one would have expected ; and, on the other hand, M. Valleix considers it rather rare. 6 Of 3392 autopsies of children under two years old, M. Baron found pleurisy in 205, or six per cent.; and of 181 autopsies of children from 2 to 15, the pleura of 158, or eighty-seven per cent, was affected. 7 Dr. Eberle' regards it as more common than is supposed. Mr. Crisp met with six cases of pleurisy in forty-one autopsies of children under two years of age. 8 Dr. Battersby has recorded six cases of simple or complicated pleurisy. 9 MM. Ftilliet and Barthez have recorded eighty-five cases of pleurisy under fifteen years of age. M. Hache states that he has met traces of pleurisy in eighty-one cases out of 194 post-mortem examinations ; and M. Barrier has given fourteen cases. Erom these facts we may infer that pleurisy is not so rare a disease in children as many have supposed. Perhaps, indeed, this supposition may be the cause why so little attention was paid to the subject until lately. It is only recently that any very accurate researches have been undertaken into the distinction between pneumonia and pleurisy in children. We are indebted to Meissner, Henke, and Heyfelder, 10 in Germany; to Billard, Constant, 11 Baron, 12 Berton, 13 Rilliet and Barthez, and Barrier, in France; to Crisp, 14 West, and Battersby, 15 in these countries ; and to Stewart, Eberle', Condie, and Meigs, in America, for the principal information we possess. 504. Symptoms. — Pleurisy may be either primary or secondary, simple or complicated, acute or chronic. It will be found to be modified somewhat in early infancy. Billiet and Barthez have also described the disease occurring in children of a broken down constitution under the name cachectic pleurisy. 505. Primary Acute Pleurisy commences generally with depression and loss of appetite, occasional vomiting, weakness, slight cough, and a degree of fever, which subsides after a time. In some cases there are rigors ; in all the child seems ill, uneasy, and cross. In other cases 1 Jahrbericht iiber die Leistungen des Unentzeldlischen Kinderkranken Instituts, &c. 2 Sixth Annual Report of Ptegistrar-General. 3 Weekly Tables of Births, &c, January, 1847. 4 Dr. Battersby, Dublin Journal, Nov. 1847, p. 349. 5 Mai. des Enfans Nouveaux-nes, p. 529. 6 Clinique des Mai. des Enfans, p. 198. 7 De la Pleuresie dans l'Enfance. 8 London Med. Gaz., Dec. 25, 1846. 9 Dublin Journal, November, 1847. I0 Archives, third series, vol. v. p. 59. 11 Gazette Med., 1836, p. 265. Lancette, 1837, p. 146. ' 2 Thesis, 1841. 13 Traite des Mai. des Enfans. 14 London Med. Gazette, Dec. 25, 1846. 15 Dublin Journal, Nov. 1847, p. 348. PLEURISY. — PLEURITIS. 343 the symptoms which usher in the disease are more alarming, and point rather to the head than the chest. " The child is seized with vomiting, attended with fever and intense headache ; it either cries aloud oris delirious at night, or screams much in its sleep, and, when morning comes, complains much of its head, but denies having any pain what- ever in its chest, while the short cough and hurried breathing may be thought to be merely the result of the cerebral disturbance." 1 Early in the complaint, the child complains of pain in the side (gene- rally the left) if it be old enough ; in young children it is not always easy to ascertain this, except, perhaps, by the cry, when the side is percussed. The cough soon becomes troublesome ; it is short, dry, and inter- rupted, the respiration hurried and short, especially on lying down, because of the pain caused by deep breathing. Rilliet and Barthez consider the dyspnoea to be less than in pneumonia. "Respiration," says Dr. Condie, "is performed chiefly by the action of the abdominal muscles and diaphragm, the motions of the chest being instinctively restrained by the patient, in consequence of the pain attendant upon the elevation of the ribs ; sometimes each inspiration gives rise to a sharp cry or moan, and an expression of countenance indicative of suffering." 2 In the majority of cases there is no expectoration, and when present, it is not peculiar. Mr. Crisp has noticed the throwing back of the head, and fixing it steadily there, as a peculiarity in pleuritis, and the distress occasioned by an attempt to straighten it. 3 Dr. Battersby states that he has long observed it, and he thinks it arises " from an instinctive effort to avoid painful motion of the chest, by fixing the ribs, and giving full play to the abdominal respiration. This position of the head in pleuritis may be distinguished from that attending cerebro-spinal arachnitis, or other affections of the nervous centres, by all change of posture being followed by great uneasiness and screaming, while in the latter the infant is not so restless, nor crying so constantly, especially when moved or held erect, as in pleu- ritis." 4 This fixing of the head backward occurs in pericarditis also, and in other affections ; and I must confess I have hitherto been unable to satisfy myself of its exact value as a symptom. The face is generally pale and anxious, with considerable contrac- tion of the respiratory muscles of the face, and action of the abe nasi, especially at the commencement. The tongue is moist, white, and loaded, the appetite impaired or lost. Vomiting occasionally occurs ; and the bowels, at first unaffected, are often subsequently attacked by diarrhoea. The decubitus is of little or no value in young children, as they gene- rally lie as they are placed in bed. In older children, one side or the 1 Dr. West's Lectures, p. 213. 2 Diseases of Children, p. 290. 3 London Med. Gazette, Dec. 25, 1846, p. 1104. 4 Dublin Journal, Nov., 1847, p. 371. 314 PLEURISY. — PLEURITIS. other will afford more ease. Dr. Stokes says on the healthy side in the beginning and the diseased side towards the end. The pulse is very quick at first, from 110 to 120, but it frequently subsides after a time to somewhat above the natural standard. At first, too, there is smart fever, with heat of skin, thirst, &c; but this very commonly diminishes. 506. Now let us examine into the physical signs of pleurisy. At an early stage of the disease, we find the respiratory murmur enfeebled, and gradually retreating upwards as the effusion increases. Then we may detect bronchial respiration, generally constant, but occasionally disappearing and returning at intervals, owing, M. Bouchut thinks, either to the short inspirations or the interruption to the passage of air offered by the accumulation of mucus. MM. Rilliet and Barthez class this among the earliest symptoms of pleurisy; they found it present on the first, second, or third day. The sound in pleurisy is peculiar and metallic in its tone, differing in that and in its progress and duration from the bronchial souffle of pneumonia. Generally speaking, it is heard posteriorly, and at an early period, over the whole upper portion; at a later period, chiefly about the inferior angle of the scapula or the interscapular space. It lasts for some little time, and then disappears in the course of one, two, or three days ; or it may persist longer, and be audible either during inspiration or during both inspiration and expiration. When the case is simple and the termination fatal, it may be heard until the end. Rilliet and Barthez heard it after the twenty-seventh day, in a child who died on the twenty-eighth. But when the disease subsides, the bronchial souffle is superseded by feeble respiratory mur- mur, more rarely by frottement, and sometimes by pure respiration. In some few cases, this peculiar characteristic is absent. Rilliet and Barthez explain the frequency of the bronchial souffle by, 1. The comparatively greater narrowness of the chest in children than in adults ; 2. The greater number of respiratory movements ; and 3. In certain cases, the small amount of effusion. 1 Frottement, which is so characteristic a symptom of the early stage of pleurisy in adults, is comparatively rare in children. Both MM. Baron and Rilliet and Barthez agree that, though rare at the begin- ning, it is often present during the resorption of the effused fluid. The latter authors have never heard it in children under five years of age. Mr. Crisp, however, speaks of its occurrence in all his cases. Bronchophony and ego-phony occasionally accompany the pleurisy of children — the latter generally in the early stage in acute cases. It is heard ordinarily at the posterior and inferior part of the chest. It is more distinct in older children, though audible at all ages. When it is not present in very young children, there is generally a peculiar reso- nance of the voice. Percussion affords evidence of great value at the commencement of the disease. The dulness may be somewhat obscure, but as the disease advances it becomes more marked, keeping pace with the feebleness of 1 Mai. des Enfans, vol. i. p. 149. PLEURISY. — PLEURITIS. 345 respiration and the bronchial souffle, until at length the side of the chest becomes absolutely dull. This lasts until the disease begins to subside, and marks not only the locality but the duration, according to its per- sistence. By degrees, as the bronchial respiration is replaced by the feeble or pure respiration, the chest becomes more sonorous, and at length perfectly clear. As in the adult, change of position will modify the results of percus- sion as well as of auscultation. Taupin, 1 Baron, Rilliet and Barthez, Trousseau, and Bouchut, lay great stress on the absence of vibration when the effusion is consider- able, as was first noticed by Reynaud, Hudson, and Stokes. M. Bouchut conceives that this sign alone distinguishes it from all other inflamma- tions. If the hand be placed on the chest of a healthy person, we feel a remarkable vibration both of the respiration and voice; but if there be effusion, there will be no vibration perceptible, either from the respi- ration or the voice; and this is exactly the opposite of what we find in pneumonia. Dr. Stokes, however, mentions that it is inapplicable to many cases of boys and girls, before the change of voice, on account of the natural feebleness of the vocal vibrations. 2 Dr. Battersby thinks it impossible to detect this vibration before the eighth year. On inspection of the chest, the affected side appears immovable dur- ing respiration ; there is no expansion, no movement of the ribs. The measurement of the chest is by no means easy with infants and young children, nor does it yield much information early in the com- plaint, nor when it runs its course rapidly. When the attack is pro- longed several weeks, there is a notable difference in the two sides of the chest, in proportion to the effusion. The affected side is enlarged, the intercostal spaces are raised to the level of the ribs, or even pro- truded so that the ribs are not quite visible, and neither the sternum nor spine occupies the centre of the chest. When the fluid is absorbed, the affected side is contracted, but not to any great extent. It is very remarkable that neither Baron, Rilliet and Barthez, nor Barrier, have met with effusion so considerable as to displace the heart. M. Heyfelder has observed in chronic pleurisy considerable deformity, with curvature of the spine, and a displacement of the heart from its ordinary position. My very intelligent friend, Dr. Battersby, has re- lated four such cases, 3 and I have seen several. Thus, although the rational signs of pleurisy are not very clear, "we can hardly mistake the physical signs. In the earlier stage, feebleness of respiration, succeeded by the bronchial souffle, with marked and in- creasing dulness on percussion, absence of vibration in the side affected, perhaps egophony or vocal resonance, and at a later period, if the effu- sion be great, dilatation of the chest and dislocation of the heart. 507. When pleurisy attacks an infant at the breast, the symptoms are necessarily more obscure, and the physical signs less readily ascer- tained ; there is fever, quick breathing, and cough, but whether pain or 1 Recherches sin- le Dingnostique des Mai. de Poitrine chez les Enfans. 2 Diseases of the Chest, p. 498. 3 Dublin Journal, November, 1847, p. 353. 346 PLEURISY. — PLEURITIS. not it is not easy to determine, unless we infer it from the child crying when the cough is troublesome. The infant is evidently very ill ; it sucks less eagerly, is fretful and heavy, and as the disease advances it loses its appetite; is sometimes attacked by diarrhoea ; the fever is occa- sionally remittent, with nocturnal exacerbations; the respiration is quick, hurried, and panting, and the cough frequent. The usual physical signs are present ; feeble respiration, bronchial respiration, dulness on percussion, except just at the beginning, and the absence of vibration when the hand is placed on the affected side. 508. Acute Secondary Pleurisy may occur in the course of any other disease, but it seems peculiarly apt to develop itself in the progress of pneumonia, either from contiguity of structure or in consequence of the opening of an abscess (480) into the pleural cavity. The symptoms which mark its commencement vary a good deal ; it may begin in young children by convulsions or by sudden orthopncea. More frequently it commences with sudden and severe pain, with in- creased difficulty of breathing, and cough. The hurry of breathing and the rapidity of the pulse are often very great. The physical signs are somewhat modified, and in the case of pleurisy supervening on pneumonia have been thus stated by Rilliet and Bar- thez : "When effusion is superadded to pneumonia, it happens occa- sionally, but very rarely, that there is a complete absence of the respi- ratory murmur instead of bronchial respiration. Ordinarily the souffle is considerably increased in intensity ; sometimes it has even a cavern- ous tone, and if there be any mucus agitated by the rush of air, giving rise to a raile, one might mistake so far as to fancy that a cavity had been formed in the lung. At the same time the voice sounds so shrill that it is literally painful to the ear. If we percuss the chest, the dul- ness is absolute, whereas, a short time before, it was but relatively dull. We lay it down, then, as a principle, that tohen a pleuritic effusion su- pervenes in a child laboring under hepatization of the posterior part of the lung, all the abnormal sounds which were perceptible in the diseased part are considerably exaggerated, and the resonance on percussion lost." 1 This peculiarity, however, is not observable in all cases ; it requires for its production that the hepatization should be sufficient to prevent the compression of the lung ; so that if a complete absence of the respi- ratory murmur succeeds to the symptoms of pneumonia, we may infer that the hepatization is neither extensive nor profound ; but, on the other hand, if the souffle, the resonance of the voice, and the dulness, are suddenly exaggerated, it is an evidence that the pneumonia was deep and extensive. 509. Very frequently the progress of the disease is much more rapid than in simple pleurisy ; in other cases the duration may be more or less prolonged. In favorable cases, the symptoms gradually diminish, both locally and generally ; but in fatal cases they increase, and the smallness and feebleness of the pulse, the coldness of the extremities, paleness of face, and general sinking of the powers of life, warn us of the final result. 1 Mai. des Enfans, vol. i. p. 152. PLEURISY. — PLEURITIS. 347 But either primary or secondary pleurisy may pass into the chronic form. 510. Chronic Pleurisy may either be the issue of an acute attack, or the disease may assume this form from the beginning. In the former case the symptoms gradually diminish to a certain point, but not beyond, the fever continuing more or less, but especially in the evening. In the second the symptoms are much more indefinite, and steal on insidiously. There may be little or no fever, the pain is uncertain, and not limited to one particular spot, or there may be none at all. The cough is slight, and at first there is but little distress in respiration ; the effusion, however, increases, the respiratory murmur is feeble or absent ; there is occasionally the bronchial soufflet, with marked dulness on percussion, and absence of vibration. On inspecting the chest when the effusion is considerable, we may perceive the enlargement of the side and the consequent deformity, the protrusion of the intercostal spaces, and perhaps the displacement, of the heart. Heyfelder has remarked that the child lies on the affected side, which is slightly cedematous, with its knees drawn up, in a crouching position. The child meantime becomes emaciated and pale ; the evening ex- acerbations are marked, followed by sweating during the night ; the appetite is lost, and at the end of some weeks or months the child sinks, quite worn out. It is quite possible, however, that the child may be saved, either by the absorption of the effusion, its removal by expectoration, or by a surgical operation. 611. Complications. — These are not frequent ; Rilliet and Barthez have rarely seen any that could be fairly connected with the pleuritic inflammation. Convulsions sometimes usher in the attack, and occasionally there are some irregular cerebral symptoms connected with secondary pleu- risy. Rilliet and Barthez mention a case of meningitis which occurred in the progress of pleurisy, which itself was developed during the ex- istence of Bright's disease, but upon which of the two the meningitis depended it would be hard to say. Pneumonia may itself complicate primary pleuritis ; it is not very uncommon to find a thin layer of the pulmonary tissue inflamed beneath the serous membrane. 512. Terminations. — Acute primary or secondary pleurisy may terminate, — 1. In resolution, with gradual subsidence of the inflamma- tion, and re-absorption of the effusion ; 2. In absorption of the fluid by the lungs, and its vicarious expectoration from those organs ; 3. In chronic pleurisy ; 4. Chronic pleurisy may terminate by re-absorption of the fluid ; 5. By its vicarious expectoration ; and 6. By a sponta- neous opening through the parietes of the chest, as in the case related by Dr. Battersby. 513. Morbid Anatomy. — In the majority of cases, the pleura of the side affected is found smooth, pale, and semi-transparent ; in others, regularly and finely injected, or exhibiting patches of ecchymosis, espe- 348 PLEURISY. — PLEURITIS. dally underneath the false membranes. In one case, Rilliet and Bar- thez found the pleura beneath the false membrane very vascular and softened, and in another case thickened. The sub-serous tissue is occasionally vascular. More or less fluid is found in the pleural sac ; sometimes simple or bloody serum, with flocculi of lymph ; sometimes the fluid is thick, yellow, and puriform, or of an intermediate character. The colorless, viscid, stringy fluid which we find occasionally is re- garded by Rilliet and Barthez as the result of inflammation. When there is a communication with the external air, the effusion may acquire a fetid odor. In most cases the effusion naturally occupies the most depending position, rising in the serous sac according to its amount ; in other cases, as in adults, it is contained in sacs formed either by old adhesions or recent false membranes. The pleura costalis and pleura pulmonalis are frequently covered with false membranes of varying size and thickness. Sometimes they are soft, and deposited in small patches; or they may be extensive, but very thin ; or several of their laminae may be super-imposed, forming a thick, solid layer. They are generally of a whitish-yellow color, but near the surface of the lung we find a tinge of red. Their free surface is irregular, unequal, occasionally nodulated, and sometimes connected with the opposite pseudo-membranous layer by bands. When the disease is of old standing, the fluid portion becomes ab- sorbed, the false membranes become dry and thin, forming adhesions, intimate or loose, between different portions of the opposite surfaces. Laennec has admirably described the change from false membranes to adhesions, and to his work I must refer the reader, as the process is essentially the same in adults and children. 514. When the pleurisy is simple, the lung is pressed back either totally or partially to the vertebral column, its volume is diminished, and its substance is flaccid, smooth when cut, impenetrable to the finger, presenting that condition which has received the name of carnification. The extent of this change will, of course, correspond to the amount of the effusion. But in other cases the lower lobe of the lung is solid, heavy, and but slightly pressed back to the vertebral column. Its substance resembles the lung in a state of hepatization, but is firmer and less penetrable by the finger, and on pressure less sanguinolent fluid escapes. In such cases it is pretty certain that the hepatization preceded the effusion ; the lung, having become more solid, could not be compressed by the fluid beyond a certain point, but still it is more condensed by the pres- sure than it would otherwise have been. Rilliet and Barthez have at- tempted to point out the anatomical characters when the pneumonia*- succeeds to the effusion, but without much success. In the case they mention, the superior lobe was carnified and compressed, the inferior exhibited the different stages of pneumonia, was friable, sank in water, and on pressure no sanious fluid escaped. . 515. The same authors observe that simple pleurisy is more fre- quently unilateral than double, and rather more common on the right PLEURISY. — PLETJRITIS. 349 side than the left ; and that when complicated with pneumonia it is still more frequently unilateral, but that the left side is more commonly af- fected. Taking all the cases, they found that pleurisy, complicated or simple, was more frequently unilateral than double, and more common on the left side than the right. Thus, in eighty-five cases, the disease affected the right lung only in thirty, the left in thirty-eight, and both in seventeen ; but of twenty- one cases of simple pleurisy, the right side alone was affected in eleven, the left in eight, and both sides in two cases. M. Baron has arrived at nearly the same conclusion. All M. Barrier's fourteen cases were unilateral except two; in twelve, it was seven times on the right, and five times on the left side. In six simple cases, it was five times on the right, and once on the left ; in six cases complicated with pneumonia, it was four times on the left, and twice on the right. Dr. Battersby rather agrees with Dr. Copland, that " pleurisy in every form, in children as well as in adults, is much more frequent in the left than in the right side. of the chest;" and this is in conformity with my own observations. The most frequent morbid lesion is the false membrane ; the next, the turbid serum; and least common, pus. The former is often the only lesion. The quantity of these products of inflammation varies, but it is seldom great. Rilliet and Barthez, Baron, and Barrier, state that the effusion is generally very inconsiderable, and in none of their cases was it sufficient to cause displacement of the heart. M. Hey- felder mentions cases from which six pints (chojnns) of pus were re- moved by operation. Dr. Battersby has related several cases in which the effusion was sufficient to dislocate the heart from its usual situation, and I have seen three or four. As to the adhesions, Rilliet and Barthez remark that in the great majority of cases they are parieto-pulmonary, next, costo-pulmonary, and lastly, interlobular. They met with costal false membranes alone in one case, interlobular in four, pulmonary in seventeen, parietal and pulmonary in fifty-six, parietal, pulmonary, and interlobular in one case. Of 137 cases in which adhesions existed, sixty were of the right pleura only, thirty-one of the left only, and forty-six of both. In ninety-three cases adhesions were the sole inflammatory product. 516. Causes. — The age of the child appears to afford no exemption from the disease, but how far it enters fairly into the list of causes it is not so easy to say. It may certainly occur at any age, from a day old upwards. Billard and Berton believe that simple pleurisy is more com- mon among infants than is generally believed, but that it is much more so after five years; and M. Barrier's researches confirm this opinion. Rilliet and Barthez state that of twenty-one cases of simple pleurisy, eight occurred from one to five years, and thirteen from six to fifteen ; and of sixty-one cases complicated with pneumonia, forty-four were from one to five years old, and seventeen from six to fifteen. Dr. Stewart thinks that at the age of three years pleurisy is as com- 350 PLEURISY. — PLEURITIS. mon as among adults ; M. Barrier, that it is rare before the sixth year. Dr. Battersby thinks that Dr. Stewart is nearest the truth, judging by his experience. Secondary pleuritis, or pleuritis combined with pulmonary diseases is more frequent among young children. In 3392 autopsies of children from one to two years old, M. Baron found pleurisy in 205, or six per cent. ; and in 181 autopsies from two to fifteen years old, the pleura presented evidences of inflammation in 158, or eighty-seven per cent. ; that pulmonary complications existed in two-thirds from one day to one month old ; in four-fifths, from one month to one year ; and in eight- ninths from one to fifteen years. M. Hache found the pleura inflamed in eighty-one out of 194 autopsies, and in none was it the simple dis- ease. M. Valleix mentions that of ninety-two cases under two and a half months, examined by M. Vernois, fourteen only showed signs of pleurisy, and of the whole number, one-sixth had been so affected. Mr. Crisp, in forty-one autopsies of children under two years old, dis- covered pleuritis in six ; in one, simple ; in five, combined with pneu- monia. M. Bairier observed no case of pleuritis independent of pneu- monia before the sixth year ; very few between the sixth and tenth ; but from the tenth to the fifteenth it was nearly as common as with adults. 517. From the researches of Rilliet and Barthez, it would appear that simple pleurisy is more common among boys than girls ; in twenty- one cases, twenty were boys and one a girl. Secondary pleurisy is equally common in both, but what they call cachectic pleurisy prevails more among girls than boys. In eighty-two autopsies of boys, M. Hache found traces of pleurisy in forty-two, and only in forty out of 112 autopsies of girls. Children of a weak, scrofulous constitution seem to be more liable to the disease than those of a more healthy habit. M. Baron considers the disease more prevalent in winter ; Rilliet and Barthez in the month of April. Impure air, insufficient food, inadequate clothing, a prolonged sojourn in a hospital, lying too long on the back, seem to exercise as much in- fluence on the production of pleurisy as upon pneumonia. Exposure to cold is, perhaps, the principal exciting cause, but Rilliet and Barthez have seen it result from external violence. 518. Simple pleurisy may occur secondarily in the course of rheu- matism, scarlatina, Bright's disease, &c. ; it is rare in the course of measles, although it may occur as secondary to the pneumonia which so often attacks children in measles. Secondary pleurisy more frequently complicates pneumonia than, per- haps, any other disease, either from contiguity of tissue, or by the rupture of a small abscess (480). It occurs, also, in tubercular disease of the lungs, in like manner, either by extension, or by the softening and evacuation of a tubercular mass. Bouchut mentions that he found pleuritis in twenty-three out of sixty- eight autopsies ; i. e., it was combined with acute pneumonia in nine,' PLEURISY. — PLEURITIS. 851 with tubercular pneumonia in six, -with entero-colitis in five, and with other different diseases in three cases. 1 519. Diagnosis. — The characteristic signs of simple pleurisy are the feeble respiration, gradually diminishing from below upwards, bronchial respiration, dulness on percussion, vocal resonance or egophony, and the absence of vibration. When the effusion is great, we may observe the prominence of the intercostal spaces, the deformity of the chest, and the displacement of the heart. In pleuro-pneumonia, as we have seen, the sounds increase in inten- sity, the dulness is absolute, the bronchial souffle almost cavernous, and the voice painfully resonant. No doubt the diagnosis in the commencement of the illness is often difficult, but yet I agree with Dr. West, who, after mentioning the diffi- culties, remarks : " But even then, and in spite of all the circumstances which have been enumerated as tending to mislead, you will seldom be wrong if you regard as an instance of pleurisy any case in which, symptoms like those of pneumonia having set in suddenly and severely, auscultation fails to detect the crepitus of pneumonia, and discovers only feebleness of the respiratory murmur on one side, with or without a more or less marked bronchial character in the breathing. 2 There is also something peculiar in the aspect of the child, breathing shortly and quickly, holding the chest fixed, and moving cautiously as if fearing pain, which has led me to suspect pleurisy even before asking a question. 520. Prognosis — The prognosis in pleurisy will vary according to the age of the patient and the circumstances of the case. Simple primary pleuritis, in children above five years of age, Rilliet and Bar- thez found to be a benign disease, and to terminate favorably when acute. Out of twenty-one cases to which they refer, none died. Hache, Constant, 3 \ . delocque, 4 Barrier, and Battersby, 5 concur in this opinion. J Of seventy-six cases treated at the Institution for Diseases of Chil- dren at Vienna, but two died. Mr. Crisp and Dr. Copland, however, give a different opinion ; the former considers it a disease of great danger, and the latter " that its effects are more to be dreaded, the younger the child which becomes the subject of it. The combination of pleurisy with pneumonia appears more serious than either disease existing alone, for of five such cases, related by Rilliet and Barthez, two died, and five out of six in M. Barrier's ex- perience. Chronic pleurisy Billiet and Barthez consider as still more unfavorable, contrary to the opinion expressed by M. Barrier, who found acute pleurisy more fatal than chronic ; and Dr. Battersby re- marks, there are many cases on record of recovery from uncomplicated empyema, after the occurrence of deformity of the chest, and even after the evacuation of the fluid by a natural or artificial opening. Dr. 1 Mai. des Nouv. Nes, p. 345. 2 Lectures on Diseases of Infancy and Childhood, p. 214. 3 Gazette Med. de Paris, 1837, p. 265. 4 Lancette Fraucaise, 1837, p. 146. 5 Dublin Journal, November, 1847, p. 385. 352 PLEURISY. — PLEURITIS. Hughes performed paracentesis in four children between seven and nine years of age, and all recovered ;* and Heyfelder in three cases, between six and seven years old, with perfect success. 2 521. Treatment. — The treatment of acute pleurisy does not differ very much from that of pneumonia. If the disease be primary, and the child strong, we must have recourse to liberal bloodletting, either from the arm, or by leeches to the side, or both. It may, very likely, be advisable to repeat this if the attack be severe, and the first attempt be only partially successful ; but in this we must be guided very much by the intensity of the disease, and the strength of constitution pos- sessed by the child. In secondary pleuritis it will probably be necessary likewise, but we must carefully estimate the importance and results of the primary dis- ease, as it is possible that this may preclude very active remedies for the secondary affection. After the proper treatment for acute pneu- monia, for instance, and the exhaustion and weakness produced by that affection, it is evident that, should pleuritis suddenly arise, our treat- ment of the latter must be very much modified. As a general rule, in chronic pleurisy bloodletting is rarely called for ; certainly, if we detect the commencement of the disease, it would be advisable, but this is seldom the case ; and at. the period when we are called to see the child, the mildness of the symptoms, the absence of fever, &c, rather indicate another line of treatment. 522. If there be much fever, with a quick, firm pulse, and, above all, if pneumonia exist, we shall derive great benefit from the employment of tartar emetic for a few hours, given so as to produce slight nausea, but not vomiting. Dr. Condie speaks very highly of a combination of tartar emetic and nitre given in the following form : — , R. — Nitr. potassaa, gj. I Antim. tartar, gr. ij. Sacch. alb. ^ij. Aquae, §iv. A teaspoonful to be given every two or three hours, according to the age of the patient. 523. Calomel, either alone or combined with James's powder, ipe- cacuanha, or tartar emetic, is a most valuable remedy. Small doses may be given two or three times a day from the commencement, and continued until the violence of the disease abates, unless diarrhoea should occur, or the gums become tender. If the state of the bowels forbid the continuance of the calomel, even though guarded by the pulv. cretse cum opio, or Dover's powder, we may substitute the hydr. cum creta;. I have before remarked that mercurial diarrhoea in children is nearly as good a sign of the constitution being under the influence of the mineral as ptyalism in the adult. The treatment by calomel, when it can be borne, is well suited to those cases of secondary pleuritis in which bleeding and tartar emetic 1 Guy's Hospital Reports, Nos. 3 and 4, 1844. 2 Arch. Gen. de Med., third Series, vol. v. p. 59. PLEURISY. — PLEURITIS. 353 are counter-indicated, and in chronic' pleurisy, where they are unneces- sary and unsuited. 524. I need hardly state that the bowels should be kept free through- out the attack. At the commencement, a brisk purgative will be found very beneficial; but, in repeating it, we must be careful not to occasion diarrhoea, if we wish to persist in the use of mercury. When diarrhoea exists, a little compound powder of chalk, with the powder of chalk and opium, may be given, or chalk mixture, with aro- matic confection and a few drops of laudanum. 525. After the first acuteness of the disease has subsided, when the pulse is quieter, and the fever nearly gone, very great benefit will be derived from blisters, small ones and repeated, over the side affected. They are peculiarly applicable to secondary and chronic pleuritis, in connection with calomel and diuretics. In some cases, a sharp liniment will be sufficient, applied alternately to the back and front of the chest. 526. The majority of writers are agreed upon the benefits to be derived from diuretics, given not in the very early stage of the dis- ease, but after the fever has somewhat subsided — and continued for some time. In secondary and chronic pleurisy, they are also of great value, not merely as a derivative, but as probably promoting the absorption and evacuation of the fluid effused into the chest. Squills, digitalis, and nitre, may be combined with the calomel, or formed into a mixture with mucilage, syrup, and water, or combined with an expectorant. Some mixture should be ordered to soothe the cough, and with this the diuretic may very well be combined. Dr. Eberle speaks highly of the tinctura sanguinariee canadensis. Warm baths at the beginning are very soothing, but at a more ad- vanced period of the disease they may exhaust the patient too much. As in bronchitis and pneumonia, I have found the patient derive benefit from a constant poultice of bread and water, or linseed meal, applied to the chest — over the dressing, if a blister have been applied; if otherwise, next to the skin. The diet must be low and simple until the acute stage be past, but then it may be gradually improved. The utmost care will be necessary during convalescence. 527. I have already alluded to the operation of paracentesis in chronic pleurisy. The success of the operation seems to have varied in different hands. Dr. Henry Bennett, in his paper, 1 states that Boyer had per- formed the operation several times, but without success ; that Dupuy- tren had seen only two successful cases out of fifty ; Sir A. Cooper only one; Gendrin not one out of twenty on which he operated. Dr. Bennett himself has seen three unsuccessful cases. On the other hand, he has recorded six successful cases out of nine by Dr. Davies, and several by Dr. Hamilton Roe. Herpin succeeded in one case, and Heyfelder in three. Dr. Hughes mentions that within 1 Lancet, December 30, 1843. 23 354 PLEURISY. — PLEURITIS. the last four or five years the operation must have been performed from twenty to thirty times in Guy's Hospital. 528. As to the place and mode of operating, Mr. Cocks observes : "Auscultation and percussion are the best and surest means to detect the presence and the situation of the fluid, and on this and this alone we must place dependence. In the great majority of instances, the existence of the fluid will be most clearly indicated at the lateral and posterior part of the chest, in a position somewhat central between the upper and lower boundaries; and in every case which has come under my own hands, I have had occasion to tap below the angle of the scapula, between either the seventh and eighth or the eighth and ninth ribs, and at a point distant from one to three inches from the angles of the bones." " Our incapability of judging of the exact positions of the diaphragm, and the alterations which are liable to occur about the floor of the chest, from recent or old adhesions between that muscle and the base of the lungs, would lead me to deprecate the practice of making a low puncture. When we have the choice of two or three intercostal spaces, I would select the upper, or at any rate the middle one, as the least obnoxious to those casualties which may induce a failure in our object. Any advantage supposed to result from a depending opening can readily be obtained, as I shall presently show, by adapting the position of the patient to our purpose." 1 Previous to the operation, Mr. Cocks always employs Dr. Babington's exploring needle, of which he speaks most highly, and deservedly. The instruments he employs for evacuating the fluid are, of course, the tro- car and canula, but of a smaller size than usual. He prefers them of one-twelfth of an inch in diameter, and about two inches in length, and of a circular rather than an oval shape. In some cases of oedema of the subcutaneous tissue, a longer instrument may be required. Mr. Cocks thus describes the operation itself, which inflicts very little pain : " It will be found most convenient to let the patient sit across the bed, so as to admit of his body being readily lowered and supported over the edge. The spot having been determined upon, it is advisable to make a small puncture in the skin, just at the upper edge of the rib, with a narrow-bladed lancet, through which opening the exploring needle, and subsequently the trocar, may be inserted. This preliminary step is not absolutely necessary ; but, as the skin is by far the most impene- trable and resisting of the tissues to be traversed, its previous division will render the introduction and withdrawal of the canula more easy, less forcible, and attended with a minor degree of pain and alarm to the patient. The exploring needle having been first introduced, and the presence of fluid ascertained, the trocar and canula may then be car- ried into the chest through the same track, giving the instrument a slight obliquity upwards, which will enable it to clear the edge of the rib. The depth to which the trocar must be passed will, of course, depend much on the thickness of the parietes, the presence of fat, muscle, or oedema, for which due allowance should be made ; and in most instances the penetration of the pleura will be appreciated by the 1 Guy's Hospital Reports, 1844, No. 3, p. 67. PLEURISY. — PLEURITIS. 355 sensation conveyed to the fingers of the operator, especially if the integument has been previously incised, so as to diminish materially the friction. " The remainder of the operation consists in getting rid of as much fluid as the strength and condition of the patient will bear, and care- fully avoiding the admission of air into the cavity. On withdrawing the trocar, the fluid will at first be found to flow in a steady and equable stream, slightly augmented in force at each expiration. After the lapse of a shorter or longer period, the flow will become checked at each in- spiration, and then the body of the patient should be gently lowered into a horizontal posture, and turned slightly over to the affected side, so as to bring the cavity directly over the opening ; and in this position he should be duly supported by assistants. The fluid will now recom- mence flowing in an uninterrupted stream ; and when it again begins to flag, a still further quantity may be obtained, if the state of the patient permit it, by directing an assistant to make steady and continu- ous pressure on the lower part of the chest, by grasping it on either side with the hand. This may be kept up for a period varying from a few seconds to a minute, until a continuous stream can no longer be ob- tained, when the canula should be immediately withdrawn. The greatest care should be taken to remove the tube, and thus close the opening, while the chest of the patient is yet in the grasp of the assistant ; but if he relax the pressure while the communication with the pleural cavity be still open, air will infallibly rush in. " During the whole process of evacuation, the unremitted attention of the operator should be directed to the stream of fluid, which he should never allow to become completely interrupted during the effort of inspi- ration. The admission of the slightest quantity of air is immediately indicated by a peculiar sucking noise, which cannot be mistaken, and which should be the signal for the withdrawal of the canula. The wound requires nothing but the application of a small dossil of lint and a strip of plaster, and the patient may then be laid down on the bed. If he complain of faintness during the operation, some wine or ammonia may be given." 1 Dr. Hughes and Mr. Cocks have given the following resume of twenty- five cases in which the operation was performed : " Of these twenty-five cases in which paracentesis thoracis was once or several times per- formed, thirteen may be fairly stated to have recovered, so far as regards the effusion into the pleural cavity. Two may be justly mentioned as having at least partially recovered. One of these has, after seven years, a fistulous opening into the pleura; and the other has still some, though comparatively a very small quantity of fluid in the right pleura, but feels so much better as to be actually in search of employment in his profes- sion. Ten have ultimately died of other diseases, generally connected with that for which the operation was performed, but entirely inde- pendent of its performance. Of these ten cases ultimately fatal, six have died of phthisis ; one of gangrenous pulmonary abscess of the op- posite side ; one, after three months, of chronic pneumonia ; one rather 1 Guy's Hospital Reports, 1844, No. 3, p. 74. 356 PULMONARY PHTHISIS. suddenly, with hydrothorax in the other pleura ; and one, a case of pneumothorax with effusion (in which the operation was performed simply with the hope of affording temporary relief), of pneumonia and pericarditis." 1 CHAPTER IX. PULMONARY PHTHISIS. 1. This fearful malady, though less frequent than in adults, is by no means uncommon among the children of the poor, and such as are seen in foundling or children's hospitals, poor-houses, &c. ; in private practice, among more wealthy families, I do not think it is very common, except where it forms a part of a more general development of tubercles in scrofulous children. The characters, symptoms, course and termina- tion, very much resemble the same disease in the adult, so that it will be unnecessary for me to enter minutely into the different parts of its history. There exist, however, differences sufficiently marked to be worthy of notice, and which have a practical bearing upon our treat- ment. These deviations from the ordinary course of phthisis, I shall point out as we proceed, as briefly as I can. 2. Experience has shown us that tubercular deposition is exceedingly common in infancy and childhood : thus M. Lombard found that one- eighth of the infants who died from one to two years old in the Hopital cles Enfans Malades, at Paris, were tuberculous ; two-sevenths of those from two to three years ; four-sevenths from three to four years ; and three-fourths of those who die from four to five years old. M. Papa- voine makes a very similar report. M. Guersent calculates that tubercles are found in two-thirds or five- sixths of all the children from one to fifteen years of age, whose bodies are examined after death. M. Barrier states that he found tubercles in thirty-eight per cent, of those who died from two to five years of age ; seventy-two per cent, in those from five to eight years ; 100 per cent, in those from eight to eleven years ; and seventy per cent, in those from eleven to fifteen years. In 130 autopsies, he found that tubercles ex- isted in seventy-five. 2 Thus we see that the frequency of tubercular deposition is very great in the earlier years of life, and we further find that the organs most commonly affected are the lungs and bronchial glands ; but yet the lungs are not so invariably the seat of the morbid product in children as in the adult, for whereas M. Louis found in 125 adult cases, but one ex- ception to the law, that wherever tubercles were deposited in any organ, they were also found in the lungs, MM. Rilliet and Barthez met with forty-seven cases out of 312 tuberculous patients, in which the lungs 1 Guy's Hospital Reports, 1844, No. 4, p. 366. 2 Mai. de l'Enfance, vol. i. p. 329. PULMONARY PHTHISIS. 357 were entirely unaffected. This is the first deviation I have to bring before the reader. Dr. West has constructed a table, showing the com- parative frequency of the occurrence of tubercle in different organs in adults and children, which I shall take the liberty of extracting. Of 100 cases in which tubercle was deposited in some of the viscera, it was present Children from 1 to 15 years. Adults from 20 years and upwards. According to According to According to Rilliet and Barthez. Louis. Lombard. 84 100 100 79 28 9 46 33 19 42 33 40 13 6 34 2 1 27 22 1 19 10 16 2 15 2 1 11 0.8 2 6 • 3 In the lungs " bronchial glands " mesenteric " " small intestines " spleen " pleura " peritoneum " liver " large intestines " membranes of the brain " kidneys . " brain " stomach . " heart and pericardium 3. Symptoms. — The disease may set in during the course, or towards the termination of some other affection, especially if tubercular, and, of course, the symptoms will be modified more or less by the concurrent disease, or by the condition in which a preceding one may have left the patient. Or it may commence quite independently, and then the symp- toms resemble very much those in the adult, differing rather in degree than in kind. 1 The child, at the commencement, seems unwell, loses its appetite, acquires a delicate semi-transparent look, complains of erratic pains in the chest, &c, even before alarm is excited by a cough. At first the cough is slight, dry, and more distressing by its frequency than its se- verity : as the disease advances, it becomes more troublesome, sometimes almost incessant, in other cases occurring in paroxysms. In a few cases, the cough is comparatively rare, attracting but little attention, but, nevertheless, it is present in almost every case. Rilliet and Barthez thus speak of this symptom: " The cough, once present, persists through the entire duration of the disease. It presents, it is true, great varia- tions in its characters and its intensity, but it is rare to find it sus- pended either completely or for a time. In one infant alone have we seen the cough commence after haemoptysis, cease after a time, and not reappear until after a recurrence of the accident." 2 The respiratory movement is rarely natural, in general it is hurried, and sometimes extremely rapid, even up to 40, 60, or 80 in the minute, accompanied by an amount of dyspnoea, in some degree in proportion to the amount of tubercular deposit, whether the tubercles be softened or in a crude state ; or it may depend upon an accession of pneumonia or bronchitis, but if neither of these exist, it is stated to be a tolerably accurate measure of the extent of the disease. With some children we 1 Barrier, Mai. de l'Enfance, vol. i. p. 649. 2 Rilliet and Barthez, Mai. des Enfans, vol. iii. p. 277. 358 PULMONARY PHTHISIS. see the entire chest dilate, in others respiration is mainly accomplished by the movements of the diaphragm, and in a third class it is entirely costal. In infants, there is no expectoration, and very rarely in children under six years of age ; whether it be that none is thrown off, or that it is swallowed, is not easy to decide ; from six to fifteen years, it is more abundant, and presents much the same character as in the adult, but it is not so easy to infer from them the presence of a cavity. Nor is hsemo- ptysis at all common; it is extremely rare at the beginning, and in the course of the disease it occasionally just tinges the sputa. Towards the end it may occur more abundantly, and may even terminate life some- what abruptly. MM. Rilliet and Barthez never saw it either at the commencement or in the course of phthisis, but in five cases the parents reported that it had occurred. Pain and uneasiness in the thorax is of uncertain occurrence ; many patients are too young to complain of it ; many have it not. When it does occur, it is sometimes behind the ster- num, sometimes between the shoulders or in either side. Night perspirations, although they do occur, are much less common than in adults. 4. Thus affected, the child rapidly loses flesh and strength, and the color of the skin is altered, but the symptoms which especially charac- terize the hectic fever of consumption in adults, such as the quick hard pulse, heat of skin, hectic flush, perspirations and general irritability, are generally less intense. This M. Barrier is disposed to attribute to the less frequent occurrence of suppuration and cavities. Dr. West thus sums up the peculiarities of the symptoms as they occur in children: " 1. The frequent latency of the thoracic symptoms during its early stages. 2. The almost invariable absence of haemo- ptysis at the commencement of the disease, and its comparatively rare occurrence during its subsequent progress. 3. The partial or complete absence of expectoration. 4. The rarity of profuse general sweats, and the ill-marked character of the hectic symptoms. 5. The fre- quency with which death takes place from intercurrent bronchitis or pneumonia." 1 5. It is evident that the symptoms already enumerated, although sufficient to excite our fears as to the disease, are by no means so cha- racteristic as those in the adult, and are inadequate alone to assure us of its true nature. But by adding to them the information afforded by percussion and auscultation, even though that be not always so certain as we should wish, we shall generally be able to remove all doubt. There are some peculiarities in the results of auscultation and percussion, which deserve our attention, and which have been succinctly pointed out by M. Barrier. " On account of the great resonance of the chest in chil- dren, it would require, in order to produce much dulness on percussion, that the tubercles should be both numerous and agglomerated ; there- fore, a very dull sound in children indicates a greater amount of tuber- cularization than an equally dull sound in adults. Moreover, in adults, the tubercles are generally concentrated at the top of the lung, produc- 1 Diseases of Infancy and Childhood, p. 301. PULMONARY PHTHISIS. 359 ing a circumscribed dulness rarely appreciable, whereas in children, this concentration at the summit being less frequent, and the dissemina- tion of the tubercles more general, the dulness is less circumscribed, less intense, and consequently less evident. But on the other hand, where dulness exists in adults, it corresponds generally to the advanced stage of phthisis, that is, to the presence of cavities ; but with children, phthisis remains most frequently in the first stage up to the time of death, and the dulness corresponds to the crude condition of the tubercles." 1 The increase of sonoriety which we may occasionally observe in adults where cavities are formed, is necessarily less frequent in children be- cause cavities are so. In some cases where the tubercles are thinly scattered through the lungs, the results of auscultation may be almost negative ; but where they are collected in certain numbers, although both attention and an educated ear may be necessary, we shall generally be able to ascertain the true state of the case. One of the earliest auscultatory phenomena, in the stage of crude tubercles, is the prolonged expiratory murmur, first noticed I believe by the late Dr. Jackson, of Boston, U. S., and confirmed since by the re- searches of Andral, Fournet, &c. M. Hirtz, of Strasburg, has noticed a variation in the expiratory murmur in this stage, which he terms the bruit expiratoire rapeux ; the sound is at once rougher and clearer than the normal murmur. According to M. Fournet, 2 it is not only modified by a degree of roughness and dryness, but its intensity and duration are increased in comparison with the inspiratory murmur, which is diminished, although it also requires a degree of roughness, dryness, and difficulty. Occasional changes in the tone of the respiratory sounds may, however, modify or obscure the foregoing peculiarities. These changes consist at first of a clearer murmur than natural, which may gradually increase to what M. Fournet calls a timbre soufflant et bronchique, which may exist from the first to the last stage of tubercles. The same author has ascertained that all these changes commence with expiration, but that by degrees at a later period they involve inspiration also. Another sound, which has been termed a bruit de froissement, or craquement sec, has been mentioned as peculiar to the stage of crudity; but not only are these sounds obscure and observed with diffi- culty, but it would seem that their precise value and significance are not yet ascertained. MM. Billiet and Barthez regard the hardness (durete) of respiration, the prolongation of expiration with the sonoriety, as the most character- istic symptoms, but which are liable to be changed or masked by various circumstances. They attempt further to distinguish between miliary tubercles and the yellow or gray infiltration ; in the former, they state that the respiration is rough, expiration prolonged, and the sonoriety unaltered; in the two latter cases, by the feebleness or absence of the respiratory murmur, and the diminution of loss of sonoriety. 3 There do not appear to be any special signs which correspond to the 1 Mai. de l'Enfance, &c, vol. i. p. 651. 2 Recherches Clin, sur 1' Auscultation et sur la Premiere Periode de la Phthisie. 3 Mai. des Enfans, vol. iii. p. 247. 360 PULMONARY PHTHISIS. softening of the tubercles until these are in process of elimination, and cavities commence to form. If the cavities are situated in the upper part of the lung, and are sufficiently large, we shall have the mucous rale, cavernous respiration, gurgling, perhaps pectoriloquy, and dulness, just as in the adult. Whilst the cavities are small, the value of the mucous rale "will depend upon its being limited to the situation of the tubercles, as it may also arise from bronchitic irritation, and when it is general, the probability would be that it does so. However, it must not be forgotten, as Rilliet and Barthez observe, that cavities do not always give rise to these peculiar signs, but rather to bronchial symptoms, as bronchial respiration, mucous rale, broncho- phony and dulness, and also that symptoms of cavities may be present without any cavity at all. The vocal resonance is changed in phthisis, during the earlier stage, especially in those parts where the tubercles are numerous or agglome- rated; the voice becomes more resonant, and occasionally we find bron- chophony ; at a later period, when cavities are formed, we may have pectoriloquy. In children as well as in adults, the vibration of the parietes of the thorax is diminished during the crude stage, and increased over large cavities, if any such form. These phenomena are generally present in children as well as in adults, nor are they much more difficult to ascertain generally ; the chief obstacle arises from the restlessness and unwillingness of the child to submit to examination, but with gentleness, patience, and a little coaxing, we may always attain our object. Externally, the two sides of the thorax may present different degrees of mobility, according as one side is more affected than the other. Oc- casionally, when cavities exist on one side, we may perceive a depres- sion of the subclavicular region, and this part is less dilated during in- spiration. According to M. Hirtz, the thorax becomes more cylindri- cal, i. e. the transverse diameter, which in the normal state is greater than the antero-posterior, gradually diminishes. Lastly, we may proba- bly perceive a difference of volume between the two sides of the chest ; but M. Barrier has given a case which shows that this is not always a proof of a greater amount of disease in the smaller. Dr. West thus enumerates the more important peculiarities in the phenomena observed by auscultation in the child : " 1, the smaller value of coarse respiration, prolonged expiration, and interrupted breathing, owing to their general diffusion over the chest, and to their occasional existence independent of phthisis ; 2, the apparent and to some extent the real exaggeration of the signs, both of the early and of far advanced disease of the lungs, in some cases of bronchial phthisis ; 3, the loss of that information which the phenomena of the voice furnish in the case of the adult ; 4, the small value of inequality of breathing in the two lungs ; 5, the difficulty of detecting minute variations in the sonoriety of the chest ; and 6, the existence of dulness in the interscapular region, together with moderate resonance of the upper parts of the chest, and tolerably good respiration there, which are characteristic of the pre- sence of enlarged bronchial glands." 1 of Infancy and Childhood, p. 302. PULMONARY PHTHISIS. 361 6. I have already mentioned that in many cases the symptoms are but slight, for some time after the commencement of phthisis ; but as the disease advances they assume a much more serious character, though not steadily progressive. We may observe great fluctuation ; some days the child seems better, with less cough and dyspnoea, and better appe- tite and spirits ; then an attack of bronchitis, or perhaps pneumonia, throws the child into a very distressing and alarming state; or the con- currence of bronchial phthisis presents a more aggravated condition than usual. As the disease advances, we find the cough generally more troublesome, the respiration more hurried and attended by wheezing, with little or no expectoration; if the child be young, it becomes rapidly emaciated and very feeble. Some degree of hectic may ensue, with par- tial night-sweats, but not at all as well marked as in adults. The mouth frequently becomes aphthous, and the stomach and bowels deranged ; and though diarrhoea is not uncommon, it does not alternate with the night-sweats as in the adult. "In a very large proportion of cases of phthisis, the functions of all the organs of the body become at length so much disturbed, and nutrition generally so much impaired, that the patient dies, because the whole machine is worn out. But though this is the case in many instances, yet it often happens, even where the powers had long seemed nearly exhausted, and the body wasted almost to a skeleton, that death is far from tranquil, but is preceded by hours of severe agony, for which it is not easy to account. In many cases, and especially in those where the disease runs a rapid course, the fatal termi- nation is due to an attack of intercurrent bronchitis or pneumonia, which is sometimes supposed to have been the patient's only disease, until a post-mortem examination reveals the tubercular degeneration of the lungs, to which the inflammatory affection was but secondary. Death from haemoptysis is rare, and still rarer is the perforation of the lung by the walls of the cavity giving way at some point, and thus producing pneumothorax. The abdominal symptoms sometimes mask the thoracic, and the patient dies of tubercular peritonitis, who, had life been pro- longed, would have sunk eventually under pulmonary phthisis. Many children in whom the signs of incipient phthisis have appeared, die of acute hydrocephalus, excited by the membranes of the brain having become the seat of tubercular deposit ; and some, in whom the disease has attained a more advanced stage, are suddenly carried off by head symptoms, the cause of which is explained by the discovery of large masses of tubercle in the cerebral substance. Convulsions, however, sometimes precede death for several hours, or head symptoms of greater or less intensity constitute the most striking feature in the patient's history for some days before death takes place, and yet an examination of the body throws no light upon the cause of their occurrence. Some- times, too, the symptoms that precede death are those of fever of a typhoid character, rather than of serious mischief in the chest." 1 Such is the graphic picture of the termination of phthisis from the pen of no ordinary observer. From the beginning to the conclusion, 1 Diseases of Infancy and Childhood, p. 309. 862 PULMONARY PHTHISIS. the melancholy cases advance from bad to worse, with but rare intervals of comfort to the bystanders, fewer still of hope for the little patients. The entire duration of the disease varies a good deal. According to Rilliet and Barthez, it averages from three to seven months. M. Bar- rier states that the non-acute cases are not so prolonged as in the adult, and that the course is shorter in proportion as the child is younger. Dr. West mentions that he has known cases persist two, three, four, or nearly five years before terminating fatally. I should be inclined to think Rilliet and Barthez's estimate within the mark, at least for pa- tients in private practice. 7. Modifications and Com/plications. — 1. Now and then we meet with unusually rapid cases of the disease; and, in such cases, we are liable to fall into an error of diagnosis, inasmuch as the symptoms present all the characters of an acute disease, and there is not time for the peculiar symptoms to manifest themselves. M. Barrier states that such are more common than in adult life. Dr. West has given the following case in illustration: "A remarkable instance of this came under my notice some years ago, in the case of a little boy, nine months old, who was fat and ruddy, and had always had perfectly good health until the 10th of April. On that day, he was taken with symptoms which his mother supposed to be those of a bad cold. On account of this he was kept in the house, and various domestic remedies were employed, though without any improvement, and, on April 24, he came under my notice. There did not then appear to be any urgent symptom, though the child seemed much oppressed at the chest. The case appeared to be one of rather severe catarrh, occurring during the period of denti- tion. The gums were lanced, and a mixture containing the vinum ipe- cacuanhas was ordered, to which, finding the symptoms did not abate, small doses of antimonial were added on the 27th. On the 30th, I was informed that the child was much worse, that his dyspnoea was greatly increased, and that his hands and feet had been swollen for the last forty-eight hours. I found the little boy breathing fifty times in the minute, with great oppression at the chest, the face much flushed, the skin dry, the trunk hot, the limbs cool, and the hands and feet much swollen. Auscultation detected generally diffused small crepita- tion through both lungs, with indistinct bronchial breathing at the upper and back part of the left side. Three hours after this visit, the child died without a struggle, on being lifted out of bed for his mother to apply some leeches to his chest. On examining the body after death, a very thick layer of fat was found everywhere beneath the integuments. The lungs presented an extreme degree of tubercular degeneration, and many of the bronchial glands were enlarged by the morbid deposit to the size of a pigeon's egg. None of the tubercle in the lungs was softened ; but it existed both in the form of yellow mili- ary tubercle of tubercular infiltration and of masses of crude tubercle formed by the agglomeration of many separate deposits. The pulmo- nary substance in the intervals between the tubercular deposits was of a bright red color in the first stage of pneumonia, and in many parts bordering upon the second stage; and there was very considerable PULMONARY PHTHISIS. 363 injection of the bronchial tubes. The various abdominal viscera con- tained tubercle, but it was not far advanced in the mesenteric glands." 1 2. On the other hand, the disease may assume an unusually chronic form, and, instead of terminating in two or three months, may run on to a year, or even more. In such cases, however, we are not exposed to the same liability to error in our diagnosis. The patient, or the pa- rents, however, suffer more from the fluctuations of hopes and fears. I shall again trespass upon Dr. West for an illustration. " In March, 1842, I saw a little girl, six years old, whose father had died of phthisis, and who had had a cough ever since she suffered from measles, two and a half years before. Her mother's anxiety had been excited by the increase of this cough, and by the child's losing flesh during the few weeks previous to her coming to me. Auscultation at this time dis- covered that air entered the lung in the left infra-clavicular region more scantily than in the right, and that the respiration was coarse and attended with much creaking at the upper part of both lungs. In May, the general symptoms were much improved, and the creaking sounds were no longer heard. For many months, the child continued to ap- pear tolerably well, though her cough never ceased entirely; but in the early part of the winter of 1844 her health completely failed. Exami- nation of the chest in the beginning of December elicited great defi- ciency of resonance at the upper part of the left lung, both in front and behind. Bronchial breathing, intermixed with large mucous rale, was heard in the left suprascapular region, and abundant moist sounds pervaded the lung posteriorly. In the left infra-clavicular and mam- mary regions, the respiration was very deficient, and accompanied with distant moist sounds. Extreme coarseness of the respiration was the only morbid sound heard at the upper part of the right lung, and the breathing on that side was puerile in other parts. In January, 1845, the child had slight haemoptysis, which recurred occasionally at intervals of a few weeks or months until her death, but was not profuse at any time. In September, 1845, resonance was slightly impaired under the right clavicle, and also in a greater degree posteriorly as far as the angle of the scapula. There was absolute dulness of the left side as far as the nipple in front and the angle of the scapula behind. There was no natural breathing in the left lung, but the respiration was bronchial, and accompanied with large mucous r&le as low as the nipple, the rale being smaller and the admission of air scanty below that point. About the left scapula, there were cavernous sounds and distinct gurgling, smaller moist sounds lower down. In the right lung, respiration was puerile in front, except quite at the upper part, where the breathing was coarse, and attended with mucous rale ; and posteriorly the characters were still more marked. It cannot be necessary to detail the results of the subsequent examination of the chest, which showed that disease advanced slowly in the right lung, though there was at no time proof of the existence of a cavity there. The child's condition fluctuated; some- times she seemed almost dying under an aggravation of all the symp- toms, and then again she rallied, and was able to walk about, and 1 Diseases of Infancy and Childhood, p. 302. 364 PULMONARY PHTHISIS. seemed tolerably comfortable. Life was prolonged until June, 1847, and she had seemed almost as well as usual until a very few days before her death.'' 1 This case, we see, lasted five years at least. I have under my care at this moment a little girl who has been similarly affected for two years, and as yet only the upper third of the left lung is involved, the remainder of that lung and the whole of the right being free. She is delicate, but quite able to go about, with but little cough, no night-sweats, little expectoration, no haemoptysis, some degree of emaciation, and a feeble appetite. Dr. West mentions another case, which has lasted still longer; and I doubt not that similar cases are occasionally met with by other medical men. 8. Bronchitis. — I have already mentioned that the course of phthisis is often much modified by attacks of bronchitis, which are sometimes at- tributable to cold, and at other times occur without any assignable cause. They are marked by increase of fever, more rapid breathing, more dis- tressing cough, &c, and by the presence of bronchitic rales in one or both lungs. The extent varies ; sometimes it is very considerable, and accompanied with great exhaustion ; in other cases it is much slighter. By degrees the attack may subside under appropriate treatment, and the patient gradually recover a certain amount of health and comfort, but if not, it will, of course, hasten the progress of the primary disease, and shorten the patient's life. 4. Pneumonia. — Another frequent complication of pulmonary phthisis in early life is pneumonia, which, according to Rilliet and Barthez, occurs more frequently before than after the tenth year. If it occur at an early stage before attention has been drawn to the tuberculous deposit, a su- perficial examination may easily lead to an erroneous diagnosis. Seve- ral causes for the attack have been enumerated by Rilliet and Barthez. "1. It may result from the local irritation of the pulmonary tubercle, and then it surrounds the latter, and we find the tissue of the lung hepa- tized and mixed with a variable quantity of miliary tubercles. It may either be lobar or lobular, but the latter form is more frequent. 2. The lung being very tuberculous, the pneumonia may be situated at the part most free, i. e. at the base, like the terminal pneumonia of adults ; it is always lobar, and can hardly be attributed to the irritation of the tu- bercles, but most likely to the susceptibility acquired by that part of the lung upon which its functions depend. 3. When the lungs are but slightly tubercular and other organs very much so, pneumonia may be developed which is not under the local influence of the tubercle. It is a secondary inflammation, analogous to that which complicates chronic catarrhs, and which exhibits the characters of cachectic phlegmasia. 4. In cases where the tubercles are few, the pneumonia may be alto- gether independent of this cause, and is due to some other disease, as measles, hooping-cough, &c." 2 Both lungs may be attacked, but when one only is affected by .lobular pneumonia, it is more frequently the right, and when by lobar pneumonia, the left lung is more liable than the right. 1 Diseases of Infancy and Childhood, p. 306. 2 Mai; des Enfans, vol. iii. p. 243. PULMONARY PHTHISIS. 365 I have already mentioned the difficulty of diagnosis, unless' sufficient care and attention be paid. It is of great consequence that we should ascertain the presence of tubercles, and not hastily assume that the case is one of ordinary pneumonia. " The existence of a considerable amount of tubercular deposit in the lungs may be imputed in those cases in which the degree of oppression of the chest has, from the very com- mencement of the illness, been altogether out of proportion to the se- verity of the catarrhal or bronchial symptoms with which the disease set in. A further evidence of its nature is afforded if the skin, though very dry, present a less considerable or less pungent heat than attends simple pneumonia, while the pulse from the very outset is less devel- oped. Suspicion would be strengthened if the frequency of respiration very greatly exceeded the amount of mischief disclosed by auscultation, and especially if the rapidity of the breathing, though so great that it would excite the most serious alarm if the case were one of pneumonia, should yet continue the same for days together, without marked deteri- oration in the patient's condition. Auscultation also would throw much light on the nature of the case, for the sounds detected in the chest would be the subcrepitant and mucous rales rather than the small crepi- tation of pneumonia, while, though the smaller sounds would be disco- vered at the lower part of the chest, the greatest dulness on percussion would generally be detected at the upper part, and bronchial breathing would very likely be perceived more or less distinctly in the same situa- tion." 1 We must also take into account the constitution of the child and of his immediate relations, the presence of scrofulous disease in any of them will naturally confirm our suspicion of the existence of tubercles, and we must carefully observe the accordance or discordance of the signs and symptoms of each disease. The danger of this complication is very great, not merely as to the immediate shortening of the patient's life, but as destroying whatever little hope there may have been of a favorable issue, so that our prog- nosis should in all cases be very guarded. 5. Bronchial Phthisis. — But pulmonary phthisis in children differs from the same disease in adults by the more frequent occurrence of tu- bercular deposition into the bronchial glands, or bronchial phthisis as it is termed. In the adult, this occurs about once in four cases of phthisis, but it is subsidiary to the pulmonary affection ; in children, it constitutes a very important disease, often more considerable and nearly as frequent as the deposition in the lungs. Dr. West states that tubercle existed in the bronchial glands in fifty-four out of fifty-five cases that came under his notice in which it was present in some organ or other ; in eleven of these cases it was in an incipient state; in twenty-five, all the glands were affected by it ; in twelve, the tubercle was both generally diffused and was more or less softened ; in two, the tubercle was in a firm, friable, cheesy state, and in four it had begun to undergo the cretaceous change. 2 1 Diseases of Infancy and Childhood, p. 303. 2 Ibid., p. 290. obb PULMONARY PHTHISIS. This form of disease generally occurs between the ages of two and six years, though it is by no means limited to that period. The symp- toms differ a good deal from those in the adult ; the attention may be first attracted by a severe attack of bronchitis, either after measles or independent of it. The cough and dyspnoea are the most prominent symptoms, the former is frequent and severe, recurring in paroxysms somewhat resembling those of hooping-cough, or those we observe in vesicular bronchitis. The respiration is hurried and oppressed with considerable wheezing, the veins of the neck are swollen and those of the surface of the thorax become dilated. " The great fluctuations which take place in the condition of the patient constitute one of the most striking characteristics of this form of phthisis. Attacks of bronchitis sometimes come on, during which the respiration becomes painfully ac- celerated and oppressed, and the paroxysmal cough is merged, for a time, in a constant hacking or suppressed attempts at coughing. These bron- chitic symptoms, which often seem to threaten life, and which sometimes actually destroy it, clear up by degrees, in the majority of cases, but leave the child with a severer cough and more hurried respiration than before, while it loses flesh rapidly, and not infrequently sweats a good deal about the head and upper part of the trunk. Accommodation of posture, too, in many instances, becomes necessary to the comfort of the little patient, who perhaps can breathe only when supported in its mother's lap, or when much propped up in bed. It is seldom when the disease has reached this degree of severity that there is entailed so large a measure of tubercular affection of the lungs and other viscera, as to render recovery quite hopeless, and the characteristic signs of bronchial phthisis become lost, by degrees, in those of ordinary consumption. Sometimes, however, a long pause takes place in the progress of the disease, even though thus far advanced; the cough, which had acquired fresh intensity, gradually abates ; the respiration is no longer habitually wheezing ; the patient can repose in any attitude ; the flesh lost is re- gained ; and were it not that the cough still continues, though less frequent and less severe, that the breathing is more hurried than natu- ral, and that auscultation contributes still further to undeceive us, we might fancy that all ground for anxiety was passing away, and that the child was on the high road towards recovery. In some cases, too, in which symptoms such as have been described are observed, recovery does eventually take place. It is seldom possible to say in any case by what means this recovery is brought about ; sometimes no doubt the tubercular matter makes its way into the air-tubes, and is got rid of by expectoration. Once I observed the disappearance of most well-marked general signs of consumption in the case of a girl eight years old, during the copious expectoration of a tenacious mucus in which were small quantities of a substance like broken down cheese, or grains of boiled rice, and which attenuated with an expectoration of thick puri- form matter more or less tinged with blood. In the case of this child, an attack of measles, while in her seventh year, had been succeeded by cough, the formation of abscesses in her neck, and a frequent puriform and sanguineous discharge from her nose. These abscesses had not been long healed, when her mother's alarm was excited by her expectorating PULMONAKY PHTHISIS. 367 blood, mixed with the phlegm which she brought up when coughing. Though not much emaciated, the child looked unhealthy, her pulse was very feeble, and there were many small petechia on her extremities. The lungs, however, were tolerably free from disease ; for nothing more was heard during auscultation than a good deal of rhonchus mixed with some moist sounds, which were most evident at the upper part of the chest. Expectoration such as I have described continued for nearly three months, in the course of which the child by degrees lost her cough and acquired strength under the use of steel and other tonics. Two years afterwards no auscultatory signs of disease were perceptible, except a little creaking under both clavicles, and at the end of five years even this had disappeared." 1 The signs and symptoms which accompany this affection are by no means always very characteristic; there may be but few signs present, or the cough, dyspnoea, &c, may be owing to the coincident deposition of tubercles in the lung, and if the latter be pretty well advanced, it will be quite impossible to distinguish between them. If, however, the patient be of a tuberculous cachexia, and has been placed in circum- stances to favor its development, and if the general symptoms, such as cough, dyspnoea, expectoration, &c, exist without any physical signs of disease of the bronchi, lungs, or pleura, we may have ground for sus- pecting the existence of bronchial phthisis. According to Mr. Barrier, 2 the results of percussion are completely negative, when the disease is limited to the glands, and in general auscultation is little more satisfac- tory. Sometimes, however, the swollen gland compresses a bronchus, diminishing its calibre, and then the respiratory murmur will be enfee- bled in that part of the lung to which the tube is distributed. In such cases the clear sound on percussion, combined with the feebler respira- tion, cannot be attributed to tubercles of the lung, but would seem to justify our considering the case to be one of tubercular deposition in the bronchial glands. Both M. Becquerel and M. Barrier have verified, after death, a diagnosis founded upon this combination. Again, if the signs of a cavity appear in the neighborhood of the mediastinum, but nowhere else, we may presume without much hesitation, that they result from the suppuration of tubercular masses in the glands, and which may be voided through the larger bronchial tubes. The palpitations and anasarca which are sometimes produced by the tubercular matter in or near the mediastinum, pressing upon the larger vessels, are not of much value as to diagnosis, inasmuch as neither is uncommon in pulmonary phthisis. So that, upon the whole, it is evident that the distinction during life between bronchial and pulmonary phthisis is one of great difficulty, depending upon minute symptoms and close and accurate observation. At an advanced period, this is of no great consequence ; but as the progress of the former disease is much slower, it may be some comfort at an early period to know that the disease is one which, at least, admits of a considerable prolongation of life. But more than this, for it seems undoubted that bronchial phthisis is to a 1 Dr. West, Diseases of Infancy and Childhood, p. 295. 2 Mai. de l'Enfance, vol. i. p. 657. 368 PULMONARY PHTHISIS. certain extent a more curable disease, or rather one in ■which recovery more frequently takes place ; and that, in various ways, either the tubercular matter may be absorbed, or it may be converted into creta- ceous substance, or the gland may suppurate, and emptying itself com- pletely into the bronchial tube, may heal ; and, if it be an isolated gland, the child may recover ; but such cases are rare. Death, however, rather than recovery, is the ordinary termination of the disease, either by suppuration of the tubercular masses which ex- hausts the patient, or while the tubercles are yet in a crude state; but more commonly by the participation of the lungs and other organs in the tubercular degeneration. The prognosis, therefore, is at best very doubtful, and in most cases very unfavorable. 6. Emphysema and (Edema. — Rilliet and Barthez mention that both these secondary affections occasionally accompany tubercles of the lung ; but the former does not appear to hold any definite relation to them, whereas, the latter is either the direct result of the tubercles, or of the pressure exercised by them upon some of the pulmonary vessels. 8. Morbid Anatomy.' — The pathology of pulmonary phthisis in chil- dren does not vary very much from the same disease in adults, and therefore I feel it the less necessary to enter fully into details. In the large majority of cases, both lungs are engaged ; out of seventy cases, M. Barrier found six only in which one lung alone was involved, and of these six cases, five were of the left lung, and one of the right. In sixty-four cases, both lungs were engaged, even though in a third of the cases, the disease was but slightly advanced. In twenty-two, the left lung was most affected ; in nine the right, and in thirty-three they were about equally so. As in adults, the apex of the lung is the part first and chiefly affected, the tubercles diminishing in number, and being less advanced as we descend. Unlike adults, in whom death seldom takes place until after the estab- lishment of suppuration and the formation of cavities (provided there are no complications), we find death occur in children, in whom almost all the tubercles are in a crude state, or at least before large or nu- merous cavities are formed. This many arise either from the greater rapidity with which extensive depositions of tubercle take place, causing death before there has been sufficient time for suppuration, or from the coincident occurrence of tubercles in other organs or glands. In eleven of thirty-three cases related by M. Barrier, there were either no cavities or extremely small ones. When tubercularization has gone to a certain length, the pleura is rarely found in a state of perfect health ; adhesions are very common, and tubercles are by no means rare. The bronchial glands, as I have already remarked, seem to be more frequently affected than the lungs themselves ; for M. Barrier states that of seventy-nine cases, sixty-nine had tubercles in the lung and bronchial glands, four in the bronchial glands only, and one in the lungs only. Dr. West mentions that tubercle existed in the bronchial glands in fifty-four out of fifty-five cases in which it was present in some organ or other; in eleven, it was in an incipient state; in twenty-five, all the PULMONARY PHTHISIS. 369 glands were affected by it ; in twelve, the tubercle was both generally diffused and was more or less softened; in two, the tubercle was in a firm, friable cheesy state ; and in four, it had begun to undergo the cretaceous change. Any of the glands may be thus affected ; but the most important are those lodged in the mediastinum. As a general rule, the enlarged glands produce less inconvenience from compressing the neighboring parts than we might expect ; never- theless, we have sometimes to complain of such effects. The bronchial tubes may be compressed and flattened, or their coats may be thinned, eroded, or destroyed, the covering of the gland supplying their place and completing the wall of the tube. This, in the course of time, may give way, and the softened tubercular matter be poured direct into the bronchial tube. M. Guersent is said to have found the entire gland enucleated and passed into the tube. The pulmonary artery and veins may be compressed, and to this they are peculiarly exposed from their connection with the glands. The aorta may also be compressed, and its caliber diminished. M. Becquerel mentions a case of M. Durand's, of a girl whose trachea, large bronchi and aorta, were compressed by tubercular glands, which had thus apparently given rise to hypertrophy of the left ventricle. Compression of the vena cava thus effected may give rise to partial or general dropsy. The oesophagus is rarely altered in volume. As to the tubercles themselves, as in the adult, they may present themselves in the lungs in the form of miliary tubercles, or in masses, or diffused more generally through the substance of the organ. Whe- ther in the lungs or bronchial glands, the matter may be in either a crude or a softened state. In a crude state, the tubercles are either gray and semi-transparent or whitish or yellow, with a carious appear- ance, which generally succeeds the earliest stage. In the glands, the matter is sometimes deposited in such quantity that, instead of remain- ing isolated, several are joined, and form irregular masses of large size, in which, by dissection, we can trace the fibrous envelopes of each gland; but in the end these often disappear, and then the tumor will be simply surrounded by a general cyst. After a time, suppuration occurs, commencing generally in the centre of the tubercular mass, and proceeding to the centre until the whole is softened and evacuated by means of a communication with some of the bronchial tubes. A similar process takes place in the tuberculous glands; but, after the mass is softened, the attempt is made to evacuate the matter by perforating the cyst and reaching the nearest bronchial tube, through which the puriform matter is evacuated. An empty bronchial cyst may be mistaken for a true pulmonary cavity, if care be not taken; but it may be distinguished by its fibrous capsule, and also, according to Rilliet and Barthez, by the perforation into the bronchial tube being situated laterally. Occasionally, the suppuratory bronchial glands have perforated the oesophagus, and even the pulmonary artery, according to M. Berton. Tubercular matter, whether in the lungs or bronchial glands, may undergo calcareous transformation, though it is rare ; and this has been mentioned as one mode of cure. M. Becquerel has occasionally ob- 24 370 PULMONAEY PHTHISIS. served a steatomatous condition of the glands, which he regards as a transformation of tubercular matter. Dr. West enumerates four points in which tubercles in the lungs of children differ from those in the adult: 1. In the greater frequency with which gray granulations and crude miliary tubercles exist in the lungs independent of each other and of any other form of tubercular deposit ; 2. The greater frequency with which yellow infiltration of tubercle is observed in early life; 8. The greater rarity of cavities; and 4. The abundant deposit in the bronchial glands.* I do not presume to present this sketch to the reader as anything like a complete account of the pathological anatomy of tubercle, which will probably be already familiar to them from the perusal of the various valuable works we possess on pulmonary diseases, but rather as a notifi- cation of the peculiarities which it assumes in children, and of some points in which it differs from the disease in adults. Neither do I deem it at all advisable to enter into the causal origin of tubercles, how far they are independent of or how far they result from inflammation, &c, &.c. Such questions are doubtless of deep interest, and much light has been of late years thrown upon them, but they would be unsuitable in a work like the present ; and I must refer my readers to the various works on diseases of the chest, where they will find the subject treated with knowledge and acuteness far beyond mine. 9. Causes. — There can be no doubt that a scrofulous constitution, whether inherited or acquired, is the most influential predisposing cause. Neither can we be surprised that close, dark, damp, unventilated dwell- ings, insufficient clothing, and scanty or improper food, should induce that condition of body which renders the liability to phthisis so fear- fully greater among the poorer population of towns and cities. The immediate cause of the attack is very often, if not generally, ex- posure to cold in some form or other; or the disease may succeed to some of the eruptive diseases, or to ordinary bronchitis or pneumonia in children in whom the predisposition exists. 10. Diagnosis. — 1. In the early stage of the disease, the difficulty will be to distinguish between phthisis and bronchitis; but in the for- mer, we may have some degree of clulness at the upper portion of the lung, and a mixture of the crepitus of tubercles, neither of which will be found in bronchitis. The constitution of the child will also some- times throw light on the diagnosis. At the same time, we must not forget that both diseases may be present. At a later period, the pa- thognomonic characters are very different. 2. From 'pneumonia. — A similar difficulty besets us here, for pneu- monia may complicate the case as resulting from tubercles, and to dis- tinguish this from simple pneumonia is by no means easy. We may derive some guidance from previous auscultation, if the lungs were then free from the secondary disease, and also from the duration of the pneu- monia ; or, if it be prolonged with alternations of increase and diminu- tion, we may suspect that it is tubercular. Again, tubercles are at an early stage confined to the upper part of 1 Diseases of Infancy and Childhood, p. 288. PULMONARY PHTHISIS. 371 the lung, simple pneumonia more frequently occupies the inferior por- tions, and the small crepitus of the latter disease is quite distinguishable from the tubercular rales ; and, lastly, the amount of fever is much greater in pneumonia than in uncomplicated phthisis. At a later pe- riod, when the tubercles are softened and perhaps cavities formed, the diagnosis from simple pneumonia is comparatively easy. 3. I have already enumerated the distinctive points, slight as they are, between bronchial and pulmonary phthisis ; and I may add that in many cases such a diagnosis is not only very difficult, if not impossible, but somewhat unnecessary, as the diseases very seldom occur or con- tinue long separately. 4. As to some other diseases from which it is desirable that phthisis should be distinguished, Dr. West observes that "it is important to bear in mind that strumous dyspepsia, as it has been called by many writers, is of more frequent occurrence in childhood than in adult age, and that its symptoms may be all that mark the advance of phthisis in the lungs until within a month or two of the patient's death. A definite com- mencement can always be assigned to the commencement of remittent fever ; and the great heat of skin, the very rapid pulse, the intense thirst, and the delirium at night which attend it, even in its less severe forms, are symptoms which, if borne in mind, would prevent our mis- taking for it those slighter and more vague ailments that are experienced during the first stage of phthisis. The referring the symptoms of in- cipient consumption to the presence of worms in the intestinal canal is a mistake even less excusable. The natural temperature of the skin and natural frequency of the respiration, the appetite at one time as raven- ous as it is deficient at another, the tongue either clean and moist or thickly coated, the condition of the bowels, which is generally one of constipation, and the marked relief which almost always follows the action of purgatives, are indicative of the presence of worms sufficiently characteristic to guard the attentive observer from error." 1 11. Prognosis. — The prognosis is of course more or less unfavorable in all cases, absolutely so in most, as many more cases prove fatal than the contrary, few of those in whom the disease is fully established being rescued from an early death. Yet cases of restoration do occasionally occur, not frequently, but just in sufficient numbers to induce us to tax to the utmost our care and skill to give the patient the benefit of the slight chance in his favor. We should be a little guarded in attempt- ing to fix the duration of life, as we have seen that in some cases the disease seems almost indefinitely prolonged. 12. Treatment. — I need say but little on this subject, as in principle the treatment of the disease in adults and in children is substantially the same, differing only in details. Perhaps the first and most important point to which our attention should be directed, is the air which the child breathes, and the atmo- sphere in which he lives. We must take care that this be pure, fresh, dry, and warm ; the rooms should be thoroughly ventilated and cleaned in the absence of the patient, and then when sufficiently warmed, the 1 Diseases of Infancy and Childhood, p. 294. 372 PULMONARY PHTHISIS. child may be brought back. During the winter months, I am strongly in favor of confining the child, not merely to the house, but to two or three rooms on the second or third floor if possible, so as to avoid expo- sure to draughts of cold air, and to sudden atmospheric changes and cold winds. If circumstances permit a change of climate, it is often of very great service. The South of England or Ireland, and still more the South of Europe, offer all possible advantages of this kind to the invalid. Even in summer, in this climate, undue exposure may do great mis- chief, and a prevalence of north or east winds, or damp weather, should be the signal for confinement to the house. When the wind is mild, the air dry and genial, then exercise in the open air, in the early stages of the disease, is beneficial, but at a more advanced stage, it should be very moderate, for obvious reasons. Inner garments of spun silk, web, or flannel, should be worn both winter and summer, as securing an equable warmth, and as a protection against a sudden chill, but they should never be worn in bed, as they then only increase the perspiration. Careful attention must be paid to the diet ; it should be at once simple yet nutritious, as very few patients recover who are not able to take a full share of nourishment. Milk in any form, farinaceous food, certain leguminous vegetables, jellies, broths, beef tea, and even solid animal food may be allowed, subject to the condition of the patient, the state of the digestive system, the stage of the disease, &c. Nay, in some cases even wine or beer may be advisable. On the other hand, if the stomach and bowels be weak or out of order, a careful selection must be made of those substances which experience has shown to be best tolerated by the stomach. As to the most suitable remedies, I shall not attempt to go through the list of those which have been proposed. It will be quite sufficient to point out a few of them which appear to deserve our confidence the most. In very few cases indeed is bloodletting admissible, and then only to the extent of a few leeches. These cases are generally those in which the disease is complicated by pneumonia, but even then our espe- cial object must be to exhaust the patient as little as possible. Counter-irritation is useful, and it may be practised by means of small blisters, the size of a watch glass, below the clavicle, or by the lini- ment, or by daily painting the same part with strong tincture of iodine. Much stress has been laid upon emetics, purgatives, chalybeates, &c, by different writers, and although I doubt not there are cases in which they may be beneficial, I fear their success has in no degree kept pace with the hopes which have been excited. The three remedies upon which most reliance seems to be placed are iron, iodine, and cod-liver oil. M. Barrier, however, speaks disparagingly of iodine, and even attributes to it an injurious influence upon the digestive functions. Iron has been supposed to counteract in some way the tuberculous cachexia, and Dr. Dupasquier, of Lyons, has derived more advantage from the iodide of iron than from any other preparation. My own experience is confirma- tory of his — and I have found a convenient form to be a grain of the PULMONARY PHTHISIS. 373 salt to an ounce of syrup, of which a teaspoonful may be given three times a day to a child of three years old. At the present moment the most popular remedy is cod-liver oil, and whether from the iodine it contains, or from its nutritive qualities, it is not easy to determine, but we certainly have quite evidence enough to prove its great value in this disease. As a tonic, bark in some form is often useful, and for the relief of the cough, a mixture may be ordered containing ipecacuanha squills, and a little laudanum. Hydrocyanic acid has considerable control over the paroxysmal cough. Chalk mixture, with opium and some astringent, may be employed, if the bowels are relaxed. 13. As to prophylactic measures, these consist mainly in incessant care and watchfulness — securing pure air, warmth, or even temperature, good diet, and guarding against cold, damp, improper food, &c. A very important point with infants who are likely to have inherited this pre- disposition, is to secure a healthy wet nurse from the country, and to let her suckle the child somewhat longer than the usual time, until the distress and irritation of teething be over. As the child advances, the opposite extremes of carelessness and over-care should be equally avoided, and when the intellect develops itself, we ought to be careful that the child be not stimulated to over-exertion or to too close application. SECTION III. DISEASES OF THE HEART. 529. Before entering upon the consideration of the malformations or diseases of the heart, it appears to me that I shall be doing good service to my readers by extracting from the valuable work of Rilliet and Barthez their conclusions as to the normal state of the heart, and the results of auscultation and percussion in infants. They are based upon the examination of 193 cases, from fifteen months to fifteen years, and are as follows : — " 1. The circumference of the heart does not increase in proportion to the age ; it is nearly the same from fifteen months to five years and a half; from this time it increases irregularly up to puberty, but at the age of five years the limit is more marked when we measure the heart filled with coagula, as when empty its progression appears less irregu- larly increasing. "2. The distance from the base to the point anteriorly is nearly the half of the entire circumference at the base of the ventricles. " 8. The maximum thickness of the walls of the right ventricle varies little according to age ; it is generally two millimetres up to six years, after which it is ordinarily three or four. "4. The maximum thickness of the left ventricle is less than one centimetre up to six years old ; after which it is one centimetre, or a little more. " 5. The relative thickness of the two ventricles is generally, as pointed out by M. Guersent, as three to one or as four to one, rather more than less. "6. The maximum thickness of the septum is nearly the same as the left ventricle ; rather more than less. " 7. We will add a remark, the result of our notes, that the thickest part of the right ventricle is quite at the base, near the auricular open- ing ; of the left ventricle, one or two centimetres from the base ; and of the septum, from two to three centimetres. It follows that the more considarable the thickness the nearer it is to the middle of the height. " 8. The size of the right auriculo-ventricular orifice continues much the same up to the fifth year ; it scarcely increases up to the tenth ; but from this age its increase is marked. " 9. The left auriculo-ventricular opening, always smaller than the right, increases somewhat more regularly, and presents often the same dimensions as the distance from the base of the heart to its apex. DISEASES OF THE HEART. 375 " 10. The aortic orifice shows but very slight increase between fifteen months and thirteen years. " 11. The pulmonary orifice, on the other hand, increases notably from the age of six or eight years, so that, whilst previously it is about equal to the orifice of the aorta, afterwards it is much more consid- erable." 1 Eilliet and Barthez found no perceptible difference in their measure- ment between the two sexes. 530. I shall now extract their account of the results of auscultation of the heart and percussion : — ■ " The precordial region presents ordinarily a diminished resonance, though rarely absolute dulness, in a portion of its extent between the nipple and the sternum, and is from four to seven centimetres vertically, and from four to eight transversely. This comparative dulness, there- fore, occupies a space, circular or elliptical, whose greater transverse diameter runs from the nipple to the sternum, and sometimes to the xyphoid cartilage, so that the nipple is central as to the height, and at the left extremity of this diameter. With children above six years, the nipple will sometimes be found above this centre. " The ear applied to this elliptical space perceives easily the two sounds of the heart ; the first is almost always duller (sourd) than the second. Around this central space the heart's action is weaker, accord- ing to the distance, although we can generally perceive the sounds, or at all events the second sound, all over the thorax anteriorly. " Ordinarily they are as audible, if not more so, beneath the right clavicle as the right nipple, owing, doubtless, to their being conveyed by the aorta superiorly ; but in a small number of cases the pulsations of the heart are transmitted more plainly to our ears in the region of the liver than superiorly. " In the normal state we have never heard the pulsations of the heart posteriorly. " In the great majority of cases, the sounds of the heart succeed each other with regularity, and the interval between them is always the same in the child ; some transient irregularities were merely exceptional and without value. Lastly, the radial pulse was always felt by the finger, just as the ear applied to the prsecordial region perceived the end of the first sound ; or, more correctly, the pulse corresponded to the com- mencement of the interval which separates the two sounds." 2 1 Mai. des Enfans, vol. iii. Appendix, p. 662. 2 Ibid., vol. iii. p. 265. 376 MALFORMATIONS. CHAPTER I. MALFORMATIONS. — INTRA-UTERINE DISEASES. — CYANOSIS. 531. It will be sufficient to enumerate very briefly the principal mal- formations to which the heart is subject, referring the reader for minute details to the elaborate works of Meckel, 1 Geoffroy St. Hilaire, 2 and to M. P. H. Berard's excellent article in the Diet, de Medecine, in thirty volumes. These malformations may be divided into — I. Anomalies as to Number. — There are examples of children born without hearts, but of course this is incompatible with extra-uterine life ; and as a general rule, such cases occur only in acephalous foetuses. Double hearts only occur in instances of diplogenesis. II. Anomalies of Position and Situation. — Instances have occurred of the apex of the heart being directed laterally to the right or left ; and it is said to have been placed vertically. When the heart is displaced, it may still remain on a level with the chest, as in those cases where, the parietes not being closed, it is pro- jected externally. M. Vaubonais relates a case in which " the heart was external, hung to the neck like a medal." Other cases are related by Buttner, Martinez, Haller, &c. Or the heart may be found elevated to the neighborhood of the head {ectopie cephalique of M. Breschet) as in the case related by MM. Bres- chet, Beclard, and Bonfils, where it was found in one between the bones of the jaw, and adhering to the tongue; in another, attached by its apex to the vault of the palate, and in a third, adhering, on the one hand, to the placenta, and on the other to the head. Or, lastly, the heart may be depressed into the abdominal cavity, in consequence either of an opening through the diaphragm, or from the absence of that muscle. In the former case, if the abdominal parietes are complete, the individual may live for years, as in the cases related by Ramel 3 and Deschamps. 4 When the abdominal parietes are incom- plete, life cannot be prolonged, even if the child be born alive, as in Mr. Wilson's cases. 5 III. Malformations which do not permit the Mixture of Arterial and Venous Blood. — These cases are rare, and of little importance, in- cluding examples of bifurcation of the apex, multiplication of the cavi- ties, &c. 6 1 Manuel d'Anatomie GeneYale, &c. 2 Hist, des Anomalies de l'Organization. 3 Journ. de Med. de Chir. et de Pharmacie, 1778, vol. xlix. p. 423. 4 Journ. de Med., vol. xxvi. p. 275. 5 Philosophical Trans., 1789. 6 Paget on the Congenital Malformations of the Heart. CYANOSIS. 377 IV. Malformations which permit the Mixture of Arterial and Venous Blood. — These are, of course, of much greater importance, and some of them will involve a more lengthened consideration. According to M. Berard, the following are the principal instances : 1. When the heart forms but a single cavity, into which the vessels open at once. 1 2. When it consists of two cavities, an auricle and a ventricle, as in the cases of Wilson, 2 Standen, 3 Faure, Mayer, Ramsbotham, 4 Mauran, 5 and Breschet. 3. Where the foramen ovale remains open. I shall return to the consideration of this latter case and its consequences presently. 4. M. Billard has included among the malformations of the heart, a narrowing of its orifices, which, however, may possibly have been the result of intra-uterine disease. He attributes it to a disproportionate growth in the heart and the orifices ; i. e. the latter do not increase as fast as the former, and thence result various disturbances of the circu- lation, and certain aesthetic affections. 6 532. Let us add, here, that during intra-uterine life the serous mem- brane of the heart and pericardium may be the seat of inflammation. I examined a foetus recently in which I discovered intense pleuritis and pericarditis. Organic diseases, also, are occasionally observed. Bil- lard mentions a case of scirrhus ; Denis, hypersarcosis ; Cruveilhier, of aneurism of the aorta ; and Billard, of aneurism of the ductus arterio- sus, &c. 7 CYANOSIS. 533. Before entering upon the examination of this disease, which appears to be the consequence of a communication between the right and left sides of the heart, through the open foramen ovale, it is neces- sary to inquire as to the period when this foramen is ordinarily closed, and the mode by which it is effected, as we shall be then better able to judge of the results of its non-obliteration. I must here avail myself of the minute and interesting observations of M. Billard. 8 He states that "out of nineteen infants of a day old, the foramen ovale was com- pletely open in fourteen ; in two, partially closed ; and in two others, quite closed. In the same infants the ductus arteriosus was free and full of blood in thirteen ; partially obliterated in thirteen ; completely so in one. In the same infants the umbilical arteries were open near their insertion into the iliacs, but their calibre was diminished by a re- markable thickening of their parietes. "Infants of Two Days old. — Of twenty-two, there were fifteen of whom the foramen ovale was very free; three in whom it was almost obliterated; and in four, entirely closed. In thirteen, the ductus arte- 1 Manuel d'Anat., vol. ii. p. 305. 2 Philos. Trans., 1798, p. 346. 3 Ibid. 1805, p. 228. * London Medical and Physical Journal, June, 1829. 5 Philadelphia Med. Journ., Aug., 1827. 6 Mai. des Enfans, p. 605. 7 Grsetzer, Krankheiten des Foetus, p. 160. 8 Mai. des Enfans, p. 605. 378 CYANOSIS. riosus was free; in six, partially obliterated; and in three, completely so. In all, the umbilical arteries were more or less closed, but the um- bilical vein pervious. " Infants of Three Days old. — Of twenty-two, there were fourteen in whom the foramen ovale was quite open; in five its obliteration had commenced; and in three it was completely closed. The ductus arte- riosus was free in fifteen ; its obliteration had commenced in five, and was complete in two only; but in these two the foramen was closed. The umbilical vessels were empty and even obliterated in all. "Infants of Four Days old. — Out of twenty-seven cases, in seventeen the foramen was open, and in six of them the opening was large and distended with blood; and in the remaining eleven, it was simply free; its obliteration was commenced in eight, and was complete in two. The ductus arteriosus was permeable in seventeen, partially closed in seven, and completely so in three. The umbilical arteries were obliterated near the umbilicus, but still dilatable near their iliac insertions. The umbili- cal vein and ductus venosus were empty and contracted. " Infants of Five Days old. — Out of twenty-nine cases, thirteen had the foramen ovale open, but not equally so ; it was nearly closed in ten, and effectively so in six others. The ductus arteriosus was open in fif- teen ; largely so in ten of them; partially obliterated in five; nearly completely in seven ; and quite so in seven others. The umbilical ves- sels closed in all. " Infants of Eight Days old. — Of twenty cases, the foramen ovale was free in five only ; it was incompletely closed in four ; and completely so in eleven. The ductus arteriosus was obliterated in all except three; the umbilical vessels in all. " We find from this last examination that the foetal openings are gene- rally obliterated in eight days, but that we may find them free at that age, or even at twelve or fifteen days, without the child suffering in con- sequence. " From the facts laid down before us, it follows that the foetal open- ings are not obliterated immediately after birth ; that the period when this takes place is very variable, but that in eight or ten days the fora- men ovale and the ductus arteriosus are generally closed. " From our examination we find that the umbilical arteries are first obliterated, then the umbilical veins, next the ductus arteriosus, and lastly, the foramen ovale. The persistence of those communications for some days after birth should not be regarded as a disease, seeing that it is very common, that it produces no ill effect, and that it is owing to the mode of obliteration." 534. I shall next present to the reader M. Billard's account of the mode in which this obliteration is effected, merely premising that his observations have been confirmed by M. Berndt, of Vienna. If any apology be necessary for such long extracts, it will, I trust, be found in their importance, and in the fact that they are unique. " If we examine the disposition gradually assumed by the foramen ovale, from a short time after conception up to birth, we perceive that the form of this opening, the arrangement of the surrounding parts, and especially of the Eustachian valves, become such that the blood, which CYANOSIS. 379 at first flowed freely from one auricle into the other, meets by degrees with more difficulty in doing so. Sabatier has strongly insisted upon this point. Thus, then, a modification in the organization of the heart has forced the blood to modify its course ; this fluid, inert by itself, is in immediate dependence upon the motor power which projects it, and directs it into the channels in which it ought to flow. If so, it follows that other changes will equally take place in those parts which the blood ought to forsake ; anatomical changes which, altering the form and modi- fying the action of the organs, will impress a new direction upon this fluid. Now, if we examine the umbilical arteries and the ductus arte- riosus, we shall find that in progress of obliteration their coats become thickened. This thickening of the umbilical arteries is especially re- markable at their insertion into the umbilicus ; at that spot they often present, after birth, a fusiform contraction, which diminishes the calibre of the arteries, and is able to resist the force of the column of blood projected by the iliac arteries." .... "Thus two causes force the blood, after birth, to abandon the course it took during intra-uterine life: 1. The establishment of respiration and the pulmonary circula- tion. 2. The modification of structure which the umbilical arteries un- dergo. Moreover, there is an experiment which proves that the con- tractility of the umbilical vessels can suspend the flow of blood through them. If we divide the cord, after birth, at some distance from the naval, the jet of blood is at first very strong, then it becomes slower, and afterwards stops altogether ; and if we cut off another portion, the same phenomenon occurs. It is owing, of course, to the contraction of the arteries upon the blood : and if this contractility exist near the um- bilicus and within the abdomen in a greater degree, on account of the greater amount of elastic tissue, one can understand the resistance they will be able to offer to the course of the blood in its more tranquil flow after birth. By degrees, as the infant grows older, the vascular tube is converted into a ligament. "That which happens with the umbilical arteries is observed also in the ductus arteriosus. In the embryo it is as yielding as other arteries, easily dilated by the column of blood which flows through it, without resistance, to the aorta. But at birth, and afterwards, its parietes be- come by degrees thicker by a sort of concentric hypertrophy which diminishes the calibre without apparently diminishing the size of the vessel, and in consequence of this resistance the blood which is ob- structed passes into the pulmonary arteries. At this period the duct presents the appearance of a pipe, whose walls are very thick and perfo- ration very moderate." . . . "If it be necessary that the foramen ovale and the ductus arteriosus should undergo organic changes which prepare and lead to their obliteration, one can easily perceive that the modifications may sometimes be effected prematurely, in others, very tar- dily ; so that on the one hand we find the foramen ovale closed soon after birth in some infants, or for a long time patent in others, and in most instances requiring some considerable but uncertain time for the com- pletion of these changes. Thus we may explain the irregularity ob- served in the time at which an independent circulation is established, 380 CYANOSIS. without considering it as the cause or effect of disease of the heart or lungs. " However, the result will, no doubt, be an incomplete oxygenation of the blood, since all that the heart projects to the different parts of the body has not previously traversed the lungs, nor is in contact with the blood so renewed. "But after all, is it necessary that the blood of a new-born infant should be as highly oxygenated as that of an adult ? Is it not suitable that the recently completed and tender tissues of its organs should not receive blood too active — that the materials of nutrition should not be charged with principles too exciting, whose action upon the infantile organs might prove injurious to health, and even impede the progres- sive establishment of independent life ? I think so, and see no reason for rejecting the opinions which result from the examination of the cir- culating system in new-born infants. These conclusions are supported by another consideration, viz: that the lungs might be exposed to fatal congestions, if all the blood sent from the heart were conveyed to these organs by the pulmonary arteries. The ductus arteriosus, by allowing the superabundant blood to escape by it, relieves the respiratory organ, and permits a freer entrance of air into it than would take place if it were in a state of congestion, thus favoring the establishment of inde- pendent life by the persistence of those arrangements which were neces- sary during foetal life. Thus all is connected in a chain, the disposition of parts and the exercise of their functions ; everything progresses in order, and by transitions foreseen and provided for, so that no sudden and unexpected change disturbs the harmony of the vital phenomena. " If those openings persist much beyond the period already indicated, then, indeed, disease may be the result." 1 After reading the valuable researches of M. Billard, we shall be better prepared to consider the disease in question, properly called " the blue disease," " morbus ceruleus," or cyanosis. 535. Cyanosis consists in a blue, violet, or purple color of the surface of the body, and especially of those parts which are usually of a fresh or rose color, as the lips and other mucous surfaces, cheeks, &c. 2 The color is very marked in the face, hands, feet, and genitals, and less deep in other parts of the body, presenting the aspect of extreme venous congestion. The color deepens during excitement or exertion, giving a very distressing appearance to the patient. The extraordinary color, however, would be of little consequence, were it not that it is attended with other disturbances of a more serious character. The action of the heart is very subject to derangement upon the slightest excitement or exertion ; the patient suffers from palpitation, fainting, &c, accompanied by bruit de soufflet, or the purring sound ; and there is, as we should expect, a marked disposition to serous effu- sion. The respiration is consequently and equally disturbed; hurried breath- 1 Mai. des Enfans, p. 605. 2 Copland's Dictionary, p. 199. "Blue Disease." CYANOSIS. 381 ing, panting, dyspnoea, with a sense of suffocation, follow the least ex- ertion, or occur in paroxysms without any cause. In fact, as Dr. Copland remarks, "it may be said that the disorder is made up of a succession of paroxysms and remissions. In the paroxysms alone we observe those frequent faintings, that tumultuous palpitation of the heart, and suffocation, which endanger the life of the patients. No rule can be relied on as to the recurrence of these paroxysms ; in fact, if it be certain that they are brought on by over-exertion, fatigue, and violent mental agitation, it is equally certain that they occur without any as- signable cause, and are more frequent in winter than in summer. " The length of the paroxysm varies ; it sometimes last several hours, and generally abates gradually. " The termination of cyanosis is fatal to most patients, but some appear to recover entirely ; others live for many years." 1 536. Pathology. — One circumstance is common to almost all these cases, and is discoverable in making a post-mortem examination ; I mean some mode of communication between the two sides of the heart. This may be effected in various ways : — 1. The foramen ovale may remain open or may have been reopened ; and M. Gintrac 2 remarks that along with this patency there is gene- rally an obstacle to the passage of the blood from the right auricle into the right ventricle, or more frequently from the right ventricle into the pulmonary artery. This obstacle he found in twenty-seven out of fifty- three cases ; in twenty-six of the twenty-seven the impediment was in the pulmonary artery. 2. The inter-ventricular septum may be perforated, as in some of M. Louis's cases. 3 3. The ductus arteriosus may remain open, and, according to Louis, this is often coincident with the patency of the foramen ovale. 4. The two auricles may open into the right ventricle, as in MM. Gintrac's and BreschetV cases, with perforation of the inter-ventricu- lar septum, or, as Haller 5 mentions, with one auricle for the two ven- tricles. In one of M. Gintrac's cases, the two auricles opened into the right ventricle, between which and the left ventricle there was a con- siderable opening. The aorta took its origin from the left ventricle. 5. The pulmonary artery and the aorta may arise from the left ven- tricle, the right being almost obliterated, with a communication by means of the persistent foramen ovale, or perforation of the inter-ventricular septum. Hoist, of Christiana, and Gintrac, have related a case of this kind. 6. The insertion of one or all the pulmonary veins into the vena cava superior. 7. The presence of a second pulmonary artery arising from the right ventricle, and opening into the aorta ; or supplying the place of the aorta, which was obliterated after giving off the cephalic and brachial trunks. 1 Diet, of Pract. Med., part. i. p. 200. 2 Observations et Recherches sur la Cyanose, 1824. Paris. s Meuioires et Recherches Anatomico-pathologiques, p. 328. * Repertoire Gen. d Anatom., vol. ii. 5 De Monstris, vol. i. 382 CYANOSIS. 8. The transposition of arterial or venous trunks, as, for example, the implantation of the pulmonary artery upon the left ventricle, and the aorta upon the right, whilst the veins remain in their normal situa- tion ; or the opening of the veins into the left ventricle, the pulmonary veins, or even into the aorta. 9. The pulmonary artery may be completely obliterated. 10. The heart may consist of one auricle and one ventricle, as in the batrachise. 11. There may be two superior vense cavse, one opening into each auricle. 537. M. Louis has remarked the rarity of narrowing of the auriculo- ventricular, or the ventriculo-aortic orifices of the left side, he having met one case only, and that a slight one, in his twenty cases ; whereas, in the same cases, there were ten examples of narrowing of the orifices of the pulmonary artery, and one of occlusion of the auriculo-ventricular communication by ossification of the tricuspid valves, which were per- forated in many places. The narrowing of the pulmonary artery may be owing to the ossification of the sigmoid valves, united by their free edge, or to a species of diaphragm pierced in the centre, or by an ap- proximation of the parietes of the artery to the corresponding ventricle. M. Louis conceives the changes to have been either malformations or the result of intra-uterine disease. 538. The condition of the heart itself is worth notice in these cases. M. Louis observes that, with one exception, his twenty cases were all examples of aneurism of one or more of the cavities of the heart. Dila- tation of the right auricle occurred in nineteen cases, with hypertrophy in six, and thinning of the walls in two. The right ventricle was dilated in ten cases, hypertrophied in eleven, and in five the hypertrophy and dilatation were coincident. But the left auricle was dilated only in three cases, hypertrophied in two, and the left ventricle dilated in four, and hypertrophied in three cases. 1 M. Bouillaud states that the volume of the heart was augmented in eleven out of fifteen cases, and that in the majority of cases it was owing both to hypertrophy and dilatation of the right cavities. In ten cases the right auricle was dilated, in five of them it was hypertrophied also ; in five others it is not stated ; in five there was hypertrophy ; in five others it is not stated. In ten cases the right ventricle was hyper- trophied, and the hypertrophy was concentric. 2 M. Bouillaud has also mentioned that in four of his cases the peri- cardium contained from three ounces to a pint of serum ; in two cases it was mixed with flocculi of albumen, and in one case there was false membrane and granulations on the surface of the right auricle. 539. There is some difference of opinion as to whether the communi- cation between the two sides of the heart is congenital malformation, or the result of accident or disease. M. Louis, who has examined the question with his usual minute care, has arrived at the conclusion that it is an original malformation; but M. Bouillaud thinks that the per- 1 Mem. et Recherches Anatomico-patkologiques, p. 334. 2 Traite des Mai. du Coeur, p. 685. CYANOSIS. 883 foration of the inter-auricular or inter-ventricular septum may have taken place from causes which have left no traces. M. Ferrus 1 also objects to attributing all the cases to original malformations, because of the sudden development of the consequences, which he thinks could not have been so long postponed if the cause had been longer in existence. M. Fabre, 2 however, very justly replied to this, that he has often dis- sected children in whom these malformations existed, but in whom the symptoms never occurred. He differs from M. Louis, in thinking the absence of any traces of disease about the opening a conclusive proof that it is a malformation ; and he concludes that in the majority of cases the communication is congenital, especially between the auricles, but that the perforation of the inter-ventricular septum is sometimes accidental. 540. The effect of this intercommunication one would suppose to be the immediate mixture of red and black blood, or the reduction of the heart to the condition of a single one ; but such is not invariably nor necessarily the case. There will probably be no mixture of blood, although the foramen ovale be open, unless there be hypertrophy and dilatation of the right side of the heart, with narrowing of the auriculo- ventricular opening; and in like manner it will require a narrowing of the arterial orifices to occasion a mixture of blood where the ventricles communicate. And the coincidence of these changes is not unfrequent. M. Jules Cloquet and M. Bouillaud agree pretty nearly with this view of M. Louis, that when the foramen ovale remains open, the ductus arteriosus is pervious, the aorta springs from both ventricles jointly, and when to the communication between the right and left side of the heart there is superadded an obstacle to the free current of blood in the for- mer, a considerable quantity of black blood must, of necessity, mix with the red. The endocardial murmurs which are occasionally present are, no doubt, due to the narrowing of the auriculo-ventricular or arterial ori- fices, or to regurgitation. 541. But are we to conclude that the discoloration of the skin is owing to the mixture of arterial and venous blood ? M. Louis says : " It is, then, impossible to maintain, either from reason or experience, that the blue color is due to a mixture of black and red blood, and the more that it appears that this mixture occurred in almost every case, whereas the blue color was by no means constant. Let us add, with M. Fouquier, that the skin of the foetus, in which black blood circu- lates, is not blue." He adds: " Morgagni seems to have given the true explanation in the case which we have quoted from him. To account for the livid color, he remarks that the constriction of the orifice of the pulmonary artery, in consequence of ossification, must have caused great embarrassment of the circulation; that the blood stagnated in the right ventricle, right auricle, and consequently in the entire venous system." 3 Corvisart seems to doubt whether the blue color is owing to this admixture of blood. 1 Diet, de Med., en 30 vols., vol. ix. p. 536. 2 Bibliotheque de He'd. Prat., vol. v. p. 379. 3 Recherches sur plusieurs Mai., pp. 336, 344. 384 CYANOSIS. M. Billard states that cyanosis is not the invariable result of the persistence of the foramen ovale, or the passage of the venous blood into the arterial system, inasmuch as there are many cases in which this took place without such results ; but it is probably due either to this mixture or to deficient oxygenation of the blood, whether there be intercommunication, or whether the blood be incompletely changed in the lungs. M. Bouillaud expresses a similar opinion ; he regards cya- nosis as essentially due to a deficient oxygenation of the blood, whether the structure of the heart be perfect or not. The late Dr. Stille thought that no one lesion is to be considered as the anatomical character of cyanosis, but that it depends simply upon any cause, which, acting at the centre of the circulation, will produce a stasis of blood in the capillary system. Dr. Chas. D. Meigs regards cyanosis as asphyxia resulting from black blood in the brain, and not in the lungs; that the danger consists in the cerebral condition, and is to be removed by supplying the brain with oxygenated blood ; and, lastly, that the blue color is caused by the presence of black blood in the capillaries. The prolongation of life, according to M. Louis, bears no relation to the symptoms, nor to the supposed condition of the blood. The sub- jects of this disease may die in infancy, or may live to twenty, thirty, or fifty years of age. Neither is it incompatible with the due develop- ment of the intellectual faculties. 542. Treatment. — As far as the disease depends upon organic imper- fection of the heart, so far it is evidently beyond the reach of our means of cure, although some alleviation may be afforded. We are not, however, to conclude that no reparation is possible, because we cannot effect it or discover how it is to be done. It is for us to assist the efforts of nature by securing the conditions most favorable to the present comfort and permanent benefit of our patient, such as bodily and mental repose, a pure, mild air, with careful attention to the sto- mach and bowels. M. Bouillaud recommends bloodletting during a paroxysm ; but Dr. Copland objects to this, as seldom relieving the paroxysms, and naturally increasing the disease. Counter-irritation to the chest, by dry cupping, mustard poultices, or blisters, may be of use. "I have derived," says Dr. Copland, "more advantage from stimu- lating pediluvia, frictions of the surface of the body and lower extre- mities, and the administration of gentle antispasmodics and stimulants. In one or two instances, I conceived that some advantage was derived from the preparations of iron, combined with the fixed alkaline car- bonates." 1 Dr. C. D. Meigs's remedy as applied to infants at birth is very inge- nious. It occurred to him when in attendance upon a case. He thought, "If I bring the septum auricularum into an horizontal attitude, will not the blood in the left auricle press the valve of Botalli down upon the fora- men ovale, and thus save the child by compelling all the blood of the right auricle to pass by the iter ad ventriculum, and so to the lungs to 1 Dictionary of Practical Medicine, part i. p. 201. PERICARDITIS. 385 be aerated." 1 He accordingly placed the infant on its right side, the head and trunk inclined upwards about twenty or thirty degrees. Im- mediate relief was afforded; the child became quiet, breathed more naturally, and acquired shortly its natural color. Dr. Meigs states that he has thus repeatedly succeeded, and he quotes abundant testimony from his pupils to the same effect. CHAPTER II. INFLAMMATION OF THE PERICARDIUM. — PERICARDITIS. 543. The only diseases of the heart of which I shall treat are inflam- mation of the investing and lining membrane, i. e., pericarditis and endocarditis, with a slight notice of their consequences. It is only since Laennec's brilliant discovery of the power of auscultation in de- tecting disease that we have had the means of acquiring information about these affections during life; but it is within a few years that our knowledge has acquired any degree of certainty. Previously, dissection had proved the occurrence of pericarditis in childhood, but such was its obscurity that it was generally passed over in works on diseases of children. Cases were published by Lieutaud, Schmidel, and Koppel. Krukenbergius 2 and Roux 3 detailed some which occurred during the course of scarlatina and measles, and Vieussieux, Davis, "and Wells, others which occurred during an attack of rheuma- tism. Puchelt collected most of the scattered cases, and published them in a memoir, with others he had observed himself ; but it was not until the labors of Stokes, Watson, and others, in Great Britain, and Bouil- laud, in France, that much light was thrown upon the disease, either in the adult or in children. Since then, it has been noticed by Billard, Rilliet and Barthez, Condie, West, &c, in children. 544. Pericarditis, or inflammation of the serous membrane which lines the pericardium and covers the heart, is not a very common dis- ease of infancy and childhood ; but neither, on the other hand, is it extremely rare. In 700 autopsies made by Billard at the Hopital des Enfans Trouv&s, he found seven presenting evidences of pericarditis. 4 Dr. West states, "In six out of 170 cases in which the state of the tho- racic viscera was carefully examined, he discovered evidences of inflam- mation of the pericardium or endocardium, or both." 5 At a meeting of the South London Medical Society, in the debate on Mr. Crisp's paper on pleurisy in children, Dr. Todd stated it to be his 1 Obstetrics, p. 641. 2 Jahrbucker d. Ambulatorischen Klinik, vol. i. Halle. 3 De Carditide exsudativa, p. 47. 4 Mai. des Enfans, p. 623. 5 Lectures on Diseases of Infancy and Childhood, p. 317. 25 386 PERICARDITIS. opinion that the pericardium was oftener the seat of inflammation in young than in older persons, and by no means rarely so in infants. 1 The disease may either be acute or chronic; of the latter, however, we know but very little, as it is the acute symptoms which generally attract attention. Again, it may be either primary or secondary, the former being ex- ceedingly rare. It is seldom met with in adults, according to Dr. Latham, and still more rarely in children. Our chief knowledge of the disease in the living subject is drawn from those cases in which it occurs in the course of other diseases, such as rheumatism, the eruptive fevers, pleu- risy, &c. 545. Dr. West has given a case of idiopathic or primary pericarditis, which I may be excused for copying, on account of its rarity and inte- rest. The subject of it was "a healthy boy, eleven years old, who, on May 8, 1843, complained of feeling cold, and began to cough. The chilliness was succeeded by fever, and he continued gradually getting worse till the 13th, when I visited him for the first time. He had had no other medicine than a purgative powder. On May 13th, I found him lying in bed, his face dusky and rather anxious, his eyes heavy, and his respiration slightly accelerated ; coughing frequently, but with- out expectoration; skin burning hot, and pulse frequent and hard. He made no complaint, except of slight uneasiness about the left breast. On examining the chest, there was found to be very extended dulness over the heart, with slight tenderness on pressure. A very loud and prolonged rasping sound was heard in the place of the first sound, loud- est a little below the nipple, though very audible over the whole left side of the chest, and also distinguishable, though less clearly, for a considerable distance to the right of the sternum. The second sound was heard clearly just over the aortic valves, but was not distinct else- where, being obscured by the loudness of the bruit. Respiration was good in both lungs. " The child was cupped to ovj. between the left scapula and the spine, and gr. i. of calomel, with the same quantity of Dover's powder, was given every four hours. "On the following day", it was found that the sense of discomfort in the chest had been relieved by the cupping, and that the child had slept well in the night. He looked less anxious, though his eyes were still heavy and suffused, and his skin was less hot and less dusky. His pulse was 114, thrilling, but not full. There was now slight prominence of the cardiac region, and the heart's sounds were obscurer and more dis- tant than on the previous day. The bruit was now manifestly a friction sound, louder at the base than at the apex of the heart, and altogether obscuring the first sound, while the second sound could be heard over the aortic valves. Six more leeches were applied over the heart, and the hemorrhage from their bites was so profuse as to occasion some faintness. Mercurial inunction was now superadded to the treatment previously employed, and the child's condition continued through the 15th to be much the same as it had been on the previous day. On May 1 Medical Gazette, Dec. 25, 1846. PERICARDITIS. 387 16th, there was some improvement in the general symptoms, and the pulse was softer. The friction sound was now no longer audible, but a loud rasping sound was heard in the place of the first sound. The second sound was now distinguishable at the apex of the heart, as well as over the aortic valves, and its character was quite natural. On the 17th, the mouth was slightly sore, and the dose of the remedies dimi- nished. On the 22d, the soreness of the mouth was considerable, and all active treatment was discontinued on that day. The child gradually regained his strength, but the bruit accompanying the first sound con- tinued, and was heard a month afterwards, with no other change than being rather softer and more prolonged. Four years afterwards, I saw him again. He had continued well in the interval, and had never suf- fered from palpitation of the heart, nor from any other ailment referable to the chest; but his pulse was small, jerking, and not always equal in force, and the natural character of the first sound was altogether lost in a loud, prolonged bruit." 1 This case is of great value, both on account of the accurate picture of the disease it presents, and from its simple character and history. The characteristics of the heart disease are pretty much the same, whether as a primary or secondary affection. 546. Symptoms. — The symptoms of pericarditis are not very striking, and in infants are necessarily more obscure than in adults, because a very young child's expression of pain or uneasiness is always more or less confused. When it occurs in the course of other diseases, also, our attention maybe so fixed upon the important primary affection, that we may overlook the slight but essential changes which mark the incursion of a new disease. No better illustration could be given of the value of a rule which I have adopted for many years, and which I strongly recommend to my readers, viz: when first called to see a child, no matter for what disease, to examine every organ of the body, and to repeat this examination at intervals of a few days. By so doing we shall often ascertain the commencement of secondary affections before they give rise to any complaint of distress. Probably the earliest symptom we shall notice of the disease in question will be uneasiness or pain in the left side of the chest, in the precordial region, near the left mamma ; this pain will be expressed if the child be old enough, or if not we may detect it by the position in bed, the restrained inspiration, the suffering on percussion, or on being moved. In Constant's, Mayne's, and Billard's cases it was pretty severe; in Puchelt's, not very acute; and in Rilliet and Barthez's cases it occurred but rarely, and was not severe. It will be less marked, or at least less pathognomonic, when the pri- mary disease is pleurisy or pneumonia; but in fever or rheumatism any uneasiness in the left side of the chest ought at once to excite our sus- picions, and direct our most careful attention to the state of the heart. The respiration, too, has a peculiar character in general; it is not the dyspnoea of obstructed lungs, nor is it any form of cerebral respi- ration, but it is high, rapid, yet restrained and suffocating, with quick 1 Lectures on Diseases of Infancy and Childhood, p. 307. 388 PERICARDITIS. movement of the alee nasi, and a difficulty of speaking sentences, as though the interruption to the short, quick inspirations, necessary in speaking, were intolerable. This again will be masked if there exist any pulmonary disease, but in other cases it is very striking. If there be no disease of the lungs, there will be but little cough, if any, but when these organs are affected, we may be at a loss to separate and distinguish the symptoms peculiar to each disease. Palpitation, owing to irregular action of the heart, is seldom trouble- some, but the violent action of the organ is sometimes felt in a distress- ing manner. The pulse is very quick, strong, and wiry. The face has an anxious, drawn, distressed, almost frightened expression; in two cases Billard observed spasmodic movements of the limbs ; the child cries often, as if suffering extremely, and generally objects to lying flat down in bed. 547. But all these signs would only excite our suspicions that some grave lesion existed ; they afford us no precise information as to its nature. This we can only obtain by a careful estimate of the physical signs ; but then it is satisfactory to know that these are amply suf- ficient. The natural sounds of the heart are dull or muffled, though generally distinguishable. This obscurity increases for some days, occasionally varying ; its maximum is just beneath the mamma, and it appears to depend either upon the effusion of fluid, or upon the exocardial mur- murs occasioned by the disease. In eight out of nine cases related by llilliet and Barthez, both sounds were obscure ; in one, one of the sounds only. Although the sounds are muffled, they are not weakened, but, on the contrary, may even be louder than natural, with increased impulse. The exocardial murmurs are thus described by Dr. Williams: "Those of pericarditis are various sounds of superficial friction, which are quite characteristic. At first this sound is soft and rustling, like the rubbing together of two pieces of paper or silk stuff; and it may accompany only part of the natural sounds, from which, however, it is obviously distinct, in being much more superficial. It is generally heard first about the middle of the sternum, or to the left of it, corre- sponding with the base of the heart or the attachment of the auricles ; it afterwards increases in loudness and duration, being heard beyond the immediate region of the heart, and accompanying not only the periods of the natural sounds, which it disguises, but also the interval between them. It thus gets a sort of continuous jogging rhythm, cor- responding with the movements of the heart, which is like that of the saddle when one rides on horseback ; and when, as it generally hap- pens, the friction sound becomes harder, and more like the creaking of leather, its resemblance to the noise of a new saddle is quite ridicu- lous. In some cases the noise is crackling, like that of crumpled dried membrane or parchment." " These friction sounds are certainly caused by the rubbing of lymph on the pericardium proper, and on its sac." 1 1 Diseases of the Lungs, p. 235. PERICARDITIS. 389 When effusion takes place, so as to separate the opposing surfaces of the pericardium, these friction sounds are, of course, impossible, so that they are heard chiefly during the early stage of the disease, and again when the process of absorption has removed the principal portion of the fluid, except in those cases where there is little effusion. The sounds are generally audible in whatever position the child may be placed, but in two cases Rilliet and Barthez found them more evident in a sitting posture. Along with these exocardial murmurs we occasionally hear a bruit de soufflet accompanying the first or second sound of the heart, but this does not result from pericarditis, but from coincident endocarditis, of which I shall speak presently. If the effusion be small, the respiratory murmur will be audible in the pericardial region, but if large, the lungs will be, to a certain ex- tent, displaced. Dulness on percussion is another sign of considerable value ; it is almost always more absolute than usual in the prsecordial region, but its extent will depend upon the amount of effusion. When this is con- siderable, the dulness will be proportionally extensive, and not only so, but the prsecordial region acquires a degree of prominence ; the inter- costal spaces are protruded, and subside as the effusion is absorbed. Thus the physical signs of pericarditis are muffled sounds and increased force of the heart, exocardial murmurs, dulness on percussion, and ful- ness or prominence of the praecordial region. 548. I have already mentioned that the pulse is quick, the skin is hot and feverish, the tongue loaded or white, the appetite lost, and the bowels often disordered. In other words, the entire constitution sympathizes with and suffers from the diseased condition of its central and most im- portant organ. 549. Cases, however, occur in which the symptoms are much more obscure, nay, which may hardly indicate the region affected. My dear friend, the late Dr. Hunt, gave me the notes of the following case, which strikingly illustrates the fact: "George M'Donnell, set. seven months, a large healthy child, awoke screaming from sleep, about 6 A. M., on Monday morning. He was bathed and fomented without relief. On Monday Dr. Hunt saw him, and found the state of the skin, abdo- men, and his general appearance, natural. He drank freely, but not greedily, and without pain or difficulty ; pulsation of the fontanelle regular ; respiration high, apparently painful, but not difficult ; the alse nasi were not in movement, nor was there any heaving of the chest. After crying continuously for some minutes, he would then give two or three screams. This state continued until 8 A. M. of Wednesday, he having never slept more than a few minutes the whole time. At this time the pulse was scarcely to be felt, the body was cold, and the side on which he was lying was dark red, like the appearance of cadaveric congestion. This appearance, and the sinking of the pulse, were said to have existed from an early hour the preceding night. He died at 11 A. M., without convulsion or struggle. Dr. Hunt was for some time inclined to regard it as a case of cerebral disease; but on making a post-mortem examination, the pericardium was found universally ad- 390 PERICAEDITIS. herent to the heart by fresh lymph, except In one small space which •was filled with milky fluid. The lungs and pleurae were healthy." This case is very valuable as showing the occasional obscurity of these cases, and also as another instance of idiopathic pericarditis. 550. In cases which terminate favorably, the symptoms, after con- tinuing a certain time, gradually diminish, the abnormal sounds become less and less audible, or the dulness becomes more limited and less abso- lute, and the child recovers its usual health. These are the most for- tunate cases, and their duration varies from one week to a month and more. The course of the fatal cases is much more rapid, terminating often in three or four days. Rilliet and Barthez mention one case of small- pox, which proved fatal in twenty-four hours after pericarditis set in. But there is an intermediate class of cases, and perhaps more nu- merous than either, viz : where life is saved, but a certain amount of injury to the heart remains permanent, requiring a long time to repair, even if the normal condition be ever restored. There may or may not be much evidence of its existence — some increase of impulse, and a liability to palpitate from exertion or mental emotion. Or it may give rise to remote consequences of more or less importance, and requiring great attention. Let us inquire into some of these conditions and con- sequences. 551. I. In the process of cure the fluid may be entirely absorbed, allowing the two surfaces of serous membrane, covered by a layer of lymph, to come into contact, and between them adhesions may be formed, so complete, that the pericardial cavity shall be entirely ob- literated. This is almost complete reparation, as Dr. Latham remarks, but still it is unsound, and may lead to further evil, although this is a point not quite understood as yet. Dr. Latham observes, " I have, indeed, often met with ' this almost complete reparation, and this least degree of unsoundness,' appertaining to the pericardium after death, where inflammation had been formerly suffered. But it has been ac- companied with unsoundness of the endocardium also ; and further dis- organization, in the shape of a threatened muscular structure and a dilated ventricle has been superadded, and all have been notified by symptoms during life. 1 It is, however, very doubtful in these cases what share in the production of the mischief is due to the disease of the pericardium, and what to the endocardium. ir. But, instead of a close and universal adhesion of the serous sur- faces we may have part adherent and part free, or there may be several adhesions and several perforations or cavities. At first sight this would seem to be of no consequence, or of rather less importance than the former case; but this is not so, for these loose spaces are very liable to fresh attacks of inflammation and its results. "After death from secondary pericarditis, the heart has been found apparently surrounded with many little separate abscesses, which have turned out to be col- i Lectures, &c, comprising Diseases of the Heart, vol. ii. p. 111. I cannot refer to Dr. Latham's work without expressing my sense of its great value. I know no book which contains more sound medical philosophy, or more judicious practical suggestions, conveyed in a manner jiore simple and intelligible. PERICARDITIS. 391 lections of purulent matter between the folds of the pericardium, where it had here and there failed to contract adhesion after a former inflam- mation." " Thus, the thought of a healthy child first seized with acute rheu- matism is full of sorrowful forebodings. Its heart is very likely to be inflamed, and it may die ; but whether it die or not, its heart is very likely to be damaged for life. Having had acute rheumatism once, though it may perfectly recover, it is very likely to have it again ; and whenever it again has acute rheumatism, it is very likely again to have inflammation of the heart as its accompaniment." 552. The symptoms which indicate partial or complete adhesion of the pericardium are by no means definite. When the adhesions are loose and mobile, they do not interfere with the heart's actions or sounds, and afford no sign. When closely adherent, the heart's action is gene- rally exaggerated, and Dr. Hope speaks of a "jogging, or trembling motion," but Dr. Williams does not regard this as proving an adherent pericardium. He has specified one condition in which he thinks the diagnosis plain, i. e., when the folds of the pericardium are adherent to each other, and the outer one also to the walls of the chest to the left of the sternum. In such a case, he says, " there will be, proportionally to the adhesion and size of the heart, a space in which the pulsations are always felt, and the sound on percussion is always dull in every stage of respiration, and in every position of the body." 1 553. The symptoms which mark the accession of a fresh attack of inflammation are likewise vague in character, though affording sufficient evidence that the heart is the seat. " In the first inflammation of the pericardium there is the exocardial murmur, made by the moving of its roughened surfaces upon each other. But in after inflammation of the pericardium, exocardial murmur there is none, and none can there be if its surfaces adhere completely ; and if they adhere partially, and there be a murmur, it will not have the proper attrition in it, and so will want the proper exocardial character." We must, therefore, infer the secondary attack from the local symptoms, without pretending to much exactness. Dr. Latham has given a case illustrating this, from which I shall make an extract, as it is too long to quote. " William Bean, aet. 12, was admitted into the hospital December 16th, 1833, and died on the evening of the 19th. His symptoms on admission were these : Skin hot and dry ; tongue moist and white ; pulse 140 and jerking ; swelling, and slight redness, and pain of the right wrist and hand, but of no other part of the body; breathing hurried and short, with a slight cough; pain in the precordial region, increased by pres- sure between the ribs, and by deep inspiration; excessive impulse of the heart ; inability to lie on the left side. Auscultation found the lungs admitting air freely in every part, and at a circumscribed part beneath the cartilages of the third and fourth ribs on the left side, the systole of the heart was heard, accompanied by an unnatural sound of an in- definite kind. The sound was lost when the stethoscope was removed from this spot in the least degree." The boy had had an attack of 1 On Diseases of the Chest, p. 240. 392 PERICARDITIS. rheumatism a year and a half before, with inflammation of the peri- cardium, and after death there was found evidence of two distinct in- flammations occurring at distant periods ; certain old, firm, close adhe- sions, and, in other parts, recent lymph deposited on the surface. 554. in. Lastly, we may have not merely a difference in the extent of adhesions, hut in the quantity of uniting medium. Sometimes we find a thin, slight tissue interposed, in other cases one of half an inch in thickness ; and every intermediate degree. Now this must be an im- pediment, and an incurable one, to the accurate performance of the heart's functions, though compatible with life ; and moreover, the peri- cardium in this condition is peculiarly exposed to the perils of second- ary inflammations. 555. iv. So much for the organic changes, the consequences of peri- carditis, with their dangers ; but in pericarditis we have irritations of other organs complicating the primary disease. For example, various and severe nervous symptoms sometimes arise. "Wild delirium, epi- leptic or tetanic convulsions, chorea, coma, fatuity, are the greatest and the rarest ; and muttering, reveries, transitions from torpor to excite- ment, subsultus, are the least and most frequent. But they are all akin to one another. The least may mount up to the greatest, and the greatest run down to the least." 1 556. Morhid Anatomy. — The morbid changes discovered by dissec- tion, resemble closely those of other serous membranes ; the pleurae, for example. The membrane is found occasionally injected, either generally, giving it a pale rose color; or in patches, or resembling ecchymoses. Its surface is generally polished and smooth, but in one case Uilliet and Barthez found it thickened and rough. The increase of thickness generally described is probably due to the layer of false membrane deposited upon the serous surface, and the erosions or ulcer- ation, as in Schmidel's case, to depressions in this adventitious layer. A quantity of serum is almost always the result of inflammation. The amount varies a good deal ; in general it is not very abundant ; in children from two or three to six or seven spoonfuls. When the in- flammation is very intense, it will be more abundant : generally yellow- ish, sometimes greenish yellow, like whey mixed with flocculi of lymph. But besides serum there is generally a layer of false membrane on one or both serous surfaces, of varying thickness and tenacity, but more firm and dense the longer the standing of the disease. It may, however, be limited to one serous fold, or it may occur in patches, granules, or filaments, connecting the two surfaces. When the disease becomes chronic, the fluid is absorbed, leaving the false membrane as the only evidence of the pericarditis. Ultimately, as I have already stated, more or less intimate and ex- tensive adhesion takes place between the opposite surfaces of the peri- cardium ; but as this is rather a reparative process, we do not generally observe it in those who have died of pericarditis, but in those who, having recovered from that attack, either become victims of a second or of some other disease. 1 Latham on Diseases of the Heart, p. 18. PERICARDITIS. 893 In secondary attacks of pericarditis, we find the old, firm, close ad- hesions in some parts, whilst in others there are patches of recent lymph, or small collections of puriform matter. The irregular white patches, which are so commonly observed upon the pericardium of children as well as of adults, have been proved by Dr. Paget, to be the result of circumscribed chronic inflammation. Rilliet and Barthez mention having once found the interposed false membrane of a semi-cartilaginous character. 557. Causes. — Pericarditis is more common, according to Rilliet and Barthez, in children above six years of age ; all their cases, with one exception, were from seven to fifteen years, and more above than below eleven years. Puchelt, however, quotes cases of one, two, three, and four years. I have seen the disease in an infant under a year old ; and we have had Dr. Todd's testimony that it is not unfrequent in infants. Whether sex does really influence the predisposition to the disease it is difficult to say; but of Rilliet and Barthez's twenty-four cases, twenty-one were boys and three girls. Puchelt attributes much influence to hereditary predisposition, and among direct causes he enumerates blows, falls, cold, &c. Billard conceives that its occurrence in young infants may be owing to the extra activity of the heart on assuming an independent life. 558. But a much more important point for our investigation is the diseases during whose course pericarditis is most apt to occur ; in other words, the primary diseases to which the present affection is secondary. This is of unusual importance, because we find that secondary pericar- ditis is by far the most frequent, and if we know the diseases in the course of which we may expect it, we shall be prepared to detect, and to treat it in its earliest stage. I. Bouillaud considers pericarditis and endocarditis to be essentially a part of rheumatism in the adult ; and though Dr. Williams does not go so far, he states that he has found signs of one or other in three- fourths of the cases of severe rheumatism he has examined in the last six years. Dr. Latham's experience is also to the same effect, and such appears to be pretty much the case with rheumatism in children. Rilliet and Barthez found pericarditis in four cases out of eleven of acute rheumatism ; and Dr. West mentions it as the most frequent accompaniment of this disease. He adds also the following very im- portant practical observations : " It is of importance, however, to bear in mind, that the risk of cardiac mischief supervening in any case of acute rheumatism increases in direct proportion to the youth of the patient, and that the mildness of the general symptoms, the small amount of pain in the limbs, and the almost complete absence of swell- ing of the joints, afford no guarantee that the heart may not become the seat of the most serious disease. It happens, too, less rarely in the case of children than of the adult, that the general indications of rheumatism follow instead of preceding the heart affection; so that fever, with hurried circulation and distinct endocardial murmur, may exist for two or three days, before the occurrence of pain and the 394 PERICARDITIS. appearance of swelling of the joints show that the disease of the heart is only a part of the great malady which has attacked the whole system." 1 II. It may also occur in the course of infantile remittent, although, as in rheumatism, it is more frequently endocarditis than pericarditis. III. The eruptive fevers occasionally give rise to it; thus it may arise in the course of scarlatina, as first noticed by Yieussieux and Wells, or measles. iv. We sometimes find it apparently the result of other diseases of the chest, from which it may probably have extended, owing to the con- tiguity of the tissues affected. Thus, it is not very rare to find it com- plicating pneumonia and pleuritis., Dr. West mentions three such cases, and I have seen similar ones. V. It sometimes appears to be the result of morbid changes in the blood, caused by other and more distant diseases, as, for instance, Bright's disease of the kidney ; and in such cases it may arise only shortly before death, as in a case related by Dr. Latham. 2 vi. I have already mentioned (129) that in chorea the heart often becomes the seat of secondary inflammation. This cursory enumeration of diseases which may be complicated by inflammation of the membrane of the heart, may well impress us with the necessity of watchfulness, and of repeatedly examining into its condition in all such cases. Much of our success will depend upon the early detection of the disease, and we may often overlook it if we wait until the symptoms force it upon our attention. 559. Diagnosis. — If we trusted to symptoms alone, our diagnosis would be often inexact, although even then we could have no doubt of the existence of a very serious thoracic affection ; but when, in addition, we are able to examine the chest with the stethoscope, we shall gene- rally make out the disease correctly. The distress referable to the region of the heart, the hurried respiration, the difficulty of lying down, the exocardial murmurs, the dulness on percussion, and the increased impulse of the heart, are the characteristic signs and symptoms of the disease. The only diseases with which there is much danger of our confound- ing it are pleuritis and endocarditis. I. From the former it is distinguishable by the limited extent of the dulness, the locality of the friction sounds, and the free permeable con- dition of the lungs, and the resonance of all parts of the chest except the prsecordial region. When complicated with pleuritis, we shall have all the signs of each disease present. II. In endocarditis the symptoms are very similar, but the endo- cardial murmurs are essentially different, and indicate some obstruction to the current of the blood. But the two diseases are frequently com- bined, and then, in addition to the friction or crackling sound of peri- carditis, we have the souffle of a narrow valvular orifice. In simple en- docarditis there is no increase of dulness on percussion. 560. Prognosis. — Although a very serious disease, yet pericarditis 1 Lectures on Diseases of Infancy and Childhood, p. 304. 2 Lectures, &c, on Diseases of the Heart, vol i. p. 358. PERICARDITIS. 395 is not as frequently fatal as we might d priori suppose ; nay, a consi- derable number recover when the disease is partial. When the inflammation is acute and general, of course the danger is very much greater, and is aggravated by the existence of the primary disease; yet even of such cases a proportion recover. Rilliet and Bar- thez saved their four cases of rheumatic pericarditis. In forming our prognosis, we must take into careful consideration the age, strength, constitution, and previous history of the patient, with a due estimate of the primary disease and its effects. Dr. Latham has so strikingly shown the danger dependent upon the constitution of the child in such diseases as the present, that I need make no apology for extracting some of his observations: "It goes hard with weak, scrofulous children, and with men and women whose habitual health is no better than an habitual infirmity, when they come to suffer inflammation of any vital organ ; but it often goes still harder with them after the inflammation has ceased, if much be left for repara- tion. Subjects of this unhappy constitution will struggle through a com- bined attack of inflammation of the heart and lungs, and hold out well until it has come to an end, and will afterwards die during the halting, ineffectual efforts of reparation, or only after a very long time and many vicissitudes, will reach the point of safety at last. Their constitution has given all that it could to the disease without dying, and it has now not enough, or scarcely enough left to give for reparation, or rather for that degree of reparation which is needed for present safety." 561. Treatment. — Fortunately the treatment of pericarditis is simple and intelligible, so that, having ascertained the nature and stage of the injury, we have only to bring our remedies to bear upon it promptly. The indications of cure are to abate the inflammation, to moderate the violent action of the heart, and at a more advanced stage to promote absorption. Each remedy I shall mention will, if successful, accomplish more than one of these objects. When called to a case of acute pericarditis, whether primary or se- condary, the first thing is to take away some blood, either from the arm or by cupping or leeching, if the child will bear it, and in proportion to its strength. If the heart disease be primary, it will bear it well, and not only once, but twice or three times, if necessary. If the disease be secondary, and the primary disease have not much reduced the child, blood must be taken; in almost all cases of rheumatism, for instance, there will be no counter-indication. But when the child has been run down foy measles, scarlatina, pleu- risy, &c, or was originally of a weak, scrofulous constitution, we must be more cautious ; perhaps three or four leeches may be borne, applied to the prjecordium, or if not, we must then depend upon calomel and opium, with counter-irritants. 502. Calomel alone, or in combination with a small quantity of opium, squills, or digitalis, is next in value to bleeding. We should commence its exhibition in all cases immediately, and proportioning our dose to the age of the child, the state of the bowels, &c, and guarding against diarrhoea, we should endeavor to bring the child as quickly as possible 396 PERICARDITIS. under its influence. Mercurial inunction may be used at the same time that calomel is given internally, and both should, if possible, be con- tinued until either soreness of the" gums or mercurial diarrhoea gives proof that the constitution is affected. In the first instance the mercury is employed for its antiphlogistic properties, but afterwards it may be continued in smaller doses, or re- sumed, for the purpose of removing the fluid effused into the pericar- dium. Dr. Latham has some valuable observations upon this subject, to which I gladly refer the reader. 1 As an adjunct to these remedies, and especially for the purpose of quieting the inordinate action of the heart, digitalis has been recom- mended, and it has the additional advantage of acting as a diuretic. It may be given either in powder, infusion, or in tincture, but its effects must be carefully watched, and, if necessary, the medicine suspended. It is better to commence with small doses at first, say a drop or two, three times a day, for a child of a year old, and gradually increasing it according to the effects. The German writers recommend its combination with the calomel, or we may add a little squills to it by way of securing the action upon the kidneys. If digitalis cannot be borne, Rilliet and Barthez recommend the nitrate of potash, to which Puchelt adds Glauber's salts and cream of tartar, with absolute repose, low diet, and moderate warmth. 563. Counter-irritation is of considerable value when the first acute- ness of the disease is subdued after bleeding, &c, and also subsequently to promote absorption of the fluid; and the best mode is to apply a small blister for a short time, and repeat it near to the former. The bowels must be kept free, but severe purgation should be avoided. Let the child be kept perfectly quiet, both mentally and corporeally ; there should be no attempt to enforce discipline ; and those who are in health may patiently bear with and humor the caprices of a child suffer- ing under so distressing an affection. The child must be kept in bed, comfortably clothed, and in the position it finds most comfortable. The diet must be antiphlogistic, with some modification in the case of children who are much worn down, or of weak constitution. I would most strongly advise my readers who wish to obtain a prac- tical knowledge of this disease to study carefully the chapter on the subject, in Dr. Stokes' admirable work on Diseases of the Heart, &c. 1 Diseases of the Heart, vol. i. p. 260, et seq. ENDOCARDITIS. 897 CHAPTER III. INFLAMMATION OF THE LINING MEMBRANE OF TIIE HEART. — ENDOCARDITIS. 564. Endocarditis, or inflammation of the membrane lining the heart, seems more common than pericarditis, both in adults and children, though they are frequently combined. Rilliet and Barthez record six- teen cases, and in two others the disease existed, but was only disco- vered after death. The attack may be either acute or chronic, the latter fully as fre- quent as the former, and either primary or secondary, the latter being, as in the case of pericarditis, much more common than the former, and more frequent than primary pericarditis, according to Dr. West. 565. Symptoms. — The phenomena which indicate the commencement of endocarditis, are very slight and obscure ; a slight febrile movement, which subsides in a little time ; the respiration somewhat accelerated, and possessing the peculiar character I noticed in pericarditis; obscure pain in the prsecordial region ; and some difficulty in lying upon the left side, may be all the symptoms developed; 1 on which account it be- comes of great moment to watch those diseases in which it is apt to occur, that we may detect its commencement. "Tn cases of acute rheumatism," says Dr. West, "you are aware of this danger ; you do not wait till the patient's sufferings inform you that the mischief has been done, but you are on the watch against the first threatenings of its approach ; and your sense of hearing gives you earlier information and surer information concerning this than all the other signs together. But if the same evil against which you guard thus sedulously in cases of rheumatism, may occur independently of it, and may scarcely give warning of its approach until it is almost, or alto- gether, too late to cure, a measure, at least, of the same precaution, should be observed at all times; and in no instance of febrile disturbance in early life, how simple soever the case may seem, should you consider the examination of the patient complete without auscultation. With all your care, there will, probably, still be cases in which the commence- ment of the heart affection will escape your notice ; in which you will accidentally make the discovery of its existence when auscultating the chest for some other purpose, or in which the gradual supervention of the signs of valvular disease will call your attention to it long after the ailment has become chronic. 2 1 Rilliet and Bavtliez, Mai. des Enfans, vol i. p. 232. 2 Lectures on Diseases of Infancy and Childhood, p. 308. 398 ENDOCARDITIS. 566. The physical signs are pretty decided and characteristic. The sounds of the heart are energetic and regular, though hardly so clear as usual, and with the first sound there is a bruit de soufflet, either dis- tinct from the contraction, or more or less masking it. It is heard generally in the mammary region, sometimes clearer at the apex, and in other cases at the base, and extending upwards, according as the tricuspid or mitral valves may be the principal seat of the disease. This endocardial murmur may be heard at the commencement of the attack, and, unless in those rare cases where the return to health is complete, the souffle will remain for a long time as evidence of an in- jured heart. As pericarditis often co-exists, exocardial murmurs may accompany the bruit de soufflet, indicating the complex character of the disease, but ceasing long before the sounds from the diseased valves disappear. In simple endocarditis the precordial region is not more dull on per- cussion than usual. 567. But from the obscurity of the symptoms, and the slight consti- tutional disturbance, the disease may run on into the chronic form before we are consulted, and then we shall be at once presented with the phenomena of the disease, and of some, at least, of its consequences, mixed, very likely, with the symptoms of the primary disease, whether bronchitis, pneumonia, pleurisy, or fever. There is generally more or less cough, sometimes dry, in other cases with expectoration ; the respiration is also accelerated, partly owing to the primary disease, but principally to the affection of the heart. The breathing is panting, hurried, and as if a moment's interruption would be followed by suffocation. The pulse is always quick, small, and thread-like ; sometimes, though by no means always, the patient complains of pain or uneasiness in the region of the heart. The surface is seldom hot, although in some cases there are abundant perspirations. Rilliet and Barthez have not found the face so characteristic as in adults : sometimes the alee nasi were in action, and in all the countenance expressed anxiety and suffering. In some cases the child can lie on either side, but in most I think it requires to be propped up by pillows. A large proportion of cases suffer from anasarca, partial or general. Rilliet and Barthez met with it in nine out of twelve cases. Other and more distant consequences of the condition of the heart I shall describe presently. The physical signs are those which indicate injury of the valves of the heart, and the results of such injury, dilatation or hypertrophy, or both. The heart's action is more extensively heard than usual ; sometimes dull but energetic ; in others, and perhaps more frequently, clear and superficial. Ordinarily they are distinct, but sometimes confused and running into each other. Mental emotion or sudden movement occasions violent palpitations. In all cases a bruit de soufflet accompanies or immediately follows the first sound of the heart. Heard from the beginning, it persists ENDOCARDITIS. 399 after the patient has apparently recovered, or until death, if the disease prove fatal. 568. Unlike acute endocarditis, when the chronic form has continued for some time, there is a diminution of resonance on percussion, amount- ing in many cases to absolute dulness, and much more extensive than natural. The following case, given by Dr. West, affords an excellent picture of this form of disease : " Nothing could be more gradual than the advances of the early stages of the disease of the heart in the case of a little girl, eleven years old, who came under my notice in the month of March, some years ago. Her mother stated that, though not robust, she had never had any definite illness, but that for the last year she had been growing thinner, and had suffered from palpitation of the heart, which had by degress become more and more distressing, and that for the past three months she had suffered likewise from cough. The child, when brought to me, was greatly emaciated ; her face was anxious and distressed ; her breath short, so that it was with difficulty that she walked even a short distance. She had frequent short cough, without expectoration, and she suffered much from palpitation of the heart, and a sense of discomfort at the chest. The heart's action was violent ; dulness in the prse cordial region was extended ; a very loud, harsh, rasping sound accompanied the first sound of the heart, loudest towards and to the left of the nipple, but heard over the whole of the chest, both before and behind. Various remedies brought slight but temporary relief to her sufferings, and she grew worse every month. She became more and more emaciated; the distress at the chest and the palpitation of the heart increased ; her cough became more violent, and once she had an attack of hemoptysis. For about a month before her death the cough altogether ceased, but she was now altogether unable to leave her bed from increasing weakness ; the palpitation continued unmitigated, and her extremities became slightly anasarcous. During the last week of her life, her respiration was extremely difficult, and became increasingly so till she died on the 10th of October. " The lungs were very emphysematous, and much congested, but not otherwise diseased. The heart was extremely large, but its right cavities did not exceed the natural size. The pulmonary valves were healthy, the edges of the tricuspid valve were slightly thickened ; the left auricle was enormously dilated, but its walls were not all attenu- ated ; the pulmonary veins were much dilated ; the left ventricle was dilated, its walls were thickened; the 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 existed likewise a slight thickening of the edges of the semilunar valves of the aorta." 1 569. Such or such like is the history of those cases of endocarditis, which, giving rise to injury of the valve and consequent hypertrophy, run a fatal course within the space of some months: incipient obstruc- tion to the circulation, constant dyspnoea, palpitation, exhaustion, ema- 1 Lectures on Diseases of Infancy and Childhood, p. 309. 400 ENDOCARDITIS. ciation, and death. But all do not necessarily thus terminate. The patient may recover, i. e., her life may be saved, with an injured heart, and in this exact condition it may remain for five or six years, neither improved nor getting worse, suffering from palpitation, dyspnoea, and some pain on exertion or mental emotion. " The child who has had the precordial murmur ever since it suffered a certain rheumatic attack, is just the same child it was before, except that it cannot join in any pastime requiring rapid movement, for then its heart palpitates, it loses its breath, and is obliged to sit down." 1 Dr. Latham adds: "I have lately seen a young lady, thirteen years of age, whom I attended three years and a half ago, under an attack of acute rheumatism attended by endocarditis. The symptoms during the attack referable to the heart were completely characteristic of the disease, and carried to such extremity as to keep life in peril for several days. It was, perhaps, the severest case I ever saw recover. She did recover, however, but never lost the murmur and occasional palpitation. At present she has the appearance of perfect health ; she even bears the marks of premature womanhood. She goes to school, plays about like other girls, but can- not run so fast or so far as the rest, or use bodily exertion beyond a certain amount, without dispnoea and palpitation, and some pain in the region of the heart. For all other purposes she is absolutely well. In examining the state of her heart when she is quite free from all excite- ment, I find no extraordinary impulse either of extent or of degree. It is felt only at the apex. Neither do I find any extraordinary extent of dulness on percussion. A systolic murmur is audible everywhere within the precordial region, most audible at the apex, more faintly at the base. From the basis upwards towards the right clavicle, in the course of the aorta and subclavian artery, it is entirely lost ; towards the left clavicle, and in the course of the pulmonary artery, it is very loud, but not at all hard in the carotids. From the apex the murmur extends far round towards the left axilla and the back. Here I pre- sume that the rheumatic inflammation has done a permanent injury to the endocardium on both sides of the heart, and that the mitral valve and the semilunar valves of the pulmonary artery have undergone change of structure." The same author mentions the case of two young ladies in whom similar evidence of valvular injury had existed from childhood, but whose health has never suffered in consequence, and he asks : " Do not these facts give intimation of a certain protective power, probably in- herent in the growing heart, whereby it can accommodate its form and manner of increase to material accidents, and to repress or counteract their evil tendencies ?'■' I have a little patient in whom I accidentally detected a bruit de soufflet with the first sound of the heart some years ago, without being able to trace the disease to its commencement. Like Dr. Latham's case, his health does not appear to suffer, and the heart disease remains stationary. 570. Consequences. — But this is far from being the general result of 1 Latham on Diseases of the Heart, vol. ii. p. 89. ENDOCARDITIS. 401 such cases. There are certain consequences which seem to he the ne- cessary effect of permanent disease of the valves from endocarditis. I. I should first mention, however, that the lining membrane of the heart, once having been the seat of inflammation, seems as liable as the pericardium to a repetition of the attack; with this difference, however, that the signs indicating it, the palpitation, dyspnoea, impossibility of lying down, strong impulse, and loud murmur, are much more charac- teristic and definite than those of secondary attacks of pericarditis. Both Dr. Latham and Dr. West mention cases of this kind, with a melancholy foreboding of the future history of such cases. " The val- vular disease, and the heart's efforts to overcome its consequences, have already led to a considerable degree of hypertrophy of the organ ;- the danger of each acute attack will be aggravated by the old disease, and every fresh inflammatory seizure will add to the chronic mischief, until, in the course of time, the disorganization of the heart will have ad- vanced so far as to render it unable to perform its office sufficiently well to maintain existence any longer, and a life of suffering will then be closed by a painful death." II. Attenuation and softening of the left ventricle, either alone or combined, may be the result of valvular disease, giving rise to a feeble impulse but loud sounding action of the heart, and to other and deeper derangements of the circulation, near or distant, and of a passive cha- racter, such as effusions of serum or blood, congestions, &c. III. But a more common result, with children at least, is the produc- tion of hypertrophy with dilatation, i. e. when the substance and size of the heart are both increased, the cavities, or some of them, are larger than natural, and the walls are thicker. The left ventricle and auricle are most frequently the seat of this morbid change. There can be no doubt that it is the result of valvular injury, and that it is a kind of reparation at the same time ; an obstacle existing to the passage of the blood, an increase of force is required by the heart to overcome it, and to prevent the consequences of such interruption. " A loud, systolic, endocardial murmur, and an excessive impulse of the heart, and a larger space of precordial dulness than natural there, are the sure and authentic signs of an injured valve, and hypertrophy of the left ventricle." 1 But the rhythm of the heart's action may be perfectly regular, and the pulse betray no sign of the existing mischief. The general circulation, too, may be perfect, and the color and heat of surface quite natural. But although in itself, and to a certain extent, a process of repara- tion, this augmentation of size and force may become a deadly evil in its result. The most common effect of this state of the heart is the effusion of serum into the cellular membrane, first of the lower extremities, then of the body, upper extremities, and face. In some cases, similar effusion may take place into the serous cavities with alarming results. Again, a child laboring under hypertrophy of the heart is liable to congestion, hemorrhage, or inflammation of different and distant organs, of an active character, and attended by very serious consequences. The 1 Latham on Diseases of the Heart, vol. ii. p. 296. 26 402 ENDOCARDITIS. same diseases apparently as those from attenuation, but of an opposite character, and requiring a different treatment, they seem, upon the ■whole, more manageable. 571. Morbid Anatomy. — The morbid changes from endocarditis are not so numerous nor so marked as in other serous membranes, for the very obvious reason that the current of blood must sweep away with it all the serum which may be effused, and a great portion of the lymph ; still, enough remains to afford evidence of the disease, now that we know what to seek for. On opening a heart which has suffered from this dis- ease, we find the lining membrane vascular, and of a red color gene- rally, or in parts when the inflammation is recent. A certain amount of coagulable lymph is deposited upon the valves, either in patches or like small beads. The mitral valve is the most frequent seat of these depositions, then the tricuspid. At a later period, there may be no vas- cularity nor any traces of recent lymph, but the valves are thickened, irregular, retracted, or incomplete, sometimes cartilaginous, and occa- sionally, but rarely, osseous. Now and then there are vegetations upon them, or the chordae tendineas may be shortened. Whatever be the pe- culiar modification of the lesion, the effect is to render the valves less pliable, less capable of closing the orifice, or of yielding to the current of the blood ; hence the endocardial murmur, and the remote conse- quences of obstructed circulation. When the valvular disease is of old standing, we may find hypertro- phy and dilatation about equally frequent, according to Rilliet and Bar- thez, who also mention that they have found the hypertrophy limited to the inter-ventricular septum, and to the columnse carneas in connection with diseased valves. 1 The tissue of the heart is almost always in its normal condition, red and firm. In one case only, Rilliet and Barthez found it soft, flaccid, and of a yellowish red. 572. Causes. — It is extremely difficult to specify the causes of endo- carditis, except in general terms, inasmuch as we see so little of the disease except as a secondary affection. It does not appear that either age or sex have much if any predisposing influence. Of eighteen pa- tients mentioned by Rilliet and Barthez, affected with acute or chronic endocarditis, the numbers of boys and girls were equal. It is as a secondary disease, however, that its principal interest con- sists, and the primary affections in which it occurs are the same as those enumerated when speaking of pericarditis, with which it is very often combined. I. The most common primary disease is acute rheumatism, at any stage of which the heart may become affected. We may easily detect its invasion, if we are on the watch. The increase of the heart's action, the hurried respiration, the anxiety of countenance, and the endocardial murmur, will at once indicate the new and formidable enemy with which we have to grapple. II. I have seen it come in the course of infantile remittent quite sud- denly. A few hours before, the child was going on very well, without 1 Mai. des Enfans, vol. i. p. 220. Dr. Hope on Diseases of the Heart, 3d ed., p. 203, et seq. ENDOCARDITIS. 403 any local affection, when, suddenly, dyspnoea, very quick pulse, pain in the chest, and bruit de soufflet, made their appearance. III. In like manner, we may find it complicating any of the eruptive fevers, especially scarlatina and measles, when we least expect it, and without any warning. On this account, let me repeat the advice already given, to look carefully to the heart at each visit in all these diseases. The hypertrophy and dilatation result naturally, and to a certain extent as a reparative process, from the obstruction offered to the circu- lation, and the necessity of an increase of force to overcome it. Rilliet and Barthez mention that deformity of the chest (from rachitis) may give rise to hypertrophy, as it certainly may to considerable confusion in the heart's sounds. 573. Diagnosis. — There is perhaps less difficulty in the diagnosis of endocarditis than of pericarditis, and there is not much danger of their being confounded. We may certainly overlook either when both are combined, but practically this would not be of much consequence. The general symptoms are much the same, but the presence of endo- cardial murmurs, the bruit de soufflet, de scie, and de rape, with the first chiefly, or with both sounds of the heart, and the absence of the friction sound, will render the diagnosis clear. At an early stage, the dulness is less absolute and less extensive in endocarditis, and the patient suffers more from palpitation. In the chronic stage, we have the murmurs, an increase of dulness, oedema or anasarca, with palpita- tion upon the least exertion. There is a class of cases among adults which seems a little puzzling at first. I allude to those in which bruit de soufflet and other murmurs are heard in the heart and large vessels, not from valvular disease, but from some change in the component parts of the blood, e. g., in patients in a state of angemia. This I have often found in women laboring under amenorrhoea ; but we have the satisfactory testimony of Dr. West that it is not the case with children under seven years of age, and that at a later period it is very rare. 574. Prognosis. — The prospects of the patient are always very seri- ous and doubtful. They may recover from immediate danger, and life may be safe for the present, and even, in some rare cases, for years; but sooner or later, it is to be feared that some of the consequences I have enumerated will either terminate life or render its continuance a burden. 575. Treatment. — The treatment of endocarditis is almost identical with that of pericarditis. When acute, bleeding, general or local, calomel, digitalis, and diuretics, with counter-irritation subsequently, are all the means at our disposal. As I have entered fully upon their employment in pericarditis, there is no occasion to do so now, as what was then said applies to the present disease just as well. The necessity for absolute quiet is even greater, or, at least, more obvious, in endocarditis ; for mental emotion, disturbance, or exertion, increase the dyspnoea and palpitation to a most distressing degree. 576. A second attack of inflammation must be met in the same way, but, perhaps, less actively, according to the condition of the patient, and certainly with less hope of being successful. 404 ENDOCARDITIS. Whether any means at our command are sufficient to arrest or con- trol the hypertrophy and dilatation is at least doubtful, but by judicious regimen we may often prevent inconvenience, and by timely and well- considered treatment may relieve some of the consequences, such as anasarca, local congestions, &c. Diuretics for the removal of effu- sions, calmants for tranquillizing the action of the heart, and local antiphlogistics in moderate degree, will at least afford a chance of relief, and of the prolongation of life. SECTION IV. DISEASES OF THE DIGESTIVE SYSTEM. CHAPTER I. INTRA-UTERINE DISEASES.— CONGENITAL MALFORMATIONS. 577. A considerable variety of intra-uterine diseases of the digest- ive system have been observed and recorded. Thus Orfila, Veron, 1 Cruveilhier, 2 Billard, and others, speak of muguet observed at birth, and evidently existing during intra-uterine life. Cases of oesophagitis have been mentioned by Billard 3 and Orfila ; of gastritis by Siebold, 4 Billard, and Orfila ; of peritonitis and enteritis by Weisberg, 5 Chaus- sier, 6 Veron, 7 Duges, 8 Billard, Canes, Cruveilhier, 9 Simpson, 10 and others. Numerous cases of infants born jaundiced are on record. Some of the mothers had jaundice, others bowel complaints, &c. Panarola, 11 Kerkring, 12 Schurig, Schultz, 13 Wrisberg, 14 Sentin, 15 Billard, and others, have described such cases. Billard 16 has seen tubercular granulations, and Orfila mentions that the liver is occasionally hypertrophied, fatty, tuberculous, transposed, softened, or indurated. 17 It is enough for my purpose thus slightly to prove the existence of morbid actions in utero, analogous to those observed in after life, thus completing the circle of disease. With those whose effects continue after birth, and with certain malformations or arrests of development, affecting as they do the comfort or even the life of the child, I must enter more into detail. I shall, in the remainder of the chapter, notice hare-lip and cleft palate, which are arrests of development, and imper- forate anus, which is a malformation. These are of too much import- 1 Seance de l'Acad. Roy. de Med., June 28, 1825. 2 Anat. Pathol., liv. 15, p. 13. 3 Mai. des Enfans, p. 274. 4 Journal fur Geburtshiilfe, vol. v. 5 Dissertatio de prteternaturali et raro intestini recti cum vesicae urinarise coalitu, &c, 1779. 6 Bull, de la Faculte de Med. 1821, vol. x. 7 Recherches des Mai. des Nouveaux-nes, 1821. 8 Gynsecologie, vol. ii. p. 251. 9 "Anat. Pathol., liv. xv. pp. 2, 3. 10 Edin. Med. and Surg. Journal. 1! Obs. Med. Pentecost., p. 137. 12 Spicilegium Anat. Obs., 57. 's M. N. C. Dec. 1. An. 6, 7, p. 355. 14 Descriptio Anat. Embryon., 1764, Obs. 1. 15 Beitrage zur ausiibenden Arzneiwissenscbaft, vol. i. p. 29. 16 Mai. des Enfans, p. 421. 17 Graetzer Krankheiten des Fotus, p. 155. 408 INTRA-UTERINE DISEASES. ance to be omitted, although the reader will find them fully treated in every systematic work on surgery. For most of the information I have been indebted to Mr. Cooper's invaluable Dictionary. 578. Hare-lip. — This congenital deformity consists of a perpendi- cular or oblique division of the upper lip, either directly below the sep- tum of the nose or one of the nostrils. The upper lip, thus divided, is generally movable, but in some ; cases the two portions are closely attached to the alveolar process. The space between the divided por- tion varies ; sometimes it is considerable, in other cases but slight. But the cleft is occasionally double, constituting what is called " double hare-lip," and in such cases we find a small portion of the lip in front between the fissures. In a great many cases the arrest of development is confined to the lip ; in other cases it extends along the soft parts of the palate even to the uvula ; and in others the bones of the palate are incomplete. Again, the jaw may be incompletely ossified in front, leaving a cleft between ; or one portion may project more than the other. The lower lip may also be affected, but this is a very rare malformation. Every one, probably, has witnessed the deformity occasioned by the simplest form of hare-lip, which is much aggravated when it is double. But there is more than deformity resulting, for it often hinders an in- fant from sucking, and at a later period interferes with the facility and perfection of speech. All these evils are greatly worse when the lower lip is fissured, and even the health may suffer. 579. Treatment. — It is evident that this deformity can only be reme- died by a surgical operation; and as all mothers are naturally anxious to have it relieved as soon as possible, the first question relates to the age at which the operation should be undertaken. The earlier the age at which it can be done safely the better, but then it must be remembered that very young infants are very liable to con- vulsions, and on this account it is generally deferred until the child is about two years old. Sir Astley Cooper sanctioned this, having known a fatal result from operating earlier. Mr. Cooper mentions having suc- cessfully operated upon a child five months old, and upon another a year old. Le Dran, B. Bell, and others, operated upon infants even at ear- lier ages; and Dupuytren has fixed upon three months as the most favorable age. 1 My friend, Surgeon Smyly, who has had great experience in this operation, has favored me with the following note illustrating the point in question: — " The infant on whom you saw me operate for hare-lip was two months old. I removed the needles the third day ; I, however, applied adhesive plaster, to prevent accidents. The child has been able to suck well since. In cases of single hare-lip I always prefer operating early ; the operation is much easier of performance, as the child can make no resistance, the wound heals faster, and deformities of the nose and palate are more easily redressed when the patient is very young, and before teething has commenced. I have looked over the notes of some cases : 1 Clin. Chirur., vol. iv. p. P0. HARE-LIP. 407 one, the youngest I ever operated upon, was only a fortnight old, the others from one to four months. In none of them have I seen any un- pleasant symptom to deter from operating early. " I never saw convulsions follow in any case operated upon for hare- lip, and hemorrhage is as easily controlled in the young infant as in an older child. I generally take the precaution of compressing the coro- nary arteries with Dieffenbach's forceps. In looking over my notes I was surprised to see so many cases in which the cleft was on the left side, i. e. in three-fourths of the cases." Dr. O'B. Bellingham, Prof. R. Smith, and others, agree with Mr. Smyly in preferring an early age for the operation, but other sur- geons of this city, I am informed, prefer a later period. 580. Whatever be the time chosen for operating, all surgeons are agreed that the object is to reduce the fissure to the condition of an incised wound, by removing the edges of the divided portions, and keeping them in contact until adhesion takes place. There has been some difference of opinion as to whether this approximation should be effected by sutures or by adhesive plaster and bandages. M. Louis offered a weighty oppo- sition to the sutures, but notwithstanding, the twisted suture is now generally used. "No modern surgeons doubt that a hare-lip may be cured by means of adhesive plaster and uniting bandages quite as per- fectly as with a suture ; and all readily allow that the first of these methods, as being more simple and less painful, would be preferable to the latter, if it were equally sure of succeeding. But it is considered far more uncertain in its effect. To accomplish a complete cure, the parts to be united must be maintained in perfect contact until they have contracted the necessary adhesion, and how can we always depend upon a bandage for keeping them from being displaced ? What other means, besides a suture, afford in this respect perfect security?" 1 When about to perform the operation with the twisted suture, we should first examine whether the lip be adherent to the gum, and if so they must be separated by the knife. When the frenulum is in the way of the operation it must be divided. " In the operation for single hare- lip," says Mr. Cooper, " the grand object is to make as smooth and even a cut as possible, in order that it may more certainly unite by the first intention, and of such a shape that the cicatrix may form only one narrow line. Hence in this country the edges of the fissure are cut off with a sharp knife. One plan is to place any flat instrument, such as a piece of horn, wood, or pasteboard, underneath one portion of the lip, and then, holding the parts stretched and supported on it, to cut away the whole of the callous edge. Another is to hold the part with a pair of forceps, the under blade of which is much broader than the upper one ; the first serves to support the lip, the other contributes also to this effect, and at the same time serves as a sort of ruler for guiding the knife in an accurately straight line. When the forceps are preferred, the surgeon must of course leave out of the upper blade just as much of the edge of the fissure as is to be removed, so that it can be cut off with one sweep of the knife. This is to be done on each side of the cleft, 1 Cooper's Surgical Dictionary, p. 656. 408 CONGENITAL MALFORMATIONS. observing the rule to make the new wound in straight lines, because the sides of it can never be made to correspond without this caution." In University College Hospital the margins of the fissure are usually re- moved by transfixing the lip with a long, sharp-pointed, narrow bis- toury, just above the upper end of the cleft, and then cutting towards the red portion of the lip, while the part is held and stretched out by the surgeon himself or his assistant. One side of the cleft is thus pared off, and then the other, particular care being taken to remove a small piece of the red part of the lip on each side, lest an ugly notch should be left in that situation. This is the plan ordinarily followed by Mr. Liston. In France the edges of the fissure are always taken off with a pair of strong, sharp long-handled scissors, invented for that purpose by M. Dubois. Two silver pins, made with steel points, which admit of an easy removal, are next to be introduced through the edges of the wound, so as to keep them accurately in contact, the lowest pin being introduced the first, near the inferior termination of the wound, and the upper pin afterwards, about a quarter of an inch higher up. A piece of thread is then to be repeatedly wound round the ends of the pins, from one side of the division to the other, first transversely, then obliquely, from the right or left end of one pin above to the opposite end of the lower one, &c. Thus the thread is made to cross as many points of the wound as possible, which greatly contributes to maintaining its edges in even apposition. Lastly, the steel points of the pins are to be taken off, or if not made to slide off, they are to be supported by small dossils of lint, placed between them and the skin. In the University College Hospital Mr. Liston employs largish common needles, the heads of which have been dipped in sealing wax, and after they have transfixed the lip, he takes off their points with a pair of cutting forceps. " In- stead of pins made with steel points, Dr. Barton, of Philadelphia, pre- fers using a piece of iron wire, with a point made by simply cutting it with a pair of scissors. Thus he avoids the risk of the steel point slipping off the pin and remaining within the lip." "It is obvious that a great deal of exactness is requisite in introducing the pens, in order that the edges of the incision may afterwards be precisely applied to each other. For this purpose some surgeons previously place the sides of the wound in the best position, and mark with a pen the points at which the pins should enter and come out again. The pins ought never to extend more deeply than about two-thirds through the sub- stance of the lip, and it would be a great improvement always to have them of a flat instead of a round shape, and a little curved, as this is the course which they naturally ought to take when introduced. The steel points should also admit of being easily taken off when the pins have been applied, and perhaps having them to screw off and on is the best mode, as removing them in this way is not so likely to be attended with any sudden jerk, which might be injurious to the wound, as if they were made to pull off. In general the pins may be safely removed in about four days, when the support of sticking plaster will be quite sufficient. After the operation, compresses and a bandage for keeping HARE-LIP. 409 forward the cheeks are sometimes employed, but they may in general be dispensed with, because irksome to children, and the occasion of rest- lessness. This is what is called the twisted suture, and is the most generally used for hare-lip ; but there are other circumstances and other modes of operating which require a moment's notice. 581. It occasionally happens that there is a considerable projection of the upper jaw (especially when the hard palate is divided), sufficient to offer a serious obstacle to the union of the two portions of the lip. The ordinary practice has been to remove this portion, but as that de- stroys the harmony of the upper and lower jaw, it has been proposed and practised successfully by Desault, Dunn, and others, to employ compression first so as to reduce the prominence, to its proper level, and then operate for the hare-lip. M. Gensoul in a case seized the pro- jection with a strong pair of forceps, and brought it down into its place by main force. " M. Dupuytren had a peculiar method of operating in some cases of complicated hare-lip. He observed that when the labial tubercle was inserted very close to the point of the nose, its union to the lateral parts drew the lip upwards, and exposed the gums and teeth, while the nose itself was pulled clown and flattened in a most ugly manner. Hence he conceived that it would be better to employ the labial tuber- cle in forming the lower part of the partition of the nose, and to unite at once the lateral portions of the lip. He first divided with a bistoury the fold of mucous membrane uniting the labial tubercle to the osseous one, and then, with a pair of cutting forceps, removed all such por- tions of the latter as projected beyond the anterior level of the jaws. He next pared off the sides of the cutaneous tubercle and its lower edge. These things having been clone, the vertical margin of the fissure on each side was cut off with a pair of scissors. The two lateral por- tions of the lip were now brought together and united with two pins ; and the fresh cut bleeding middle tubercle was laid over the bony par- tition of the nostrils, of which it was to form the lower portion. A third pin was applied, so as to include at once the upper end of each part of the lip, and the loose extremity of the reflected tubercle. Lastly, two interrupted sutures united the angles of this tubercle to the lateral portions of the lip. The sutures were assisted with straps of adhesive plaster and a bandage that made pressure on the apex of the nose, so as to keep the flap from being too much stretched." 1 Instead of the twisted suture Sir Astley Cooper preferred the com- mon interrupted suture, on account of the danger of separating the new adhesions when withdrawing the pins. The threads of the common su- ture can be cut and easily removed. When the hare-lip is double, the operation is the same in principle, and had better be completed at once instead of making two operations, as the older surgeons advised. Occasionally hare-lip is complicated with cleft palate, and now and then, after the hare-lip is cured, this fissure closes ; in other cases there must be some artificial substitute contrived. This brings us to the second of the malformations. 1 Cooper's Dictionary, p. 657. 410 CONGENITAL MALFORMATIONS. 582. Cleft Palate. — There are three degrees or forms of this con- genital malformation: first, when the fissure is simple, and confined to the soft palate ; secondly, when there is a partial division of the bony- palate; and thirdly, when this division involves a greater or less inter- space between the lateral portions, and almost always a fissure in the alveolar process and the upper lip. The operation for each respectively has been termed staphylorrhaphy, staphyloplasty, and uranoplastic. 583. I. Staphylorraphy. — Mr. Cooper describes MM. B,oux's and Berard's, Mr. Smith's, and Mr. Liston's method of performing this operation. In M. Roux's plan, the apparatus required consists- — I. Of three broad flattish ligatures, composed of three or four strong threads. 2. Of six small, curved, flat needles, two for each ligature. 3. A porte- aiguille. 4. A pair of dressing forceps. 5. A probe-pointed bistoury. 6. Scissors with long handles and short blades, bent laterally to an obtuse angle. " The patient being seated opposite the light, and the mouth kept open, the surgeon takes hold of the right edge of the fissure with the forceps held in his left hand, while with the right he conveys into the pharynx the porte-aiguille armed with a needle, the point of which is of course turned forwards. The point of the needle is then carried back to the posterior surface of the velum, and passed through it from behind forward near the lower end of it, and about three or four lines from the margin of the slit. The point of the needle is to be passed out as far as practicable, and then taken hold of with the forceps. The porte- aiguille being now removed, the needle is drawn into the mouth with the forceps, and along with it the ligature with which it is threaded. After the patient has recovered his tranquillity, and washed out his mouth, the other end of the ligature is to be passed in a similar way through the left side of the velum, and the two ends are to be brought out at the commissures of the lips. Then a second ligature is to be applied near the angle where the two sides of the velum meet, and a third at the middle point between the other two ligatures. The left side of the fissure is then seized, depressed, and rendered tense with the ring- handled forceps, and the excision of its margin begun with the curved scissors, and completed with a straight probe-bistoury applied on the outer side of the forceps, and with its back directed towards the root of the tongue. Thus a slip is to be removed about half a line in breadth. Particular care must be taken to let the slip extend a little above the front angle of the fissure. The same proceedings are to be followed on the opposite side, the two incisions being made to join at an acute angle above the point just now specified. It only remains to tie the ligatures. The surgeon begins with the lowermost one, which is first to be tied in a simple knot. As soon as this has been duly tightened with the fore- finger, it is to be taken hold of with the ring-handled forceps, and kept from slipping until another knot is made. The same plan is to be adopted with the two upper ligatures. Finally the ends of each liga- ture are to be cut off as useless." No other dressing is requisite: the patient must avoid all exertion of the part, such as laughing, talking, sneezing, and even swallowing, as CLEFT PALATE. 411 much as possible. The upper ligatures may be removed on the third or fourth day ; the lower ones should remain a day or two longer. If the union be not complete, the edges may be touched with the nitrate of silver. 584. M. Berard's method is apparently more simple. With the left hand he seizes the left border of the fissure with a tenaculum, and with the right he passes a curved needle, held by the forceps and armed with a ligature, from before backwards, on a level with the upper angle, until its point can be seized with the forceps when it is drawn through. Another ligature is passed in like manner through the opposite edge, and as many ligatures are thus inserted as the fissure requires, and then the edges of the fissure are removed and the ligatures tied. ■585. Mr. N. R. Smith, of the United States, employs a curved needle mounted on a handle, and armed with a ligature. The front of the needle is passed from behind forward until the ligature appears, and can be seized with a tenaculum and drawn through. The needle is then withdrawn, and passed through the other side of the fissure. After a sufficient number of ligatures have been inserted, the sides of the velum are to be tightened by means of them, and the edges removed by scissors or knife. The ligatures are then to be tied. 586. Mr. Liston's method is as follows: "A narrow, sharp-pointed knife, held by the further end of the handle, is introduced through the edge of the fissure at its anterior margin, and run back to the apex of the one-half of the uvula. This may be laid hold of, and made tense by means of the sharp-pointed forceps. The same proceeding is re- peated on the other side." The ligatures are introduced with needles fixed in handles, and of different sizes and curvatures, the eyes being near their points. They are passed through the velum about a quarter of an inch from its free edge and towards it, and through two-thirds of its thickness. Each needle carries a double ligature, the noose of which is caught by a blunt hook and pulled out into the mouth, while the in- strument is withdrawn. A second and smaller ligature is carried through opposite to the first, and by means of this second thread the first and double one is brought through. By a repetition of this plan two, three, or more points of interrupted suture are made. After the edges have been brought together by one or two points, no difficulty will be expe- rienced in carrying others through both edges by means of a more curved instrument in a handle, or by the use of a small needle carried in the points of a pair of strong and well-fitted forceps. Before the ligatures are finally secured, the parts being put upon the stretch, an incision should be made on each side towards the alveolar ridge, through the anterior surface of the velum. By this method Mr. Liston finds that the edges may be more easily brought together, and the strain is taken off the threads, so that there is less risk of their making their way out by ulceration. Mr. Liston deems the operation very liable to failure. 1 In two cases upon which Sir Philip Crampton operated in the year 1842, that distinguished surgeon deviated from the ordinary mode of 1 Cooper's Surg. Dictionary, p. 1078. Liston's Practical Surgery, p. 472. 412 CONGENITAL MALFORMATIONS. securing the ligatures, and from the usual treatment subsequently. Mr. Hamilton, who relates the cases, observes: "The difficulty of tying the second knot on the ligature without suffering the first to become opened by the strong retraction of the edges of the fissure, effected by the mus- cles of the palate, has always been acknowledged. This difficulty, however, was effectually removed by an ingenious suggestion of Mr. M' Clean's, of Stephen's Green. After the ligatures had been passed through the palate at the distance of one quarter of an inch from the cut edge of the fissure, and brought out at the mouth, their ends were passed through a small perforated metallic bead, such as are used in making purses. The bead was then pushed down along the ligatures, closing them as it descended, until it touched the approximated edge of the wound ; it was then compressed by a pair of strong, blunt-pointed forceps, and the ligatures were thus firmly secured, without a knot, at the required degree of tension. The other and most important peculi- arity in the treatment consisted in allowing the patient an ample supply of soft food during the whole period of the treatment. Boiled bread and milk, custard, soup, and jelly, were given twice or thrice a day, and the patients were not confined to their beds." 1 587. Professor Fergusson, of King's College, London, has proposed a modification of this operation, founded upon a more careful investi- gation of the anatomy of the parts. 2 He regards the action of the levatoves palati and the palato-pharyngei muscles as an obstacle to the closure of the fissure, and he proposes to obviate this retraction by dividing these muscles. " ; As a preliminary step to the ordinary ope- ration, I suggested the division of the levator palati on each side, and also, if it seemed needful, of the posterior portion of the fauces, whereby large portions of the palato-pharyngei might be cut across. I also then thought that the anterior pillars, each containing the palato-glossus, might possibly require division. To effect these different incisions, I used a small peculiarly curved blade for the levator muscle, and common curved scissors for the others." 3 Mr. Fergusson prefers a free incision through both mucous membrane and muscle. "I still retain the opinion that there is no better mode of introducing the stitches than by means of a slightly curved needle set in a handle. The point of the instru- ment, armed with a smooth round waxed silk thread, is passed from below upwards, about a quarter of an inch from the cut margin of the fissure, and made to appear in the middle of the gap, when the thread is seized with the forceps, drawn three or four inches out of the mouth, and then the needle is withdrawn. A similar manoeuvre is followed on the opposite side. The two threads are then tied together by the ends which have been thus drawn out of the mouth, and by withdrawing one of them the other will be carried through the aperture opposite to that where it was first introduced. Hitherto, the thread has been double ; now one end must be drawn through the apertures and out at the mouth, and so the thread is ready to be tied. Two, three, four, or five threads are introduced in this way, and then, after the cut margins of the flaps 1 Dublin Journal, Jan. 1843, p. 324. 2 Trans, of Royal Med. and Surg. Society, vol. 27. Practical Surgery, p. 530. 3 London Journal of Medicine, No. 1, p. 21. IMPERFORATE ANUS. 413 are sponged free of blood and mucus, the various threads are fastened." Mr. Fergusson prefers " a moderate degree of tightness, rather than that the edges should be kept asunder by saliva or mucus." He also agrees with Sir Philip Crampton in allowing the patients the use of fluid food. In Roux's experience, two-thirds of the simple cases, and one-third of the complicated, derived benefit from the operation. Dr. Mutter, of Philadelphia, succeeded in nineteen out of twenty-one operations ; Dr. J. M, Warren, of Boston, in thirteen out of fourteen ; Mr. Fergusson has given a notice of twenty-four cases, in which the operation was performed according to his suggestions, in twenty-one of which it was successful. 1 588. Staphyloplasty. — Dieffenbach's method of performing this ope- ration consists in making an incision along the palate on each side of the fissure, and afterwards drawing the edges together by ligatures. " The Indian staphyloplasty consists in raising up a flap of soft parts from the roof of the mouth, and twisting its pedicle round, so that the flap may be adapted by means of suture to the loss of substance in the palate." I must refer my readers to the different writers on surgery for the various attempts which have been made to remedy this defect by the substitution of an artificial palate. If it be necessary at all, it is at least desirable to wait until after the age of puberty, and therefore the subject hardly comes within the scope of a treatise on diseases of chil- dren. 589. Imperforate Anus. — In this malformation the lower portion of the intestine terminates in different ways, which materially affect the operation for its relief and the results. 1. The anus may be closed by a thin membrane, the rectum being perfect ; in such cases the membrane generally projects, the blue color of the meconium is discernible, and there is a feeling of fluctuation or something very like it to the touch. 2. The rectum may terminate an inch or so above the anus, and there will then be no projection, the skin will retain its natural color, and the parts will feel firm and solid. 3. Sometimes the intestine does not de- scend lower than the upper part of the sacrum. " Dr. Palmer dis- sected a case where the colon, after reaching the vicinity of the left kidney, began, as it descended, to form a sigmoid flexure, but, previ- ously to its arrival at the concavity of the left ilium, made a sudden turn to the right, and crossing the psoas muscle, reached the projec- tion of the sacrum, where it terminated without entering the sacrum at all. With this malformation was combined an imperforate meatus uri- narius and other considerable deviations of the genital organs from the natural structure." 2 4. Occasionally the colon terminates in a cul de sac, the rectum being entirely wanting. 5. Although the anus may be perfect, yet if there be a closure of the rectum by membrane higher up, as sometimes happens, the result will be the same. 6. In any of these cases there may be an attempt to afford relief naturally by an opening 1 London Journal of Medicine, No. 2, p. 117. 2 Med.-Chir. Journal, 1816, vol. i. 414 CONGENITAL MALFORMATIONS. into the bladder, as in a case lately under my care, or into the urethra, in the male, or vagina in the female. In a fatal case lately under the care of Dr. Sawyer, of this city, and of -which he has made a careful dissection, he found that the rectum opened into the urethra, anterior to the membranous portion. 590. We can easily understand that this malformation must speedily be attended with very serious or fatal consequences. If relief be not afforded, the infant perishes with symptoms of strangulated hernia. Mr. A. C. Hutchinson recommends that the operation should be de- ferred until from twenty-four to sixty hours after birth, the advantage being, that the intestine being distended by the meconium, will be a guide to the operator in making an incision. At all events, within a moderate time after birth, an attempt must be made to afford relief by evacuating the contents of the intestine. 591. When the anus is merely closed by a membrane projected down- wards by the meconium, whose color is discernible, the operation is sim- ple, and consists in making a crucial incision through the centre of the prominence and removing the corners. After the rectum is emptied the wound must be kept open by a portion of a bougie, elastic gum catheter, or, what I found answer equally well, a small glyster-pipe. It is little matter what means are used, if the end be attained. 592. But when no external appearance denotes where the anus ought to be, and when the touch gives us no information, the case is much more difficult, inasmuch as we know not how far distant the intestine may be from the surface, and consequently are ignorant how far we may have to penetrate before relief be afforded. " However," as Mr. Cooper observes, " it is the surgeon's duty to do everything in his power to afford relief. For this purpose, an incision an inch long, or rather more, is to be made in the situation where the anus ought to be, and the wound is to be carried more and more deeply in the natural direction of the rectum. The cuts are not to be made directly upwards, nor in the axis of the pelvis, for the vagina or bladder might thus be wounded. On the contrary, the operator should cut backwards along the centre of the concavity of the os coccygis, where there is no dan- ger of wounding any part of importance. In all cases of this kind the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recommended, until he reaches the feces, or has cut as far as he can safely reach with his finger. If he should fail in finding the meconium, as death must unavoidably follow, one more attempt ought to be made by introducing upon the finger a middle- sized trocar in the direction, but calculated to reach the rectum, with- out danger to other parts, viz : upwards and backwards in the median line. The canula may be left in the puncture, and secured there with tapes, so as to afford an outlet for the feces. In some observations on this subject, addressed to the Medical and Chirurgical Society by Mr. A. Copland Hutchinson, he recommends an elastic gum catheter to be substituted for the canula, after a week ; and when the tube can be dis- pensed with, a sponge tent, or a piece of bougie, to be worn twelve out of the twenty-four hours." IMPERFORATE ANUS. 415 M. Wolff, after cutting to the depth of two inches without finding the gut, was enabled to reach it by means of a pharyngotomus, and the child recovered. The great difficulty appears to be to prevent the wound closing. Mr. Bell states that it was only by most assiduous attention for eight or ten months that he obviated the necessity for another operation. Mr. Mil- ler, of New Haven, had to repeat the operation ten times before the child was eight months old. In the case under my care I had to repeat the operation once, and by great care it has perfectly recovered. A portion of a catheter, or bougie, a short glyster-pipe, or, in short, any matter which can be maintained in the wound, and which reaches into the intestine, will answer the purpose. 593. If the obstacle should be high up, the anus being perforate, we must endeavor to ascertain its nature and extent ; if it can be relieved by dilatation well and good, if not it must be divided either with a blunt- pointed bistoury or a pharyngotomus, and the opening maintained by a bougie. When, in addition to an imperfect or imperforate anus, there is an opening into the bladder, vagina, or urethra, the best remedy for the latter is making the former more free ; the more feces pass through the anus the less will escape by the supplementary passage ; it is rarely necessary to do more. In my case the feces passed by the urethra before and a few days after the operation ; but as the one passage became more free, the other ceased to be used altogether. The attempts to remedy this formidable defect do not appear to have been as successful as we might have hoped ; by far the larger number of children die after the operation, but how far the operation has a share in the mortality it would be difficult to say. A small number recover, and I am inclined to think that those upon whom the operation is per- formed with the least delay have the best chance. The little boy upon whom I operated is now seven or eight years old and healthy. A 'case of recovery is related recently by Dr. Thompson, of Tennessee. 1 594. But suppose that we cannot reach the intestine in the way already pointed out, and that we must conclude that there is some ex- traordinary malformation, as in Dr. Palmer's case, what is to be done ? If we do nothing the child's death is certain, therefore some risk may very properly be incurred. In 1720 M. Litere proposed to make an artificial anus by opening into the sigmoid flexure of the colon, above the left groin. M. Dumas tried this plan in 1788, but the infant died. In 1793 it was practised with complete success by M. Duret, of Brest, and M. Pilore, of Rouen. Dessault, Ouvrard, and Roux, lost the cases in which they tried it. 2 " The operation consists in making an incision a little above Pou- part's ligament, about two inches in length, and on the outer side of the curve of the epigastric artery : the skin, superficial fascia, aponeu- rosis of the external oblique muscle, the lower fibres of the internal oblique and transverse muscles, the fascia transversalis, and the peri- 1 Philada. Med. and Surg. Journal, Aug. 15, 1853, p. 81. 3 Velpeau, Nouv. Elem. de Med. Operat., vol. iii. p. 983. 416 DENTITION. toneum, are to be divided in succession. As soon as the peritoneum has had a small puncture cautiously made in it, a director is to be in- troduced into the opening, which is to be enlarged with a probe-pointed bistoury. The distended bowel, of a livid or greenish color, presents itself in the wound, and, being opened in the same direction as the wound, a tent or piece of full-sized elastic gum catheter should be placed in the new passage. The introduction of a ligature through the mesen- tery is sometimes advised, but as my observations apply only to open- ing the sigmoid flexure of the colon, such expedient is out of the question." 1 Though we may be justified in having recourse to the operation as a dernier ressort, the results do not seem to afford much hope of success. CHAPTER II. DENTITION. 595. Before we proceed to examine into the consequences of severe dentition, it may be as well to lay before the reader the ordinary course of dental development, in which medical interference is rarely necessary. Meckel, Sims, and others, agree that the formation of the teeth com- mences at a very early period of embryonic life, by an ossific deposit upon the pulp, which is extended and developed from without inwards, so that the grinding surface and shell of the tooth are first formed, with a central cavity, which gradually diminishes as the osseous matter in- creases, to form the body : last of all the roots are formed. The teeth are inclosed in a capsule consisting of two lamellae, from the union of which the pulp is developed: and the entire, at birth, are inclosed in and covered by a considerable thickness of gum. " The membrane which secretes the enamel invests the course of the tooth, and adheres firmly to its neck. As ossification advances, the crown of the tooth rises, and the membrane of course accompanies it. On the tubercles and cutting edge of the tooth the crystallization of the enamel is first completed, and the process continues until the neck is reached ; the membrane covering it, becoming gradually thinner and less vascular, is at last quite absorbed. The absorptive process goes on in the gum covering the tooth, which at last presses through, and is said to have cut the gum." 2 596. The period of the first dentition is subject to some variation, but as a general rule we may say that it occupies from the seventh month to the twentieth or thirtieth. The teeth commonly appear in each jaw in couples ; thus about the seventh month we find the two central incisors of the lower jaw appear; then, after a short time, those 1 Cooper's Surgical Dictionary, p. 211. 2 Askburner on Dentition, p. '69. DENTITION. 417 of the upper jaw, followed after an interval by the lower lateral incisors, and then by the upper lateral incisors. From the twelfth to the four- teenth month the four first molar teeth appear, and from the sixteenth^ to the twentieth the lower and upper canine teeth; last of all the four last molars. The succession here stated has been observed by Serres and De la Barre to be the general order in which the teeth become ossified, and Dr. Ashburner's experience agrees with theirs. The lower incisors generally appear first, and Dr. M'Clintock has suggested that in this order there is a beautiful provision for the pro- tection of the mother. The tongue of the child protects the nipple from irritation by the lower teeth when sucking, but it cannot from the upper ; if, therefore, the upper teeth appeared first, the nipple would be exposed to injury from which, for a considerable time at least, it is now guarded. M. Trousseau states the succession thus : 1. The two inferior median incisors. 2. The four superior incisors. 3. The inferior lateral incisors, and the first four molars. 4. The canine, and 5. The last four molars. But although this sketch may indicate sufficiently well the usual process of teething, it is a rule to which there are many exceptions, a law from which there are many deviations. Children are occasionally born with teeth, or cut them shortly after birth. I knew a child who was found to have three well-developed teeth at birth, and others who cut two and four the first fortnight of their life. Dr. M'Clintock saw one child, at the Hospital, born with the two middle upper incisors cut. Haller has noted nineteen cases of the precocious appearance of the first teeth. Denman mentions a child born with teeth, and Ashburner one of a child who cut the two incisor teeth of the lower jaw before three months old. Louis XIV. of France, B-ichard III. of England, and Mirabeau, were said to have been born with teeth. Neither do they always appear in pairs. I have a little patient in whom the right lateral incisor of the upper jaw did not make its ap- pearance before three years old, although she possessed all the other incisors, canine teeth, and some of the molars. Occasionally, the late- ral incisors appear before the central ones, or the canine teeth before the incisors. On the other hand there is often great delay before the teeth appear. Van Swieten mentions a healthy child that did not cut a tooth until it was nineteen months old ; Underwood one at twenty-two months ; Dumas one beyond seventeen months ; and Serres quotes a case from Lanzoni of a little boy who did not cut his first teeth until he was seven years old. Dr. Ashburner saw " a child twenty-two months old be- ginning to cut its first tooth, which was an incisor in the upper jaw." Fouchard gives an instance in which, at six years old, the child had but the front teeth, and Rayer one in which the four canine teeth did not appear till thirteen years of age. Very frequently, this order of succession is violated; the upper inci- sors may appear before the lower, the molars before the canine teeth, or even before the lateral incisors, and perhaps all the upper teeth taking precedence of the lower. Dr. Hamilton observes : " In some rare cases, the grinders come out before the cutting teeth, and the usual order of succession is changed. It is not uncommon, too, for several 418 DENTITION. pairs to succeed each other rapidly, and then for a considerable period to elapse before the rest advance. In general, the later the commence- ment of teething the shorter are the intervals between the several pairs." 1 For further examples of abnormal variations in teething, I must refer the reader to Meckel's Anatomy, and to the special works on the teeth. 597. Let us now consider the second dentition, second set of teeth," says Dr. Ashburner, in his excellent little " have long existed in the jaws. It has been remarked that the germs of the first dentition are attached, in the foetus, immediately to the membranous folds which at this period constitute the gums ; and that those of the second dentition are suspended from them by means of small pedicles. When the capsules of the first dentition were advancing towards their development, and were approaching the upper part of the gum, those of the second appeared to retreat into the depths of the jaw, and hung to the gums by their pedicles. The pedicle in the process of growth is destined to perform an important part. It becomes a fibrous canal, communicating between the alveolar margin and the cell in which the capsule is lodged. It is apparently periosteum ; but, what- ever may be its real nature, it leads to the tooth, and becomes continu- ous with the external layer of the dental membrane." " The gums grow, they enlarge ; as their volume increases, the germs of the per- manent teeth continue to develop the organs they have to form. These germs are inclosed in cells in the bony substance of the jaws. Up to the age of five, six, or seven years, the jaws of a child may be said to contain two sets of sockets," 2 which are kept distinct by a bony lamina. But whilst this process of growth and development of the jaw and second set of teeth is going on another commences, having reference to the first set. The root is gradually absorbed, so that if we remove a loose primary incisor, we shall find it more or less deprived of root, according to the time absorption has been going on, and apparently seated on the gum rather than inserted into it. When the absorption is far advanced, the tooth becomes dead and loose, and when completed it falls out or is removed by the child itself. Previous, however, to the decadence of the first incisors, we generally find a molar tooth of the permanent set make its appearance behind the last molar of the first set, the jaw having expanded so as to afford sufficient space. The age at which these first appear is stated differently; by Soemmering at seven or eight years ; by De la Barre at five or six ; by Bell at six and a half, and by Ashburner at about six years, although he saw them cut through in one case at three and a half years. The incisors are some- times shed before the molars appear. This condition, of course, increases the total number of teeth. The first set consists of twenty, and then four permanent molars make the number twenty-four. Soon after the appearance of these molars (or sometimes before), at the age of five, six, or seven years, I have said that the central incisors 1 Diseases of Infants, p. 73. 2 On Dentition, p. 62. DENTITION. 419 loosen and fall out ; and, the same process of absorption extending to the roots of the other deciduous teeth, they are likewise shed success- ively, and, as a rule, pretty much in the order in which they appeared, but with uncertain and considerable intervals between each pair. The temporary incisor and canine teeth are thus replaced by permanent incisor and canine teeth, and the four deciduous molars in each jaw (two on each side) by four bicuspid teeth, making twenty-four, which, with eight more (four molar and four wise teeth), make the full set of thirty-two. Now " let us inquire into the epochs for the appearance of all these teeth. We have seen that the two deciduous central incisors of the lower jaw, belonging to the first set, fall away about the age of seven years. The vacant spaces are soon to be occupied by a couple of incisor teeth, which cut through the gums with edges that are serrated — an ap- pearance that time takes away. When these teeth are half up, the two superior central incisors fall away, and are succeeded by two much larger teeth. In consequence of the want of a perfectly normal instance of healthy growth, it is very difficult in London to fix the time when the next two incisors, the lateral of the lower jaw, should fall out. Irregu- larities in this respect are very numerous, for the perfect consent be- tween the growth of the teeth and that of the jaws is wanting. The common occurrence is that of a pressure, from deficient growth of the jaw, turning the newly arrived central incisors out of their line for a time, producing an angle at the median line instead of a continuous arc ; and their backs appear to be pushed towards each other. In most cases, the jaw increases in time, and the teeth assume their proper stations. About a year is occupied in shedding the four central incisors, and ano- ther year in that of the four lateral incisors. The anterior bicuspid teeth of the lower, then those of the upper jaw, are next to be shed. These occupy another year. The posterior bicuspids go next, and then comes the turn of the cuspidati or canine teeth ; but very often the canine teeth take precedence of the posterior bicuspid. The falling out of the posterior deciduous molars and canine, and replacing by these teeth, is a process that lasts from about nine and a half till twelve. In the mean time, the jaws manifestly enlarge, particularly at the posterior part. Spaces are found behind the first permanent molars. These teeth appeared at six years of age, and before thirteen and a half four new molars are cut. " The individual has now completed the development of twenty-eight teeth, and is nearly ready to encounter the further unfolding of the frame which is implied by the changes attendant on puberty. Three or four years seem to be required for a due perfection in the growth of the organs of reproduction ; and during the remainder of this septenary period the system adds accretion to the body, while four new molar teeth are put forth, completing the full number of thirty-two teeth in the mouth. These last four, cut between seventeen and twenty-one years of age, are the wise teeth, or dentes sapientiae." Deviations from the ordinary rule are just as common with the second dentition as with the first, and all we can attempt is an approximative estimate. 420 DENTITION. 598. From what has been said, it will be perceived that the resist- ance to the first set of teeth arises first from the fibrous capsule, and secondly from the gum, which is tolerably thick over the teeth, and of a dense texture. Through these structures the tooth must force its way by pressure, and consequent absorption, as it ascends. As the tooth rises, the anterior and posterior walls^ of the gum appear to separate, and the edge spreads out and becomes broad; the gum swells, its texture is less dense and more vascular, and it rises on either side the central line or ridge until this appears rather as a depression. As absorption proceeds, the gum immediately over the tooth becomes thinner and paler, until we can distinctly trace the edge of the tooth through it. At length the gum is pierced and slightly retracted, and the tooth is said to be cut. Occasionally, I have noticed a drop of straw-colored fluid between the tooth and the surface of the gum, giving it the ap- pearance of a vesicle. The second dentition gives much less trouble, and for obvious reasons. The teeth which supply the place of the first set have little more than the resistance of their own capsules to overcome. The vacancy left by the first is merely healed over, and easily opened by the second, which so soon succeed. The additional molar and wisdom teeth, of course, meet with as much or more resistance than the first set. 599. If the child be healthy and the process of dentition favorable, the suifering is not great, and the distress is almost entirely local. For some time before, the gums are much swollen ; there is an abundant flow of saliva from the mouth; the child dribbles, as it is called, inces- santly, and thrusts its finger, or anything it can seize, into its mouth ; and if we put our finger into its mouth, instead of sucking as hereto- fore, it attempts to relieve the irritation of the gums by biting. Up to this time, the mouth is quite cool. As the teeth advance in the gums, the latter swell and become softer and tender, but with a feeling of tension and itching, which makes the infant anxious to close them upon something, or to press something against them, even though this be ac- companied with some degree of soreness. There are occasional stings of pain, as we know by the sudden cry of the child ; and if there be several teeth coming forward, or if the gums appear inflamed, the mouth will feel hot to the finger. The child now bites vigorously; its mother does not escape with impunity, and it carries everything it can seize to its mouth. It is fretful and uneasy, does not sleep as quietly as usual, and the bowels may be rather more free than at other times. The drib- bling continues until the tooth is cut through. The irritation may ex- tend to the lining membrane of the nose, or to its nerves, and the child be observed to sneeze frequently and to rub its nose. It would seem that dentition is commonly more severe in the winter than in the summer, and certainly more so in large cities than in the country; and its consequences are more serious in badly nurtured child- ren of delicate constitution, and among the poor. This, I think, is a pretty accurate description of a case of easy den- tition, in which the local distress is not excessive, and there is neither fever nor sympathetic irritation. So long as this is the case, inter- ference is unnecessary; there is no reason for lancing the gums, and DENTITION. 421 the slight diarrhoea is beneficial. Ivory, caoutchouc, or gutta percha rings, for the child to bite, are useful. Davies prefers a flat ivory ring ; but, in my opinion, by far the best thing is a finger-shaped crust of bread, or a biscuit, if care be taken that the infant do not break or bite off a piece. 600. Now let us turn to the cases of severe dentition, in which we find the local symptoms considerably aggravated. The mouth is hot, and in some cases dry ; the gums are of a bright or deep red color, much swollen, and very tender. The child is not now inclined to bite, on ac- count of their tenderness, and in some cases even sucking gives pain. The suffering is very considerable ; the child is restless, cross, and uneasy, crying bitterly without any cause, and refusing to be comforted and amused by its usual playthings. Its sleep is disturbed ; sometimes it cannot settle to sleep, at others, after sleeping for a while, it awakes up crying. Its thirst is great, and it takes cold drinks with avidity. The flow of saliva may be nearly arrested, or it may be excessive, and occasionally the submaxillary glands are enlarged and tender. The cheeks are flushed, especially after sleep. If the local inflammation continue to increase, we may find the ap- pearance of muguet on the inside of the lips or cheek, or the gums may ulcerate. The local treatment is simple enough. The distress results from inflammation of the gums, excited and kept up by the pressure of the teeth, and it will be almost instantly relieved by dividing the gums freely with a gum lancet. 601. There are one or two points, as regards lancing the gums, which I should wish to impress upon my junior readers. First, that, in order to perform the operation effectually, the gum lancet should have a back spring like a knife, and not an open back like a bistoury ; for it is almost impossible to lay open the gums thoroughly with an instrument that is not firm and steady, and still less with a common lancet, although that has been recommended. Secondly, that a slight scarification of the gums for the relief of teething is of no use whatever ; they must be cut down until we feel the lancet touch the tooth, and to the full extent of the swollen gum and a little further. I have often seen the irritation continue as severe as ever after an incision over the central incisors, because the operator had not noticed that the lateral ones were pressing forward, and so of the other teeth. Moreover, when the suffering is very great, or in the case of the molars, or with the canine teeth, which commonly make their appear- ance between the lateral incisors and first molars, it is quite necessary to make a crucial incision down to the tooth, so as to free it com- pletely. And I would beg to impress on the student that, owing to the fright of the mother or nurse, and the cries and resistance of the child, to lance the gums effectually is by no means an easy operation, but one that requires both firmness and deliberation to avoid, on the one hand, cutting too superficially or too limitedly, and, on the other, wounding the mouth or tongue. 422 DENTITION. Lastly, in severe cases the operation will have to be repeated. It is a very good plan when the sympathetic irritations (of which I shall speak presently) do not speedily subside, to run the lancet along the old incisions every three or four days ; it gives no pain, and prevents the wound from closing over. It is a mistake to suppose that the gum when healed is more resisting to the tooth than if it had not been lanced, unless a very long time have elapsed ; and it is to be presumed that ordinarily no such early lancing will be necessary, but when it is so the gum must of course be reopened. The repetition may be necessary, either because the gum has healed, or because the first operation was ineffectual, or as a pre- caution if the sympathetic irritation continue. In very severe cases, when the ordinary lancing does not seem to afford adequate relief, we have been advised to shave off the entire edge of the gum over the tooth with a bistoury. I have never found this necessary, but I had a case lately in which I was obliged to use the lancet thirty or forty times, each tooth requiring several operations, and the suffering continuing until all were cut. From this case, and some others like it, I am inclined to believe that there is an irritation of growth as well as that arising from the resistance of the gum, for the latter I took care to remove or prevent. In very rare cases the bleeding from the wound has been excessive, but it may be arrested by pressure, astringents, or caustics. 602. Besides lancing the gums freely, it is desirable that the bowels should be more free than at ordinary times, and even if they are some- what purged it will not signify, as this is by far the safest local irrita- tion a child can experience during dentition. If, however, they should be too much moved, and with griping pain, we may easily moderate by chalk mixture with aromatic confection, and a drop or two of laudanum to the ounce, according to the age of the child, taking care only to moderate and not to arrest the action of the bowels. If the gums are disposed to ulcerate it will be well to apply a little borax and honey to them occasionally, or a little acid and water ; but in general they are so much relieved by the lancing that they recover their healthy state without any application. 603. But the suffering occasioned by dentition is not confined to the mouth ; if it exceed a certain amount, or in children of an irritable constitution, the irritation is reflected by the nervous system to some other organ or system of organs. The sympathetic irritations occur pretty much in the following order. I. The most common disturbance is irritation of the bowels, as I have already mentioned, diarrhoea, with griping pain, and sometimes tenesmus. If it be not excessive it seems rather a relief, and as it is the least injurious of all the irritations resulting from dentition, we should rather moderate than altogether arrest it. The child will certainly become weaker, thinner, and its flesh soft and flabby, but this will rapidly be remedied when the teeth are through. When it is excessive, and the quantity and frequency of the discharge are great, we shall find it necessary to interfere with a mixture of chalk and laudanum, as just recommended, increasing the laudanum if neces- DENTITION. 423 sary, or adding tincture of kino or catechu. If there be much pain and flatulence, an occasional warm bath and the use of a liniment com- posed of half a drachm of laudanum to two ounces of compound cam- phor liniment, will be found of great service. If this fail, a mustard and linseed-meal poultice (one-third of the former to two-thirds of the latter), or a blister to the epigastrium for an hour or two, may answer the purpose. Vomiting does not always coexist with the diarrhoea of dentition, but it does sometimes, and may prove very troublesome, especially because it deprives the patient of food, and renders the administration of reme- dies difficult, so long as it continues. As a general rule, it is the con- sequence of irritation, and not of inflammation, and will be relieved by the division of the gums, and the exhibition of half a drop or a drop of laudanum, or counter-irritation to the epigastrium. M. Cruveilhier has described an affection, apparently caused by den- tition, under the title " Maladie gastro-intestinale des enfans avec des- organization gelatiniforme," in which thirst, vomiting, and purging, with collapse, are the leading symptoms. This disease, however, is so much more serious than the ordinary vomiting and purging of dentition, as to deserve a distinct notice; and the same may be said of the disorder noticed by M. Guersent. In all these affections of the digestive tube, warm baths, emollient fo- mentations, poultices, and slight counter-irritants to the abdomen, are exceedingly useful ; but we must also regulate the diet carefully. If possible, the child should have its natural food, and but little besides, if it agree with him ; but if it be already weaned, the diet should be of the simplest kind — boiled milk or milk and water, rice milk, thin arrow- root made with milk, bread jelly, &c. 604. II. Next to the stomach and intestinal canal, and often coinci- dent, the most frequent seat of irritation is the skin. Patches of papu- lar eruption appear on different parts of the body, particularly the face and disappear after a time ; or the child may be attacked by some more permanent eruption, such as crusta lactea, prurigo, eczema, &c, espe- cially of the scalp, which, while it affords relief for the time, becomes itself a very troublesome disease, requiring special treatment, and which, unlike many other irritations, is not necessarily cured by the liberation of the teeth. If any disease of the skin should exist previous to dentition, it will be found much more difficult, if not impossible, to cure it, until that process is completed. Even when apparently cured, the irritation of teething will cause the eruption to reappear. The relief of the gums is then an essential part of the treatment of the cutaneous affection. We often find that during dentition the parts behind the ears be- come soft, tender, and inflamed, with a discharge which keeps these parts excoriated and sore. Among the poor this is regarded as a mat- ter of course, and little or no efforts are made to cure it until after the teeth are through ; but if we relieve the gums, the ears may be also restored to their natural condition by a little black wash and gentle purgatives. As it is a natural derivation, it might be unwise to stop it unless other means were adopted for the relief of the original irritation. 424 DENTITION. 605. in. Probably the next sympathetic irritation, in point of fre- quency, is some irritation of the nervous system. This may develop itself in different localities, and with different degrees of intensity. I saw the other day a single attack of spasm of the glottis, resulting from teething, and relieved by lancing the gums. Or the spasm may return frequently in the course of the day, and continue for weeks, alternating with convulsions. Lancing the gums is absolutely necessary, and generally relieves the child, but as the attack is apt to return with each tooth, further measures must be adopted. The bowels should be kept rather more free than usual, warm baths given occasionally, the gums freely divided at the first sign of dental irritation, and if necessary, a blister applied behind the ear, or to the back of the neck, or if more permanent counter-irri- tation be desired, a seton of three threads of silk inserted into the arm. Fresh air is very desirable, and if possible, a change of air from the town to the country. For further details I must refer my readers to the chapter on spasm of the glottis. But, instead of spasm of the glottis, the child may have a fit of con- vulsions, partial or general, limited to the muscles of the face or one extremity, or involving the whole body. The symptoms and treatment have already been described ; the most important point to remember is, that although dentition may be the sole cause, lancing the gums, warm bath, and purgatives may not be all that is necessary for the cure, but we may be obliged to have recourse to bloodletting or leeching, with subsequent counter-irritation. Lastly, the distress of teething may give rise to paralysis of an arm or a leg or both together, or of the muscles of one side of the face. It may occur with the first dentition; but asDr.Fliess has observed, it is more common during the second. It is remarkable for the suddenness of its attacks ; the child may appear quite well the previous day, but during the night it is uneasy and restless, grinds its teeth and screams or groans. There may be some thirst, a degree of heat about the head, and feverishness. The next morning it is found to have lost the power of an arm or leg, or in rare cases of both : the limb is warm but hangs powerless, and from the gravitation of the blood is of a darker color than the other. Sensibility is either much diminished or altogether lost : the child rarely complains of pain, but sometimes of a sense of dragging from the shoulder. When one side of the face is affected, the distortion will attract im- mediate attention, the mouth is drawn to one side whenever the child attempts to speak or is excited, and the greater the excitement, the more marked the distortion. When perfectly, quiet, the face in most cases appears quite natural. The attack does not often prove fatal ; if the teeth be cut through naturally or liberated by the lancet, the paralysis may gradually wear off and the child recover the use of the limb or face, or the paralysis may become chronic, without any very obvious disease of the nervous system, the limb remaining powerless or nearly so, and gradually be- coming atrophied, or the distortion of the face continuing during life. Lastly, when the paralysis resists all treatment, we find symptoms DENTITION. 425 gradually developed which indicate disease of the spinal cord and brain. The child is attacked with dyspnoea, palpitations, twitching of the eyes, squinting, and at length becomes comatose and dies. We have seldom an opportunity of ascertaining the state of the spinal marrow by a post-mortem examination, but in one case of the kind, who was killed suddenly, Dr. Fliess found a remarkable degree of vascu- larity about the roots of the brachial nerves, the membranes were reddened and the whole circumference seemed congested, 1 but there was no real organic change. It is clear, therefore, that this is a disease of reflex irritation. The proper treatment consists in relieving the irritation of the gums, in the first instance by a very free scarification, and if necessary by the removal of the primary teeth, then by cupping or leeches to lessen the vascular congestion about the roots of the nerves. The limb may be wrapped in flannel, and mild purgatives given. The application of stimulants or electricity to the affected limb is of no benefit at first ; when the disease has become chronic they may be worth trying. 606. IV. Affections of the chest, bronchitis, pneumonia, &c, are often attributed to the irritation of teething ; and without calling in question the possibility, I am inclined to think that in many of these cases it is merely a coincidence. The child takes cold when teething, and as undoubtedly it will be difficult to cure the pulmonary affection until the gums are relieved ; the two are connected as cause and effect. In addition to the proper remedies for the disease, we should always lay open the gums, whenever we have reason to suspect the slightest irritation from the teeth. 607. Many other diseases are enumerated as resulting from dentition, but those I have named are the principal ones. The list has, no doubt, been lengthened by including coincident affections arising from other causes, just as the mortality attributed to dentition embraces many cases in which death resulted from the secondary or synchronous dis- order. At the same time I differ from those who go to the opposite extreme, and deny all secondary diseases, and nearly all fatality arising from dentition. Formerly it was extremely difficult to comprehend the mode in which the secondary affections occur ; but since Dr. Marshall Hall's brilliant discovery of the reflex action of the nerves, we understand so far that the irritation of the gums, conveyed to the nervous centres, is thence reflected, or rather projected to some other organ ; but of the laws which determine the particular organ or system thus affected we know as yet but little. In conclusion, I would beg my junior readers to bear in mind that many diseases which prove obstinate in infancy and childhood, but which originated quite independent of dentition, may owe their persist- ence to an access of teething arising during their course, and that we shall fail in curing them unless we first relieve the gums. In fact, the diseases which are easily cured at other times, become excessively obsti- 1 Journal fiir Kinderkrankueiten, June and July, 1849. Lond. Journ. of Med,, Jan. 1850. 426 STOMATITIS. nate during dentition, and it will be well always to ascertain the state of the teeth whenever we find such diseases do not yield to our treat- ment. This applies equally to most of the diseases of infancy, and especially to diseases of the skin, during both the first and second den- tition. With the exception of diseases of the skin and the bowels, the second dentition rarely excites any sympathetic affection, nor is the local irri- tation great. The posterior molars and the wisdom teeth give a good deal of pain, which may be relieved by a touch with the lancet. CHAPTER III. INFLAMMATION OF THE MOUTH. — ERYTHEMATOUS STOMATITIS. 608. Inflammation of the mouth is sufficiently common among children of all ages, from birth to ten or twelve years old, and we find it varying in extent and intensity, constituting the simple or erythe- matous stomatitis, muguet or pseudo-membranous stomatitis, aphthae or ulcerated stomatitis, and gangrene or cancrum oris, described by authors. In simple or erythematous stomatitis, the mucous membrane is ob- served to be unusuall} 7 - red, either generally, in points, or in patches. The entire surface of the mouth may be involved, or only the mucous membrane lining the cheek, or merely the gums, and in the latter case we find them spongy, with their edges rounded, swollen, and somewhat loosened from the teeth. The mucous membrane thus affected, is, as I have said, of a deeper or brighter color than usual, puffy, and extremely tender to the touch. The mouth is very hot, and, except at the begin- ning, there is a profuse secretion of a colorless bland saliva. The child is extremely uneasy, restless and fretful, and, when suck- ing or eating, is evidently in great pain. In addition to these local symptoms, in many cases we shall find the bowels disordered, with flatulence and griping. Very little fever accompanies this affection, except in those cases where the child is, in addition, suffering from dentition. 609. Causes. — The causes to which the disease may generally be attributed are either a disordered condition of the intestinal canal, or dentition. Both give rise to irritation at the commencement of the digestive tube ; and in the latter case, if the patient have already teeth in one jaw, their pressure upon the opposite gum, already swollen by the teeth approaching the surface, very frequently converts irritation into positive inflammation and slight ulceration, which may spread to the neighboring parts. Any irritating matters taken into the mouth may give rise to stomatitis, and it not unfrequently occurs in the course of certain eruptive fevers, as measles and scarlatina. 610. Treatment. — In its simple form, the disease involves no danger, and is easy of cure. The bowels should be freed by a brisk purgative, MUGUET. 427 if they be at all confined ; but if there be irritation and diarrhoea, we shall clo better to quiet that before clearing the intestinal canal. If the child be teething, the gums must be freely lanced, and, these sources of irritation being removed, very simple local treatment will be sufficient. Cool emollient drinks, which the child will eagerly take, are the best application in the acute stage ; and when this is past, we may gently apply a little honey, then a little borax and honey, in such proportions as the patient can bear. If this fail, we may try a mixture of honey, alum, and water, in the proportion of one part of alum to fifteen of honey, and seven of water, as recommended by M. Bouchut. But the great point is to restore the stomach and bowels to their healthy con- dition. Generally speaking, the attack subsides easily, but if neglected or badly treated, or if more than usually severe, it may give rise to muguet, aphthae, or ulceration. CHAPTER IV. MUGUET.— PSEUDO-MEMBRANOUS STOMATITIS. 611. This common affection of infancy and childhood has long been known to practitioners under various names, as aphtha lactantium, aphtha lactamen, aphtha infantilis, although its true nature and seat is a modern discovery, due chiefly to the labors of Guersent, 1 Lelut, 2 Billard, 3 Valleix, 4 &c. By many it has been and still is confounded with the vesicular aphtha, or thrush, though no two diseases can be more distinct, muguet being an abnormal secretion upon the mucous membrane of the mouth, and thrush consisting of a vesicle or pustule formed beneath the epithelium. Muguet may be either idiopathic or symptomatic, either a primary or a secondary affection. 612. Symptoms. — After inflammation of the mouth has continued for a longer or shorter time without yielding to treatment, or without our being aware of any previous inflammation, we may observe in different parts of the mouth small points or patches of a curdy matter, at first, if the child be sucking, probably mistaken for the remains of milk. This matter, however, is adherent to the subjacent membrane, although by a little trouble it may be removed. These points or patches sometimes disappear in a few hours, if the attack be very slight; but if severe they increase and coalesce, so as to 1 Diet. deMed., art. Muguet, Stomatite. 2 Arch. Gen. de M6d., vol. xiii. p. 335, 1827. 3 Traite des Mai. des Enfans, p. 199. 4 Cliuique des Mai, des Eufans Nouv. Nes, p. 202. 428 MUGUET. cover more or less of the mouth and fauces, as by a false membrane ; or, after disappearing for a short time, they may return and increase. This pellicle is of a white color when unstained ; but it is ocpasionally tinged yellow or reddish, as Billard has observed, by bile, or blood exuding from the mucous membrane, and this particularly in severe and fatal cases. It may occur at any period of infantile life (or at a later period), but it is more frequent during the first year, as the result of derangement of the stomach and bowels ; but when children of this age are crowded together, badly tended, and insufficiently nourished, then the disease displays itself in its severest form. If the mouth be carefully examined before it is entirely covered by the white pellicle, the intervening mucous membrane will generally be found more vascular than natural, dryer, of a brighter or deeper red color; and if we detach a portion of the pellicle, the surface underneath will be seen to be highly inflamed. In addition to the local condition of the mouth, there are few consti- tutional symptoms ; the child is uneasy, and may find it difficult or painful to suck; and, although very thirsty, the effort of drinking occa- sionally gives great pain, nay, in some cases, I have seen it impossible. This, perhaps, may be owing to the extension of the disease to the oesophagus, of which I shall speak presently. The skin is hot and dry, although the pulse does not seem to be much quickened. M. Billard "counted the pulse and beatings of the heart in forty children, aged from one to twenty days, affected with it, and found fifty, sixty, sixty-four, eighty, and, in one instance, 100 pulsations in the minute." The conclusions to which M. Bouchut has arrived are: "That there are two varieties of muguet, idiopathic and symptomatic ; that both depend upon the general condition of the individual ; the first upon a bad state of the constitution, and the second upon deranged health from organic disease ; that the only proper symptoms are the local ones, i. e. the condition of the mouth ; that the general symptoms depend upon the disease in the course of which muguet occurs ; that ordinarily they are those of enteritis, but that they may be those of pneumonia, tuber- cular phthisis, hydrocephalus, &c." The local phenomena, then, which characterize the disease, are pre- cisely the same, whether the latter be primary or secondary, but the general symptoms are often much more severe than I have described, especially when the disease is epidemic, in hospitals, or when it occurs as a secondary affection, as will appear presently. 613. Pathology. — Careful and repeated investigation has established beyond dispute essential difference between muguet and aphtha. Mu- guet is not seated beneath the mucuous membrane generally, nor does it involve the destruction or disorganization of that tissue. It is a curdy matter deposited upon the surface, quite removable, and which, in fact, is constantly thrown off, leaving an unbroken surface beneath. What then is the matter, and how does it originate ? Opinions differ upon this point. M. Auvity and others have regarded muguet as a disease of the mucous follicles, but the minute researches of M. Lelut MUGUET. 429 seem to have refuted this opinion, inasmuch as he never could detect any prolongation of the false membrane into these follicles, but found it perforated at their orifices; and this observation upon the living was abundantly confirmed by careful examination after death. 614. M. Lelut describes two varieties of muguet: one, creamy, in patches, of a creamy consistence, easily removed by lotions or slight friction, and which is seated upon the mucous membrane ; the other in flocculi, irregularly filamentous, yellow, and either under the epithe- lium or at least so adherent to the mucous membrane that the latter may be removed with the deposit. Further, he concludes that this false membrane is analogous to other false membranes which are found in- ternally or externally, to the secretions of the mucous membranes, and to the epithelium itself; and this conclusion was attained by submitting each to the same chemical tests, with the same results. M. Lelut's researches would seem to prove that on the edges and inside of the lips and cheeks, and on the central portion of the palatine vault, the false membrane is beneath the epithelium ; but that on the other parts of the mouth and in the oesophagus it is either upon the epithelium, or, if originally beneath it, it rapidly so transformed it as to render it undistinguishable. 1 M. Billard regards the deposition as coagulated mucus, and Guyot as mucus modified by excess of fibrin. 615. M. Bouchut rejects the opinion of Lelut that muguet is analo- gous to other false membranes secreted by the mucous membrane, and considers that it is a vegetable parasite, formed according to the laws of spontaneous generation ; and he gives the following extract from the report of the Academie des Sciences, the exactness of which he states he has many times proved: "A portion of muguet being placed under the microscope, it is seen to be composed of a mass of cryptogamic plants. It consists of conical elevations of twenty-five millimetres in diameter, each one consisting of separate portions, provided with roots, branches, and sporules. " The roots are implanted in the cells of the epithelium ; they are cylindrical and transparent, of 1.400 of a millimetre in diameter ; and in their development they perforate each series of cells composing the epithelium to arrive at the surface of the mucous membrane. The trunks or stems which grow from the surface of the epithelium are equally transparent, interrupted at distances by divisions, and inclosing in their cavities corpuscles. Like the roots, they are cylindrical and rectilinear, 1.4 of a millimetre in length, and 1.400 of a millimetre in thickness. These stems are divided into branches, which again subdi- vide, bifurcating at a very acute angle. The branches are composed of oblong distinct cells, inclosing in their interior one, two, or three trans- parent knots (noyaux), their sides here and there exhibit sporules, of which there is a great number at their extremity. The diameter of these sporules is from 1.200 to 1.400 of a millimetre. These crypto- gamia have considerable analogy with the mycodermia of the porrigo favosa, and resemble the genus sporotriehium of botanists." 2 1 Archives Gen. cle Med., vol. xiii. p. 360. 2 Manuel Prat, des Mai. des Nouv. NtSs, p. 174. 430 MUGUET. M. Bouchut agrees with M. Lelut as to the red and dry condition of the mucous membrane underneath the muguet, but differs from him in regarding the muguet as a growth upon the epithelium everywhere. He describes the mode of extension from the mouth to the pharynx, oeso- phagus, and stomach; and he mentions distinctly having seen the disease in the large intestine and around the anus, thus confirming the obser- vations of Lediberder, Billard, and Valleix. Dr. West observes : " I cannot pretend to decide, from personal ob- servation, the point at issue between the supporters of these two con- flicting theories, but my opinion decidedly leans to the adoption, as generally correct, of that view which sees in the deposit of aphthae and muguet the result of an inflammatory process ending in the formation of false membrane, wherein a parasitic growth may become developed." " The frequency of the parasitic growth in the false membrane is possibly dependent on the actual transplantation of its sporules from one patient to another, by means of the cups, spoons, &c, used by them in common, and generally without sufficient attention being paid to insure their perfect cleanliness. Whether, in any case, the deposit of these sporules upon the surface of the healthy mucous membrane is followed by the development of the confervae and the alteration of the epithelium of the mouth, is a question to which it is not possible at present to give a satisfactory reply. For my own part, I should greatly hesitate to answer it in the negative." 1 Dr. Berg, of Stockholm, in a valuable work upon the thrush in children, but which appears to me to be rather a description of muguet, regards it as a parasitic disease, and has given at great length its mi- croscopic characters. " The white coating," he says, " consists of epi- thelium thickened by the swelling of its constituent cells, and from this epithelium there springs a parasitic fungus of greater or less quantity, so that the chief portion of a patch of aphthae is composed either of epithelium or else of parasitic growth. Now, the relative proportions of these two substances seem to depend upon the length of time that has elapsed since the growth of the parasite commenced, which varies in different children, and it is also in relation to the diversity of the epi- thelial thickening. More or less of molecular albuminous matter is also to be found in these patches. When the parasitic growth and the epithelial condensation is confined merely to the extremities of the smaller papillae (as at the point of the tongue), they have the appear- ance of small isolated specks, but when they appear upon portions of the mucous membrane where the papillae are less prominent, and where the intervals between them are filled by a denser epithelium, the white coating then assumes those forms of circles, of interlacing bands, or of hemispherical elevations, so frequently observed in parasitic vegetations, when they are permitted to increase freely without any mechanical obstacle to their growth. Lastly, when both the epithelial and para- sitic growths alike proceed vigorously, those spots which at first were isolated, coalesce more and more into a continuous covering, the cohe- sion of which is maintained not merely by the natural adhesion of the 1 Diseases of Children, p. 337. MUGUET. 431 epithelial cells, but also by the interlacing of the parasitic fibres among themselves and between the cells of the epithelium." 1 Further, Dr. Berg concludes that, " 1. The aphthous parasite can propagate itself in appropriate menstrua out of the body, and this not only when the aphthous crust is mingled with various animal fluids, but also when completely separated and cleansed from these. 2. Its growth in such cases proceeds not only in a temperature equal to that of the human body, but likewise in one that is much lower. 3. Aphthae seem to require for their growth the presence of a body containing azote, such as albumen, as also that of materials for the generation of acid. 4. Out of the body, aphthge seem to develop themselves in two different forms, either in that of a great preponderance of sporules — when a white filmy membrane forms on the surface of the fluid — or, again, they appear chiefly as stems ramifying through the fluid or aggregated into a felt-like mass. A solution of potassa will always dissolve the molecular deposit of albumen, leaving the fibres and cells of the parasite totally unchanged. It is very pleasant to recollect that we may recognize and cure the disease, may in fact understand all about it practically, and control it, notwithstanding these microscopic difficulties and doubts. The im- portant facts we know are, that, as the result of an inflammation of the mucous membrane of the mouth or digestive tube, a deposition of curdy matter may take place in the mouth, or in other parts of the digestive canal, and that generally this matter is upon the epithelium, and does not involve the destruction of the subjacent membrane. 616. Causes. — I have already alluded to the greater prevalence of this disease in the early months of life, at a period when the constitu- tion is peculiarly tender, the digestive tube scarcely reconciled to its new functions, and when mismanagement is no immediately and seriously injurious. Even under careful treatment we meet with it, but much more frequently when the infant is exposed to bad food, impure air, or insufficient clothing. I quite agree with the opinion of MM. Baron and Billard that the disease is not contagious in the ordinary sense ; but that it may be communicated by contact under certain circumstances, e. g. to the nip- ples of the nurse, I have no doubt, because I have seen it, and this agrees with the experience of MM. Guersent and Mariay. Dr. Berg considers the parasitic growth to be favored by the large proportion of sugar and starch in the food of children, and he believes that the disease may be conveyed from one child to another by spo- rules or fragments of sporules in the dried state, floating in the atmo- sphere, but that it is more frequently propagated by the bottles from which children having the thrush have been fed, or by the nipple, especially when two children are suckled by one nurse. He succeeded in propagating it also by applying aphthous crusts to the mucous mem- brane of the mouths of healthy children. It may also prevail either epidemically or endemically. In places where many infants are congregated, I may say it prevails at all times. 1 British and Foreign Med. Review, vol. xxiy. p. 423. 432 MUGUET. According to Billard " it prevails with almost equal intensity and at all times at the Hospice des Enfans Trouves. In the quarter ending in March, 1826, out of 290 patients, there were thirty-four cases of it. In the quarter ending in June, out of 235 patients there were thirty- five. In the quarter ending in September, out of 213 there were 101 cases ; and forty-eight in^the quarter ending in December, among 189 patients. M. Baron has seen it prevail among a number of individuals at certain periods, without being able to assign for its cause any influ- ence from temperature.'' 1 617. But no doubt the most frequent cause is to be found in the primary affection to which muguet is secondary, and we shall now in- quire into these complications, and for this purpose I shall avail myself of the minute researches of M. Valleix. I am tempted, however, as a prelude, to give a short summary of his experience of the disease in twenty-four cases in the Infirmary of the Hospice des Enfans Trouves. All the infants were less than a month old, and were strong and vi- gorous. Most of them had been sent to the infirmary on account of pemphigus or pustules. In one only did muguet exist at that time, and there were no grounds for suspecting its communication to the others by contagion ; the less so, indeed, as one-fourth of the infants sent to the infirmary are so attacked. The appearance of the false membrane was preceded some days by an attack of erythema of the thighs. After the erythema had con- tinued for four or five days, diarrhoea supervened, at first moderate, but increasing rapidly, the evacuations being yellow at the beginning. At the same time the pulse was accelerated from 80 or 90 to 116, 130, or even 140 ; the face became pale and of a dull yellow color. To these symptoms were added most frequently (in nineteen out of twenty cases) a marked swelling of the papillae at the extremity of the tongue, and shortly after, a vivid redness of that organ which soon spread to the rest of the mouth. In eight cases ulceration of the palate occurred about the same time. The redness and swelling of the tongue indicated the invasion of muguet, the grains of which in twenty cases appeared on the first day. In seven cases they were developed at the same time on the inside of the cheeks, but commonly the tongue was the part first affected. At first a few grains were observed on the tongue, then irregular masses on the inside of the cheeks, and strips on the vault of the palate, and coalescing they formed a layer more or less thick. This morbid production was always white at first, and only became yellow towards the termination in five cases. It was at first adherent, and any attempt to detach it made the mucous membrane bleed, but afterwards it could easily be removed. During the develop- ment of the false membrane the former symptoms (erythema and diar- rhoea) persisted, and new ones were added. The stools almost always became green, but in no case could any portion of false membrane be detected in them. The heat of the mouth was rarely increased, but the tongue was dry in thirteen cases. 1 Mai. des Enfans, p. 167. MUGUET. 433 When the muguet was very abundant it occasioned considerable dis- tress, -which the infant evidenced by rolling about the tongue and moving the jaws, as though to remove some unpleasant substance. At the same time it refused the breast, and cried if the fingers were intro- duced into the mouth. Meteorism of the abdomen supervened in twenty cases: in four, previous to the appearance of the muguet ; in the remainder, during the greatest intensity of the disease ; and was attended by symptoms of colic, and in some cases by tenderness. Vomiting occurred in only five cases, and the matter ejected was sometimes yellow, sometimes colorless. After the diarrhoea had continued for some time, ulceration of the ankles or heels took place, the patient became agitated, inter- mittingly at first, but afterwards constantly, and the pulse became rapid. The heat of skin was in proportion to the quickness of pulse. " Towards the end of the disease, all the symptoms seemed to dimi- nish, but it was only to give place to collapse. The erythema became less vivid ; the ulcerations were covered with crusts ; the diarrhoea di- minished or ceased entirely; the infant refused the breast, and would scarcely drink ; the muguet diminished, and ordinarily consisted only of a few grains on the tongue. The pulse fell to 80, 70, or even 60 in a minute ; the heat was succeeded by chilliness, at first of the extremi- ties, and afterwards of the whole body ; the agitation gave place to almost complete insensibility ; the cries were changed into groans ; the emaciation and pallor became extreme, and the face acquired the ap- pearance of decrepitude. " About this period were developed in certain cases inflammations, not very acute, characterized by cedematous swelling, obscure redness and pain ; they occurred in the nose, lower lip, and neck. At this time also abscesses, occasionally numerous, were formed in different parts of the subcutaneous cellular tissue, and in one case gangrene of the inte- guments of the limb occurred. At last death closed the scene without pain." 1 The mean duration of the disease was 17J days in the fatal cases, and 16| in those who recovered. Three distinct periods were remarked. The first, from the commencement to the appearance of the muguet; the second, from this time to the termination of the febrile stage ; and the third, the. period of collapse. " Autopsy revealed various lesions. In nineteen cases false mem- brane was found in the mouth ; in ten the palate was ulcerated. The oesophagus was almost always occupied by false membrane, and in all the cases there were lesions of the gastro-intestinal mucous mem- brane, the result of inflammation. In a small number ulcerations were found. The liver, the spleen, the kidney, the bladder, the larynx, tra- chea, and bronchi, presented nothing abnormal, but in eight cases there was hepatization of the lungs. The circulating system was unchanged, except in one case. The skin and cellular tissue exhibited evidences of the lesions with which they had been affected." 1 Clinique des Mai. des Enfans, &c, pp. 209, 210. 28 434 MUGUET. I shall add M. Valleix's resumS of the special condition of the gastro- intestinal canal in twenty-two cases : merely premising, that, as far as the stomach was concerned, the localities of these morbid changes were as follows : — At the larger extremity, in 13 cases. On the anterior parietes, in 12 " On the posterior parietes, in 11 " At the greater curvature, in At the smaller curvature, in 11 I. As to the lining membranes of the stomach, there was found — 1. Softening of the mucous membrane, with thickening and redness, or some other alteration of color, in 6 cases, i. e., Occupying almost the entire stomach, with redness, in . . 3 cases] Occupying a limited portion of the surface, with redness, in. . 2 " j fi Occupying a limited portion, with brown discoloration, and soften- ing of the other coats of the stomach, in .... 1 case J 2. Softening, with redness, without thickening, occupying the entire "] extent of the stomach, in 3 cases L 5 Occupying a limited portion, in 2 " J 3. Softening, with neither redness nor thickening, occupying the entire extent of the stomach, Occupying a limited portion, in . Alterations of color without thickening or softening, General rose color, in General brown color, in .... Deep red color, punctated, in . No change in No data in 2 " 1 case 5 cases 1 case 1 » II. As to the mucous membrane of the small intestines, there ex- isted — 1. Extreme softening, with thickening and redness, in . 2. Considerable softening, with thickening and redness, in . Considerable softening, with thickening, but without redness, in Considerable softening, with redness, but without thickening, in . 1 case. Considerable softening, with neither redness nor thickening, in . 2 cases. 3. Slight softening, with thickening, but without redness, in . . 1 case. Slight softening, with redness, but without thickening, in . . 1 " Slight softening, with neither redness nor thickening, in . . . 4 cases. 4. The natural color and consistence, in in. The condition of the mucous membrane of the large intestine is thus stated : — 1. Extreme softening, with thickening, and of a punctated brown color, in Extreme softening, without thickening, and of a bright red color, in 2. Considerable softening, with thickening and redness, in . Considerable softening, with thickening, but without redness, in Considerable softening, with redness, but without thickening, in Considerable softening, with neither redness nor thickening, in 3. Slight softening, with thickening, but without redness, in . Slight softening, with redness, but without thickening, in . Slight softening, with neither redness nor thickening, in . 4. The natural color, consistence, and thickness, in in 1 case. 1 " 2 cases. 4 " 2 << 2 " 1 case. 2 cases. 3 " 3 «i It does not appear that M. Valleix was able to trace the false mem- brane further than the stomach in more than one or two cases ; Veron, Davies, Eberle, and Condie have not been able to trace it beyond the • Clinique des Mai. des Enfans, &c , p. 267. MUGUET. 435 oesophagus, whilst Guyot and Billard have found it through the entire alimentary canal. I have seen a similar false membrane around the anus at the same time that it appeared in the mouth ; and though I have not traced it through the alimentary canal, I feel scarcely a doubt that it occasionally extends throughout. It would appear from these researches that muguet is chiefly second- ary to a diseased condition of the mucous membrane of the digestive tube, and that softening of the mucous membrane is the principal form of this disease. We have seen that children attacked by muguet may also suffer from pneumonia, as a complication, and occasionally they are attacked by bronchitis. 618. Diagnosis. — There is no difficulty in the diagnosis when once the false membrane is formed, inasmuch as the only disease with which it can easily be confounded is aphthae, and from this it is distinguished by the integrity of the mucous membrane underneath the creamy depo- sition, and by the fact that the latter is seated upon the membrane generally; whereas, in aphthae, we shall have small grayish ulcers or pustules in the mucous membrane. Previous to the appearance of the muguet, the disease of the mucous membrane resembles some forms of gastro-enterite ; nor is it of conse- quence to make a very nice distinction, if it were possible, for in most cases the muguet is secondary to such an affection. 619. Prognosis. — Idiopathic muguet, in tolerably healthy children, and uncomplicated with organic disease, is of short duration, and of comparatively little consequence. After a few days, the false membrane becomes thinner and less continuous, resembling in appearance the patches or points by which it commenced; by degrees it peels off, leav- ing the mucous membrane moist, and somewhat smoother and redder than natural ; and the little patient, relieved from the soreness and dis- tress in swallowing, appears quite recovered. In this simple form of the disease we do not meet with fatal cases. But it is not so when muguet occurs in dilapidated constitutions, or with extensive disorder of the alimentary canal, or in the course of chronic diseases ; the mortality is then considerable, resulting, how- ever, not so much from the muguet as from the primary disease, or from the complications. The affection of the mouth is important, as indicating the state of the constitution ; but it is to the primary affection that our attention should be directed. M. Baron had 109 fatal cases out of 140, M. Valleix twenty-two out of twenty-four, all of which labored under entero-colitis ; and, in addi- tion, eight of them had pneumonia and one meningitis. M. Bouchut observed forty- two cases in the Hopital Necker, fourteen of which were idiopathic, and of these none died. In the remaining twenty-eight, the muguet was symptomatic of visceral disease, and of these twenty died, fourteen of chronic entero-colitis, complicated in five cases with pneu- monia, four of acute entero-colitis, three of pneumonia, and one of hy- drocephalus. The remaining eight were affected with entero-colitis or phthisis, and left the hospital suffering from muguet. 620. Treatment. — The two forms of muguet are so far different that 436 MUGUET. the one is a local affection, dependent, no doubt, to a limited extent, upon the general condition of the child, whilst the other is secondary to some pre-existing disease — an additional symptom, in short, and little more — and of course the treatment will vary accordingly. In primary or idiopathic muguet, if the disease be slight, some mu- cilaginous wash, slightly acidulated, and applied with a brush, or a little honey placed on the tongue, with a gentle purgative now and then, a warm bath, pure air, and wholesome nourishment, will be all that is ne- cessary. If the child have been too early deprived of its natural food, or if the suck appear to disagree with it, it will be quite necessary to provide a healthy nurse for it. In some cases, we must add to the wash or to the honey either chloride of soda (one-fourth part), as Guersent and Darling recommend, or a small portion of alum, as Billard advises, or a little borax. M. Trousseau, at the Hopital Necker, uses equal parts of borax and honey with great success. I have found this extremely useful, but I prefer commencing with a smaller proportion of borax. Dr. Hecker recommends a solution of the sulphate of zinc, M. Dug&s a lotion containing the vegetable acids, and M. Bretonneau the applica- tion of a powder consisting of half a grain of calomel triturated with a few grains of sugar, three or four times a day. Dr. Condie prefers borax rubbed up with white sugar. Alkaline remedies are favorites with Dr. Berg, as he found them arrest the formation of the parasite, and at the same time soften the epithelium and aid in throwing off the crusts ; but after this treatment has been employed for some time, he advises a change to acid and astringent applications. In some obstinate and severe instances, it may be necessary to apply stronger remedies, such as nitrate of silver in solution (gr. x or gr. xx to oj), or muriatic acid and water or honey (5j of the former to oj of the latter). 621. In all these cases, it will be advisable to give small doses of the hyd. c. creta, with rhubarb, two or three times a day, so as to act gently upon the bowels, unless diarrhoea should be present, in which case chalk mixture, or mucilage and water, with a drop or two of laudanum to the ounce, and a few grains of aromatic confection, will form a useful mix- ture, of which a teaspoonful may be given three or four times a day. When the looseness of the bowels is corrected, we may then commence with the mercury and chalk. In the cases where the constitution of the child is much deteriorated, I have found great benefit from small doses of quinine, say one-third of a grain three times a day ; and it may be combined with the pow- ders already mentioned, or given separately. The diet must be carefully superintended. In many cases, the infant cannot suck ; it must, therefore, be fed with a spoon. Milk, alone or with water, arrowroot, gruel, with a little wine whey occasionally, will be their best food. Older children will require that their food should be nourishing and soft, so as not to irritate the inflamed mucous mem- brane. APHTHA. 437 As the false membrane is only an accidental accompaniment in second- ary muguet, our first care must be directed to the primary disease, and the local affection of the mouth will follow its course, diminishing or increasing according to its state. The local remedies just named may be used, but success with the mouth will mainly depend on our curing the primary complaint. Of that, I shall speak hereafter. CHAPTER V. APHTELE. — THRUSH. — FOLLICULAR STOMATITIS. 622. Aphthae, or thrush, is a very common disease of infancy and childhood, and has been noticed by most writers from very early times ; for instance, it is mentioned by Hippocrates, Galen, Aretaeus, and Cel- sus, and in our own country by Harris, 1 Moss, 2 Rosenstein, 3 and since then by all writers on diseases of children. The earlier descriptions, however, were so far inaccurate that they confounded muguet with aphthae, and simple thrush with ulceration, or even gangrene of the mouth. Like muguet, aphthae of the mouth may occur at any period of infan- tile life from birth, or it may attack adults, but certainly it is more fre- quent in children under four or five years of age ; and this we should expect, because it appears to be dependent upon some derangement of the digestive system, and the stomach and bowels are more apt to be disturbed in early life than subsequently. Denis 4 and Billard 5 regard muguet as more common with young infants, and aphthae about the period of the first dentition. 623. Symptoms. — The symptoms will naturally vary according to the extent of the disease, which may be confined to the mouth, and exhibit either few and distinct or numerous and confluent aphthae, and also according as the affection is primary or secondary. Take, for example, the case of a child in pretty good general health, whose mouth has become thus affected. We shall find a few vesicles or small ulcers, if the top have been rubbed off; and the mother is sure to direct our attention to the prominent fact that the infant does not like to be fed, that it cries, and resists sucking still more, or, perhaps, that it positively refuses to suck at all. This is not to be wondered at, for nothing could be better calculated to give the child pain, except, perhaps, the scouring the nurses give the mouth by way of cure. 1 De Morbis Infantum, p. 81. 2 On the Management and Nursing of Children, &c, p. 185. 3 On the Diseases of Children, p. 27. 4 Recherches des Mai. des Nouv. Nes., p. 109. 5 Traite des Mai. des Enfans, p. 213. 438 APHTHA. The mouth is extremely hot, the lips often swollen, and the saliva constantly dribbling, partly from its excessive secretion and partly from the difficulty of swallowing. The breath is often very disagreeable, and the bowels will generally be found to be out of order. In the milder cases, however, there is no fever or constitutional disturbance. 624. But when the aphthae are numerous and confluent — when they extend into the oesophagus, and when, as generally happens in such cases, the primary disease is severe, and has broken down the health of the child, then the case presents another aspect altogether. The appearance of the patient changes ; it becomes pale and anxious, with a restless, fretful, and distressed expression, irritable and whining, unable to suck or to swallow without great pain, if at all. It becomes greatly emaciated; the stomach and bowels show signs of great disorder, partly from irritation, and partly from want of proper nutrition ; vomit- ing is frequent, and diarrhoea almost constant, with watery or green- colored stools. The skin is hot and dry, the mouth hot, swollen, red, and covered with aphthae, the dribbling is excessive, and the pulse quick but feeble. When the disease extends to the pharynx, the glands are apt to en- large, and the irritation or inflammation may extend to the trachea, altering the character of the voice, and rendering it harsh or hissing. When the thrush is secondary, or when complicated with other or- ganic affections, the symptoms of the primary or secondary disease may predominate, so that the thrush will appear merely as an aggrava- tion. 625. Pathology. — I have already stated that muguet and aphthae differ, in that the former is a vegetable growth deposited upon the sur- face, and the latter an ulcerative process beneath the epithelium. Dr. Bateman defines the disease thus: "The aphthae are small whitish or pearl-colored vesicles, appearing on the tongue, the lips, and the in- terior surface of the mouth and throat, generally in considerable num- bers, proceeding to superficial ulceration, and terminating by an exfo- liation of white crusts." 1 Some writers have classed them as pustules, others as ulcers, with- out investigating their seat. Bichat, with his usual acuteness, started the question as to whether they were an affection of the chorion of the mucous membrane, or of the papillae, or of the follicles; a question Avhich Gardien hesitated to answer, but upon which the researches of Billard have thrown much light. He regards the disease as an inflam- mation of the muciparous follicles of the mucous membrane. In an early stage of the inflammation, " they appear on the internal surface of the lips and cheeks, on the pillars of the velum, and the palatine arch, and the inferior surface and lateral parts of the base of the tongue, under the form of small white points, sometimes exhibiting a colored spot in their centre, slightly prominent, and often surrounded by a slightly inflammatory circle." "The follicular points enlarge, pre- serving also their circular primitive form, and from their central aper- ture there soon issues a white matter, which is at first compressed by 1 On Cutaneous Diseases, p. 263. APHTHA. 439 the epithelium, but which escapes on that membrane becoming ulcerated. The follicle, when ruptured, is no longer a prominence, but a superficial ulcer with rounded edges, sometimes sharply defined, more or less tumefied, and almost always surrounded by an inflamed circle, of a fiery red. The border and centre of this slight ulcer often secrete a white pultaceous matter, like a slight scab, which is separated and expelled with the saliva." 1 Berg, Robin, Gruby, and Green, 2 however, consider the disease as a vegetable growth, the spores of the plant adhere firmly to the isolated or imbricated epithelial cells, and that the number of spores greatly exceeds the filaments. The vesicular or pustular character of the aphthae, then, appears to be owing to the limitation by the epithelium of the space occupied by the white matter issuing from the follicular orifice, and certainly the appearance is sufficiently exact to justify Bateman's description. The distinctive character which is practically important, appears to be the small ulcer with its inflamed base. These aphthaa appear first on the edges of the tongue, the angles or inside of the lips, from whence they spread with more or less rapidity over the tongue and inside of the cheeks to the fauces; and as they will be found in different stages, the mouth acquires the appearance of irre- gular superficial ulceration with white cream-colored sloughs. 626. That the oesophagus and even the stomach may be thus affected is admitted by most writers, but they are not agreed as to whether the disease may extend lower. Moss 3 and Underwood 4 notice the appear- ance of aphthae at the anus, and assume this as a proof that the dis- ease extends through the bowels ; and Bateman mentions that such extension of the disease is supposed to take place, but very properly observes that the redness and partial excoriation about the anus, so frequently observed in the complaint, may be owing to the acrid nature of the discharges from the bowels. Armstrong* states that from the oesophagus " it is continued quite through the stomach and intestinal canal to the anus, at least it makes its appearance very plainly at this part." Marley observes : " I saw a case some time since, where I had little doubt but that the disease ran its course to the verge of the anus ; 6 and Gardien mentions this exten- sion as a fact well known. Dr. Bateman notices that the trachea is occasionally affected with aphthae, but that they very rarely extend to the nose. When the aphthae are numerous and coalesce, covered by the white sloughs, they resemble and may be mistaken for muguet, but a little care will avoid this error, for in the latter no ulceration can be dis- covered, and it is plain enough in the former, notwithstanding the crusts, and moreover we shall be able in some part of the mouth to detect the enlarged follicle before exudation has taken place. 627. These small aphthous ulcers may assume a more extended and i Mai. des Enfans, p. 209. 2 Med. Times, July 2G, 1851. 3 On the Management and Nursing of Children, p. 188. 4 Diseases of Children, p. 155. 5 Ibid., p. 24. 6 Ibid., p. 52. 440 APHTHA. formidable state of ulceration, and even become gangrenous ; but there is an appearance which has been mistaken for gangrene, against -which we should be on our guand. Billard thus describes it : " Sometimes, when the follicular points are ulcerated, the borders of the ulcers, in- stead of being covered with a slight creamy exudation, exhale a small quantity of blood, which ^concretes under the form of a slight brown scab, mistaken by some authors, as in malignant sore throat, for a gan- grenous eschar." "Before pronouncing these eschars to be gangrenous, the nature and causes of the brown scabs covering the aphthous ulcera- tions should be examined with the greatest care. This mistake might produce very serious consequences, for we might be led to treat with stimulants and tonics a disease which it would be more rational to treat by simple antiphlogistic remedies." 1 628. Causes. — We find the disease most common in pale, delicate, and unhealthy children, whose constitutions have been injured by neglect, bad food, vitiated air, want of cleanliness, and over-crowded habitations. It is not unfrequent with spoon-fed infants, and, as we might expect, it prevails very extensively in hospitals for children and foundling hospitals. Dr. Hamilton is of opinion that thrush is induced by "specific contagion," and Marley and others speak of the disease being excited in infants who had sucked from a breast previously used by a child so affected. It is said to have prevailed epidemically in some parts of Holland. But though occasionally a primary affection, it is by far more fre- quently secondary to an affection of the alimentary canal, similar to that in muguet, or it is the result of deteriorated health and constitu- tion resulting from various diseases. 629. Prognosis. — From what has been said, it is pretty clear that, when aphthae are a purely local complaint, occurring in a tolerably healthy subject, few in number and distinct, there is no danger to the child. With proper treatment the white crust will fall off, and the little ulcer heal in a few days. This is not the case in the severe form of the disease. The child is in great danger from the suffering, the want of food, the vomiting, and diarrhoea; if these be not checked, it will run down rapidly beyond the reach of assistance. Add to this the danger arising from the primary disease, or from subsequent complications, and it is evident that the case is a very serious one. i The extension and coalescence of the aphthae, the dark color of the crusts, the unhealthy appearance of the small ulcers, the emaciation, the small quick pulse, &c, are very unfavorable symptoms. 630. Treatment. — Dr. Bateman observes very truly, that "in the milder degrees of aphthae lactantium, slight remedies are sufficient to alleviate or remove the disease. The acidity in the first passages is often readily corrected by some testaceous powder, which, if the bowels be not irritable, may be joined with a little rhubarb or magnesia, or by the 'pulv. contrayervse co. if they are in the opposite state and weakly. At the same time the nutriment of the patient should be regulated by 1 Mai. des Enfans, p 211. APHTHA. 441 attending to the diet and general health of the nurse, or, if the child he not suckled, bj procuring a wet-nurse, when that is practicable, which often speedily cures the complaint." 1 If the surface of the mouth be very irritable and tender, the first local applications should be of a bland and soothing character: a little cream, or the yolk of eggs mixed with a little syrup of poppies, as recommended by Van Swieten; or the lips and tongue may be lightly covered with pure almond oil. By degrees, and in proportion to the decrease of the soreness, astrin- gents may be applied, and of these perhaps the best is the borate of soda mixed with powdered sugar or honey. Dr. Armstrong speaks very highly of a " solution of white vitriol in barley-water," in the propor- tion of half a scruple of the former to eight ounces of the latter at first, and gradually increasing its strength. For very young infants the juice of boiled turnips sweetened with sugar or honey. Etmiiller and Dr. Shaw advise honey of roses and spirit of vitriol or sea salt, but Under- wood thinks no application superior to borax and honey. 631. In severe cases of the disease the same astringents may be used locally, or we may wash the mouth with a weak solution of the nitrate of silver, which I have found beneficial ; but unless we can change the state of the constitution we shall do but little good. For this purpose, if the child be still at the breast, the nurse should be changed ; or the food, if the child be weaned. In addition to milk, barley, bread jelly, or arrowroot, we may give wine whey or wine and milk pretty freely. For older children we may order chicken broth. If the stomach do not reject medicine, we may prescribe the hyd. c. creta\ with rhubarb if the bowels be costive, or with the pulv. cretse co. c. opio if diarrhoea be present. A drop of laudanum in milk, once or twice a day, will often quiet the bowels when more bulky medicine only irritates. If there be much vomiting, it will be better to administer these or analogous medicines by the rectum, and employ the stomach for nutriment only. Dr. Armstrong and others recommend us to commence by an emetic followed by a brisk purgative, but this will entirely depend upon the condition of the child when we first see it. If the stomach be loaded and the bowels confined, it may do very well, but in the majority of cases, especially if at all advanced, it would be somewhat hazardous. The following case, related by Marley, 2 is a good illustration of the value of Dr. Armstrong's suggestion in certain cases: "It occurred in a child about two years and a half old. The aphthae were from the commencement of a brownish hue, and in the course of a day or two became nearly black; the teeth were loaded with a brownish fur ; there was a copious flow of saliva; the breath was remarkably offensive, re- sembling much that of a person in a state of salivation ; the pulse was of a quick and jerking nature; no appetite whatever; in fact, the mere appearance of food produced a sensation of nausea. There was uni- versal lassitude. In this case I commenced with a dose of castor oil, which was retained on the stomach and operated well. This was fol- 1 On Cutaneous Diseases, p. 267. 2 Diseases of Children, p. 53, 442 ULCERATED SORE MOUTH. lowed the next day by an emetic, which brought away an almost in- credible quantity of bilious matter for so young a child, after which I treated the case with bark and ammonia. The only local application used was a lotion composed of decoction of bark and muriatic acid. The case got well." " When the aphthae assume a brown hue, or appear in a state of de- bility consequent on acute diseases, the general strength must be sup- ported by light tonics and cordials, with proper diet, such as a weak decoction of cinchona or cascarilla, or the solution of the tartrate of iron, with rhubarb, light animal broths, and preparations of milk with the vegetable starches." 1 Chlorate of potash may also be given in doses of from two to five grains, three times a day. Dr. Hamilton very properly lays great stress upon cleanliness, ad- vising that the child should be washed all over, and a clean dress put on every twelve hours. If the anus should become excoriated, as often happens, it should be washed four or five times a day with warm water, and, after being dried, may be bathed with lead lotion or black wash, or powdered with lapis calaminaris, or anointed with zinc cream. CHAPTER VI. ULCERATED SORE MOUTH — ULCERATIVE STOMATITIS. 632. At first sight there appears a similarity almost amounting to identity between this disease and aphthae, but in the latter the disease is limited to the muciparous follicles, the ulceration commencing around their orifices ; in the former the inflammation of the mucous membrane may run on into ulceration at any part and in an irregular manner. Aphthae occur also in young infants, but Rilliet and Barthez have found ulcerated sore mouth more common after five years. 633. Symptoms. — According to M. Taupin, 2 the disease commences in the gums, which are swollen, red or violet, bleeding, and soon cover- ed with a soft layer of grayish matter. From the gums the' inflamma- tion and ulceration spread to the corresponding portion of the mucous membrane lining the mouth and lips, the small whitish spots by which it commences enlarge and coalesce until they form the large gray patches covering the erosion or ulceration. Generally speaking, the lesion is of small extent, affecting the gums, and exhibiting a few patches inside the cheeks or lips, more frequently one side than both, and oftener, the left than the right, according to 1 Bateman on Cutaneous Diseases, p. 268. 2 Journal des Connois. Med.-Chir., No. 10, April, 1839. ULCERATED SORE MOUTH. 443 Rilliet and Barthez ; but in some rare cases it is much more extensive, involving the vault of the palate, as well as the other parts of the mouth. If the treatment fail and the inflammation persist, the patches in- crease in thickness by the secretion of additional layers, and the ulcer- ation deepens ; the layers of false membrane are detached and quickly renewed, and thus the disease is perpetuated. If, on the contrary, the inflammation diminish, the patches are thrown off, the ulcers become cleaner and fill up, and their raised borders subside. Then the epithe- lium is reformed, and there, remains only a deeper redness, marking the situation of the ulceration. M. Taupin states that the mucous membrane in these places remains thickened and somewhat hard, but Rilliet and Barthez regard the sub- mucous tissue as the seat of this thickening. The submaxillary glands are swollen, and if the attack be severe they become hard and painful, but the surrounding cellular tissue does not participate in the inflammation. The breath is generally offensive, and when the disease is extensive the odor is not unlike or much infe- rior to what we observe in gangrene. In severe cases we find externally considerable swelling correspond- ing to the ulcerations, and when pressed it feels soft, quite unlike the hard, resisting, circumscribed swelling in gangrene; the skin is neither smooth, nor shining, nor hot. More or less salivation attends the complaint. If severe, the mouth is kept open, the lips protruding, and the saliva dribbling over the swollen and ulcerated surface. This appearance is very characteristic of the disease. 634. The suffering is very considerable ; the child is restless and uneasy, moaning, and putting its fingers to its mouth, and finding it more or less difficult to eat or drink. In severe cases, with infants, sucking is out of the question, and the child can only be nourished by the spoon. There is almost invariably some derangement of the stomach and bowels, often preceding, always following, the affection of the mouth. Occasionally the symptoms of entero-colitis are very marked, and such complications, whether primary or secondary, not only augment the distress and suffering of the patient, but materially influence his condi- tion and add to the danger. When the inflammation is moderate, the heat of skin will be natural and the pulse unaltered; but when of considerable extent and intensity we shall find more or less fever, with a quick and rather weak pulse, loss of appetite, disordered bowels, emaciation, &c. The disease may be prolonged for some time, although, generally speaking, it is not very tedious. Much will depend upon the constitu- tional condition of the child, upon the primary or secondary complica- tions, and upon the extent and depth of the ulcerations, the deeper ones requiring more time to fill up: moreover, the child is very liable to re- lapse. 635. Pathology. — The disease commences as stomatitis, as already described. The mucous membrane of the mouth is swollen, inflamed, and hot, sometimes of an equally diffused redness, sometimes in patches ; 444 ULCERATED SORE MOUTH. the gums are also swollen, red, and spongy. After the inflammation has continued for some time, we find a number of small whitish, or yel- lowish patches, slightly prominent. Beneath the epithelium, which is thicker than natural, we find these whitish points to consist of a pseudo- membranous secretion, similar to that found in the pustules of smallpox on the eighth or ninth day. This concretion is pretty firmly adherent to the subjacent parts, and covers a small ulcer with irregular borders which bleed when touched, and of uncertain form, sometimes round, sometimes longitudinal. 1 If the disease increase, this false membrane forms a yellow, broad, and thick layer, underneath which we find a co-extensive superficial erosion of the mucous membrane. This is the milder form of the complaint. If not checked, the ulcer- ation deepens, the edges are red or of a violet color, and the surface covered with a reddish-gray layer. When the gums are mainly affected they appear red or violet, swollen, softened, bleeding, and covered with a pultaceous secretion. The ulceration spreads transversely, and is rather narrow, and by the destruction of the gingival tissue, the teeth are loosened, and sometimes fall out. The ulcerations of the tongue and inside of the cheeks are of a rounded form ; those of the lips and their commissure are longitudinal and spread rapidly. 636. Causes. — Although an infant may be the subject of ulcerated sore mouth, yet both M. Taupin and MM. Rilliet and Barthez state that they have found it more frequent in children from five to ten years of age than at any other period, and in boys than in girls. Like other kindred affections of the mouth, it may appear at the time and connected with dentition, and it may be dependent upon a disor- dered state of the stomach and bowels, or a deteriorated constitution, which in children so certainly results from insufficient or improper food, want of cleanliness, vitiated air, damp or unwholesome dwellings, or the crowding together too many individuals in too small a space. It may also occur in the course of other acute or chronic disorders, as pneumonia, eruptive fevers, &c, which entail constitutional injury. It is endemic in certain wards of the Hopital des Enfans Trouves, according to M. Taupin, who also believes it to be contagious, i. e. to be communicable by using the same spoon for feeding, &c. And occasionally also it appears to prevail as an epidemic. 637. Treatment. — The first indication is to remove the predisposing and exciting causes if possible. Thus if the child be young and have been spoon-fed, we ought to procure a wet-nurse for it, if it be not too old to suck; and if already weaned, the food should be changed. If it occur at the period of dentition, the gums should be freely scarified, and the child removed away from its companions to a dry, airy apartment, and kept scrupulously clean. Even if the teeth are -complete, we shall often derive benefit from slightly scarifying the gums ; or, if the inflammation be severe, apply- ing a leech or two to other parts of the mouth. ! Taupin, Jour, des Connois. Med.-Chir., No. 10, April, 1839. ULCERATED SORE MOUTH. 445 If this be not necessary, or after it have been done, the mouth should be carefully washed by means of a syringe and warm water, or a piece of lint dipped in water; we shall then be able to judge accurately of the state and extent of the ulcerations. In slight cases it will be sufficient to wash the mouth with emollient or mucilaginous or slightly acidulated lotions, or to apply powdered sugar, or a weak mixture of borax with honey or sugar. If these milder remedies fail we may try M. Bonneau's plan, and apply the dry chloride of lime or powdered alum. The end of the finger, or the end of a small roll of linen, should be moistened and dipped in the powder, and gently rubbed over the ulcers twice a day, and this application must be continued until the surface is healthy and beginning to heal. The mouth should be cleaned with a syringe and water a few minutes after each application. In ordinary cases I have found the borax and honey in the usual proportions answer the purpose exceedingly well. Dr. West regards the internal administration of the chlorate of pot- ash as almost specific. He prescribes from three to five grains, dissolved in water and sweetened, every four hours — previously giving a purgative, if the bowels be confined. 638. But in very severe cases, before applying the borax and honey or alum, it will be necessary to touch the surface of the ulcers with nitrate of silver, or even muriatic acid, or the acid nitrate of mercury, and, after the slough has separated, then to have recourse to the milder applications. It sometimes happens that a carious tooth, though it may not have originated the inflammation, will certainly augment and perpetuate it. In such cases, it will be advisable to have it removed, as a preliminary to other treatment. Very great attention must be paid to the state of the stomach and bowels. If disease exist there, it will be in vain that we treat the mouth judiciously if that be neglected. Purgative medicine may be necessary, or diarrhoea may require to be checked; and if there be evidences of more serious disturbance, for example, of entero-colitis, it must at once be treated in the way we shall mention hereafter. The same may be said of every other complication, whether primary or secondary. The diet must depend a good deal upon the state of the constitution. If the child be exhausted or broken down, broths may be given freely, and wine whey may be necessary ; but if it be a local affection merely, and the child otherwise robust and healthy, moderate or even low diet will be advisable. 446 GANGRENE OF THE MOUTH. CHAPTER VII. GANGRENE OF THE MOUTH. — CANCRUM ORIS. — GANGRENOUS STOMATITIS. 639. This very formidable disease has been noted more or less cur- sorily by the older writers ; for instance, by Butter, in the sixteenth century; Van der Voorde, -who called it waterJcanker ; Van Swieten, who gave it the name of gangrene; Boot, Berthe, Dease, &c. ; but we are indebted for our more accurate knowledge of the disease to the re- searches of Baron, Isnard, Guersent, Constant, Taupin, Richter, Cu- ming, Duncan, Hueter, Rilliet and Barthez, &c. It has been described under various names, as water-canker, noma, gangrene of the mouth, cancrum oris, stomacace, necrosis infantilis, can- cer agneux des enfans, &c. 640. Symptoms. — Mr. Cooper gives the following definition of the disease: "A deep, foul, irregular, fetid ulcer, with jagged edges, on the inside of the lips and cheeks, attended with a copious flow of offensive saliva. It is a perfect specimen of phagedenic ulceration, and in its worst forms not unlike hospital gangrene, as I have seen in several deplorable instances. It also resembles the ulceration and sloughing in the mouth produced by mercury." 1 There appear to be several phases of the disease, differing in degree, if not more essentially. One variety is described by Dr. Cuming, of Armagh, as occurring in children between twenty months and seven years of age. " The ulceration commences generally in the gums, from whence it extends to the lips or cheeks. Sometimes it is of an acute, sometimes of a chronic nature, and as it approaches to one state or the other it is more or less attended by sloughing. In the very worst cases, however, though the sloughing is considerable, the ulceration is always predominant, and by its means the destruction of parts is prin- cipally effected. This form of the disease, which seems to answer to the affection described as cancrum oris by authors, bears a resemblance in some respects to the ulceration and inflammation of the mouth produced by mercury." 2 I must say that this form of disease hardly deserves the name of gan- grene ; it appears to me rather to have been an aggravated form of the ulcerative stomatitis first described. Another variety has been described by Richter 3 and others, in which we find spots of gangrene, limited in extent, at the angles of the lips or upon the cheeks, occurring suddenly and with little general disturb- 1 Surgical Dictionary, p. 332. 2 Dublin Hospital Reports, vol. iv. p. 341. 3 British and Foreign Med. Rev., vol. vii. p. 470. GANGRENE OF THE MOUTH. 447 ance. In some instances, there is a red spot for a few days preceding the gangrene. When the sloughs separate, we see that the gangrene was but superficial, there being very little loss of substance. Such cases are apt to occur after acute affections of the skin, as measles, scarlatina, smallpox, &c, and generally heal without trouble. Dr. Marshall Hall has published six cases, in five of which the dis- ease commenced externally in the lip or cheek: " In one case the pa- tient did not survive the extreme irritation of the system in general, which attends the commencement of this affection : in four others life was prolonged until a considerable portion of the soft part of the face and mouth was destroyed by mortification, and the latter patients died from exhaustion. In a sixth the patient survived the affection alto- gether, after experiencing an extensive sphacelation of each cheek, of a part of the tongue, and of the contiguous gums, and even of a portion of the jaw-bone." "In this disease frequently, when the little patient has appeared to be convalescent from the previous indisposition, some part of the face has been affected with pain, induration, swelling, and erythema, and the child has become cross, irritable, feverish, and rest- less. At no distant period, usually on the succeeding day, a dark purple or livid spot has appeared, which has soon assumed a dark brown colour, losing its purple hue, and at the same time its vitality. When the pa^ tient survives, the sphacelated part enlarges and becomes black, sepa- rated, loose, and extremely fetid ; the living part retains an erythematous redness, bordered by a ring of a livid hue. The internal mouth is soon involved in the affection, the sphacelus spreading into this cavity ; the teeth become loose and eventually fall out, and the breath is shockingly offensive. The child, from being restless, becomes more tranquil and patient ; it seems frequently conscious of the disgusting appearance of the affection, and dislikes to be noticed ; but there is often eventually dozing or coma. In the latter stages there is not much heat of skin, but the pulse is frequent. 1 My friend, Dr. Duncan, of this city, has more recently published a very interesting account of an epidemic resembling this disease which occurred in the North Union Workhouse : — " The age of the patients varied from about a year and a half to five years. I have no reason to believe it infectious, but in more than one instance it attacked a second member of the same family. Generally speaking, the attack was preceded for some days by diarrhoea, but, from the period of life corresponding often with the occurrence of den- tition, this feature was not always sufficient to attract the attention of the mother, and little was done to arrest its progress till the condition of the mouth was observed. The children at first did not seem to suffer pain in the bowels, and would bear the usual pressure of manual exa- mination, without inconvenience. The alvine evacuations were usually unhealthy, but they differed in appearance in different cases. Some- times they were thin and watery, but not deficient in bile : more gene- rally they were whitish and exceedingly offensive ; and in almost all of them blood was discharged, either in a fluid state or mixed with a jelly - 1 Edinburgh Medical and Surgical Journal, vol. xv. pp. 547-8. 448 GANGRENE OF THE MOUTII. like mucus. When this diarrhoea had continued a -week or ten days, the mother would mention that the child had a sore mouth, and on exa- mination it would be found that the gums were ulcerated and the fangs of the teeth exposed, and covered with a yellowish-white sordes. Ac- cording as the disease advanced the gums lost their pale flesh color, and became red, swelled, and spongy, and the margins exhibited a tendency to bleed, both spontaneously and on being touched." " The breath gradually became offensive, and the secretion of the salivary glands increased, so that the saliva used at times to flow from the mouth, and even to wet the pillow on which the patient lay. Partly from the attending fever, but principally from the tender and inflamed state of the gums, the children were unable to take food, but their thirst Avas often excessive. In no instance did I observe the teeth to fall out, pro- bably because, in fatal cases, death took place from the constitutional Irritation running so high before the local affection had time to produce its legitimate effects." " At first the disease did not appear urgent, but as soon as ulceration of the gums took place, and especially if appro- priate means to arrest its progress were not adopted, it advanced with considerable rapidity to a fatal termination. When this event occurred, it seemed due rather to the violence of the attending fever, or the in- tractable persistence of the diarrhoea, than to any peculiar changes effected in the condition of the mouth. In some of the cases the dis- ease seemed to be arrested for a time, the diarrhoea being completely checked, the alvine evacuations improved, the appetite restored, and every symptom of permanent convalescence being visible, when, after a time, the former symptoms would return in a severer form, and, resist- ing all measures of a remedial nature, hurry the victim to the grave. 1 Even this epidemic can hardly be considered as a severe form of this disease : if it were more than severe ulcerative stomatitis, it was a com- paratively mild form of gangrene. At the risk of being tedious, I am tempted to extract a very graphic description of the local phenomena of this disease, by M. Wunderlich. 2 He describes two forms. In the first, "the disease directly shows itself to be gangrene. This is noma, using the word in a limited sense, or stomatite charbonneuse of Taupin. One-half of the face (usually the left) exhibits an indistinctly defined pale or violet marbled swelling, especially on the eyelids, with a peculiar oily appearance of the skin. An erysipelatous redness of the cuticle is also frequently observed. The inner surface of the cheek is livid and of a dark red color. A small vesicle (which is often overlooked) now appears, generally on the outer surface of the cheek, near the mouth, but sometimes on the mucous membrane, and lying on a hard, dark red, and often livid ground ; this vesicle shortly bursts and becomes converted either into a superfi- cial erosion, or a deepish ulcer, which usually becomes soon covered with a slough of considerable size, measuring in diameter from several lines to an inch. It occasionally happens that there are several distinct points of origin of the morbid process, which either unite or remain isolated. The hardness and oedema of the surrounding parts increase 1 Dublin Journal, vol. xxviii. p. 3. 2 Handbuch des Pathologie und Thcrapie, vol. iii. p. 701. GANGRENE OF THE MOUTH. 449 until the whole face and occasionally the neck are swollen. An excess of saliva, often bloody or of a bluish color and of a fetid smell, dribbles from the mouth. Mastication is difficult if not impossible, while the voice becomes indistinct and speaking difficult. The external sloughing goes on extending, while the parts beneath become so rapidly affected, that in a few days, the cheek, a part of the lips and the eyelids are re- duced to a gangrenous highly fetid pulp ; and there is then a lateral opening into the mouth. The teeth, which may be observed through the opening, become loose or fall out after the destruction of thj gum ; and the adjacent portions of bone become to a greater or less extent ex- posed and destroyed. The whole neighbourhood of the gangrenous spot has a sodden, livid appearance. In this destructive process, which is almost always limited to one side of the face, and which extends much more widely on the inner surface of the cheek and in the cavity of the mouth than externally, there is a perfect absence of pain or at most a dull sensitiveness. In the rare cases in which the gangrene is arrested, there is formed an inflammatory (hyperaemic) line of demarcation, sup- puration commences in the circumference, and the gangrenous spot becomes converted into an ulcer, which gradually assumes a clean and healthy appearance, and after cicatrizing for some months, becomes healed. When there has been great destruction of tissue, cicatrization is always attended with considerable disfigurement, and the pre-existence of gangrene of the mouth may be recognized through life by the ugly, strongly-contracted cicatrix, puckering the eyelid, the ear or the neck, uncovering the eye and distorting the mouth, like the scars left on the face after deep burns. "The second form appears to be incomparably the more frequent of the two. It is however less strongly marked, and owing to its greater affi- nity with other affections and a deficiency in correct observation, there is much discrepancy in what has been written on it. It runs a slower course than the former, and does not so frequently break out with sud- denness during convalescence from acute diseases. Instead of the gan- grenous destruction with which the first form commences, we here have pseudo-membranes of unhealthy appearance on the inner surface of the cheek, and ulcers either there or on the outside of the cheek and at the corners of the mouth. They either gradually or at once assume a very unhealthy character, emit a powerful and fetid odor, and become co- vered with sloughs or viscid masses, while the neighboring parts become livid and oedematous and the destructive process affects the deeper tis- sues. From this stage its further progress is similar to that of the first form, excepting, indeed, that the gangrene does not usually extend with the same extraordinary rapidity." 1 641. In the severe form, the disease always commences in the mu- cous membrane, preceded by stomatitis, aphthse, or ulceration of the gums, lips, or inside of the cheeks, and occasionally with slight oedema. This state may persist for several days, or gangrene may set in the first day. Then the bottom of the ulcer becomes covered with a layer of gray matter evidently gangrenous, and the subjacent tissues are swol- 1 British and Foreign Med.-Chir. Review, July, 1850, p. 52. 29 450 GANGRENE OP THE MOUTH. len and hard. When this tumefaction takes place in the cheek, it may be felt like a kernel, and the skin outside is tense, shining, and white in the centre. From this moment the ulcerations extend rapidly; at first of a gray- ish color, they shortly become brown and black, covered with " putri- lage," of a fetid odor, and bleeding when touched. The edges are sometimes regular, sometimes irregular, and raised or level, according to the progress of the ulceration, which in a few hours changes their appearance. The portions of the mucous membrane of the mouth in contact with the gangrenous spots become likewise affected, and run the same destructive course. In all directions the disease extends fearfully, laying bare and destroying the bones. In a short time a livid spot is perceived in the cheek, in the centre of the kernel just mentioned ; this spot is surrounded by an inflamed base, and is soon perforated by ulceration, which from thence spreads rapidly, and in some cases destroys the entire cheek. The gums struck by gangrene are destroyed, leaving the teeth bare and loose ; the bones of the jaws are affected with necrosis, and exfoliate if life be sufficiently prolonged. " The parts," says Mr. Dease, " were continually soaked in a cold, putrid, offensive ichor, until often the whole side of the face was eat away, particularly the lips, so that the jaw-bone and inside of the mouth were exposed to view." "In this situation I have known children to live until the entire jaw-bone had fallen down on the breast, and the whole side of the face become a mass of putrefaction." 1 642. As already stated, the primary disease of the mouth is inflam- mation and ulceration, upon which gangrene supervenes, and the early symptoms are those I mentioned when describing that form of disease. The superaddition of gangrene appears in some cases to give rise to but little constitutional disturbance, and the child presents^the same general aspect as formerly. " Premonitory symptoms," M. Wunderlich remarks, " are only observed when the affection appears as gangrene and is developed in the advanced stage of improvement or convalescence of a pre-existing disease (measles, &c), for when there is pseudo-membranous or ulcer- ative stomatitis, the gangrenous mortification is only announced by a gradual exacerbation of the symptoms, or at most by a shivering, an increased appearance of collapse, hemorrhage, &c. When the gan- grene supervenes at the height of some other disease, these premonitory symptoms are rarely observed. It even frequently happens that when the earlier disease has abated to a very great degree and convalescence is considerably advanced, this fatal secondary affection will manifest itself unannounced by any premonitory symptoms, commencing unex- pectedly and suddenly by local swelling. The premonitory symptoms when they occur in these cases are not very severe, as for instance, lassitude, irritability, loss of appetite, disordered digestion, rigors, slight fever, and a somewhat suffering and collapsed appearance." In other cases the child, already weakened by previous disease, is cross, feverish, and restless, with a quick pulse and hot skin, suffering 1 Observations on Midwifery, &c, p. 126. GANGRENE OF THE MOUTH. 451 much pain from the mouth until the gangrene is completely established. Then the fever seems to subside, for although the pulse remains very quick, the skin is cooler, the restlessness diminished, and the aspect more calm. The face is of a dull pale color, and has, if I may so speak, a dead look about it. The eyelids are not unfrequently swollen, the nares incrusted, and the alse nasi dilated in respiration. The lips are swollen, and frequently exhibit their share in the mischief going on. Altogether the face has a singularly depressed and sorrowful, though tranquil, expression. The saliva is secreted abundantly, and escapes from the mouth, owing to the pain and difficulty of closing the mouth. At first it is the ordinary secretion in excess, and perhaps tinged with blood, but after- wards it becomes brown or black, mixed with gangrenous detritus. The breath is extremely offensive from the beginning, but when gan- grene is established both the saliva and breath exhibit the characteristic fetid odor. The tongue is moist, sometimes yellowish or loaded, and occasionally exhibiting the color of the gangrenous spots. The thirst is intense, vomiting rarely occurs, and the appetite is not so completely destroyed as we might expect ; in fact, when it does fail, it seems rather owing to the complications than to the disease of the mouth. The bowels are almost always deranged ; diarrhoea is generally present ; sometimes griping, with watery stools of a greenish or yellowish color. In a con- siderable number of cases the intestinal disorder seems to have preceded the gangrene, and to have constituted the primary affection. The strength of the child is greatly reduced ; it is emaciated^ weak, and helpless. 643. It has already been stated that gangrene may attack the ulcers on the first day; more generally, however, we find it set in from the third to the sixth day, and from that time the disease spreads, until, after more or less destruction of the tissues, it proves fatal at a period varying from five to eighteen days. During this time nothing can be conceived more distressing than the condition of the poor child, or more heart-rending than its appearance. As may be supposed, the great majority of cases terminate fatally, but some few cases do recover, mainly those in whom the disease is primary, the constitution good, and which remain free from complica- tions. The improvement may take place before the gangrene has spread deeply, and then the mortified portion is cast off, leaving a grayish but more healthy ulcer ; the swelling of the surrounding parts diminishes, and the constitutional symptoms improve. At a later period, should a favorable change occur, the entire gangrenous portion, both the mucous membrane and the cutaneous eschar, will be thrown off, leaving a granulating surface with healthy suppuration ; the dead bone will exfoliate, and the wound gradually fill up and contract. Some writers have stated that the form of cancrum oris which com- mences externally on the cheek is more under the control of remedies than the other forms ; and Dr. Condie considers that the disease is less frequent in America than in Europe, and more manageable. 452 GANGRENE OF THE MOUTH. 644. A peculiar form of gangrene occurs from the use or abuse of mercury, but it is of importance to know that it may arise from a very small quantity. Dr. Stokes has mentioned to me one case in which gr. iss of calomel, and in another 7 grs. had been taken, and in a third 3j of ung. hyd. had been rubbed in, and all had the disease severely. It commences by a livid tumor at the angle of the mouth or behind it, which increases, ulcerates, and eats away the cheek and even part of the eyelids. The gums are dry and hard, and there is no salivation. It may occur at any age, but Dr. Stokes has seen it chiefly in young girls of 10 or 12 years. The disease may be primary or secondary, as I have said, but it is not always easy to decide whether the complications have preceded the disease or followed it, so little attention has been paid to them comparatively. We know that intestinal disorder is a frequent concomitant ; it will certainly arise in the course of the disease, but it appears probable that in some cases the gangrene itself is rather a complication symptomatic of the state of the gastro-intestinal mucous membrane. Another very frequent and very important complication is pneumo- nia ; it occurred in eighteen out of twenty of Rilliet and Barthez's cases, and will require our most careful attention if we hope for success in our treatment. Whether primary or secondary is comparatively of little consequence; it is in itself so serious that it must necessarily exercise a predominant influence both upon the course of the disease and of the treatment, for if the gangrene were cured the patient would incur nearly equal risk from the pneumonia in his exhausted condi- tion. 645. Pathology. — MM. Rilliet and Barthez have given a minute analysis of the pathological changes in the different structures, effected by the gangrene, drawn from the post-mortem examinations of twenty- one cases they witnessed. I shall venture to give a short abstract of their record. 1 After death, the portions of the skin surrounding the gangrene rapidly putrefy, and the cheek or the lip is swollen, purplish or greenish, tense and shining, hard to the touch, and exhibiting a profound circumscribed tumefaction. At the most prominent point we find an eschar, either well-defined, round, or oval, and of a moderate size ; or it may be large and irregular, extending in different directions towards the nose, eyes, and ears, even in some cases occupying nearly the entire face. In the latter case the tumefaction is less, and not circumscribed. The depth of the eschar varies. The mucous membrane, was always affected, sometimes in a limited and regular manner, and sometimes irregular, and more extensively. The surface was reduced to a semifluid " putrilage," of a gray, brown, or black color, removable with the scalpel, and beneath which loose shreds of the mucous membrane were perceived. The gums shared in the destruction. When the gums were thus destroyed the bones were exposed and became black, sometimes affected by necrosis, and exfo- 1 ' Mai. des Eufans, vol. ii. p. 129, et seq. GANGRENE OF THE MOUTH. 453 liated. This destruction was commensurate with the extent of the gan- grene of the mucous membrane. The teeth, denuded and deprived of their support, became loose, and were easily detached, often falling out of themselves. The intermediate tissues were congested, and participated more or less in the gangrenous affection. In the milder cases, the adipose tissue was infiltrated with serosity, as were also the muscles ; and such of these parts as were not actually touched by the gangrene were dis- tinctly recognizable. But as the disease advances, or in more severe cases, mortification attacks these tissues, especially those nearest the mucous membrane, so that the brown putrefied layer is of considerable thickness (five to eight millimetres), beneath which we find the adipose tissue, and the muscles, infiltrated with serous fluid, losing their dis- tinctive organization, and becoming homogeneous, whilst nearer the skin there is a layer of cellular tissue, hardened and infiltrated, but not mortified. It was rare to find the entire thickness of the cheek affected by gangrene. 646. The condition of the vessels and nerves has always appeared doubtful. In one case, examined by M. Billard, he found " nothing remarkable." M. Taupin states that he often sought for them, but always found them confounded with other tissues, and impossible to distinguish from the softened gangrenous mass. 1 MM. Rilliet and Barthez give the following results of their investiga- tion : " In six cases we made a long and minute dissection, and we found that when the vessels passed into a portion of tissue, infiltrated, but not affected with gangrene, they were perfectly healthy, permeable, and their coats scarcely thickened; that when they touched upon a gan- grenous part, they were still permeable, but their parietes were thickened, and had somewhat the aspect of the gangrenous portion. Lastly, when they traversed a gangrenous portion, it was still possible to trace them through it, but that the entire extent of the vessel, as it traversed the mortified part, was closed from one side to the other, either by a small clot at either extremity, or by a larger one filling it throughout." Thus the artery was completely obliterated in three cases, and in as many the vein was filled with "liquid putrilage." The coats of both were thicker and softer than natural. Once only the nerves were examined : externally they appeared like the surrounding tissue ; their neurilemma was gangrenous, but the pulp was sound in color and consistence, and appeared to have resisted the gangrene. The following details show the comparative frequency of the seat of the disease in twenty-nine cases : — The left cheek (externally or internally) was affected in . . .11 cases. The right cheek 10 " The lower lip ........... 4 " The lower lip and right cheek ........ 1 case. The upper lip and right cheek ........ 1 " The left cheek, the angle of reflection of the mucous membrane, and right cheek ............ 1 " The lower lip, extending to both cheeks and upper lip, on both sides . 1 " 1 Journal des Connois. Med.-Chirurg., April, 1830, p. 140. 454 GANGRENE OF THE MOUTH. 647. So much for the condition of the parts involved in the gangrene ; but the post-mortem examination revealed other lesions connected with this disease, either as primary or secondary complications, and which are of vital importance. The principal coincident disease was pneumo- nia, and the following summary exhibits the character and seat of this disease, and of the gangrene, in the same cases : — f Of these, gangrene of the right cheek Out of 20 cases there was found double lobular pneumonia in . Double gangrene, but especially of the left cheek, in .... Gangrene of the lower lip, in . Gangrene of the lower lip and right cheek Gangrene of left cheek in Gangrene of lower lip in Double lobular pneumonia, especially on the right side (with carnification in 2 cases) in 5 Double lobular pneumonia, especially on f Gangrene of right cheek in 6 \ Gangrene of left cheek in 1 Gangrene of upper and lower lip in 1 Gangrene of left cheek in 1 Gangrene of right cheek in « ( Gangrene of right cheek in \ Gangrene of left cheek 1 in " the left side, in Lobar pneumonia of right lung in Lobar pneumonia of left lung in Carnification of left lung in No pneumonia in Thus pneumonia (lobular or lobar) existed in eighteen out of twenty cases, and occasionally, though rarely, of the same side as the gangrene. This accords with the experience of MM. Baudelocque and Taupin. In eight of these eighteen cases the pneumonia was secondary, having supervened in the course of the gangrene. Other lesions, however, were discovered ; as for example : — Entero-colitis, or softening of the intestine, in Tubercles Gangrene of the lung . . 3 ) . Gangrene of the pharynx 1 / Pleurisy ....... Pneumothorax ...... Peritonitis Pharyngitis Nephritis ....... Infiltration of the pia mater .... Hemorrhage into the arachnoid Rachitism .4 cases. 9 " 4 " 1 case. 1 " 1 " 1 " 1 " 2 cases. 1 case. 2 cases. At first sight it might be supposed that the gangrene resulted from the obliteration of the artery ; but this is not borne out by the fact that, so long as the mucous membrane is alone affected, the vessel is quite pervi- ous ; its obliteration must, therefore, be the effect, not the cause, of the gangrene. Dr. Condie states that, in the examinations he made, " the principal organs in which morbid appearances were present were the stomach, intestines, and liver. In all the cases the two former presented the indications of inflammation of a more or less chronic character; the latter appeared to be affected with hyperemia rather than any struc- 1 Mai. des Enfans, vol. ii. p. 135. GANGRENE OF THE MOUTH. , 455 tural change. In the majority of cases the mesenteric glands were greatly enlarged." "In the examination made at the Children's Asylum between June 1, 1827, and January 1,1830, the morbid appearances exhibited were — enlargement and hardening of the mesenteric glands ; a scrofulous con- dition of the glands of the neck ; and, in some instances, tubercles of the lungs. In general the whole substance of the lung was thickly studded with tubercles in various stages of inflammation and suppura- tion. The condition of the gastro-intestinal mucous membrane is not recorded." 1 In all the cases examined by Dr. Duncan, he found " either decided ulceration of the intestinal mucous membrane, or enlargement and in- creased development of the follicular glands. In one case the whole colon was an immense sheet of minute, circular, and deep ulcers ; while the portion of mucous membrane which intervened was of a bright crim- son hue." 2 648. Causes. — Cancrum oris is almost confined to infancy and early childhood. Of twenty-nine cases recorded by Rilliet and Barthez, nine- teen were from two to five years old, and the remainder from six to fifteen. Of Dr. West's six cases, two were between two and three years old; one, three ; one between four and five ; one at six and a quarter ; and one at eight years old. It does not appear, however, as was thought by Dr. M. Hall, to affect female more than male children. As might be expected, we meet the disease most frequently among the poor, and for obvious reasons. Their children are badly nourished, living in foul air and crowded rooms, surrounded by and participating in all kinds of uncleanness. Add to these exciting causes a delicate constitution and lymphatic temperament, and we seem to have all the elements for the production of the complaint. Probably for the same reasons it appears endemic in crowded hospi- tals for children, as, for instance, in the Children's Hospital at Philadel- phia, where, out of 240 children, seventy were at one time affected with the disease; and in other hospitals also. Certain localities, likewise, seem peculiarly favorable to it. It is said to prevail on the coasts of Holland, Sweden, and Denmark. According to the testimony of Thomassen and Thyssen, it prevailed epidemically in the Netherlands, as a consequence of gastric fever; and also, in 1838, in the Philadelphia Almshouse. I believe that few if any authors maintain that gangrene of the mouth is contagious, although they prudently advise the separation of the healthy from those who are so affected. 649. We have already noticed certain complications of the disease, which may be primary or secondary ; we must, however, inquire a little further, as to those diseases in the course of which cancrum oris has been found to occur most frequently. This point is one of great im- portance, because in the majority of cases it is a secondary disease, in some solely dependent upon another preceding it, or upon the state of the constitution induced by the latter. 1 Diseases of Children, p. 168. 2 Dublin Journal, vol. xxviii. p. 18. 456 GANGRENE OF THE MOUTH. M. Baron observes that "it is never a primary affection, but appears in children enfeebled by previous disease." 1 Mr. Dease remarks that, in all the cases he had seen, the children "had a pale, bloated, sickly look, large belly," &c. Dr. Huxham, in his report for 1745, mentions, " I have more than once during this month witnessed a mortification of the mouth and fauces; and, besides, a caries of the cheek and os vomeris, which occa- sioned a very painful kind of death, and that, too, after measles." Dr. Willan refers to a gangrenous eschar of the cheek occurring in a case of scarlatina. Dr. Marshall Hall states that " in all the cases which have come to his knowledge, this affection had been preceded by fever, acute disorder of the digestive organs, inflammation of the lungs, variola, rubeola, or scarlatina. This affection would, therefore, appear to be in some measure the consequence of the exhaustion, debility, or irritation induced by previous disease." 2 Dr. Cuming advances a similar opinion : " In every instance of this affection that I have met with, the constitution had been much debili- tated by the existence of previous and long-subsisting disease. In two cases that fell under my observation, the disease occurred as a sequela of measles; in another, in the advanced stage of dysentery; in a fourth, upon the termination of infantile remittent fever ; but it is more gene- rally observed at the close of the exanthemata than at that of any other of the acute affections to which children are liable." 3 In M. Poupail's seventy-two cases, the affection followed an attack of intermittent or remittent fever ; in nine of Dr. Jackson's cases, it accom- panied or followed an attack of bilious or remittent fever. MM. Killiet and Barthez agree completely with the opinion of M. Baron already quoted : " The disease, in the course of which we have most frequently known gangrene of the mouth to occur, is measles. We have occasionally observed it in scarlatina, smallpox, and pneumonia. We have also known it follow intestinal affections, hooping-cough, scro- fula, &c." And they give the following summary of the primary dis- eases on which gangrene supervened : — On measles in ....... 12 cases. Smallpox and measles .... 1 case. Scarlatina . . . . . . 1 " Scarlatina and smallpox .... 1 " (Supposed) cholera ..... 1 " Pneumonia, primary and secondary . . 2 cases. Pertussis, with or without complication . 3 " Enteritis (chronic) and complications . . 1 case. Peritonitis and softening of the intestines . 1 " Scrofula . . . . . . . . 1 " Intermittent fever , . . . . 1 " Enteritis (acute) ..... 1 " Gibbosity, &c 1 " General tubercularization .... 1 " In Dr. Duncan's cases, the primary disease appears to have been generally an affection of the intestinal canal, although several of the cases occurred after measles." 1 Bull, dela Faculte de Med., 1816, vol. v. p. 158. 2 Edin. Med. & Surg. Journal, vol. xv. p. 548. 3 Dublin Hospital Reports, vol. iv. p. 282. GANGRENE OP THE MOUTH. 457 Dr. Geo. Kennedy mentions that it occurred in the course of malig- nant typhus fever. 1 "Of the six cases which I have observed," says Dr. West, " and three of which I examined after death, two succeeded to typhus fever, two to measles, one came on in a child whose health had been completely broken down by ague, and one supervened in a tuberculous child, who had been affected for many weeks with ulcerative stomatitis in a severe form." 2 We have already seen that in ten cases out of eighteen the pneumo- nia preceded the gangrene, so that the latter disease may sometimes be primary and sometimes secondary to the pulmonary affection. Nor can we, I think, doubt that there may be an intimate relation between scrofulous tubercle of the lungs and cancrum oris. Thus we find that the diseases which are most frequently attended by gangrene of the mouth are eruptive fevers, as measles, scarlatina, smallpox, &c, intermittent and remittent fever, pneumonia, disorders of the intestinal canal, tubercles, and scrofula ; while, on the other hand, pneumonia and entero-colitis are those which most frequently supervene in the course of cancrum oris. By several writers, we find the resemblance between gangrene of the mouth and mercurial ulceration pointed out; and it has been suggested by Bretonneau, Hueter, and others, that true gangrene may follow the excessive use of mercury when the mouth is inflamed. 650. Diagnosis. — The only disease with which cancrum oris is likely to be confounded is the one last described, viz: ulcerated sore mouth. Both commence by ulceration, and in both we find salivation and a fetid odor; but in gangrene the ulcer is covered by a putrid layer, which soon becomes dark-colored; the ulceration extends more rapidly and further, there is more swelling, often an eschar on the lips or cheek, denudation of the teeth and jaw, and ultimately perforation and destruction of the cheek. In ulcerated sore mouth, none of these latter characteristics occur. 651. Prognosis. — The prognosis is exceedingly unfavorable. Very few cases, indeed, recover; and even when the gangrene appears checked, the child has to contend against very serious complications. Twenty out of twenty-one of Rilliet and Barthez's cases died, and five out of six of Dr. West's. Still, as some have recovered, it is always our duty to use every remedy against the local disease without overlooking any primary or secondary affection which may exist. 652. Treatment. — There are four indications to be fulfilled in our treatment of the disease: 1. To limit the gangrene, change the character of the surface, and remove the fetor of the discharges ; 2. To invigorate the constitution of the patient; 3. To favor the separation of the eschar; and 4. To remedy the complications, either primary or secondary. 653. The first indication is most likely to be attained by the applica- tion of powerful caustics ; weak ones are of no use. Moreover, merely to touch the gangrenous surface will have no effect; to succeed, the 1 Med. Report of Cork Hosp. for 1837-38, p. 25. 2 Diseases of Infancy and Childhood, p. 356. 458 GANGRENE OF THE MOUTH. caustic must reach the healthy tissue. Therefore the layer of gangre- nous matter must first be removed, or if the situation permit, the gan- grenous surface may be cut away, and then the caustic applied carefully and liberally once or twice a day. Various caustics have been tried, and some with success. Klatoch cured one case with pyroligneous acid ; Hueter with acetic acid ; Con- stant by the acid nitrate of mercury ; Baron by the actual cautery ; and Rilliet and Barthez by nitrate of silver and chloride of lime. M. Baron advises that muriatic acid be applied to the gangrenous spots in the mucous membrane at the commencement, and that, when the external eschar falls, we should apply the actual cautery ; or, what is still better, that the eschar should be incised crucially, and then the cautery applied. Successful cases thus treated have recently been pub- lished by an American writer, Mr. Obree. Sulphuric acid has been successful in the hands of Bruineman and Courcelles. Mr. Dease speaks highly of the spirit of sea salt (muriatic acid), which was used with benefit by Van Swieten previously. " I began," he says, " at first to give it in decoction of bark or infusion of chamomile flowers, but I could not get children to take it for a continu- ance, or in such manner as to give it a fair trial. I therefore gave it in an infusion of red roses, which was strongly acidulated with it ; this they took without reluctance. At the same time I had the gangrene frequently washed with a decoction of chamomile acidulated with the spirit of sea salt ; and when the gangrene was considerable and the discharge large, dashing the parts with the decoction, by means of a syringe, will more effectually wash away the sanies. After this was done, I ordered it to be dressed with the honey of roses and spirit of sea salt, and over all the carrot poultice to be applied. The child, at the same time, should be well supplied with broth, jelly, &c, and allowed wine liberally ; good claret will answer best." 1 Mr. Cooper prefers the strong nitric acid, with the internal exhibi- tion of sulphate of quinine and dilute sulphuric acid. Mr. Pearson extracted the diseased teeth and some pieces of bone, and directed a milk and vegetable diet, with bark, sarsaparilla, and elm bark. Locally he preferred the dilute mineral acids, burned alum, decoction of bark with sulphate of zinc, tincture of myrrh, &c. In addition to the stronger caustics, or in the intervals of using them, M. Baron recommends external and internal applications of camphor and quinine. M. Billard advises frictions, either dry or aromatic, when the oedema appears ; and as soon as the kernel is felt, the use of ammoniacal lini- ment, or a lotion of the hydrochlorate of ammonia. Richter and Rey derived benefit from the use of the chloride of the oxide of sodium. Dr. Conclie found a strong solution of copper or zinc, applied twice a day, very beneficial ; and in the Children's Hospital, Philadelphia, nitrate of silver was the only local remedy employed, and the majority recovered. Creasote was very useful in the Philadelphia 1 Observations on Midwifery, &c, p. 128- GANGRENE OF THE MOUTH. 459 Almshouse, applied after incisions had first been made through the gangrenous sloughs. After each application of the caustic for the purpose of separating the sloughs, the chloride of lime may be applied in order to destroy the odor, and it also acts as a stimulant. The mouth should be syringed freely and frequently, and the parts kept dry and clean. When an eschar appears, a conical incision should be made, and the. caustic applied and repeated every day until after the eschar separates. Rilliet and Barthez advise that the incision should also be filled with quinine. I need not say that if there be carious teeth or loose portions of bone, they should be removed, as they will keep up an unfavorable irritation. 654. For the purpose of invigorating the constitution, it will be necessary to administer tonics as liberally as the condition of the di- gestive system will admit. Bark may be given in form of infusion, decoction, or syrup, or we may prefer the sulphate of quinine from its smaller bulk ; beginning with half a grain, we may increase it to two or three grains three times a day. Dr. Cuming says : "In a few instances in which the disease had made considerable progress, I have known recovery to take place under the administration of the sulphate of quinine and carbonate of ammo- nia ; but in none of these cases had the ulceration extended so far as to involve the outside of the lips and cheeks. I have seen that Mr. Dease advises the internal exhibition of muriatic acid ; and whether we give mineral or vegetable tonics, they must be assisted by the liberal use of wine. We cannot, of course, state the exact amount, but there need be no hesitation in giving as much as the constitution of the child will bear, according to its age, and with reference to the compli- cations. Dr. Duncan found great benefit from the hyd. c. creta, with Dover's Powder, and, although not at the same time, from acidulated decoction of bark, or infusion of calumba with nitric acid. In addition, he derived the greatest good from counter-irritation to the abdominal sur- face. His principal efforts were naturally directed to the causes of the intestinal disease. 1 The diet should be very nutritious, — broths, jellies, minced meat, &c, — just as much and of the kind the child can best take. It will be necessary, however, to keep a constant check upon the tendency to diarrhoea, by chalk mixture with opium, or opium com- bined with the quinine or ammonia ; or a drop of laudanum may be given once, twice, or thrice a day in milk. The child should be kept in a large, well-warmed, and well-ventilated apartment ; but in our anxiety for pure air we must beware of draughts of cold, remembering the liability to pneumonia in this disease. The most scrupulous cleanliness, both local and general, should be observed. 1 See also Dublin Journal, Nov. 1852, p. 265. 460 TONSILLITIS. I must repeat that the most anxious care and watchfulness of the physician should be directed to the complications. Knowing that in- flammation of the lungs so frequently occurs (whether primary or secondary) in connection with cancrum oris, we ought daily to ascer- tain the condition of these organs, that by detecting the earliest incur- sion of the disease we may the more effectually apply the remedy. The same may be said of entero-colitis, which also complicates this disease. For the suitable method of treating these diseases, I must refer the reader to the chapters relating to them. Dr. Stokes has found the mercurial cancrum oris manageable, if he saw the patient within twelve hours from the setting in of the disease. He recommends that the patient should be kept sitting up in bed, that relays of leeches should be applied to the livid tumor as frequently as the strength will admit, and that the strength should be kept up by wine and good diet. If the tumor be reduced before ulceration occurs, the patient will be saved. CHAPTER VIII. TONSILLITIS. — CYNANCHE TONSILLARIS. — QUINSY. 655. This disease, which consists of inflammation of those massed of mucous follicles called the tonsils or amygdalae, and of the neighbor- ing mucous membrane, is sufficiently common in children of all ages and constitutions ; and, because it is painful and subject to ocular in- vestigation, has been noticed by almost all writers from Hippocrates to the present time. It is seldom so severe and acute in children as in adults, but is much more liable to take on a subacute form, enlarging these organs, continu- ing for a considerable period, altering more or less the tone of voice, and impeding deglutition, hearing, and occasionally the breathing. 656. Symptoms. — Generally speaking, the complaint commences with the symptoms of a cold ; the child is chilly, creeping to the fire, or ifc has regular rigors followed by fever ; it is uneasy, distressed, and cross, with a huskiness of voice and a sense of roughness in the throat, which is shortly changed for soreness and pain, especially in attempting to swallow. Sometimes, however, as Dewees has observed, it appears to be a purely local affection, without fever or any constitutional disturbance. In the other cases, the fever continues to increase for a time; the skin is hot and florid, the face flushed and puffed, the pulse rapid and full, the tongue loaded and white, with red papillas appearing through the white coating. The thirst is great ; but there is great pain and difficulty in swallowing fluids especially. Upon examining the throat, to which we are led at once by the com- plaints of the child, we find one or both tonsils enlarged, of a bright or TONSILLITIS. 461 red color ; the uvula, velum, palate, and pharynx, red, swollen, and cedematous, but generally more painful on one side than the other, and on the surface we find more or less of thick, viscid, mucous secre- tion. In some cases, patches of coagulable lymph may be observed on the tonsils, giving the appearance of small sloughs. The extent of the swelling varies according to the intensity of the attack. In severe cases, the tonsils are so much enlarged that they almost close the pharynx, and protrude the swollen uvula forwards ; and not only so, but the deeper tissues appear involved, so that the neck appears enlarged, and, from the interruption to the circulation, gives to the face and neck a flushed or congested look. Beneath the angle of the jaw, the tonsil may be felt enlarged, hard, and painful, and the carotids are seen beating strongly. The child complains of soreness of the throat, and is continually attempting to detach and expectorate the viscid mucus. Swallowing is very painful, but with soft solids less than with fluids ; more so with the saliva than anything else, because of the increased muscular effort required, and the consequent pressure upon the inflamed parts. There are darting pains from the fauces to the ears, frequently some degree of nausea ; and in a few cases, we find respiration impeded ; but this, I am convinced, is rare, the rapid and hurried breathing being ordi- narily owing to the fever. The fever may run very high, and delirium be an attendant upon the disease. This description, however, is rather of a very severe case than of the form ordinarily observed, which is marked by fever, soreness of throat, dysphagia, and inflammation of the tonsils, neither extremely distress- ing nor very persistent under ordinary management. 657. After a duration varying from a day to ten days or a fortnight, the attack may terminate in either of three ways. I. In the great majority of cases it terminates in resolution, by the gradual subsidence of the fever, the diminution of the inflammation, and the reduction of the swelling ; after which there remains a remarkable degree of weakness and lassitude. II. In those cases where the inflammation is subacute, or in those where the inflammation, at first acute, subsides only to a certain point, we have less fever and less suffering, but the disease does not subside so frankly as in the others. The fever and distress may disappear, but the swelling of the tonsils does not ; they remain enlarged, as it were hypertrophied, for a long time, or permanently, in lymphatic or scro- fulous children : they feel soft, but of two or three times their natural size. There is no pain, but some difficulty in swallowing, and in all cases an alteration in the voice, similar to what is popularly called " speaking through the nose." Children in whom the tonsils are thus left, are very liable to a return of the inflammation on catching the slightest cold. in. Tonsillitis very commonly terminates in suppuration, though not quite so frequently as in adults. After reaching the maximum of in- tensity, the inflammation seems to subside, but not the swelling ; there is less pain, but the mechanical obstacle to deglutition remains ; the 462 TONSILLITIS. patient is wearied, exhausted, and almost worn out by suffering and want of food. At length, the tissues having been thinned, the abscess points and breaks, and the patient obtains complete relief. Generally the abscess bursts internally, but cases are on record of its opening or being opened externally below the angle of the jaw. The quantity of matter is never considerable, and in some cases we may fail in detecting any, from its being swallowed, and can only satisfy ourselves of its escape by the sudden relief of the distress. 658. Causes. — The ordinary cause of tonsillitis is cold, and we find the disease most prevalent in low, damp, and cold situations, and at those times and seasons when the weather is most changeable. A second attack of the disease is more easily incurred, and excited by slighter causes than the first. In some children with enlarged and tender tonsils I have observed them affected by atmospheric changes without apparently having taken cold. 659. Diagnosis. — When very severe, the disease has some resem- blance to mumps, but in the latter the pain and swelling are chiefly in the parotid gland, and extend from the angle of the jaw to the ear, and there is no inflammation of the tonsils or redness of the neighbor- ing parts. 660. Treatment. — If we see the child immediately after the com- mencement of the attack, it is possible occasionally to cut it short by a stimulating gargle, or by strong counter-irritants externally. If these fail, or if we are not called sufficiently early, yet if the at- tack be mild, it will be easily subdued by gentle antiphlogistic measures. A brisk purgative, followed by sudorifics, fomentations, or poultices ; warm pediluvia, with low diet for a few days, will generally afford relief. When the inflammation is considerable and the fever high, we must have recourse to more decided measures. Topical bleeding, either by leeches to the neck or scarifying the tonsils, will be .necessary. The former, I think, are generally preferable, although Kopp speaks of the latter as the most prompt and efficacious remedy we possess. Occa- sionally, but rarely, it may be advisable to take blood from the arm in older children. After the leeches fall off, or when the bleeding has stopped, the most comfortable application is a light warm poultice fre- quently renewed. Great relief may also be obtained by inhaling the vapor of warm water, but this should be always done from the mouth of a jug, and never from the spout of a teapot, with children, on account of the danger of closing the lips and drawing up the water. Internally, after freeing the bowels well, we may give minute doses of tartar emetic, not so as to excite vomiting, unless the viscid mucus be very troublesome, but just so much as to lower the fever and excite the action of the skin. Loeffler and other continental physicians speak very highly of the hydrochlorate of ammonia in tonsillitis. Dr. Condie states that he has derived very great advantage from it. He combines it with ipecacu- anha and calomel, so as to give three or four grains of it every three hours. 661. There are two other remedies generally used, but often without TONSILLITIS. 463 sufficient discrimination, and about which opinions have varied ; I mean gargles and blisters. At the commencement of the attack stimulating gargles may be use- ful, but afterwards I quite agree with Dewees that either stimulating or astringent gargles are rather injurious until the decline of the disease. During its height warm water is the best gargle, or if the viscid mucus be very troublesome, we may adopt Eberle's plan of using warm water slightly acidulated with vinegar. When the inflammation and fever are subsiding, we may use either acid or astringent gargles with benefit, or we may try the vapor of vinegar and water, as recommended by Hip- pocrates, or other medicated vapors. The same rule holds good with regard to blisters. During the in- crease and height of the disease, soothing applications externally are advisable; liniments, blisters, &c, seem to do harm; but after the acute stage has somewhat passed, much benefit will be derived from stimulating liniments, mustard and meal poultices, or turpentine. I do not like blistering the throat of young children if it can be avoided, as the surface is very apt to remain very sore, or perhaps to ulcerate. 662. When suppuration seems determined upon, we ought to encou- rage it by poultices, inhalation of aqueous vapor, gargles of warm water, &c. If there be much delay before the abscess opens, and if the patient be much exhausted, or if the swelling should be so great as to interfere with the breathing, it will be better to make an opening with a bistoury, taking great care that no movements of the child give rise to mischief. Dr. Mason Good mentions that in some cases tracheotomy has been found necessary ; but such cases must be very rare indeed. The diet should be low until the disease subside, and then the child must be nourished by broths, jellies, or meat, according to its age and power of swallowing. 663. Dr. Dewees observes : " As regards the erysipelatous species of the disease, the treatment is somewhat different. We rely more on topical bleeding and the vesicatory applications, and when aphthae or sloughs appear, on stimulating gargles ; and in the event of extreme debility supervening, the system is to be supported by bark, wine, the carbonate of ammonia, and whatever else enters into the treatment of putrid sore throat." 1 When the tonsils remain permanently enlarged, we must make some efforts to reduce them, not only on account of the liability to repeated attacks of inflammation, but because they involve a disagreeable change of voice and discomfort in swallowing. Dr. Condie advises the repeated application of nitrate of silver ; others, repeated small blisters exter- nally ; others, their removal by operation. Professor Hess, of Copen- hagen, states that he has employed compression, by means of the index finger applied to the indurated tonsil, with success. This to be repeated three or four times a day ; and when the gland becomes softer, and ab- sorption commences, gargles may be used. 2 Each of these plans may succeed, and we may try any or all of them, but I would also suggest 1 Diseases of Children, p. 451. 2 Banking's Abstract, vol. ii. p. 192. 464 PAROTITIS. that the internal application of the caustic tincture of iodine, as well as the external use of the ointment, should have a fair trial previous to any operation. I have seen it very successful in several cases. As to the removal of the tonsils, I should be strongly opposed to such an operation during childhood, as it is by no means generally successful, and may leave consequences more troublesome than the disease. I do not, therefore, think it necessary to occupy the reader's time by a de- scription of the mode of operating. As to the prophylactic treatment, it is desirable, of course, that children liable to this affection should avoid all occasions of cold, and on the first sensation of sore throat should be treated with external stimulating applications to the throat, such as mustard poultices, tur- pentine, compound camphor liniment, &c, and purgatives. CHAPTER IX. PAROTITIS. — CYNANCHB PAROTIDEA. — MUMPS. 664. This is a very common disease, although it rarely attacks very young children, seldom those under five or six years of age, and, ac- cording to Dr. West, more frequently boys than girls ; but this does not accord with my experience. It consists of inflammation of the parotid gland of one or both sides, occurring together or separately ; and during certain seasons it prevails epidemically, as in Dublin and other parts of Ireland this last winter. Dr. Stewart seems to regard it as one of those diseases which a child must generally have once in its life, but which rarely occurs a second time. 665. Symptoms. — In the majority of cases the child seems suffering under a feverish cold for a few days before the local symptoms display themselves ; it is chilly, uncomfortable, cross, and complains of aching of the limbs, followed by feverish heat of skin, quick pulse, thirst, &c, and then pain is felt about the angle of one or both jaws, and difficulty of opening the mouth to speak or masticate. In other cases we have no preliminary feverishness, but the disease commences at once by pain or swelling at the angle of the jaw. The pain is soon followed by tumefaction behind the angle of the jaw, extending upward to the ear, forward a little on the cheek, and down- wards to the maxillary gland, involving the parotid gland and the sur- rounding cellular tissue. It feels firm, hard, and hot, is painful on pressure, but generally speaking the color of the skin is unchanged ; in severe cases it becomes slightly red or pink. Not only is there irregularity of the two sides of the face thus pro- duced, but I have seen the lower jaw temporarily displaced, and pushed over towards the sound side. There is great pain and difficulty in opening the mouth and in moving PAROTITIS. 465 the jaw, either to masticate or to swallow, although the dysphagia is evidently not from sore throat. One or both sides of the face may be thus affected, or, after the sub- sidence of the one, the opposite may succeed to the swelling; and it is from the extraordinary expression of sullenness thus given to the coun- tenance that the name "mumps" has been given to the disease. 666. If the attack be mild, the fever, swelling, and pain, will be moderate, and after a few days will subside without the child having suffered much distress; but in some of the severe cases the suffering is very great; the tumor is very large, hard, and exquisitely tender; the skin covering it of a reddish tinge; the difficulty of opening the mouth so great that the child can scarcely take food, and even when in its mouth, it is almost impossible to swallow it. The fever runs very high, the pulse is full and rapid, and the brain is more or less involved, with delirium, &c, which have occasionally proved fatal, according to Dr. Cullen. Moreover, in such cases the swelling extends far beyond the parotid glands, and involves not merely the surrounding cellular tissue, but the submaxillary glands, and the suffering and distress are very great. Such cases are, fortunately, rather uncommon. 667. A remarkable peculiarity of mumps is the disposition to metas- tasis. The pain and swelling of the parotid gland will sometimes suddenly subside, and the mammae in girls, or the testes in boys, become instantly affected with severe pain, swelling, and tenderness. "In the male," says Dr. Dewees, " we once saw the testes prodigiously enlarged; much suffering was endured, and great hazard was incurred by the change. Violent fever and delirium accompanied this change of seat of the disease, and it required a perseverance in very active remedies to subdue them." 1 The same was observed by MM. Eilliet and Benguier. It has been stated by Dr. Hamilton and others that this metastasis to the testes has been followed by the absorption of the gland, so that the tunica vaginalis became an empty sac. The breasts in female children become very painful, hard, and swollen, but it does not appear that they are liable to the same wasting away afterwards, nor do they run on to suppuration. Again, a similar metastasis may take place, and the brain or its mem- branes become the seat of the secondary attack ; and this is more frequent, Dr. Stewart thinks, in those cases where no metastasis to the testes or mammae takes place. This cerebral metastasis is highly dan- gerous. The child is attacked by coma or delirium, and may die in a few hours if prompt measures be not taken for its relief. Two cases of this kind are recorded by Dr. Harvey Luidsly which proved fatal. In one of them there were decided marks of inflamma- tion and congestion of the cerebellum, but none in the cerebrum. 2 668. The dilation of the disease varies much. In some cases the swelling, pain, and fever reach their maximum in forty-eight hours, and then begin to subside ; in others, not till the fourth or fifth day, and 1 Diseases of Children, p. 143. 2 Araer. Med. Journ., April 1851, p. 542. 30 466 PAROTITIS. some are prolonged to ten or twelve days. The disease is lengthened, also, in those cases in which the two glands are successively attacked. In by far the majority of cases, the attack terminates in resolution, after the height is reached ; the fever and pain subside, the swelling diminishes, and the tenderness gradually disappears. But in some rare cases suppuration takes place, and matter makes its way to the surface. 669. Causes. — Cold from damp clothing, damp beds, &c, seems to be the principal cause, where the disease is not epidemic. And in damp, marshy situations those attacks seem to be endemic, and owing to the same cause. But it prevails, also, epidemically and very extensively during damp weather, especially in winter and spring. During the spring of 1849 it was very generally epidemic in Dublin and other parts of Ireland. I heard of one school in which there were twelve, another in which there were sixteen children affected at one time, and there are probably few practitioners of this city who had not abundant opportu- nities of witnessing different children of the same family attacked to- gether or successively. M. Rilliet has published an account of an epidemic which prevailed at Geneva from March 1848 to May 1849, principally among children between five and fifteen years of age. He believes it to be contagious and analogous to eruptive fevers. An epidemic also occurred in Montpellier in February, March, April, and May 1818, and has been described by M. Ressiguier. 1 Whether it really be contagious at the time when it is epidemic, as Dr. Stewart and M. Rilliet and others suppose, is a question not so easy of solution as might be supposed, because, although children of the same family are undoubtedly exposed to the influence of contact, they are also ex- posed to exactly the same epidemic causes. 670. Treatment. — The treatment required by simple cases of paro- titis is very slight. We may administer an emetic, or a brisk purga- tive, followed by calomel and antimonials in small doses, with fomenta- tions or poultices to the tumefied jaw, and these may be sufficient. But when the swelling is considerable, the pain great, and the fever high, it will be necessary to apply leeches to the part affected, and to continue the poultices constantly, fomenting the jaw with hot water or decoction of poppy-heads whenever the poultice is renewed. The purgative may be repeated occasionally, and the James's Powder, with or without the calomel, continued until the inflammation begins to subside. Pediluvia at bedtime, or an occasional warm bath, will be found very useful. When the testicles or mammse are attacked, it will be necessary to apply leeches, fomentations, or poultices, according to the amount of inflammation. When this metastasis takes place, it has been thought advisable by some writers to apply blisters, or irritants of some kind, over the original seat of the mischief, for the purpose of bringing back the inflammation to the parotid gland. Dewees remarks : " We have always blistered the parts immediately over the parotids, and we think with decided advantage." Dr. Condie, however, does not believe that - 1 Gaz. Med., 1850. Brit, and For. Rev., Oct. 1850. PAROTITIS. 467 any good can result from tins practice, and I am induced to agree with him ; at least I have never found it necessary. When the brain is attacked, it will be necessary to meet the increased danger very promptly and actively, by the usual means of leeching, cold lotions, blisters, calomel, and James's powder, with occasional purgatives, &c. 671. During the prevalence of mumps this last winter, I have seen a disease which might easily have been mistaken for it, but which is, in truth, inflammation of the cellular tissue in the neighborhood of the parotid, and which often ends in abscess. It has been noticed by Dr. Good as phlegmone parotidsea, and by Mr. James as angina externa. In the beginning it is very like parotitis ; there is pain, soreness, and swelling near the angle of the jaw, but of one side only ; great difficulty in opening the mouth ; pain in mastication ; and febrile excitement ; but the tumor is generally below the parotid, more superficial, and the skin is more discolored. In some cases the inflammation is deeper seated and more extensive, the tumor occupying, as Dr. Condie observes, the front of the throat from ear to ear, with oedema of the face occa- sionally. Suppuration generally takes place ; the swelling becomes more prominent at one part, and paler generally ; softening occurs ; fluctuation is felt ; and ultimately the abscess bursts, or is opened, and the tumor gradually disappears. " Instead of a circumscribed inflammation and suppuration, the inflammation is occasionally deep-seated and diffused, and the pus, when it forms, is then liable to extend under the angle of the jaw to the pharynx, or downwards into the upper part of the thorax, producing extensive destruction of the cellular membrane about the neck, and great distress to the patient." When suppuration takes place, the swelling acquires a doughy feel, and an indistinct fluctuation may be perceived at one or more points. The matter is slow in arriving at the surface, and in discharging itself externally. In some instances, dis- tinct, deep-seated collections of matter form, and the pus, mixing with the dead cellular membrane, becomes putrid, and the evolution of gas thus produced causes a kind of emphysematous condition of the parts. The febrile symptoms now assume a low, typhoid character, the strength of the patient is rapidly exhausted, and death very generally ensues ; or, if recovery takes place in these extreme cases, an extensive and unsightly cicatrix deforms the patient for life." 1 672. In cases of the simple phlegmonous inflammation, a few leeches should be applied to the tumor, followed by poultices, fomentations, and a brisk purgative. Dr. Condie recommends a cold lotion after the leech-bites have ceased bleeding. The patient must be kept on low diet. Whenever suppuration has taken place, and fluctuation can be detected, the abscess should be freely opened, and poultices continued after the free evacuation of the pus. With a little care, we may generally arrange the opening so that no mark shall be visible after- wards. When the inflammation is diffused, the early stage will demand a 1 Condie on Diseases of Children, p. 192. 468 PSEUDO-MEMBRANOUS PHARYNGITIS. similar treatment ; but as soon as the swelling acquires a doughy feel, especially if there be difficulty of swallowing, impeded respiration, or cou^h, it will be advisable to make free incisions into the tumor, and then to apply poultices. If the child be much reduced, we must allow better diet, and perhaps, in some cases, wine and bark. CHAPTER X. PSEUDO-MEMBRANOUS PHARYNGITIS. — DIPHTHERITE. — ANGINA PSEUDO- MEMBRANOSA. 673. In a former chapter I described simple or erythematous pha- ryngitis, under the name of cynanche tonsillaris, or at least the descrip- tion of the one may stand for the other, for any difference between them is almost imaginary. Now we have to do with a more serious affection, having much more complicated relations ; essentially an inflammation of the mucous mem- brane of the pharynx, but which is accompanied by a secretion of coagulable lymph or false membrane, with or without a breach of the mucous surface. The disease appears to have prevailed from very early times. Are- tseus mentions it as a complication of croup ; P. Forest observed an epidemic at Alkmar, in Holland ; it appeared in Spain in the seven- teenth century ; at Naples in 1618 ; and about 1686, at Kingston, in America. A similar epidemic prevailed in Paris, from 1743 to 1748, and has been described by MM. Malouin and Chomel ; in England about the same time, and at Cremona. I cannot agree, however, with Rilliet and Barthez, that the "putrid sore throat" of Br. Fothergiil was diphtherite ; but rather gangrenous pharyngitis. We are mainly indebted for our knowledge of the disease to the labors of Dr. S, Bard, of New York, 1 M. Bretonneau, of Tours, M. Deslandes, and Rilliet and Barthez. But it is not merely as an idiopathic or primary disease that this diphtheritic affection is to be considered; it forms a very important complication of several diseases, particularly the eruptive fevers. We must, therefore, examine into its characteristics, both when primary and when secondary. 674. Symptoms. — Primary pseudo-membranous pharyngitis may commence very mildly, not unlike common sore throat, with a slight febrile excitement, or without any, the appetite and strength being but little deranged. Or in some cases the fever may be more intense, with general uneasiness, aching of the limbs, thirst, &c. ; and shortly after- wards the child will complain of soreness of the throat, increased by swallowing, especially if the bulk be small. 1 Trans, of American Philosophical Society, vol. i. PSEUDO-MEMBRANOUS PHARYNGITIS. 469 In the majority of M. Bretonneau's and Rilliet and Barthez's cases there was but little fever, but in a few cases (four altogether) the fever was intense. The epidemic character may also modify this peculiarity ; thus, in the one described by Dr. Bard and M. Ferrand, 1 there was no fever, but in the observations of M. L'Espine 2 it was intense. Pain in the pharynx is rarely severe ; it is felt at the beginning chiefly, but it does not go on increasing; sometimes it is absent alto- gether, and I may say the same of the distress in swallowing. I have seen it very considerable, with a sense of heat and local soreness, and I have also seen it entirely wanting. This is the experience of M. Bretonneau. 3 " The voice is commonly obscure and nasal, but not hoarse or whisper- ing, unless the disease extends into the larynx, in which case the symp- toms will be those of croup, already described. Cough sometimes exists, but it usually resembles in sound that produced by the action of hawking rather than a common cough, and is altogether different from the tone of the cough of laryngitis." 4 For a short time after the commencement of the disease, if we ex- amine the throat, we shall discover some redness and swelling of the tonsils, but we shall shortly perceive patches of coagulable lymph here and there on these organs, of a white or yellowish-white color, more rarely gray, with thin edges, and which, coalescing, cover the tonsils, palatine vault, and pharynx, with this lardaceous false membrane. Not only does it spread gradually over the neighboring parts, but it also in- creases in thickness, until the parts affected seem as if covered with curd, not evenly, and as if by a continuous membrane, but by patches, some large and some small, giving to the surface a lichenoid appearance, as M. Bretonneau justly describes it. Occasionally they present the aspect of a deep ulcer or fissure. More or less they will be found to cover the uvula, the tonsils, and the pharynx. Sometimes in the latter situation the layer is semi-transparent, or it may be covered with mucus, either of which circumstances may at first deceive us as to the existence of the false membrane. After the lapse of a few days, the false membrane begins to detach itself, not regularly, but here and there, leaving the mucous surface smooth and bright red ; or it may become gradually thinner, until it entirely disappears, and then, in many cases, it is renewed more or less completely, and is again thrown off, until the disease is cured. Rilliet and Barthez state that in twenty-one cases the false mem- brane occupied the tonsils only in six; the tonsils and some part of the velum palati, in four ; the tonsils, the vault of the palate, and the pha- rynx, in six ; the tonsils and the pharynx, in five. 675. The false membranes, and the parts covered by them, sometimes present a much more alarming aspect than the one just described. They appear as gray, reddish, or blackish shreds, attached to the ton- sils or palatine vault ; the soft parts of the fauces appear sphacelated ; the vault of the palate, the tonsils, and the mucous membrane of the 1 Thesis, 1827, p. 8. z Archives Gen. de He'd., 1830, vol. xxiii. p. 521. 2 De la Diphtherite, p 113, &c. 4 Meigs on Diseases of Children, p. 208. 470 PSEUDO-MEMBRANOUS PHARYNGITIS. pharynx seem detached in part, and there are gray patches, with violet- colored edges, resembling gangrenous eschars. The breath becomes very fetid, and there is profuse salivation. 1 This form is rare, and resembles the putrid sore throat of Fothergill and others, in many points. 676. Four or five days after the appearance of the false membranes, we find the submaxillary glands become painful, swollen, and tender, especially on that side on which the inflammation is most intense. The cellular tissue of the neck may also become affected, and the neck increase in volume considerably ; but this seems to be more owing to infiltration of serum than to inflammation. When the progress of the disease is favorable, the false membranes are thrown off, and not repro- duced ; the swelling of the submaxillary gland subsides, the redness of the mucous membrane disappears, and in eight or ten days the disease is cured. Cases may, however, terminate unfavorably by the extension of the false membranes to the air-passages, giving rise to croup, &c, or the disease may assume a typhoid type, but whether from the poisoning caused by the absorption of the putrid secretions, as supposed by M. Bourgeois, 2 or not, may be doubtful. "In the commencement of the disease the tongue is pointed, red at the edges, and covered on its surface with a thin layer of white mucus, through which the enlarged and florid papillae protrude. There is an increased secretion of saliva, which soon becomes dark-colored, from an admixture of blood discharged from the mucous membrane as portions of the pseudo-membranous deposit are detached, and of an offensive odor, from the vitiated state of the secretions of the throat and mouth." 3 When the attack is severe, there is considerable fever, with heat of skin, quick pulse, difficulty and pain in swallowing ; if the disease ex- tend upward into the posterior nares, the child cannot breathe through the nostrils ; and if into the Eustachian tube, the hearing will be imper- fect, or perhaps complete deafness may be produced. So far, then, we find primary diphtheritis to be characterized by a few and unimportant general symptoms in the majority of cases ; by a certain amount of fever, loss of appetite, soreness of throat, and pain in swallowing, in others ; and in all, by inflammation of the mucous membrane of the pharynx and neighboring parts, with a deposition of coagulable lymph, or curdy false membrane. 677. Secondary diphtheritis exhibits the following modification of these symptoms, according to Rilliet and Barthez : "1. It commences by vivid and general redness and swelling of the palatopharyngeal mucous membrane. 2. After an uncertain time, there appear upon the tonsils small whitish or yellow patches, in general thin, superficial, and easily detached ; most frequently limited to the tonsils, occasionally involving the uvula and palate, and more rarely the pharynx. Ac- 1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 291. 2 Journal Gen. de Med., vol. cix. p. 441. 3 Condie on Diseases of Children, p. 181. PSEUDO-MEMBRANOUS PHARYNGITIS. 471 cording to authors, we find that the false membranes of secondary pharyngitis, and particularly in scarlatina, may assume a gangrenous appearance, having a strong resemblance to some already noticed. 3. The swelling of the submaxillary gland is the same. 4. The pain, often more intense than in the primary form, exhibits the same characteristics. 5. The fever, always more intense, most generally is dependent upon the original disease." 1 678. Morbid Anatomy. — According to Bretonneau, the false mem- branes may sometimes be found on the first day of the disease, gene- rally somewhat later. They first appear as whitish or yellowish patches on the tonsils, circumscribed and resembling flakes of curd ; increasing in number and extent, they coalesce more or less completely. They adhere sufficiently firmly to the mucous membrane, vary in thick- ness, and increase by additional layers. Occasionally they are mixed with blood, and acquire a gray or brown color, which has led to the supposition of their being gangrenous. They are in direct contact with the mucous membrane, and are not covered by epithelium, according to Bretonneau, Rilliet and Barthez. The mucous membrane beneath the deposition is more or less injected and red, and often presents spots of ecchymosis. Rilliet and Barthez and Guersent conceive that in some cases there is loss of substance from ulceration ; such cases, however, are very rare. The submaxillary glands are enlarged, but rarely sup- purate ; their tissue is tender, homogeneous, and of a whitish-red color at an early period, and resembling the structure of the kidney at a more advanced stage. 679. In secondary diphtheritis, we find the mucous membrane of a bright red, rough and unequal, much thickened and softened ; the ton- sils enlarged, soft, and irregular; not unfrequently, also, we find a breach of surface : ulcerations of various forms extend in different direc- tions, deep or superficial, with level or raised edges, and healthy or unhealthy surfaces. False membranes may be generally observed at different points ; seldom over the entire fauces. They are generally thin, soft, and fragile, of a whitish, grayish, or yellowish color, and mixed with puru- lent matter. Sometimes the false membranes occupy the superior or inferior part of the pharynx, the intermediate portion being intensely inflamed, and covered with purulent matter. The submaxillary glands are enlarged, red, and soft. Considerable difference of opinion prevails as to the pathological character of the disease. Bretonneau, Guersent, and others, maintain that it is a specific inflammation ; Broussais and Emmangard, that it is a gastro-enteritis; Joly, that it is a hemorrhagic inflammation, in which colorless fibrine is exuded upon the inflamed surface ; Naumann attri- butes it to a change in the condition of the blood, in consequence of which the albuminous portion is separated and exuded ; and Andral regards the disease as hypersemia of the fauces, with exudation of coagu- lable lymph. 1 Mai. des Enfans, vol. i. p. 295. 472 PSEUDO-MEMBRANOUS PHARYNGITIS. The latter is, no doubt, a true expression of the fact ; hut neither that nor any of these opinions deserve the character of an explanation of the nature of the disease. For fuller details, I must refer the reader to M. Bretonneau's elabo- rate work. 1 680. Complications. — These are of two kinds, those which consist of an extension of the same disease, and those which result from the gene- ral condition of the patient. I. The secretion of false membranes may not be limited to the pha- rynx, but may extend itself to the nasal apertures, or into the larynx, trachea, and bronchi. This coincidence and succession is very remark- able in some epidemics. M. Bretonneau states that the angina or co- ryza appears first, then the laryngitis, then bronchitis. It is very rare that this order is reversed, and still more rarely does the disease appear in different parts simultaneously. It is especially in an epidemic that these complications occur. I am not prepared to speak positively as to the extension of the diphtherite to the stomach and intestinal canal, but I confess I think it extremely probable; for we find shreds of what looks like the false membrane voided by stool in cases of this disease; and most, I suppose, have seen the diphtheritic deposit around the anus. ii. The disease may also attack remote parts of the body, particu- larly parts covered by mucous membrane, or from which the cuticle has been removed by a blister, according to M. Trousseau. Thus, the pseudo-membranous secretion may be observed upon the lips, alse nasi, the concha, the external meatus behind the ear, in the groin, on the nipples, &c. in. Another elass of complications, dependent upon some peculiar state of the constitution, consists of hemorrhages, which, however, are absent in some epidemics, though very common in others. For instance, Bre- tonneau makes no mention of it, whilst Bourgeois and Lespine found it a common occurrence, either from the nose, from the mucous membrane, or from the skin, and to such an extent as to occasion death. iv. M. Bretonneau relates a case of the present disorder complicated by gangrene of the pharynx. v. M. Guersent has remarked that from the third to the seventh day the patient may be attacked by broncho-pneumonia or catarrhal pneumonia, which at its commencement is very insidious, and apt to be masked by the symptoms of the angina. These are the chief complications. Other diseases, as enteritis, ery- sipelas, or the eruptive fevers, may occur, but they can only be regarded as coincidences. 681. Causes. — That the same causes which give rise to simple pha- ryngitis may be influential in causing the present disease one can hardly doubt ; but it seems in general that something additional is requisite for its production. The crowding together of children in a close habi- tation may give rise to it, as was observed at St. Denis, by M. Bourgeois, 1 Des Inflam. speciales du Tissu Muqueus et en particulier de la Diphtherite, &c, pp. 240, et scq. PSEUDO-MEMBRANOUS PHARYNGITIS. 473 Most frequently, however, the disease prevails as an epidemic, and those cases which would otherwise be simple pharyngitis take on this character, and exhibit the curdy disposition. Besides the epidemics which I have mentioned at the beginning of this chapter, M. Bretonneau mentions their prevalence at Tours in 1818 and subsequent years; M. Girouard, at Sancheville, in 1824; M. Ferrand, in 1825, at La Chapelle-Veronge ; M. Guimier, at Vouvray, in 1826 ; M. Bourgeois, at the establishment of the Legion of Honor at St. Denis, in 1827-8 ; M. Trousseau, at Sologne, in 1828 ; by M. Baud, in the Canton de Vaud ; by M. L'Espine, in the Royal Military School of LaFleche, in the same year; and in the State of Ohio, by Dr. Welsh, in 1847-8-9. 1 Some difference of opinion prevails as to whether the disease is con- tagious. From the facts collected by M. Guersent, from his own expe- rience and that of others, he has come to the conclusion that it is, and in this opinion Rilliet and Barthez concur. In its secondary form, the disease may occur in the course of scar- latina, typhus fever, measles, remittent fever, &c, adding much to the distress of the patient, and sometimes to the clanger of the primary affection. 682. Diagnosis. — I. The presence of the false membrane will distin- guish diphtherite from simple or erythematous pharyngitis, although, on the first day of the attack, the aspect of the parts may be precisely the same. II. The peculiar characters of gangrene of the pharynx are equally Well marked, and so different from diphtherite that there is little danger of our confounding them ; the gangrenous eschar and odor, the loss of substance, and the absence of false membrane on the neighboring parts, are very characteristic, not to mention the difference in the symptoms and history of the two cases. Moreover, gangrene generally attacks children previously debilitated by disease, whereas primary diphtherite may occur in children who, up to that time, have been perfectly healthy. No doubt the two diseases may attack the same child, but it is certainly a coincidence only. 683. Prognosis. — The prognosis of the disease will depend very much upon the extent of the disease, its complications, the state of the child's constitution, and the character of the epidemic. If the attack be limited to the pharynx, and occur sporadically, it is generally easily cured, according to MM. Bretonneau, Guimier, and others; although in one such case related by Bretonneau, and another by Rilliet and Barthez, death took place. When the false membranes extend into the larynx and trachea, we shall have croup with all its danger ; and when the skin takes on an inflammatory action, with or without false membrane, as in the epidemic described by M. Trousseau, death may occur from exhaustion. A like result may follow in those cases in which the disease appears at the oppo- site extremity of the mucous membrane, the vulva, or anus. In secondary diphtherite, the danger will probably depend more upon 1 American Jourii. of Med. Science, July, 1850, p. 276. 474 PSEUDO-MEMBRANOUS PHARYNGITIS. the primary disease, although, doubtless, the secondary affection will in- crease it. 684. Treatment. — The indications of cure are not quite so simple as in the previous affections. Much will depend upon the extent of the disease, its disposition to penetrate into the larynx and trachea, the constitution of the child, and upon the character of the epidemic when the disease prevails extensively. Most writers, also, dwell upon the greater importance of topical applications. The principal caustic applications which have been employed are muriatic acid, nitrate of silver, powdered alum, and the chloride of lime ; and they are said to act both by preventing an extension of the false membrane, and also by changing the character of the inflammation. M. Bretonneau used the first of these applications ; and he recommends two thorough cauterizations, at an interval of twenty-four hours, after- wards milder applications. M. Guersent substituted the nitrate of silver for the muriatic acid ; but in using this we must take care that the stick is not broken and swallowed. The chloride of lime, calomel, or alum, can easily be applied to the diseased surface, either by the finger or by a small roll of lint. Some one of these remedies should be applied as soon as the distinct- ive characters of the disease appear, or as soon as the patient is placed under our care, and repeated as often as we may find necessary, judg- ing from the change produced by it. 685. If the case be a slight one, occurring sporadically, and the child in good health otherwise, an emetic may be at once administered, the bowels properly freed, and the throat painted with a solution of nitrate of silver every day or every second day ; which will probably be sufficient to cure the disease. But if the case be more severe, the inflammation and swelling greater, and the child of a robust constitution, it will be well to commence with the application of a few leeches to the throat, followed by poultices. Broussais, Emmangard, and others, have ordered the application of leeches to the epigastrium ; but unless there were decided tenderness in that region, I do not think it would be necessary ; and in no case should blood be abstracted when there are symptoms of depression or exhaustion. After the application of leeches, the case must be treated by caustics, purgatives, and perhaps by an emetic. In the intervals of cauterization, the vapor of hot water may be inhaled three or four times a day, or a slightly acidulated gargle used equally often. Internally, small doses of calomel will be found useful, either alone or in combination with ipecacuanha. Emollient drinks, iced water, lemonade, or acidulated water, should be allowed, and an occasional warm bath or pediluvium will greatly add to the comfort of the patient. There is much difference of opinion as to the propriety of blistering the throat, and I confess that I agree with those who object to it as a rule. I do not deny that there are some cases which appear benefited by it, but in general I should much prefer simple poultices, or, if we wish to excite irritation, poultices of mustard and linseed meal, or a lini- ment sufficiently strong to redden the skin. PUTRID SORE THROAT. 475 686. If the disease be epidemic, but not exhibiting a typhoid character, the treatment will be nearly the same ; a little more caution in apply- ing leeches, the prompt use of caustics, and their repetition each day until the surface exhibits an altered appearance, the exhibition of calo- mel, mild purgatives, emollient or acidulated drinks, &c. will be equally necessary. But if the epidemic show a typhoid character, we must make a consider- able change from the above plan. The parts must be cauterized, and the bowels kept free, but we must carefully abstain from bleeding, and from everything calculated to lower the system. For this form of the disease, a very useful gargle may be made with decoction of bark and nitric acid, from twenty to fifty drops of the latter to half a pint of the former. And in addition to this, we must administer bark, or ammonia, or both, internally, with a liberal use of wine, according to the circum- stances of the child. Wendt advises enemata of decoction of bark, and Rilliet and Barthez concur with him. The diet must be regulated according to the character of the attack : if there be much fever and acute inflammation, it should be mild and spare ; but when typhoid symptoms are present, the strength must be supported by beef-tea, broths, &c. CHAPTER XL PUTRID SORE THROAT. — GANGRENOUS ULCERATION OF THE PHARYNX. 687. There exists considerable confusion among writers as to this disease ; some having described under this name an aggravated form of diphtheritic sore throat, attended by dark-colored crusts, bad smell, &c; and others on the opposite side having nearly denied the existence of such a disease. M. Bretonneau, I think, has proved that the angina maligna of many writers was a modification of diphtherite, but the ob- servations of M. Becquerel, MM. Rilliet and Barthez, and others, leave no doubt of the occasional occurrence of gangrenous ulceration; and, notwithstanding the opinion of the last-named writers, to which great respect is due, I cannot but believe that the "putrid sore throat" de- scribed by Dr. Fothergill, of London, was really this disease. 1 He states that the disease was first noticed in London, and that it re- appeared in 1742. Again, in the winter of 1746, " so many children died at Bromley, near Bow, in Middlesex, of a disease that seemed to yield to no remedies or applications, that several of the inhabitants were greatly alarmed by it, some losing the greater part of their children after a few days' indisposition. Some others of the neighboring places were affected at the same time with the like disease, which, from all the 1 First published in 1748, and now included among Lis collected -works, p. 167. 47b PUTRID SORE THROAT. accounts I have met with from those who attended the sick, was that here treated of. I am informed likewise that it raged at Greenwich at the same time." Gangrenous ulceration may attack the throat as a primary disease in children hitherto healthy, as in a case lately under my care ; but it much more commonly supervenes in the course of other diseases ; or ulceration of the mouth, previously existing, whether simple or aphthous, may assume a gangrenous character and appearance. 688. Symptoms. — The disease may commence like a common sore throat, with some degree of fever, rigors, heat of skin, quick pulse, weariness, &c, but without exciting any alarm ; and the patient may then complain of soreness of the throat, pain and difficulty of swallow- ing, &c. On examination we find at first the pharynx and tonsils swollen, and of a dusky red, with perhaps a spot of commencing ulcer- ation, which enlarges daily, and shortly presents its peculiar characters. Or, as in Dr. Fothergill's cases, it may come on "with such a giddi- ness of the head as commonly precedes fainting, and a chilliness or shivering like that of an ague fit; and these interchangeably succeed each other during some hours, till at length the heat becomes constant and intense. The patient then complains of an acute pain in the head, of heat and soreness rather than pain in the throat, stiffness of the neck, commonly of great sickness, with vomiting or purging, or both. The face soon after looks red and swelled, the eyes inflamed and watery, as in the measles, with restlessness, anxiety, and faintness. The dis- ease frequently seizes the patient in the forepart of the day. As night approaches, the heat and restlessness increase, and continue till towards morning, when, after a short, disturbed slumber (the only repose they often have during several nights), a sweat breaks out, which mitigates the heat and restlessness, and gives the disease sometimes the appear- ance of an intermittent. If the mouth and throat be examined soon after the first attack, the uvula and tonsils appear swelled, and these parts, together with the velum pendulum palati, the cheeks on each side, near the entrance into the fauces, and as much of them and the pharynx behind as can be seen appear of a florid red color. This color is com- monly most observable on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this red- ness, a broad spot or patch, of an irregular figure and of a pale white color, is sometimes to be seen, surrounded with a florid red, which white- ness commonly appears like that of the gums immediately after having been pressed with the finger, or as if matter ready to be discharged were contained underneath." "The appearance in the fauces continues to be the same, except that the white places become more ash-colored; and it is now discernible that what at first might have been taken for the superficial covering of a suppurated tumor, is really a slough concealing an ulcer of the same dimensions." 1 Dr. Fothergill mentions other symptoms worthy of notice. The first is an erythematous eruption on the face, neck, hands, and breast, with some tumefaction, and occurring generally on the second day. Another phenomenon is a swollen, hard, and painful condition of the parotid 1 Works, pp. 202-205. PUTRID SORE THROAT. 477 glands on each side ; and if the disease be violent, the neck and throat are surrounded with a large cedematous tumor, sometimes extending itself to the breast, and, by straightening the fauces, increasing the danger. Delirium was a frequent symptom in those cases ; occurring the first night, bearing a direct relation to the feverish exacerbations, and equally relieved by the perspiration which broke out towards morning. The pulse was very quick for some days, but although the uvula and tonsils were much inflamed, the difficulty of swallowing was less than might have been expected. The offensive putrid smell was not only evident to those around, but even to the patient himself. In severe cases the disease extended to the inside of the nostrils, which was of a deep red or livid color, and a putrid sanies was discharged, so corrosive as to excoriate the parts over which it flowed. The lips also, and the margin of the anus, occasionally exhibited the same appearance. Dr. Fothergill thinks it probable that the diarrhoea may be owing to this discharge being swallowed. Hemorrhages from the nose, mouth, and ears sometimes occurred ; in general to a moderate amount, but in some cases proving suddenly fatal. They seemed to result from the injury of some arterial branch by the ulceration. The duration of this disease was variable. Some seemed to mend after the second day; others continued three, four, or six days, even when favorable, and the decline of the disease was marked by the dis- appearance of the eruption, the subsidence of the pulse and fever, and the throwing off of the sloughs, and the more healthy appearance of the ulcers. In unfavorable cases the diarrhoea persists ; " they generally spit very little ; the fauces appear dry, glossy, and livid; the external tumor grows large ; they void their excrements without perceiving it, and fall into profuse sweats ; respiration becomes difficult and laborious ; the pulse sinks ; the extreme parts grow cold ; and death in a few hours closes the scene." 1 689. If, as appears to me, this disease were really gangrene, it wa3 the primary form, and differed very widely in the acute character of its symptoms from the secondary form described by Eecquerel, Guersant, Rilliet and Barthez, &c. In the latter the chief general symptoms resulted from the primary malady, whatever that might be, but the occurrence of the gangrene was chiefly marked by a profound alteration of the countenance, great depression, and the small, quick pulse. Loss of appetite, thirst, and diarrhoea also existed, but they may have been the result of the original disease as well as of the gangrene. The local symptoms were often obscure and sometimes uncertain. The fetid odor of the mouth was invariable, and of great value in those cases where the ulcer could not be seen, either from its situation or the difficulty of opening the mouth. In none of Rilliet and Barthez's cases did the patient suffer any pain, and deglutition was easily effected, and not marked by the regurgitation of liquids through the nose. In one case, where the gangrene was con- 1 Works, p. 229. 478 PUTRID SORE THROAT. siderable, the patient drank and ate solid food until the day of her death. M. Guibourt mentions that one of his patients suffered severe pain and difficulty of swallowing; and in a case of M. Constant's, the patient incessantly put his finger into his mouth, as if to remove something that annoyed him. The swelling of the submaxillary glands, and of the cel- lular tissue, was not remarked except in one case, nor the abundant, fetid, sanious salivation. As we might expect, the course of so serious a disease supervening upon another complaint, and in constitutions so enfeebled, is very rapid ; sometimes, too, three or four days terminate life, and the case rarely passes the sixth. 690. Complications. — Of course, in secondary gangrene, some of the concomitant diseases which have been noticed were merely coincidences; nevertheless certain of the complications appear to be either an exten- sion of the disease, or closely connected with it. I. The gangrene may extend gradually to the neighboring parts, the nares, the mouth, the oesophagus, or the larynx. II. Even distant organs may exhibit a similar morbid action ; thus the uvula externally, or the lungs internally, have been attacked by gangrene during the course of gangrene of the pharynx. III. M. Guibourt mentions a case in which oedema of the glottis occur- red. iv. Pneumonia may occur, but it is less frequent than in gangrene of the mouth. V. In nine out of twelve cases there were tubercles in the lungs, but this we must regard merely as a coincidence. vi. I have already alluded to the occurrence of fatal hemorrhage in Dr. Fothergill's cases. I have seen the child seriously weakened by it, though not destroyed ; but Dr. Mills has related two cases in which death occurred suddenly from this cause. 1 691. Morbid Anatomy . — At the commencement of primary gangrene we find the mucous membrane of a florid or deep red color, with a white or ash-colored spot, according to Dr. Fothergill, or with an unhealthy looking ulcer at a somewhat later period. This ulcer may occupy one or both tonsils, the back of the pharynx, the posterior nares, or the commencement of the oesophagus; and as the disease advances we shall probably find it extending on either side : I have seen the uvula, velum, and soft palate entirely destroyed by it. The surface, at first grayish or ash-colored, gradually becomes dark brown. Dr. Fothergill ob- serves : " When the disease is of the mildest kind, a superficial ulcera- tion only is observable, which may casually escape the notice of a person unacquainted with it. A thin, pale, white slough seems to accompany the next degree ; a thick, opaque, or ash-colored one is a further ad- vance ; and if the parts have a livid or black aspect the case is still worse. These sloughs are not formed of any foreign matter spread upon the parts affected as a crust or coat, but are real mortifications of the substance, since, whenever they come off or are separated from the 1 Edin. Med. and Surg. Journal, Jan. 1814. PUTRID SORE THROAT. 479 parts they cover, they leave an ulcer of greater or less depth, as the sloughs were superficial or penetrating." 1 A dark reddish-brown hue may be given to the slough by the oozing of blood, but the brown color may exist independently. The odor is fetid, overpowering, perceived even by the patient, and rendering the room intolerable. . Portions of the slough may be cast off, but it is rapidly reformed ; the surface underneath has generally an unhealthy appearance. 692. The secondary gangrene described by the French writers I have named may be either circumscribed or diffused. I. Circumscribed Gangrene generally occupies the lower portion of this canal, near its junction with the oesophagus, either on its posterior or anterior surface, and consequently it is not within view during life, and we are mainly left to infer it from the putrid smell, and the acces- sion of the symptoms I 'have mentioned. The gangrenous spots are sometimes oval, sometimes round, varying in size from a pea to a shil- ling, and it is very probable that the larger are formed by the coalesc- ing of several smaller ones. The surface of these patches is depressed, gray, blackish, or quite black, the edges clear cut and yellow, and with the characteristic gangrenous smell. Beneath the slough the mucous membrane and subjacent tissue are destroyed, and so deeply, in some cases, that the muscles are clearly ex- posed. The surrounding mucous membrane appears unchanged, neither red, nor thickened, nor softened. When the slough is thrown off we find an ulcer with more or less loss of substance, and which is occasionally covered afterwards by a layer of false membrane. However limited and superficial the gangrene may be at first, it may ultimately penetrate into the larynx or extend to the epiglottis ; or it may be confined to one or other tonsil. ii. Diffused Gangrene. — This form differs widely from the former ; the eschars are quite irregular, and may occupy the entire vault of the palate, the velum, tonsils, and pharynx. The limit between the diseased and healthy tissues is not clearly defined, although the edges are sometimes formed by the detached epithelium. Sometimes the gangrene is superficial, and though extensive, scarcely penetrates below the raucous membrane. The surface is unequal, of a grayish black, easily removed by the scalpel, and of unequal thickness. The sub- mucous tissue is of a violet color ; but when the deeper tissues are affected they become of a black color, and present the appearance of a mass of detritus. This form is generally of considerable extent, and spreads to all the neighboring parts, so that the palate, the cheeks, the gums, or on the other hand, the epiglottis, and larynx, may be attacked. Diffused gangrene is rather more common than the circumscribed form. Of thirteen cases, eight had diffused gangrene, and in seven it occupied the velum palati, the tonsils, and a great part of the pharynx. 2 1 Works, p. 237. 2 Rilliet and Bartliez, Mai. des Enfaus, vol. ii. p. 169, et seq. 480 PUTRID SORE THROAT. 693. Causes. — Dr. Fothergill found the disease most frequent from September to December, but the peculiar condition of the weather seems to have little or no influence. It more frequently attacks chil- dren than adults, and children under six years rather than over, accord- ing to Rilliet and Barthez. Dr. Fothergill states that more girls than boys suifer from it ; but out of Rilliet and Barthez's thirteen cases, seven were boys and six girls. All are agreed that children of feeble constitutions, or whose health has been destroyed by previous disease, are very much more exposed to it ; and there are certain diseases whose course it complicates as a secondary affection. These are the eruptive fevers, measles, scarlatina, or smallpox, and likewise pneumonia, peritonitis, diphtheritis, and typhus fever. I have already mentioned that the milder forms of ulceration of the mouth and throat do occasionally assume a gangrenous character, pro- bably owing to the peculiar state of constitution induced by previous disease. It is said to prevail epidemically, but we have no very well authenti- cated information upon the subject. M. Becquerel, indeed, has observed a kind of epidemic in the Hopital des Enfans, and has recorded his ob- servations. 1 Some writers seem to consider it contagious. Dr. Fother- gill remarks that when one child of a family has it all the rest take it if they are not kept apart ; but I should be very much inclined to doubt its being directly communicated from one person to another. 694. Diagnosis. — In cases where the gangrene is primary, there is not much difficulty in recognizing it ; the ash-colored, brown, or black slough, the gangrenous smell, and loss of substance, would alone be sufficiently characteristic ; but in Dr. Fothergill's cases, there was oedema of the neck, and rapid sinking in the mor< were different from other affections of the throat. In secondary gangrene, when circumscribed, and situated low down in the pharynx, the diagnosis may be very difficult; and I need not say that the age of the patient, and the difficulty of minutely investigating the throat, will increase the chances of our overlooking or confounding the disease. In such cases the fetid odor will be very important ; but as that may arise from gangrene of the mouth or lungs, we can only fix upon the larynx as its seat by finding those other parts free from disease. It is true, as Rilliet and Barthez observes, that it will not signify if we do mistake as to this point ; but it is very important that we should not mistake diphtherite for gangrene, to which, in some cases, it bears a strong resemblance, the odor being occasionally fetid, and the sloughs dark-colored. If we have watched the case from its com- mencement, we shall not be likely to make this mistake ; but if not, or if we should still be doubtful, the application of caustic, by changing the vitality of the parts, and effecting the separation of the apparent sloughs, will show, in cases of diphtherite, that the mucous membrane has not really been destroyed. 695. Prognosis. — The disease is very serious, nay, very fatal. A 1 Gazette Medieale, 1843. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 481 great proportion of cases of primary gangrene die, and a still larger number of secondary cases. The profound destruction of parts, the disposition to spread, the unhealthy condition of the patient, added to the injury inflicted by the primary disease, render recovery very hopeless. 696. Treatment. — The result of Dr. Fothergill's experience was that, however acute the symptoms might be, the patient was never relieved by bleeding. He gave a mild emetic, occasionally following by warm, aromatic, and stimulating medicines, wine, broths, &c. Locally, he re- commends gently stimulating gargles ; in mild cases, a stronger one, with the mel Egyptiacum in more severe ones. Means are also to be taken to arrest the diarrhoea and hemorrhage, if present. Rilliet and Barthez recommend an attempt to limit the extent of the gangrene by muriatic acid or the application of the chloride of lime to the parts affected. An occasional emetic may favor the separation of the eschar, and may prevent the injurious effects of the putrid detritus which may have been swallowed. Gargles of decoction of bark, with nitric acid, are useful ; but if the child be too young to gargle, they may be injected with a syringe. Internally, the constitution must be invigorated by a liberal allow- ance of bark (syrup of quinine is a pleasant form for children), ammo- nia, wine, broths, &c. CHAPTER XII. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 697. Before passing to the consideration of the diseases of the stomach, I feel it right to notice the disease so well described by my friend, Dr. Fleming, in his interesting paper, 1 both on account of the alarming symptoms to which it gives rise, its simple method of cure, and because I am not aware that it has been noticed by any author before Dr. Fleming, as occurring during infantile life. The disease in question is an abscess formed behind the pharynx, and between it and the spine ; and, when acute, it appears to consist in inflammation and suppuration of the loose cellular tissue in this situation, and occasionally of a lymphatic gland, not unfrequently to be found here ; when chronic, it partakes of the nature of scrofulous abscesses. It may occur at all periods of life, from infancy to manhood. Dr. O'Ferrall has recorded a case of this affection at the age of four months, which Dr. Fleming witnessed in consultation with him. 2 698. Symptoms. — The symptoms are very characteristic, although 1 Dublin Medical Journal, vol. xvii. p. 41. 2 Dublin Hospital Gazette, 1845, March 1, p. 20. 31 482 ABSCESS BETWEEN THE PHARYNX AND THE SPINE. at first one might attribute it to some affection of the nervous system. They may be divided into the premonitory and the essential. " The 'premonitory indication of local uneasiness, but yet common to all affec- tions of the throat, complained of or otherwise, according to the age of the child, and, on examination, not accompanied with proportionate visible lesion. The essential, often very suddenly supervening, and indicated by derangement of the cerebral, circulating, and respiratory symptoms, alternating with the comparatively healthy condition of those systems, according to the alteration in the position of the indivi- dual; fixed and retracted state of the head, with rigidity of the mus- cles at the back of the neck, and more or less locked state of the jaws ; painful deglutition, impossibility of swallowing, solids and fluids con- vulsively darted forward through the mouth and nose ; repeated acts of deglutition, without the presence of any fluid in the mouth, and, on examination of the fauces, a firm projecting tumor felt beyond the base of the tongue, and, if seen, presenting a smooth, rounded, highly vas- cular appearance behind the soft palate, usually occupying the median line, but occasionally inclining to either side. These essential symp- toms, accompanied with the ordinary characteristics of suppurative fever." "Fever, more or less sthenic in its character, according to the peculiarity of constitution of the child, is always present, and, I think, precedes the development of the local symptoms." 699. As regards the chronic abscesses, the " symptoms attendant upon them are in a much milder degree of the same character with the acute ; and perhaps the more prominent are the remarkable effects pro- duced on the respiration by change to the recumbent posture. There is absence of fever, and throughout the day the child is free from any obvious illness, able to play, and join in the amusements of other child- ren. I have known them not to complain of any uneasiness in the throat, and attention to be directed to it from the raucous breathing during sleep. In fact, the symptoms much resemble those of common scrofulous induration of the tonsil. They are, hence, cases of compara- tively minor importance ; there is time to investigate them. Indeed, with them may be complicated chronic enlargement of the tonsils. I have met with them after scarlatina, after variola, and after measles. In fact, they are some of the sequelas of those cutaneous diseases, and, like them, may be accompanied with suppuration of the internal or ex- ternal ear, and so come under the description of similar cases already alluded to as described by Petit." 700. Diagnosis. — When the tumor is large, and the cerebral symp- toms intense, the case may not unlikely be set down as one of disease of the brain; or, at an earlier period, it may be mistaken for disease of the cervical portion of the spine. In all such cases, a careful examina- tion of the throat should be made, as the presence of the tumor will remove such doubts at once. Moreover, the difficult deglutition, the regurgitation of fluids through the nose, &c, point decidedly to some mechanical obstruction, and an examination will at once prove that it is not from enlarged tonsils, but from a firm projecting tumor beyond the base of the tongue, and generally in the centre of the pharynx. 701. Treatment. — Dr. Fleming's experience has proved that surgical DISEASES OF THE STOMACH. 483 interference is as effectual as it appears to be essential from the symp- toms ; and " not alone from the fact of certain fatal results from me- chanical pressure on, and interference with, vital organs, but also from the situation of the abscess being particularly favorable to extensive diffusion." In one case only has Dr. Fleming seen a spontaneous open- ing occur ; the abscess was situated high up, and the matter passed through the nose. For increasing the facility of the operation, Dr. Fleming has con- trived an instrument consisting of a trocar about four inches long, one extremity of the canula being slightly curved, the other with a ring on its upper surface to receive the forefinger ; into this canula was passed a jointed stiletto, with, at its opposite extremity, a ring for the thumb, and a movable screw, to graduate the projection of its point." The greatest caution must be observed. An assistant must hold the head firmly, and be ready to throw it forward when the puncture is made. The operator should pass his left forefinger to the back of the pharynx, and, fixing the point of it upon the tumor, use it as a guide to the trocar, so as to place it on the most prominent part of the tumor, when pressure on the stiletto will effect the object in a moment. Dr. O'Ferrall recommends that the operator should stand behind the patient, and pass the " forefinger of his left hand between the palate and the tongue, carefully avoiding the latter, until it reach the abscess. The trocar is thus readily guided to the point intended to be punctured, and thus all danger to the surrounding parts is avoided." " Dr. O'Fer- rall, in similar cases, would in future prefer a straight bistoury, having the cutting part short, as the density of the covering of such abscesses renders the plunge of a trocar unsafe." For fuller details, illustrated by very interesting cases, I must refer my readers to Dr. Fleming's excellent paper. CHAPTER XIII. DISEASES OF THE STOMACH. 702. Before proceeding to describe the different affections of the stomach and intestinal canal, I shall avail myself of the researches of Billard and Rilliet and Barthez, to lay before my readers the condition of the mucous membrane of this canal in health, as it is quite possible for an uninstructed person to mistake some of these appearances for the result of disease. Billard remarks : " Now, from the examination of the stomach in several embryos and foetuses, it appears that the internal surface of this organ is of a light red color, more or less marked ; that the internal membrane soon shows the existence of villi ; that they are more evident than in adults ; and that this internal membrane, towards the fourth or fifth month, less adherent than the other membranes, may be separated 484 DISEASES OF THE STOMACH. from them with great ease. Meckel observes that it is very thick towards the fourth or fifth month of pregnancy. At first sight it might be thought to be the case, but it should be remembered that the muscular coat is almost always raised with it ; and the subjacent cellular membrane, which, not being quite so distinct, is added to the mucous membrane, adheres to it, and is raised at the same time. At birth, the stomach of an infant is but little dilated. It incloses a quantity of ropy mucus, with which there is sometimes mixed some small grumous particles, apparently composed of concrete mucus. In stillborn children there is found a layer of mucus, more or less thick, adhering to the surface of this organ. Upon raising it with the nail or the back of the scalpel, the internal membrane is seen beneath this layer perfectly healthy. This mucus disappears after a few days ; and this is, doubt- less, what several authors, and Capuron in particular, mean by the name saburra, the removal of which it was necessary to effect imme- diately after birth. We shall see that the same thing exists in the intestinal tube, when we shall be able to appreciate more fully the nature of the advice given for the expulsion of this substance." 1 703. The same author, after describing the gradual formation of the intestinal tube, and its condition at different periods of foetal life, pro- ceeds to examine the state of this organ at birth, the matters which it contains, and the phenomena of the first alvine evacuations. " The duodenum has a rosy appearance, which is continued to the jejunum, but is less remarkable in the ilium. The jejunum has some traces of the valvulae conniventes ; the villi are equally developed, and very often in the jejunum are found some separate mucous follicles, about the size of the head of a pin, and almost always white ; some follicular plexuses, slightly projecting, also white, and often with a little black point on the top, as observed in adults, are met with in the ilium. The ilio-csecal valve is a little projecting, and the opening which it sur- rounds extremely small ; in most children it would be difficult to pass even a crow-quill. At this age it prevents the regurgitation of sub- stances and even gas from the great intestines to the small, but allows a free passage for the contents of the small intestines to the large. This can easily be proved by passing a current of water through one or the other of the extremities of the digestive tube ; in the one direction the water passes freely, while in the other it will meet with an insur- mountable obstacle. Neither do the ccseum or colon as yet present their depressions and prominences in as distinct a manner as afterwards, or as they appear in adults. After birth, the internal membrane of the digestive passages gradually loses its habitual color, and becomes of a milky white, and continues for some time flocculent. During the whole of the first year it is remarkable for this appearance, and for the abun- dant secretion of mucosity. The matters contained in the intestinal canal of a young infant vary with reference to the color and consistence. Generally there is found in the duodenum and jejunum thick mucous substances, of a white color, adhering to the walls of the intestines, sometimes collected together in certain parts, and sometimes spread 1 Mai. des Enfans, Stewart's Trans., p. 238. DISEASES OF THE STOMACH. 485 over them. They are often colored yellow, owing, probably, to the bile ; and there are also found balls or small masses of a green color, which are observed in the intestines a long time after the expulsion of the meconium. I have found them in a child eight or ten days old ; it would appear that they do not possess any irritating property, for their contact never produces inflammation of the mucous membrane. It is very common, also, to find about the ilio-csecal region an accumulation of yellow and frothing liquid ; the large intestines are always filled with meconium, of the consistence of pitch, and of a deep green color, a circumstance noted by all authors." "When all the liquid parts of the intestinal tube are removed, there still remains a layer of thick mucus adhering to the internal surface of the canal, forming on it a kind of plastering. This layer may be raised with the nail, under the form of a pellicle, resembling, to a superficial observer, portions of the mucous membrane itself. It is probably this layer of mucus that cer- tain practitioners regard as vitiated matters, or saburra, for the expul- sion of which they have recommended purgatives from the time of birth. " But whether this mucus be for no other object than protection of the mucous membrane when exposed to the contact of unaccustomed aliments, or whether it be a simple deposit of a fluid contained for a long time in the alimentary canal, attaching itself, without any use, to its surface, it never remains there but for a short time, and detaches itself, without the assistance of any purgative, by a kind of natural exfoliation. This exfoliation occurs in very thin lamellae, which, being rolled together, form the small white flocculi so frequently met with in the stools of young children ; and where the surface of the duodenum or jejunum is colored with bile, it is this layer of mucus that is colored, so that in removing it the color also disappears from the intestine." " As soon as the child has commenced a new kind of alimentation, the contents of the intestines change their appearance, the phenomena of digestion becoming, with respect to the manner in which it is performed, analogous to what it will be during the remainder of life. A great deal of importance is usually attached to the first discharge from the bowels ; and nurses are eager to administer to a child just born some mild pur- gative, under the fear of retaining, for too long a time, a substance which absurd prejudices have induced them to regard as irritating, and as capable of exercising a serious effect on the system. I am far from entertaining any such ideas, for I can see in the meconium no irritating or chemical property ; but I conceive that a prolonged retention of this matter may produce, if it be not evacuated, effects analogous to those which obstinate costiveness produces." 1 704. MM. Rilliet and Barthez have drawn their observations from children somewhat older. According to their statement, the gastro- intestinal mucous membrane is of a grayish-white, or clear rose gray, the color varied by venous ramifications. Its thickness, which is not considerable, varies in different regions, as does its tenacity. The sub- mucous tissue is of a dull white color, rather thin in general, resisting, 1 Mai. des Enfaas, Stewart's Trans., p. 273. 486 DISEASES OF THE STOMACH. and intersected by venous arborizations, more voluminous but less nume- rous than those of the mucous membrane. The muscular coat under- neath is recognizable by the direction of its pale or rose-colored fibres. The mucous membrane varies in different situations ; it is thinner and paler in the great cul-de-sac of the stomach, less consistent, and less firmly adherent to the subjacent tissue ; and this change of character is often so sudden and so complete as to give the appearance of a line marking the limits of the cul-de-sac ; in other cases the transition is gradual. The capacity of the stomach varies ; it is often considerable, but, unless disease be present, this is a matter of no moment ; in other cases the organ is much contracted. Of course the smoothness of the internal surface will be modified by these conditions. The mucous membrane of the small intestines, often colored by its contents in its superior portion, is of a grayer color than that of the stomach ; it is tolerably thick in the duodenum, but gradually diminishes towards the inferior termination. Its adherence to the subjacent tissue is but slight, and slips may easily be raised even close to the valvulae conniventes. The isolated follicles are contained in the thickness of the mucous membrane, and are not visible except under the influence of disease. The patches of follicles are, on the contrary, always, visible along the free border of the intestine, and increasing in number towards its inferior portion, as in the adult. Numerous small black points are also observed, sometimes scattered irregularly, in other cases collected in different parts, and giving a grayish-black or black color to that part of the surface. In the large intestine the mucous membrane is thin at first, and goes on increasing to the rectum, and the authors remark that it is always thinner at the lower side of the natural obstructions of the canal, e. g. at the cardia, pylorus, caput caecum coli ; and from each of these points it gradually increases in thickness until we arrive at the next obstacle. The mucous membrane of the caecum permits a number of venous rami- fications, which disappear lower down, or only reappear in the rectum; and we find a considerable number of follicles, each marked by a gray spot, with a small opening of a darker color, which leads to its cavity. 705. Let me now point out a few of the changes which take place after death, and which require to be carefully distinguished from those which are the result of disease. I. Obeying the physical laws, the fluids after death gravitate to the inferior parts of the body, and in the intestines we therefore find the vessels of the most depending portions filled with blood, and forming more or less extensive arborizations, which, however, are not always present, nor are other parts exempt from the same appearance. II. These arborizations, however, are not always cadaveric ; that is, they may be produced immediately before death, or in the act of dying, when the termination is accompanied by general congestion, as in asphyxia. When this is the case, the vessels have a deep violet color, and are rather situated in the submucous than the mucous tissue. III. At a later period the blood escapes from the vessels and colors the mucous membrane, which it penetrates as if by imbibition, forming large spots of a dull red color, in which no vessel can be discovered. DISEASES OF THE STOMACH. 487 In other cases the blood distils through the membrane, and colors the mucus of the intestinal canal ; or it may be effused beneath the mucous membrane, following the sinuous track of the vessels from which it escapes. IV. At a still later period, the mucous membrane acquires a green tinge, similar to what may have been previously observed on the abdo- minal parietes ; this is an evidence that putrefaction is considerably advanced. V. There is another change about which there is considerable dif- ference of opinion ; I allude to softening of the mucous membrane, which by some has been regarded as the product of disease, and by others as a cadaveric change, and I can scarcely doubt that both are right. As far as my knowledge extends, I am quite prepared to agree with Rilliet and Barthez, who observe : " In conclusion, we believe that simple ramollissement of the stomach, and especially of its greater cul-de-sac, may exist both as a disease and as a cadaveric phenomenon; but that, considering the circumstances of temperature and putrefaction in which we ordinarily find it, we regard it, when discovered by dissec- tion made twenty-four or forty-eight hours after death, as more fre- quently cadaveric than morbid. The intestinal mucous membrane, on the other hand, undergoes this change more frequently from disease than as a cadaveric change." 706. In conclusion, I will just enumerate the principal pathological changes which may be observed in the mucous membrane. I. Redness in the form of arborizations, bands, or vascular lines, or uniform. II. Softening, in which the mucous membrane is reduced to a kind of pulp, so that in extreme cases it may be scraped off, but cannot be raised in strips at all. This degree generally coincides with the uni- form red color. III. Thickening. — This change may occur with or without softening; it gives prominence to the parts so affected, whether only a few points or a more extensive surface. The increased thickness is demonstrated by carefully cutting through the mucous membrane only, in different parts. These three changes are the result of simple inflammation, and may be observed in any part of the intestinal canal. IV. False membranes, which may be more common than is supposed, but which are removed as secreted by the passage of matters through the intestinal canal. They may be deposited in small white patches here and there, or they may form a more extensive thin layer, white, gray, or yellow, slightly adhering to the mucous membrane, and often mixed with the fsecal matter. V. Ulcerations. — These are sufficiently common in typhoid fever and tubercular disease, and may be seated either in the mucous membrane or in its follicles. VI. Pustules. — It is very rare to meet with pustules in the stomach or intestinal canal, although such are recorded by Rilliet and Barthez. VII. Softening, non-inflammatory. — Three forms have been noticed by the authors just quoted : — 1. Simple or pultaceous ; 2. Gelatini- form ; and 3. White or opaline ramollissement. 488 INDIGESTION. Although the usual signs of inflammation may be absent in these cases, it is by no means certain that the morbid change is not a more distant result of inflammation. The evidence we possess, carefully examined, would, I think, lead us to the conclusion that the colorless softening, without vascularity, -is probably, the termination of a series of morbid actions, of which inflammation was the beginning. CHAPTER XIV. INDIGESTION. — VOMITING. — WEANING BRASH. 707. The affection which has been described under the term vomiting, and more recently termed indigestion, differs very considerably from the adult disorder so designated, although it appears equally independ- ent of organic disease in many cases. Vomiting is, no doubt, the prominent symptom, but we must distin- guish between that which results from an unhealthy or irritable condi- tion of the stomach, and that which is merely the expulsion of an excess of food. It is a natural effort of the stomach of infants, and a great advantage, that, when too much food has been swallowed, the excess is returned, whilst the proper quantity is retained, and the child is saved from the consequences of over-feeding. This is a species of organic intelligence which supplies the place of that knowledge which is after- wards acquired. " The milk is generally thrown off in an unchanged condition, and the infant is so little annoyed by the vomiting, that it will often preserve its usual placid and cheerful countenance while the milk is regurgitating from its stomach. This variety of vomiting may, therefore, be regarded rather as a salutary than a morbid occurrence ; for the superabundant nourishment, with which the digestive organs are habitually overloaded, would, doubtless, soon give rise to indigestion, and its various disagreeable consequences, if the stomach did not regu- larly relieve itself by throwing off a portion of its oppressive load." 1 Common sense will teach the mother in such cases to diminish the quantity of milk the child is allowed to take at each nursing, until it is reduced to the capacity of the digestive powers, and no other treatment will be necessary. 708. But the vomiting which occurs in the disease I am describing, does not necessarily result from the stomach being overfilled, but from its incapacity to digest what it has received, and an irritability which occasions it to reject it. It may be originally caused by over-feeding, but the effect continues after the cause has ceased. This indigestion may occur at any age. I shall notice it as we see it during suckling, after weaning, and at a later period. 709. Symptoms. — During the first year of life, while the infant is 1 Eberle on Diseases of Children, p. 205. INDIGESTION. 489 still at the breast, the earliest symptoms of the disorder we shall be able to observe will be a pallid look, languor, and considerable discomfort. The infant is evidently unwell ; it cries and whines, and appears never easy except when at the breast. It sucks greedily, without appearing satisfied, and shortly afterwards vomits the milk, either fluid as it re- ceived it, or curdled (and not a small portion — the surplus — but the whole, or nearly so), with evident distress, paleness of face, &c. A good deal of stress has been laid upon the fact of the milk being curdled or not, as an evidence of the presence of a morbid amount of acid in the stomach. Undoubtedly it is not a natural state when the milk is rejected as a solid, firm curd, but it is certainly a mistake to suppose that no change takes place in the fluidity of the milk in healthy digestion. Underwood remarks : " Not that the milk ought not to curdle in the stomach, which it always must, in order to a due separa- tion of its component parts, and which is the chief, if not the only digestion it undergoes in the stomach;" 1 and experience confirms his observation, that it is only when the curdling is in excess that it is to be regarded as an evidence of disease. Upon this excessive coagulation, M. Billard has the following ob- servations : "Van Swieten and Rosen have remarked that it is very common to meet with milk coagulated in the stomach without being digested. The authors first mentioned attribute it to the superabundance of acid in the stomach. A very evident acid smell is often detected in the mouth of a child; like that, for instance, which is observed after an attack of indigestion. I found in fifteen infants that died with other affections than those of the digestive organs, the stomach filled with coagulated milk ; there were but three exhibiting a slight injection of the stomach ; in the remaining twelve the walls of this organ were white and perfectly healthy. I am inclined to think that this coagula- tion of milk proceeded from some other cause than inflammation. Does this result from the milk taken by the child abounding in caseine, or is it the presence of acid in the stomach that so quickly coagulates this fluid ? Does this acid exist, in the first place, in the stomach ? Is it the result of the decomposition of the milk ? Does this indigestion depend upon the want of vital activity and nervous action which is dis- played in the stomach during the operation of the digestive functions ? These are questions I am unable to solve ; but, whatever be the cause of this phenomenon, I point it out as the effect of a true gastric indi- gestion, without inflammation of the organ, and without apparent lesion of its walls ; and I wish particularly to direct the attention of physicians to this fact, that they may not be led to conclude that a child is affected with gastritis whenever it is unable to digest the milk that it has taken, or when the milk is vomited some time after in a coagulated form." 2 So that a minor degree of coagulation being a part of the healthy process of digestion, an excessive degree may be owing either to ex- cessive acid, deficient nervous power or vital inaction ; and, on the other hand, milk vomited unchanged, after it has remained some time in the 1 On Diseases of Children, p. 223. 2 Mai. des Enfans, Stewart's Trans,, p. 243. 490 INDIGESTION. stomach, is an equal evidence of an incapacity of digestion. Dr. Dewees says: " If there be a deficiency of acid in the stomach, and a vomiting be produced, the milk will come up unchanged. Nausea almost always attends this variety ; the child may be observed to become pale, and evidently to struggle against the efforts of its revolting stomach. The milk is rejected with great force in a large column; and not unfre- quently a portion passes through the nostrils." 1 710. To return. The child is attacked by frequent vomiting, after which it looks pale and exhausted ; but it is as eager as ever to suck again. Occasionally much alarm has been felt in consequence of blood being mixed with the ejected milk ; but this is owing to the nipple hav- ing cracked, and the child having drawn blood when sucking. The bowels are not necessarily affected ; they are sometimes in a natural state, sometimes constipated, and occasionally too free. Nor does the child suffer generally from pain or tympanitis, although the stomach may be troubled with flatulence. This alternation of sucking and vomiting is gradually followed by emaciation and exhaustion, and a sinking of the vital powers, but there is no evidence at all of inflammation of the stomach. The child derives no nourishment from its food, and in the end, if relief be not afforded, dies of exhaustion from starvation. In such cases, however, it is not uncommon to have a new train of secondary symptoms occur, such as heaviness, stupor, convulsions, &c. ; in fact, in all cases of prolonged disorder of the stomach or bowels, the most watchful attention should be directed to the condition of the nervous system, and the most prompt efforts made to relieve the earliest symptoms of disease of these organs. If relief be not afforded to this species of indigestion, the infant may linger on for five or six weeks, gradually become weaker, thinner, and more unable to digest its food, until at length it sinks from exhaustion or from some secondary attack. 711. At the time of weaning, or soon after, the child is very apt to suffer from indigestion, in consequence of the change of food. This dis- order, however, is not confined to the stomach, but involves, apparently, the entire intestinal canal. It may come on a few days after weaning, or not for some weeks. Dr. Cheyne has given an admirable history of this disease under the term "Atrophia Ablactatorum." "The first symptom," he says, "is a purging, with a griping pain, in which the dejections are usually of a green color. When this purging is neglected, and, after continuing for some time, there is added a retching, with or without vomiting : when accompanied by vomiting, the matter brought up is frequently colored with bile. These increased and painful actions of the alimentary canal produce a loathing of every kind of food, and naturally are attended with emaciation and softness of the flesh, with restlessness, thirst, and fever. After some weeks I have often observed a hectic blush on the cheek; but the most characteristic symptom of this disease is a constant feverishness, the effect of increasing griping pain, expressed by the whine of the] child, but especially by the settled dis- 1 Diseases of Children, p. 374. INDIGESTION. 491 content of its features; and this expression of discontent is strengthened towards the conclusion of the disease, when the countenance has shared in the emaciation of the body. " In the progress of the disease the evacuations from the belly show very different actions of the intestines, and great changes in the biliary secretion ; for they are sometimes of a natural color, and at other times slimy and ash-colored, and sometimes lienteric. Towards the end of the disease the extremities swell, and the child becomes exceedingly drowsy; but these I rather conceive to arise from debility, than to be pathogno- monic symptoms. It is remarkable, in the advanced stages of the disease, that the purging sometimes ceases for a day or two, but with- out any amelioration of the bad symptoms ; nay, I think that children decay even faster than when the purging is most violent. The disease seldom proves fatal before the sixth or seventh week, and in this short time I have seen the finest children miserably wasted. I have seen, though rarely, a child recover after the disease had continued three or four months ; and again I have seen the disease cut short by death in the second, third, or fourth week, before it had reached the acme; the sudden termination having been occasioned by an incessant vomiting and purging, or by convulsions from the immense irritation in the bowels." 1 To this graphic description I have little to add, except that, in many instances, the symptoms of gastric disturbance precede those which indicate intestinal derangement, and which is the reason why I have introduced the disease here rather than under the head of diarrhoea. The disease, as Dr. Cheyne observes, is by no means rare, and, if neg- lected, is very fatal, but if taken in time is sufficiently manageable. It is more common with children who have been weaned abruptly, and at an unusually early period. 712. At a later period, the child's stomach may become disordered, and an effort may be made for relief by vomiting or purging, or both, after which the child may resume its usual health. Or the derangement may continue, the appetite may be impaired, and the food taken appear to disagree with the stomach ; the child is pale, fretful, and uneasy, especially after a meal; complains of pain in the stomach and bowels, resembling colic or spasm ; is troubled with flatulence ; and occasionally the belly is swollen and tympanitic. The breath is sour, and there are acrid eructations, with repeated vomiting of undigested or half-digested matters, after which the child seems somewhat relieved. I have noticed the prevalence of this form of indigestion, somewhat modified in different cases, during the hot weather of summer. If this state of things continue, the intestinal canal becomes irritated, and purging sets in, and the evacuations are generally of a green color, accompanied by colic. The little patient is soon reduced in flesh and strength ; his countenance is pale and depressed ; his pulse weak, and sometimes quick ; the appetite diminished, and the animal spirits sunk. Occasionally the food passes through the bowels almost unchanged, con- 1 Essay 2. On Bowel Complaints, p. 16. 492 INDIGESTION. stituting the disease called lientery. In some cases the purging alter- nates with constipation. In process of time other organs become involved ; the liver gives evidence of functional disturbance ; but by far the most serious com- plication, and one by no means uncommon, is the head, as manifested by stupor, coma, or convulsions. This secondary affection, so common towards the end of gastric or intestinal diseases, places the patient in the greatest danger, from its occurring at a time when active treatment is nearly impossible, owing to the weak state of the child. No case requires greater watchfulness, none more judicious and skilful treat- ment, than these cases ; and, do what we may, a large proportion die. If no complication occur, the indigestion may often be cured, after an uncertain duration of from a week to a month; but it may also prove fatal from exhaustion. 713. Morbid Anatomy. — As a general rule, post-mortem examina- tion reveals no trace of disease ; now and then, as Billard has observed, we may find vascular ramifications in the coats of the stomach; but this may be either the normal condition of the stomach with food in it, or a cadaveric change. Ordinarily the stomach and intestines are more bloodless than usual, semi-transparent, and unequally distended with air. The mucous membrane is pale throughout, and occasionally soft- ened. " The want of color," Dr. Stewart remarks, " is almost always the first degree of a species of softening, which should not be con- founded with a species of inflammation. The disease described by M. Cruveilhier, under the name of gelatiniform disorganization of the mucous membrane of infants, would appear, from the detail of symp- toms, to be a violent species of the disease now under consideration. M. Duges, in his Manuel d'Accouchemens, in speaking of a similar affection, remarks that he has found the interior coat of the intestines covered with a white mucus, of a pulpy consistence, and bearing a resemblance to imperfect chyle, and which inattentive observers might mistake for the softened mucous membrane. The mucous follicles, he observes, could be still seen on the intestinal surface." 1 The post-mortem appearances in "weaning brash" are thus described by Dr. Cheyne: "I observed in every instance that the intestinal canal, from the stomach downward, abounded with singular contractions, and had in its course one or more intussusceptions; that the liver was exceed- ingly firm, larger than natural, and of a bright red color; and that the enlarged gall-bladder contained a dark green bile. In some dissections the mesenteric glands were swelled and inflamed ; in others, however, they were scarcely enlarged, and had no appearance of inflammation. These contractions and intussusceptions were entirely of a spasmodic nature, as, in the latter, the contained part of the gut was easily dis- engaged from that which formed its sac, and in no part of the entangle- ment was there adhesion or even the mark of inflammation ; and the contracted portions of the intestines were again permanently dilated by pushing the finger into them. These appearances lead me to imagine that weaning brash, in its confirmed state, is imputable to an increased 1 Diseases of Children, p. 184. INDIGESTION. 493 secretion of acrid bile, or rather to the morbid state of the liver which occasions this ; of which, however, I am afraid to attempt the explana- tion." 1 714. Causes. — Before weaning, indigestion may be caused by excess in the quantity of milk, or by giving the child the breast too often, or too soon after vomiting, in order to quiet it. Deficiency or excess of the nutritive qualities of the milk, or its possessing bad or irritating qualities, may also give rise to it; and the latter condition may be caused by errors of diet on the part of the nurse, by her indolence, luxurious habits, giving way to passion, by the presence of the cata- menia, by the too great age of the milk, and by too prolonged nursing, as I have heretofore observed. 2 The process of digestion may be disturbed, and the gastric powers deranged, by tossing or moving the child about, too soon after suckling. After weaning, the most common of all causes is some error in diet ; the child is fed too much or too frequently, or upon improper food; and when the stomach, with the admirable organic intelligence which it possesses in childhood, rejects what is not proper for it, instead of taking a hint, and giving it a change of food, or at least a rest, more food is given, and probably of the same kind, so that the stomach be- comes permanently deranged, and that which was a healthy process becomes a symptom of a morbid condition. Another cause, and doubtless a frequent one, is dentition. The sto- mach and bowels are very apt to be more or less disturbed during this process ; and, though distressing, it is the least injurious of all the reflex irritations to which dentition gives rise. It ceases, also, when the irritation is removed by scarification. Underwood and others have attributed this vomiting to the suppres- sion of accustomed discharges, or the sudden cure of cutaneous erup- tions. Dewees doubts this, but Eberle mentions a case in which the child was attacked by vomiting whenever a discharge from behind the ears was dried up, and which was relieved by reproducing it. 715. Diagnosis. — The absence of permanent pain, tenderness, and fever, the weak, quiet pulse, and clean tongue, will generally suffice to distinguish this complaint from gastritis. The success or failure of the treatment will also throw some light upon the matter. But there are two other diseases with which it might be confounded at a certain period, and from which it is of the highest importance to distinguish it. Vomiting is often among the earliest symptoms of meningitis, at a period, indeed, when it sometimes requires a practised eye to detect more. But we may always find some nervous disorder, disturbed sleep, starting, staring, heaviness, flushed face, suffused eyes, headache, &c, none of which are remarkable in the present disease, and upon the presence or absence of which our decision must be made. Again, vomiting occurs in strangulated hernia, but a careful examin- ation, which in such cases, should never be omitted, will enable us to pronounce upon the presence or absence of the hernia. 716. Treatment. — The first object is to regulate and correct the food 1 Essay ii. p. 23. 2 Vide chap. iii. 494 INDIGESTION. of the infant as to quantity and quality. If the disorder can be fairly traced to an excess of milk, of course it is easy to remedy that, and it should be done forthwith. But if, as is more frequently the case, we have reason to believe that the milk disagrees with the infant, the nurse should be changed, and a new one obtained, whose milk is of a suitable age. Nay, even if there be a doubt about it, it will be better to make the change. When satisfied about the nurse, I would advise that the infant should only be allowed to take half the usual amount of suck at a time, and have it oftener, if necessary, until the stomach recovers its tone. If the bowels be confined, they should immediately be freed by an enema, as their action tends to quiet the stomach. I have found nothing so effectual in tranquillizing the gastrointes- tinal disturbance as the following mixture : R — Mist, amygdal., Aquse carui, ilil ^ss. Spts. ammon. arom. gutt v. Tincturce opii, gutt. ij. vel. iij. — M. A teaspoonful may be given, two, three, or four times a day, and at the same time some counter-irritant should be applied over the stomach: either a poultice of mustard and linseed-meal, a liniment containing a small quantity of laudanum, or a small blister. Dr. Eberle recommends small doses of calomel and ipecacuanha. " I have repeatedly succeeded in arresting vomiting," he says, "from in- ordinate gastric irritability in infants, by exhibiting the eighth of a grain of calomel, with one-sixth of a grain of ipecacuanha, every hour or two, in conjunction with the application of a stimulating poultice or plaster over the epigastrim." 1 In obstinate cases he advises "a grain or two of morphia to be sprinkled on the surface of a small plaster of common cerate, and laid over the pit of the stomach." Dr. Stewart speaks highly of rhubarb and ipecacuanha. Dr. Underwood says, "a drop or two of the aqua kali, or a little Castile or almond soap, are excellent remedies, not only as they will correct acidity, but promote the secretion of bile, as well as a generous warmth in the great passages, and assist the digestion. For which pur- pose, also, myrrh is an excellent remedy, when infants are a few months old." 2 The gums should be carefully examined, and a free incision made, if there be the least evidence of irritation from the teeth. 717. Dr. Cheyne recommends that in the beginning of "weaning brash," when the attack is slight, we should give a dose or two of rhu- barb, at intervals of two days, and a half or third of a grain of ipecacu- anha, with six or eight of prepared chalk, and some aromatic powder, every four or five hours. If there be much griping, an anodyne enema may be given. The diet must also be regulated carefully, and animal substances are better than vegetable. Eggs, fine ship biscuit, arrow- root custard, the juice of lean meat, plain animal jellies, and milk, are 1 Diseases of Children, p. 210. 2 Diseases of Children, p. 225. INDIGESTION. 495 the chief articles of nourishment. A wet-nurse would undoubtedly be the best, if the child were young and would take the breast; and the best substitute I have found for this is ass's milk. In the severe cases, Dr. Cheyne found more benefit from half a grain of calomel twice a day for some time, with anodyne enemata for the relief of the pain, than from anything else. 718. When the child is still older, if his stomach have been over- loaded, or if he have taken indigestible food, it will be well to commence with an emetic, after which we may have recourse to small doses of laudanum, with or without ammonia, and external irritation. The bowels must also be kept free, but if diarrhoea be present, with much pain, an anodyne enema may be administered. If there be any evi- dence of biliary derangement, small doses of calomel, or hyd. c. creta\ will be very useful, followed occasionally by a purgative, or combined with an astringent, according to the state of the bowels. With children of three or four years old, I have succeeded very well by combining an alkali with some vegetable bitter, after the irritable state of the bowels has been relieved. Carbonate of soda, magnesia, or lime-water and milk, may be given if there be an excess of acid in the stomach, and the dilute muriatic acid, or lemonade, if there be a deficiency. Dr. Condie speaks very highly of a combination of magnesia, extract of hyoscyamus, calomel, and ipecacuanha ; and also of a few drops of spirits of turpentine, or the ethereal solution of camphor. External irritation, by mustard lini- ment or blister, is of great use; and if there be colic, laudanum may be applied externally as well as internally. Sometimes great relief is afforded by fomentations, or by a large linseed poultice to the belly. When the disease has been arrested, tonics may be necessary. I have found great benefit from two or three grains of carbonate of soda, and as much powdered columba, three times a day. " In that form of infantile indigestion in Avhich softening of the stomach is most likely to occur, a trial may be made of hydrochloride of iron, which appears to have frequently succeeded in restoring the healthy functions of the stomach in the hands of Pommer, Herzt, Cam- merer, Droste, and others." 1 The diet must be carefully regulated, and it is far better to retrograde a little, and substitute a simpler diet than the one to which the child has been used. Milk, eggs, arrowroot, panada, &c, will answer better than animal food. 719. When the head is becoming involved, no time must be lost in making the best use we can of derivatives and counter-irritants. Mus- tard cataplasms or blisters to the legs, blisters to the head or neck, cold lotions to the head, &c, must be tried in succession. In few cases can we venture to take blood or apply leeches, and yet the disease must be checked quickly if the child is to live. Meantime, the treatment for the primary complaint must go on, except, perhaps, a more sparing use of laudanum. If the child be greatly reduced, more nourishment must be given ; 1 Condie on Diseases of Children, p. 203. 496 GASTRITIS. jellies, broths, or beef-tea will be necessary, and sometimes wine whey ; nor have I found the head symptoms increased by it, but frequently lessened as the extreme exhaustion was relieved. CHAPTER XV. GASTRITIS. — INFLAMMATION AND SOFTENING OF THE STOMACH. 720. Inflammation of the stomach and its consequences have not received very much attention from authors, until comparatively recent times, although it is probable that some of the cases described under the term "vomiting" were really of this nature. Saillant, 1 Fleisch, 2 Lesser, Maunsell and Evanson, 3 and others, have noticed the disease ; but we are more indebted to Dunglison, 4 Billard, Stewart, Condie, Rilliet and Barthez, &c. Jaeger, 5 Camerer, Morgagni, Sandifort, and Hunter, described a softening occurring at the larger extremity of the stomach ; and since their time Ramisch, 6 Vogel, Hufeland, Cruveil- hier, 7 Billard, Bouchut, Barrier, Rilliet and Barthez, &c, have thrown much light upon the subject, although there are still questions left un- decided. Inflammation of the stomach is by no means a frequent disease, nor is it always so well marked as to enable us to distinguish easily between it and functional disorder, such as I described in the last chapter ; and moreover, it is frequently combined with irritation or inflammation of the intestines. It may be either primary or secondary, but, according to Rilliet and Barthez, far more frequently the latter than the former. 721. Symptoms. — The symptoms are not always very characteristic, and in some cases are very obscure. In certain cases Rilliet and Bar- thez remark that the disease is completely latent, revealing itself by no symptom, or by some trifling phenomenon which escapes notice ; as for example, one or two vomitings after medicine containing tartar emetic or ipecacuanha; or vomiting, apparently sympathetic, at the commence- ment of the primary malady. Among these cases we find erythema- tous, pseudo-membranous, or ulcerated gastritis, and above all, softening of the stomach." 8 Ordinarily, however, as M. Saillant observes, the child complains of more or less pain, often very severe, occurring in paroxysms at short intervals, with violent contortions of the body. Vomiting is a common occurrence, both at the beginning and during the course of the disease, • Me"m. de la Soc. de Med. 1786, p. 327. 2 Die Entziindung, &c, p. 230. 3 Diseases of Children, p. 277. 4 On Diseases of the Stomach and Bowels in Children, 1824, p. 180. 5 Hufeland's Journal, May, 1811, and Jan. 1813. 6 Aug. Lit. Zietung, No. 56, May, 1S26, p. 447. 7 Anat. Path., Livraisons 4-7, &c. 8 Mai. des. Enfans, vol. i. p. 405. GASTRITIS. 497 though there may be considerable intervals. The matters ejected are, first, the ingesta, then a greenish or yellowish fluid, and, in some rare cases, according to Denis, 1 blood. We must, however, be careful, if the infant be at the breast, not to mistake the source of the blood, which may have been drawn from the mother's nipple. In some of the worst cases the vomiting is excessive as to quantity, and incessant. Rilliet and Barthez have remarked that the vomiting is more trouble- some when softening occurs, than in simple gastritis, although there is often a sudden and complete cessation for some time before death. The bowels may or may not be disturbed. In some cases there is rather obstinate constipation; in others, and more frequently, there is diarrhoea. The abdomen is generally swollen and tympanitic; the epigastrium hot, tense, and tender on pressure; the thirst great ; the appetite lost ; the tongue sometimes loaded and white, sometimes dry and red at the point and edges. The urine is generally scanty : the pulse is quick and small, but not weak; the skin hot and dry. Thus, then, the principal symptoms are the heat, tension, pain, and tenderness of the epigastrium, with vomiting, and a quick pulse and fever. 722. But the attack "may become chronic and continue for a length of time, with occasional vomiting, some degree of tension and tender- ness of the epigastrium, irregular appetite, occasional diarrhoea alter- nating with costiveness, a dry and harsh condition of the surface, febrile symptoms of a remittent character, and progressive emaciation. White softening of the stomach, with perforation, may occur in these cases; or, the irritation being transmitted to the brain, effusion into that organ may take place ; or, tubercles becoming developed in the lungs, the patient may die with all the symptoms of tubercular phthisis." 2 723. Inflammation of the stomach may result in softening, ulcera- tion, or gangrene. I do not know that there are any symptoms by which we may detect the two latter occurrences during life. Under the title "gelatinous softening," M. Gruveilhier has described a well- marked disease ; and more than once Billard has seen an accurate diag- nosis made by M. Baron. M. Billard thus enumerates the symptoms: "The disease usually commences with symptoms of violent gastritis, such as tension and pain in the epigastric region ; the substances discharged by vomiting are not only the milk and drinks, but yellow and green fluids, occurring either immediately or long after eating or drinking. There sometimes exists a diarrhoea, varying in different subjects. It will return after having ceased for one or two days. The stools are often green, like the matters discharged by vomiting. The skin is cold at the extremities ; the pulse, generally irregular, is how- ever, very inconstant; the face continually expresses pain, and is wrinkled, as if the child were crying ; the cry is painful, and the respi- ration jerking, and the general restlessness induces a belief of the existence of a cerebral affection. To these symptoms succeed a general state of prostration and insensibility, occasionally disturbed by a return 1 Mai. des Enfans Nouveaux-n£s, p. 46. 2 Condie on Diseases of Children, p. 204. 32 498 GASTRITIS. of pain, producing from time to time the same restlessness which appeared at the commencement of the disease; and lastly, at the end of six, eight, or fifteen days, and sometimes later, the patient sinks, wasted by wakefulness, continual vomiting, and pain. In very young infants scarcely any fever is manifested in the midst of this disorder. When the disease is chronic, the progress of the symptoms is slower." 1 724. Morbid Anatomy. — On post-mortem examination, the stomach exhibits the different modifications of inflammatory action I have recently noticed. 1. There may be found a diffused redness in some parts, or it may extend in bands or lines along the longitudinal folds, or in vascular ramifications; such is the erythematous gastritis. 2. Or we may discover in some portion of the stomach a pseudo-membranous secretion, analogous to that in muguet. 3. The follicular glands may be chiefly affected, enlarged, prominent, and ulcerated. 4/ The in- flammation may have terminated in gangrene with general disorgani- zation of the tissues, or a limited disorganization resembling an eschar. 2 5. The mucous membrane, or all the tissues of the stomach, may be softened. 725. But a little more detail is necessary touching this "ramollisse- ment gelatiniforme," which is thus described by M. Cruveilhier: " This softening always proceeds from the interior towards the exterior. There is at the beginning simple separation of the fibres by a gelatinous mucus, and in consequence the parietes are thickened and semi-transpa- rent. Shortly after, the fibres themselves are involved and disappear, so that the softened stomach or intestine resembles transparent gelatin in the form of a tube or a portion of a tube. If the transformation be complete, the disorganized portions are removed, layer after layer, those which remain becoming gradually thinner. The peritoneum alone resists for some time, but at length it is attacked, worn, and gives way, and perforation of the stomach results. The parts thus transformed are colorless, transparent, apparently inorganic, completely deprived of vessels, and exhaling an odor resembling that of milk. The softened portions are decomposed much less quickly than the unaltered portions. Boiling, which converts the stomach and intestines into a jelly, gives a perfect idea of this morbid alteration." 3 M. Billard has described two forms; the first, answering pretty accu- rately to the above description of M. Cruveilhier, he regards as patho- logical, but not the second species, in which the gastric tissues are simply deprived of color and softened. The great pathological questions connected with this morbid change are: 1. Is it a pathological or cadaveric change? 2. If pathological, is it the result of inflammation or a disease sui generis? M. Valleix says : " It seems to me impossible, in the present state of science, to distinguish, during life, the cases of simple pale softening with thinning, from those in which the softening is associated with evident traces of inflammation;" 4 and further on he gives his opinion 1 Mai. des Enfans, Stewart's trans., p. 267. 2 Rillet and Barthez, Mai. des Enfans, vol. i. p. 459. Denis, Mai. des Nouveaux-ne"s, p. 56. 3 Anat., Path., livr. 4-7, &c. 4 Guide de Med. Prat., vol. v. p. 188. GASTRITIS. 499 that it is the result, either pathological or cadaveric, of chronic gastritis. M. Billard observes : " What inference shall be drawn from the pre- ceding facts and considerations ? That the gelatinous softening of the stomach consists in a disorganization of the mucous membrane of this organ, caused by intense inflammation, acute or chronic ; that this dis- organization is characterized by an accumulation of serosity in the walls of the organ, a swelling and gelatinous consistence of the mucous mem- brane at a part usually circumscribed, situated generally in the larger curvature of the organ, and round which there are more or less evident traces of acute or chronic inflammation ; that this disorganization entails others, may give rise to spontaneous perforation causing speedy death ; and that it may be developed not only at the period of the first dentition, as in most of M. Cruveilhier's cases, but even in very young infants, of which I have reported examples." 1 Rilliet and Barthez regard this as, a secondary lesion, and as most likely the result of inflammatory action. M. Bouchut denies that it is an isolated disease, but a consequence of the acidity of the fluids contained in the digestive canal. 2 Jaeger, Camerer, and Zeller refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric juice. Cruveilhier and Bokitansky admit two kinds of softening, one patho- logical, the other cadaveric. Rokitansky conceives that the softening of the stomach in children is pathological, and dependent upon a disease which he regards as almost peculiar to early life. M. Barrier differs from those who regard it as a specific disease ; he thinks it most frequently cadaveric and chemical, but, if pathological, that it is the result of an anterior morbid condition. 3 Dr. Dunglison considers that there is little difficulty in pronouncing it the result of previous inflammation. 4 Dr. Carswell agrees that it may be either cadaveric or pathological ; and that when it is the latter, the symptoms are those of gastritis or enteritis ; and he adds, that there are no symptoms referable to the state of softening which we have described, considered in itself, and as a termination of inflammation of the mucous membrane." 5 Dr. Stewart regards this softening, as well as the other morbid changes, to be the result of inflammation. 6 Dr. Condie remarks : " Without denying that the stomach may be dissolved after death, in consequence of the generation in its cavity of an excess of acid ; and being well aware that a softening of the tissues of the stomach and of other parts of the alimentary canal may be pro- duced by causes affecting the nutrition, and impairing the cohesion of the various tissues, altogether independent of inflammation, we are still convinced, from the result of our own observations, that the gelatinous softening, so frequently observed in children who have died of acute 1 Mai. des Enfatis Nouveaux-nes, &c, p. 232. 2 Mai. des Enfans Nouveaux-n6s, p. 231. 3 Mai. de PEnfance, vol. ii. p. 118. 4 Diseases of Stomach and Bowels, p. 183. 5 Cyclop, of Pract. Med., toI. iv. pp. 13-15. 6 Diseases of Children, p. 249. 500 GASTRITIS. gastritis, is invariably the effect of intense inflammation of the mucous and other tissues of the stomach." 1 Dr. West "has not been able to discover any peculiarity in the cha- racter of such symptoms (of disordered functions), nor even any con- stancy in their occurrence ; nor have I observed that the disease of which the infant died has exercised any appreciable influence in predis- posing to softening of the stomach, or in preventing its occurrence." 2 Dr. West also mentions a recent theory of Dr. Elsasser. 3 " He refers the alteration of the tissues not to the gastric juice itself, but to the acids generated during the decomposition of the food contained within the stomach and intestines at the time of death, and endeavors to account for the frequency of the occurrence in the case of infants, from the facility with which a free acid is generated in the milk which forms the chief part of their sustenance. According to his researches, which appear to have been carefully conducted, the change never ought to take place when the stomach is empty, but his assertion that it never does is opposed to universal experience." 4 Further, the same excellent writer mentions, that in Herrich and Popp's work 5 there is " a table of 104 cases in which softening of the stomach was found after death from different causes and at various ages. In no instance were symptoms observed that would have enabled any one to pronounce, beforehand, that softening of the stomach would be discovered after death. In by far the greater number of cases the stomach was empty, showing that the cause was very often independent of digestion ; while the period of childhood, the rapid course of the fatal disease, and death from cerebral affections, were the only circumstances that appeared to have any clearly appreciable influence in favoring its production." It appears, then, that redness with thickening or softening, or both, are undoubted proofs of inflammation ; that false membrane, ulceration, and gangrene are equally conclusive evidence of previous or accompany- ing gastritis ; but that pale, gelatiniform softening may be either the result of disease or a change which takes place after death. The ba- lance of evidence is in favor of one at least of the forms of this curious alteration of structure being the result of inflammation, but the cause of the other is uncertain. 726 Causes. — Gastritis may arise from the continued use of improper food converting the indigestion described in the last chapter into actual inflammation, or from eating acrid substances, or swallowing poisonous matters. Nay, more, it would appear from the observations of Rilliet and Barthez that the continued use of powerful remedies, such as tartar emetic and croton oil, in secondary affections, gave rise to gastritis, even though the dose were moderate. Although these medicines are valuable, and in some cases necessary, still this should be a warning to use great care and watchfulness in their administration. As a general rule, I have not found one sex more liable to the dis- ease than the other; but of thirty-one cases of gastritis, observed by 1 Diseases of Children, p. 206. 2 Diseases of Infancy and Childhood, p. 366. 3 Die Magenei-weichung der Saiiglinge, Stutgard, 1816. 4 Diseases of Infancy and Childhood, p. 366. 6 Der plotzlichen Tod, aus inneren Ursachen, p. 330. GASTRITIS. 501 Rilliet and Barthez, twenty-three were boys, and eight girls ; and of twenty-seven cases of softening, fourteen were boys, and thirteen girls. The latter was much more frequent before the age of six than after- wards; the former nearly equal at all ages. Children of weak constitu- tions, or who have been exhausted by disease, seem more liable to the complaint. The usual exciting causes, cold, damp, exposure, bad food, crowding, &c, may influence the production of this disease as well as others; but we find that it is frequent as a secondary affection, and the principal diseases in the course or towards the termination of which it occurs are, meningitis, meningeal apoplexy, pneumonia, and the eruptive fevers. In many cases, particularly in young infants, the inflammation of the stomach is preceded by an attack of stomatitis; in others the stomatitis occurs subsequently to the gastritis. 727. Diagnosis. — The most characteristic symptoms of gastritis are, pain, heat, tenderness and tension of the epigastrium, with vomiting; and when these are present we can have no doubt of the nature of the attack, nor any difficulty in distinguishing it from the indigestion I described in the last chapter ; but in many cases these symptoms are less marked, and in some they are absent ; and then, undoubtedly, it will be difficult, if not impossible, to arrive at any certainty. We have already seen, on the highest authority, that there are no symptoms which indicate the occurrence of softening. 728. Treatment. — The first indication is, of course, to remove every possible cause. If the child be young, it will be well to change the nurse, or, if older, to substitute some bland, easily digested food for that it has been habitually using. If it be teething, the gums must be lanced freely ; and if the bowels are confined, a purgative enema should be given at once. If the symptoms of gastritis should occur during the treatment of another disease, we must, of course, give up the use of all powerful and irritating medicines, and seek to accomplish our object in some other way. Should the patient be tolerably strong, and the gastritis primary, or if secondary and the child not much reduced, it will be advisable to apply a few leeches to the epigastrium, limiting the amount of the bleed- ing, and, after that has stopped, applying a light, warm, linseed-meal poultice. If, however, the child cannot bear this, or if partial relief only be obtained by it, some irritating application will be advisable — a pretty strong liniment, mustard poultice, or a blister. I am inclined to think that the latter is, on the whole, less painful, as well as more effectual. Great advantage is sometimes derived from dressing the blistered sur- face with ointment in which there is a small quantity of opium or mor- phia. M. Billard advises the tartar emetic ointment; but I should hesitate to use this, on account of the gastric irritation it sometimes occasions, even when applied externally. The more distressing symptoms, vomiting, heat at the epigastrium) 502 GASTRITIS. &c, may often be soothed by very cold drinks, or by a small fragment of ice swallowed now and then. There is no great choice of internal medicines: a minute dose of calo- mel, or the hyd. c. cretS, two or three times a day, with a little chalk and opium, or Dover's powder, will be useful. Or we may order a mix- ture with mucilage, syrup, and spearmint water, and one, two, or three drops of laudanum to the ounce, of which a teaspoonful may be taken three or four times a day. Dr. Condie gives from one-sixth to one-half of a grain of calomel every one or two hours. " This we have known," he says, "in a large number of cases, to suspend very promptly the irritability of the sto- mach, and to produce a favorable change in the symptoms generally. In cases attended with frequent, thin, acid evacuations from the bowels, the calomel we have found very generally to arrest the diarrhoea and render the stools of a more consistent and natural appearance. We ordinarily combine with each dose of the calomel a grain or two of cal- cined magnesia, and give it mixed in a little mucilage; but when there exists \erj great irritability of the stomach, we direct the calomel, combined with a few grains of powdered gum acacia, to be placed dry upon the tongue, the child being shortly afterwards given to drink a spoonful of thin mucilage." 1 The diet must be carefully arranged — simple, bland, and unirritating it ought to be. Milk in any form, milk and lime-water, mucilage, blanc-mange, arrowroot, tapioca, sago, &c, may be used according to the age of the child. After weaning, I have found ass's milk a very nice substitute for cow's milk. But the quantity is as important as the quality ; it will be quite necessary to diminish the usual amount, nay, in some cases, to give only what is necessary to support life. 7:29. There is no special treatment for softening of the stomach; the remedies employed for the gastritis, if they are successful, will super- sede the necessity of others for the ramollissement, and if they fail we have none other more effectual. Rilliet and Barthez recommend chiefly the gummy extract of opium, or if this cannot be given internally, mu- riate of morphia is to be sprinkled over a small blistered surface at the epigastrium. Dr. Lion, of Breslau, depends principally upon external means and a suitable diet, very small quantities of food at a time, a warm bath, mild enemata, exercise in the open air, an aromatic plaster to the sto- mach, and internally the decoction of acorns, carbonate of iron, or the tinct. ferri muriatis. 2 Chronic gastritis may be treated by nearly the same means ; leeches will not be necessary, but small and repeated blistering will be most advantageous, with a warm bath occasionally, and mild unirritating diet. Dr. Condie speaks highly of a combination of calomel, ipecacu- anha, and hyoscyamus. The state of the bowels must be carefully regu- lated. ' Diseases of Children, p. 207. 2 Ranking's Abstract, vol. i. p. 177, from Casper's Wochenschrift, No. 34. DIARRHCEA. 503 CHAPTER XVI. DIARRHCEA. — CHOLERA INFANTUM. — ENTERITIS. 730. There is no complaint so common in infancy and childhood as disordered bowels, and this we can easily understand, on account of the delicacy of the mucous membrane, and the novelty, so to speak, of the functions it is called upon to fulfil, in the first instance ; and the variety and irregularity, both of quantity and quality, of the food submitted to it in after years of childhood, to say nothing of the reflex disturbances arising from irritation of other organs, and of which this is the most frequent seat. This disorder of the bowels varies in extent, intensity, and results, in every possible way. In some there is merely an increased looseness, temporary, and without any ill effects ; in others the purging continues long, with some inroads upon the constitution, but without any deviation from the normal condition of the discharges. Again, the quantity of the discharges may not only be increased, but' the quality may be very much changed, indicating in some cases a more extensive, in others a more serious morbid action ; and, lastly, this disordered function may be accompanied with symptoms which indicate the presence of inflam- mation, whose actual existence may be proved after death. And yet it is often very difficult to draw the line between functional disturbance and organic disease. The symptoms may be identical, or nearly so, and the results may be analogous. I have, therefore, thought it better to include all in the one chapter, noting, so far as I am able, the grada- tions and the symptoms significant of each. Let me remark, also, that although for the convenience of descrip- tion, gastritis, enteritis, and colitis are treated separately, yet we more frequently find them conjoined in practice, as gastro-enteritis or entero- colitis, than isolated, as the reader will find them in books. This is an inconvenience which cannot be altogether avoided. Diarrhoea, then, whether functional or the result of inflammation, 1 may be either acute or chronic, either primary or secondary. 731. Symptoms. — Dewees, Eberle, and others have classified diar- 1 M. Billard divides the disease into erythematous gastritis, with or without altera- tion of secretion, follicular enteritis, and enteritis properly so called. M. Valleix de- scribes simple enteritis, and enteritis combined with muguet. Rilliet and Barthez treat all varieties under the title of gastro-intestinal inflammation. M. Barrier speaks of acescent, follicular, serous, flatulent, and verminous diacrisis. M. Bouchut and Dr. West made a division into: 1, catarrhal diarrhoea; 2, inflammatory diarrhoea. M. Trousseau divides the diarrhoea of infants into four species: 1, bilious; 2, mucous; 3, lienteric; and 4, choleriform diarrhoea, or cholera infantilis. M. Legendre regards the majority of cases as alterations of secretion, and the morbid lesions rather as their conse- quence than their cause. 504 DIARRHCEA. rhcea, according to the character of the discharges, in the following manner : — I. Feculent Diarrhoea, in which the discharges are increased in quan- tity and frequency, but preserve their natural character, the evacuations being preceded by slight nausea, and accompanied with some pain. ir. Bilious Diarrhoea. — '* In this species the fseces are loose, copious, and of a bright yellow or green, and the bowels are stimulated to inor- dinate action by an overcharge of bile, either vitiated or not. This complaint is very frequent among our children during the heat of our summer, or as the fall approaches. The influence of a hot sun upon the action of the liver is well known to everybody. It is familiar to common observation that after a spell of very warm weather even the healthy evacuations of the adult give evidence of its rapid formation, and sometimes of its abundant absorption. Thus the feces are observed to be loaded with bile, and the urine to be deeply tinged with it ; and when the complaint of which we are treating seizes upon children, it is called the 'liver complaint.' " This action of the bowels, as in the species just considered, some- times relieves them of their stimulating contents, and will thus effect its own cure ; hence this species, like the others, may be ephemeral, and not be more formidable than the feculent species, unless the formation of bile goes on almost indefinitely, or fever be provoked." 1 nr. Mucous Diarrhoea. — The evacuations in this variety contain a considerable amount of mucus, or may perhaps consist almost entirely of it. The discharge may not be very frequent nor very large ; there is generally some little tenesmus, and occasionally a little blood. Ordi- narily, their color is greenish, or light green, and very offensive. Some- times they resemble chopped spinach ; at other times yellowish or green- ish clay, with a very bad odor. 2 Dr. Graves regards this green matter as a secretion from the mucous membrane of the small intestines, and not bile. Drs. Simon and Golding Bird 3 consider it owing to blood which has undergone a chemical change. In common with the latter physician, I have observed that in many cases these green stools are originally yellow, but become quite green in an hour or two. The mucus is at first thin and transparent ; afterwards it becomes thicker, opaque, and almost puriform. This form appears to arise from sudden transitions of the weather, or from a sudden chill. IV. Chylous Diarrhoea. — In this form the discharges are whitish or milky. There appears to be rather a deficient secretion of bile, than any obstruction to its escape, as it is never attended by jaundice. This milky fluid is supposed by some to be chyle, and Dr. Dewees asks why the lacteals do not absorb it ? and he debates whether this arises from their incapacity or from the badly concocted nature of the chyle. Might it not be well to precede these by another question — whether this fluid be chyle at all, and not rather a morbid secretion from the intestines ? — which I am inclined to believe. 1 Dewees, Diseases of Children, pp. 381-2. 2 Hamilton, Management of Infants, p. 69. 3 Med. Gazette, Sept. 1845. DIARRIKEA. 505 A child thus attacked becomes rapidly weak and emaciated, and, if not soon relieved, sinks from exhaustion. V. Lienteric Diarrhoea. — This is characterized by the transit of the food nearly unchanged through the alimentary canal. It sometimes follows some of the other species, but more frequently dysentery. The child is uneasy after eating, and soon has a desire to go to stool, when it passes the food taken shortly before. " It generally," says Dewees, " commences during the chronic state of diarrhoea, by showing, perhaps, that some one article of diet only has passed the bowels unchanged, as potato, apple, or other vegetable substance or fruit, which has been incautiously given to the child. This is pretty soon followed by other articles, as meat, &c, and finally everything almost that enters the stomach is speedily conveyed through the intestines, with little or no appearance of having been acted upon by the powers of the stomach. The appetite is sometimes voracious in this disease, and the thirst is always considerable." 1 Dr. Mason Good thinks that there is a deficiency of biliary secretion, as in the last variety ; but with this opinion Dr. Dewees' opinion does not agree : he considers that the "complaint is seated altogether in the stomach itself, and owes its existence to the too great irritability of this organ; for no sooner is food lodged in it, than it makes efforts by an increased peristaltic action to discharge it, and the intestines transmit it with equal speed to their extremity, there to be discharged." 2 732. So much for the varieties of the evacuations of diarrhoea. The other symptoms will vary in different cases, but not altogether according to the peculiar discharge. There is generally a certain amount of uneasiness and pain ; sometimes this is very considerable, accompanied by rumbling in the bowels, and an escape of flatus. There is often considerable tenesmus and forcing, so that the child is very unwilling to cease its efforts, and these are sufficient in many cases to cause a troublesome prolapse of the anus. This seems to be the result of relaxation of the sphincter ani, from the frequent discharges, and the violent forcing efforts made by the child. When once it occurs, it is generally reproduced with each evacuation, and may degenerate into a habit that will persist after the diarrhoea is relieved. If the discharge be considerable, the child is rapidly reduced in flesh, and in young infants the muscular substance becomes quite soft and flabby. It is also much Aveakened, so as not to be able to run about or walk without great fatigue. There is an expression of weariness, de- pression, and sinking about the face, in some cases resembling collapse, until reaction takes place. The eyes are sunk, surrounded by dark circles, the features are sharpened, and in prolonged cases the child acquires an appearance of age. The tongue may be either white and coated, or red, and occasionally there is a curdy matter, something like the commencement of muguet. The thirst is greatly increased, some- times quite intense, with great dryness of the mouth. At first the pulse is but little altered, but if the disease continue long and severe it becomes very quick and small, with hot skin and other i Diseases of Children, p. 391. s Ibid., p. 392. 506 CHOLERA INFANTUM. evidences of fever. The abdomen is rarely tender, on pressure, but it is sometimes distended by flatus ; more frequently, I think, at least in the earlier stages, it appears shrunk, concave, and empty. In some cases we find a sudden collapse, resembling that of cholera, after which the child rapidly sinks, unless reaction can quickly be produced. CHOLERA INFANTUM. 733. There is, however, another variety of diarrhoea which I must notice, and which seems to be far more frequent in America than in these countries. It is not, however, limited to America, but is common in other warm climates. The reader will find most valuable informa- tion upon this disease in the essays of Dr. Rush (1789), Dr. Miller (1800), Dr. James Mann (1805), Dr. Jackson and Dr. Horner (1829), and in the excellent treatises of Dewees, Eberle, Stewart, and Condie. It appears more common in the Southern and Western States, during the months of July, August, and September, and chiefly in the cities. In Philadelphia it is more frequent than in New York or Boston : " In the latter city it has been doubted whether the disease exists in its genuine form." " In Philadelphia, during a period of ten years, from 1835 to 1844, inclusive, 2583 infants perished from this complaint, being nearly 11 per cent, of the whole number of infants under five years of age who died during that period, and 5.3 per cent, of the entire mortality of the city." Dr. Condie further remarks that "the dis- ease occurs as an endemic in all the large cities throughout the Middle and Southern and most of the Western States, during the season of the greatest heats, making its appearance and ceasing earlier. or later, ac- cording as the summer varies in the period of its commencement and close. Thus in Pennsylvania, Maryland, and Virginia, Kentucky and Ohio, it commences sometimes early in the month of June, and con- tinues until October, prevailing to the greatest extent in July and August, whilst in the more southern States it appears as early as April or May, and frequently cases of it occur until late in November. Its only subjects are infants, chiefly those between four and twenty months of age, seldom attacking them younger or older, being commonly con- fined to the period of the first dentition. So generally is this the case, that an infant's second summer is considered by mothers as one of un- usual peril ; and should it escape at that age an attack of cholera, or pass safely through the disease, it is considered to have a fair chance of surviving the period of infancy." 1 In Massachusetts, in five years from 1844 to '48, inclusive, there were 852 deaths from this disease, and in Baltimore it was epidemic in 1848. 1 Diseases of Children, p. 233. During the present epidemic of Asiatic cholera (1849), my friends Drs. Asken and O'Reilly inform me that the proportion of children under five years of age admitted into two of the hospitals is in the proportion of 1 child to 25h adults, as follows : Brunswick Street Hospital — -total number of cases, 407. Children, males, 4 ; females, 8. Died, males, 1 ; females, 4. Cured, males, 3 ; females, 4. Green Street' Hospital — total number of cases, 797. Children, males, 15 ; females, 16. Died, males, 7; females, 12. Cured, 12. CHOLERA INFANTUM. 507 734. The disease is often preceded by diarrhoea, but in the majority of cases, according to Eberle, the vomiting and. purging commence to- gether, with no other premonitory symptoms than languor, fretfulness, loss of appetite, or a morbid craving for food. In -whatever way it commences, however, the characteristic vomiting and purging soon appear, with great prostration, emaciation, and sinking. From the beginning the pulse is quick, small, and somewhat tense. The tongue is covered with a slight white fur at first, but as the disease advances this may disappear, and the tongue assume a bright, dry, and polished appearance. " At first the discharges from the bowels usually consist of a turbid, frothy fluid, mixed with small portions of green bile, or of a nearly colorless water, containing small flocculi of mucus. After the disease is fully developed, the evacuations very rarely exhibit any traces of bilious matter, the biliary secretion being evidently entirely suspended. In some instances the disease commences and proceeds with such violence as to exhaust the vital powers and terminate in death in the course of a single day. More commonly, however, the vomiting and purging are not so rapid as to prostrate the system immediately, and the dis- ease continues for five or six days before convalescence begins or fatal exhaustion ensues. In many instances the vomiting, in the course of four or five hours, becomes less and less frequent, and finally ceases altogether, or recurs two or three times daily, while the diarrhoea goes on until at last it assumes a strictly chronic character. In the early stages of the disease the little patient is evidently harassed with pain- ful and distressing sensations in the stomach and bowels ; and when the discharges are violent and very frequent, the muscles of the abdo- men and even those of the extremities are apt to become affected with spasmodic contractions. If the disease do not terminate fatally during the first few days, rapid emaciation ensues, the hands and feet become cold and pale, while the head and body are always preternaturally warm ; the skin is usually dry and harsh, and acquires a peculiar welted appearance, particularly on the inner part of the thighs and over the abdomen. The countenance becomes pale and contracted, the eyes in- animate and sunk, the nose sharp, and the lips thin, dry, and wrinkled. " The thirst is always very great, more especially after the disease has continued for some days, and no drink is palatable but cold water, which is generally thrown up soon after it is swallowed. Food of every kind is usually loathed and refused. If the disease be not subdued or moderated by proper remedial means, the little patient by degrees be- comes somnolent ; he sleeps with the eyes half open, rolls his head about when awake, and at last sinks into a state of insensibility and coma, and dies in a paroxysm of convulsions, or under symptoms re- sembling those of acute hydrocephalus. When the disease is of pro- tracted duration, or assumes a chronic form, the alvine discharges generally acquire a dark, very offensive, and acrid character. The digestive powers become so enfeebled that almost everything taken into the stomach passes through the bowels in an imperfectly digested state. Aphthae finally appear on the tongue and inside of the cheeks ; the face acquires a bloated or osdematous appearance ; the abdomen becomes 508 CHOLERA INFANTUM. tumid and tympanitic ; the parts about the anus are excoriated by the acrid discharges, and towards the fatal conclusion spots of effused blood under the cuticle sometimes appear on various parts of the body, more especially on those upon which the patient lies. The little patient at last lies in a comatose and insensible state, with the eyelids half open, and the eye turned up so as completely to hide the cornea." 1 This admirable description of Dr. Eberle at once points out the simi- larity and also the dissimilarity between the symptoms and course of cholera in infants and in adults ; but there are one or two other symp- toms, pointed out by Dewees, which are worthy of notice. One of them is a "crystalline eruption upon the chest, of an immensity of watery vesicles, of a very minute size. The best idea we can convey of the ap- pearance of this eruption is to imagine a vast collection of vesicles ap- parently produced by flirting an equal number of very minute drops or particles of boiling water, and each particle producing its vesicle." 2 Dr. Physick, Dr. Rush, and Dr. Condie, have witnessed examples of this eruption, but it appears to have escaped Dr. Eberle. Dewees considers it an invariably fatal symptom, but Dr. Condie says that he has " in many instances known the patient to recover, even w T hen this eruption has been the most extensive and distinct." It may, however, "readily escape observation, if not looked for; it requires that the surface in which it has spread itself should be placed between the eye and the light, and viewed nearly horizontally." " There is another symptom," Dr. Dewees adds, "which attends the last stage of this com- plaint, which is much more common but not less fatal, which is, the thrusting of the fingers, nay, almost the hand, into the back part of the mouth, as if desirous of removing something from the throat. The popular opinion is, that there is a worm irritating the back part "of the fauces. And we may mention another which we do not remember to have seen noticed, which is, the escape of a live worm or worms in the chronic stage of this affection. If the worm come away dead, there is nothing in the circumstance; but if alive, it is a fatal sign." 2 735. The duration of this disease varies very much, sometimes ter- minating fatally in five or six hours, in other cases running on for many weeks. Children sometimes recover from the most hopeless condition, and in all such cases bilious matter reappears in the stools ; and always when this occurs, together with warm moisture of the skin, and a better pulse, we may hope for a favorable issue. But when the pulse is weak and thready, and the evacuations watery and colorless, or reddish and mixed with flocculi of mucus, with uneasiness and restlessness, or stupor and insensibility, we may fear the worst. 1 Eberle on Diseases of Children, p. 283. I may just observe upon this last symptom, which, with the half-open eyelid, gives such a distressing look to the child ; that any one who has watched a baby go to sleep, or even carefully traced their own physical sensa- tions during the initiatory part of this process, must have observed that the turning up of the eyeball is almost invariable ; that in fact, it is one of the natural and healthy phe- nomena of sleep. 2 Diseases of Children, p. 417. ENTERITIS. 509 ENTERITIS. 736. At the commencement of a bowel complaint, it is by no means easy to decide -whether it be an ordinary case of diarrhoea, or whether there may not be inflammation of the mucous membrane of the intestine, as the symptoms are much alike. Even at a later period, the distinction is not very marked; nor is the difficuly lessened by the fact, that when the diarrhoea has continued for some time as a functional disturbance, it is very liable to degenerate into enteritis or entero-colitis. Enteritis may commence, then, with moderate diarrhoea, which does not interfere with the child's comfort or its amusement for six or seven days, at which time there supervenes pain in the belly, fever, thirst, loss of appetite, and increase of the diarrhoea. Or the attack may be more sudden, with headache, vomiting, diarrhoea, pain in the bowels, fever, thirst, and loss of appetite. Or as I have seen in young infants, and verified by post-mortem examination, it may present at first neither pain, vomiting, purging, nor tenderness, but merely profound collapse. Other symptoms, as pain, diarrhoea, may subsequently be developed, but it is important to bear in mind that in- fants may die of enteritis with but little pain, and with no vomiting, purging, or tenderness, but in them the vital collapse is most marked. The ordinary symptoms then are vomiting, diarrhoea, heat, and tension of the abdomen from flatulence, and tenderness on pressure. The amount often varies; it is seldom very intense with young children. The tongue is found generally moist, red at the end, and along the edges; there is a disagreeable taste in the mouth, and the breath is offensive. The thirst is great, and the appetite lost. The vomiting continues for some days, and then subsides. The diarrhoea generally continues throughout the complaint, but in some cases it ceases as the disease advances. The abdomen is distended, and is painful when pressed ; rarely at the epi- gastrium, according to Rilliet and Barthez, but rather in the umbilical region or iliac fossae. The temperature of the abdomen is increased in proportion to the intensity of the inflammation, and is greatest when the disease is at its height. The color, consistence, and odor of the discharges vary much, nor do I believe that any very important inferences are deducible therefrom. They are sometimes green, sometimes yellow or reddish, brown, or clay- colored. Rilliet and Barthez give the following as the constituents of the stools, the varying proportions of which will influence the consistence and color : 1. The residue of the food, incompletely di- gested. 2. A secretion of serosity, which is not always present. 3. Mucus, which is almost always present, enveloping the more solid por- tions ; it is variously colored by the bile, is soft and gelatinous. 4. Bile, which colors the stools, and, alone or mixed with mucus, forms the clear or green flocculi. 5. Pus, the presence of which it is difficult to ascertain, unless the fecal matter be somewhat solid, upon which it then appears as streaks or lines. 6. False membranes, or their debris, are occasionally detected. 7. Blood, not fluid, nor occurring as hemorrhage, 510 ENTERITIS. but mixed with fecal matter, in strise, brownish or bright red, or sanious, from mixture with mucus or pus. 1 M. Billard mentions, that in four cases he found an exhalation of blood from the mucous membrane in erythematous enteritis. 2 The evacuations are almost always voluntary, and passed consciously, except towards the termination of the disease ; but in some cases the urgency is so sudden and so great that the child has not time to call for assistance, and has, therefore, erroneously been supposed to have involuntary motions. As the disease advances, the skin becomes dry, pale, yellowish ; the face wrinkled, old-looking, and expressive of depression and distress ; the debility and the emaciation are very great. M. Jadelot lays great stress upon the lineaments of the face. " One of the most certain marks of abdominal affection is the first general lineament, which extends from the commissure of the lips to the lower part of the face, where it loses itself; the second, the nasal lineament, extends from the inside of the alae of the nose, and surrounds the whole of the orbicularis oris muscle. These are not to be always seen in very young infants, yet some trace of them may be observed, as a fold, on the commissure of the lips, or outside of the orbicular muscle, corresponding with the nasal lineament. When the child suffers violent pain, there is a corrugation of the skin of the forehead; and indeed the sudden appearance of wrinkles in any part of the face almost always indicates the presence of abdominal pain, and demands the attention of the physician, for they are invariably marks of distress not to be overlooked. A pinched expression of face, without the presence of any particular lineament, in very young infants, is always a sign of gastro-intestinal inflammation." 3 737. Chronic Diarrhoea. — Functional disturbance of the bowels, if not fatal, may subside into a chronic form of diarrhoea; acute enteritis may also be succeeded by the chronic phase of the disease, and the similarity between these chronic disorders is even greater than between the acute forms. The bowels continue relaxed, with a considerable variation in the character, quantity, color, and consistence of the dis- charges, occasional griping pain, tympanitic inflammation of the abdo- men, great general emaciation, loss of appetite, thirst, foul tongue, &c. The fever assumes a kind of remittent type, but is never very intense; the pulse is rather quicker than natural, but weak. The surface is dry, and becomes of a dirty color. Dr. Dewees has included "weaning brash" in his description of chronic diarrhoea, and in some instances it may fairly be so denomi- nated, but it is generally more acute, and the irritation involves the stomach as well as the intestinal canal. 738. Let us now briefly notice the complications of this intestinal disorder, or those secondary affections which are most apt to occur in its course. I. We found, when treating of muguet, aphthge, ulceration of the gums, cancrum oris, pseudo-membranous pharyngitis, &c, that in a great 1 Mai. des Enfans, vol. i. p. 494. 2 Mai. des Enfans Nouveaux-nes, &c.,p. 202. 3 M. de Salle's translation of Underwood. Stewart on Dis. of Children, p. 253. DIARRHCEA. 511 proportion of cases they were secondary to an inflammatory affection of the intestinal canal ; and every day's experience shows us that at least the milder forms may occur in the course of acute or chronic diarrhoea, where no decided evidences of actual inflammation are present. ir. Children suffering from any of the varieties of diarrhoea, from cholera infantum, or from enteritis, are very liable to affections of the nervous system, and this either at the commencement, or after the pri- mary disorder has continued some time. Tn the first, we find the diarrhoea set in furiously with high fever, heat of skin, quick pulse, &c, and then a convulsion partial or general. In the latter case, and by far the more frequent, the convulsion is generally preceded by sleepi- ness, starting, wildness of eye, stupor, or coma ; the cerebral irritation advances more slowly, but is even more to be feared. A post-mortem examination does not necessarily afford evidences of meningitis, but yet the complication requires a modification of similar treatment, and will prove equally fatal if the remedies be not early and skilfully applied. in. Dr. Stewart states that there are many marks of irritation in the pulmonary system ; but my experience would rather confirm the obser- vations of Rilliet and Barthez, that this is a comparatively rare compli- cation. No doubt a child suffering from diarrhoea will occasionally have a short cough, but I do not think that we often see bronchitis well marked in such cases. 739. Morbid Anatomy. — I. So long as the diarrhoea is not inflam- matory, a ]Jost-?nortem examination will reveal but few changes beyond the presence of the peculiar secretion in the intestines. Out of twenty-eight cases, M. Legendre observed four in which there was not the slightest change in the mucous membrane, although the disease had lasted from three weeks to four months. He considers that the morbid conditions which are found are the consequence of the pro- longed secretion. 1 M. Billard has discovered enlarged muciparous follicles, but not inflamed, in children dying from excessive serous discharges ; and this I believe is nearly all the positive alteration observed, unless the disease run on into inflammation. Most of the morbid appearances recorded as having been noticed in cases of diarrhoea, were the result of inflam- mation, and prove the cases not to have been mere irritation, or to have transcended those limits. We shall presently enumerate them. Dr. West has quoted in a note the experience of Messrs. Friedleben and Fleisch, from the Zeitschrift fiir Rationelle Medicin, vol. v. 1846. " Their observations are founded on fifteen infants, all of whom were under one year old, who were brought up either exclusively, or in a great measure, on artificial food, and who died, after long-continued illness, in a state of atrophy ; or else sank rapidly under profuse watery diarrhoea. In cases of the former class — a state regarded by the writers as the result of chronic inflammation of Peyer's glands — were the chief morbid appearances ; while in those instances where death took place rapidly, a swollen and congested condition of the same bodies, betokening, as they believe, their recent inflammation, was almost 1 Recherches, &c. sur quelquesMal. de l'Enfance, p. 867. 512 CHOLERA INFANTUM. always present. They found, too, that in all these cases the disease of the colon was comparatively slight, and was evidently secondary to the more serious changes in the small intestine." 1 M. Legendre alone, I believe, has noticed the fatty degeneration of the liver in prolonged diarrhoea. The organ is not increased in size, nor is its specific gravity diminished, but its color is mottled with yel- low patches. 2 II. In cases of cholera infantum., the liver is almost always engorged, and generally greatly enlarged. Dr. Dewees speaks of its occupying two-fifths, 3 Dr. Lindley 4 one-half, and Dr. Horner 5 two-thirds of the abdominal cavity. It is firmer and more solid than natural, but with- out perceptible change of structure. There are abundant evidences of inflammation in the stomach and small intestines ; red, inflamed patches, inclining to purple, may be observed, especially in the duodenum ; nor are they limited to the small intestines, as Drs. Jackson and Dewees thought, Dr. Horner and others having found them in the large intes- tines. Dr. Horner has added another pathological characteristic to those observed before ; he has shown that very extensive inflammation of the mucous follicles of all the intestines is present, in this agreeing with the observations of MM. Billarcl, Roederer and Wagler. III. The morbid changes discovered in the mucous membrane of the small intestines in enteritis are very similar to those we noticed in the stomach. Redness, partial or general, occasionally limited to a small portion of the intestine, with or without ramollissement. This erythe- matous inflammation is the most common ; pseudo-membranous enteritis is more rare, and is seated at the lower portion of the intestine. Sim- ple ulceration is comparatively rare ; most commonly the ulceration is follicular. But here again we meet with inflammation of the follicles and of the groups of glands. The isolated follicles are prominent, rounded, and giving to the finger the sensation of a grain, somewhat soft, about the size of a pin's head ordinarily, and occasionally some- what larger. They are more voluminous in the upper than the lower portion. Paler and more transparent than the rest of the mucous membrane, they are sometimes surrounded by a red circle. When punctured, there escapes a drop of serous fluid. The glands of Peyer are frequently inflamed, and become swollen and thickened, and are easily removed by scraping with the scalpel. Their surface may have a mammelonated appearance, or be equally developed and prominent ; red, or of a rose color ; smooth, with a number of depressed points, the orifices of the mucous follicles. 6 Dr. West thus sums up the alterations he has observed in the small intestines: "They consist in a more or less intense redness of the mucous membrane, which appears thickened, and presents something of a velvety appearance, shaded over with numerous dark spots, the ori- 1 Diseases of Infancy and Childhood, p. 895, note. 2 Recberches sur quelques Mai. de l'Enfance, p. 376. 3 Diseases of Children, p. 400. 4 American Journal of Medical Science, vol. xxiv. p. 305. 5 Ibid, for February, 1829. 6 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 478. ENTERITIS. 513 fices of the solitary glands. In other instances, the surface of the reddened mucous membrane appears slightly roughened, as if sprinkled over with fine sand ; while near to the caecum the roughening is often greater, the membrane appearing elevated into rough, orange-colored prominences, separated by narrow lines, of a dead white color, which mark the situations where, by the destruction of the mucous membrane, the subjacent tissue is exposed." " Besides this affection of the mucous membrane of the ilium, Peyer's glands are not unfrequently very well marked in the lower part of the small intestine ; and their surface presents a punctated appearance, due to the unusual distinctness of the orifices of the sacculi which compose each gland. Occasionally a few of them are congested and swollen, and once or twice I have ob- served one or two spots of ulceration on that cluster of Peyer's glands which is situated close to the ileo-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." 1 The mesenteric glands are most frequently unaffected ; sometimes they have been observed to be increased in size and congested, but in general they retain their normal appearance and size. Softening of the mucous membrane is extremely common in infants, either limited in extent or extending throughout the intestine. 740. In some rare cases, traces of cerebral congestion, or of disease of the membranes of the brain are discoverable, but in general, even when head symptoms have occurred, but little information is obtained by a post-mortem examination. The lungs are almost invariably healthy, and the mucous membrane free from inflammation, quite justifying the remark I made as to the rarity of such complication with diarrhoea. 741. Causes. — All the varieties of irritation and inflammation of the intestinal canal are as common with infants as with older children. I do not think we can say more common, although the delicate unused condition of the mucous membrane might well predispose them to it. 2 The chief causes of diarrhoea are, cold, damp, improper food, or excess of proper food, dentition, and variations of atmospheric tem- perature. On a comparison of the results of five years' observation at the Children's Infirmary, Dr. West found that In the three months, Nov. Dec. and Jan. diarrhoea formed 7.2 per cent, of all cases of disease. Feb. March, and April, 8.3 " May, June, and July, . . 18.0 " " August, Sept. and Oct. . . 24.4 " " Dr. Condie very truly remarks that food, which is ordinarily suit- able, will sometimes disagree with the same children, and give rise to diarrhoea ; and during infancy, of course, the babe will be affected by any change in the nurse's milk, whether the result of bodily or mental conditions. 1 Diseases of Infancy and Childhood, p. 394. 2 West, Diseases of Infancy and Childhood, p. 388. 33 514 ENTERITIS. The loose discharges about the period of dentition appear connected with the enlargement and inflammation of the mucous follicles, as Billard has observed ; and M. Bouchut found that only twenty-six out of 110 actually escaped at this age, whilst forty-six suffered very severely. 1 Mucous diarrhoea occasionally follows the suppression of cutaneous eruptions, or the drying up of sore ears. 742. Qholera infantum seems limited by age, few cases occurring beyond the second, and never beyond the fifth year. " During twenty years, the deaths from cholera infantum in Philadelphia amounted to 8576 ; namely, in infants under one year of age, 2122 ; between one and two years, 1186 ; between two and five years of age, 268." "The influence of a high atmospheric temperature in the production of cholera infantum is shown by the fact that its prevalence is always in proportion to the heat of the summer, increasing and becoming more fatal with the rise of the thermometer, and declining with the first appearance of cool weather in the autumn. A few hot days in succession in the month of May are sufficient to produce it ; while in the height of its prevalence, a short period of cool weather will diminish, if not entirely suppress it." 2 But heat alone is not sufficient ; it requires in addition confined and impure air, for we find that the disease is nearly confined to large cities — that little or none is seen in the country, although the heat is quite as intense. Infants who have been prematurely weaned, and children whose diet is bad or in excess, are extremely obnoxious to an attack, and probably the irritation of dentition may be among the pre- disposing causes. The causes of enteritis are almost identical with those of diarrhoea. Unwholesome food, irritating matters, excess, dentition, cold, impure air, &c, are as likely to give rise to the severer as to the milder affec- tion. 743. But we must not forget that diarrhoea, whether functional or organic, may in any or all of its varieties be a secondary affection, and that this may either be the result of the primary disease, or of the remedies employed in its cure. Thus we find that in the course of the eruptive fevers, meningitis, bronchitis, pneumonia, &c, diarrhoea is very apt to set in, and espe- cially when these have been treated by calomel, tartar emetic, or pur- gatives. The symptoms do not differ materially from those already enume- rated, although they are more or less masked by the predominance of the primary disorder. We find diarrhoea, pain, and perhaps some de- gree of tenderness, tympanitic swelling, and tension of the abdomen ; which may subside, all but the diarrhoea ; the tongue is moist, red at the point and edges, the face becomes pale and wrinkled, with the naso- labial trait well marked, the eyes are hollow, &c. ; and this condition may continue until either the primary disease is cured or proves fatal. Or the attack may come on more suddenly and more severely in the course of an acute disease, with excessive vomiting, copious diarrhoea, 1 Mai. cles Nouveaux-nes, p. 196. 2 Condie cm Diseases of Children, p. 215. ENTERITIS. 515 tension and enlargement of the abdomen, with a disproportionate de- gree of tenderness (so as almost to lead us to suspect peritonitis), great exhaustion, &c. 744. Diagnosis. — I. The distinction between diarrhoea from exces- sive secretion, and that which is the result of enteritis, is by no means easy, not only from the similarity of symptoms and course, but also because the former is very apt to run on into the latter. The most characteristic difference is the amount of fever, the pain, and the ten- derness on pressure, which are much more marked in the latter. II. On the other hand there is less acute tenderness, less pain and fever, in enteritis than in peritonitis ; the expression of countenance is different also. in. The previous history will almost always show that the head symptoms are secondary, and that, therefore, we are not called upon to treat simple meningitis. The previous, and in most cases the pro- longed diarrhoea, and the gradual development of nervous symptoms, are very unlike the course of the disease when primary. 745. Prognosis. — I. In simple diarrhoea, if we see the case early, our prognosis will upon the whole be favorable ; but if the disease be of longer standing, and have resisted the ordinary means of relief, we cannot conceal from ourselves that considerable danger attends the complaint. A cessation of vomiting, a decrease of the purging, sub- sidence of the abdomen, and the return of appetite, constitute the favorable symptoms, while an increase of these symptoms with higher fever, or sinking, or the accession of any complication, especially of the head, will leave but little hope. It is scarcely possible to have a more fatal complication than a cerebral attack towards the termination of an exhausting diarrhoea. II. The same observations will apply to moderate cases of enteritis. In severe cases, the prognosis is more unfavorable, and the chances of some fatal complication greater. in. Cholera infantum is a most fatal disease; a very large proportion of children are carried off by it. 746. Treatment. — The first duty is to remove every possible cause of the disease. If we have any reason to suppose that the nurse's milk does not agree with the child, it will be necessary to change the nurse; and it will be well to choose one whose child is rather older than our patient, as the younger the milk the more likely it is to purge the infant. If the child be weaned, we must correct any errors of diet, either as to quantity or quality, and, as a general rule, substitute a bland, milky, or farinaceous diet for any kind of animal food. Ass's milk for young children, arrowroot, tapioca, panada, &c, are all very wholesome in irritations of the intestinal canal. If the teeth be at all at or near the surface, or even when at some distance, if the child suffer from irritation of the gums, they ought to be freely divided down to the teeth, and rather beyond the limits of those coming to the surface. Very often the irritation which a child would bear in health without any inconvenience will be quite sufficient to neutralize the effect of our remedies when diarrhoea is present. 516 ENTERITIS. 747. These points being attended to, we have next to consider what medicines we shall employ, and, on the supposition that irritating mat- ters require to be removed, many physicians commence with a purgative of rhubarb, magnesia, or castor oil. Undoubtedly, if such matters were in the intestinal canal, this would be right, but disordered evacuations are no proof of it ; and I very much prefer calming the irritation first, and then, if necessary, clearing out the bowels. For this purpose, nothing is better than the chalk mixture with some aromatic and a drop or two of laudanum to the ounce. I find that small divided doses answer just as well as larger ones ; and I prefer laudanum to syrup of poppies, because, if fermentation take place with the latter, the acetate of morphia is formed, and the child may get an overdose. Mucilage, syrup, sal volatile, aniseed water, with the same amount of laudanum, will answer equally well, with the advantage of being slightly stimulant. Or the hyd. c. creta may be combined with the pulv. cretse c. opio, or with Dover's powder, in proportions according to the age of the child. A starch enema, containing a few drops of laudanum, will often relieve the irritation quicker than anything else, and, given at bedtime, will secure a good night's rest. It may be repeated as often as ne- cessary. If the discharges be acid, we may combine an alkali with the fore- going. I have found great advantages in obstinate cases from the use of ex- ternal irritation, either by mustard and meal poultices, or the compound camphor liniment with laudanum. A plain poultice applied twice a day affords great comfort, or the abdomen may be fomented. If the discharges continue and are still excessive, a more decided astringent may be given ; the infusion of catechu, or decoction of log- wood, or the tincture of kino; or catechu may be added to the chalk mixture. Dr. West speaks most highly of the extract of logwood and tincture of catechu, five grains of the former and ten minims of the latter, to be given three times a day, in some sweetened aromatic water, to an infant a year old. " Pure argil has been of late much used in diarrhoea accompanied with acidity, as it forms with the acids an astringent salt. The substance is prepared from the sulphate of ammonia and alumina, by exposing it to a strong red heat in a crucible. Argil in the form of a white powder possesses great astringent powers. Riecke recommends the formulas which are subjoined." 1 R. — Emuls. sem. papav. ^iijss. Argillse puras, J}ij. Syr. althsese, ijss. — M. A teaspoonful for a child two years old. 1 Stewart on Diseases of Children, p. 198. ENTERITIS. 517 R. — Argill. pune ^ss. Gum. Arab. gj. Sacch. alb. gij. Aquas fceniculi, giij. — M. A teaspoonful for a child a year old. 748. The foregoing treatment seems so far suitable to any of the va- rieties of diarrhoea ; but some modifications have been suggested in the different species. In mucous diarrhoea, we are advised to endeavor to restore the action of the skin as well as to restrain the discharge, and for this purpose ipecacuanha has been recommended by Good, Dewees, Stewart, Condie, &c. Dr. Good gives it alone or united with opium, Dr. Stewart alone or with cretaceous preparations, and Dr. Condie combines it with calomel, acetate of lead, and hyoscyamus. As an astringent, Dr. Stewart speaks highly of an infusion of the root of the geranium maculatum, half an ounce to a pint, and also an infusion of the bark of the rubus villosus, or common blackberry. To an infant of six months, a teaspoonful may be given five or six times a day, and a tablespoonful to a child of two or three years. Dr. Eberle recommends a few drops of the balsam copaiba in emulsion when mucous diarrhoea is somewhat chronic; and Dr. Con- die has found it very useful. In bilious diarrhoea we are advised first to clean out the bowels, and then to give small doses of calomel with laudanum, or the hyd. c. creta with Dover's powder. Dewees recommends the tartrate of antimony in small doses, but I confess I should be very unwilling to give it, lest it should increase the gastric irritation, or perhaps give rise to gastritis. M. Trousseau recommends the neutral salts, ipecacuanha, and, if there be much mucous disturbance, opium. 1 The child should be removed to a cool atmosphere, have a tepid or warm bath daily, and drink plentifully of gum water, rice water, &c, aud be supported by a bland farinaceous diet. In chylous diarrhoea Dr. Dewees advises low diet, rennet whey, or gum water, anodyne injections at night, and minute doses of calomel during the day — "say a quarter grain every four hours, with the twen- tieth of a grain of opium." "We have thought we derived advantage from the application of a blister to the back of the neck, and keeping the body unusually warm." 2 Very much the same kind of treatment is recommended for Uenteric diarrhoea ; abstinence from much food, and that given to be milky or farinaceous; frictions to the abdomen, chalybeate water, with a minute dose of laudanum, fresh pure air, &c. Dr. Dewees ordered friction with tartar emetic ointment; but for reasons before stated, I very much prefer compound camphor liniment, or a mustard and meal poultice, or a blister. M. Trousseau states that the stools are acid, and to correct this he gives either magnesia, from one to five grains daily ; lime-water, one scruple to one drachm; or the bicarbonate of soda from two to eight grains. In addition he advises mineral baths, containing from two to six ounces of sulphate of iron, sulphurous or aromatic baths, with decoc- 1 Banking's Abstract, vol. iv. p. 202. ' Diseases of Children, p. 891. 518 ENTERITIS. tions of sage, lavender, or rosemary, a pint of red wine, and common salt; fresh air and sunshine. 749. In cholera infantum the great desideratum is to tranquillize the stomach ; until that is done not only is the disease unchecked, but the suitable remedies cannot be exhibited. For this purpose Dewees recom- mends warm water to "encourage the puking," and enemata of warm water to clear the bowels. This appears to me to be acting upon the supposition that there is some irritating matter still in the stomach and bowels; and, with all respect to Dr. Dewees and others who have advo- cated the same plan, I believe it to be an error, or at all events an assump- tion of which we have no proofs. That discharges are foul and acrid does not prove that they cause the evacuations ; it only proves that such discharges have their origin in disordered action or secretion, and it is to that our attention should be directed. Calomel in small doses rubbed up with sugar ; or the hyd. c. cretti with Dover's powder, or small quantities of laudanum in a mixture, may be given with very good effects. Anodyne injections, warm baths, warm and stimulating frictions to the extremities, with stimulants internally, if there be much threatening of collapse, must all be tried. A blister over the stomach will often arrest the vomiting. " When the vomiting persists, we have found a few drops of spirits of turpentine, or of a solution of camphor in sulphuric ether, repeated at short inter- vals, seldom fail in removing it. When the vomiting is violent and frequent the application of a few leeches to the epigastrium "will be found decidedly advantageous. When everything else fails we have very seldom been disappointed in removing irritability of the stomach by the administration of the acetate of lead in solution." Dr. Eberle recommends the plan first adopted by Dr. Parrish, of blistering behind the ears in cholera, and the administration of small doses of calomel and ipecacuanha, and a stimulating poultice over the abdomen. If we suspect the existence of acid in the stomach and bowels we may combine chalk with the calomel, or we may adopt Dr. Kuhn's plan of giving magnesia with ammonia. Dr. Condie gives Kuhn's formula as follows : R. — Magn. calcin. "&'iv. Pulv. g. Arab. Qj. Sacch. alb. gij. Aq. menth. pip. §ss. Aquas font. §ijss. Aquas ammoa. pur. gtt. xlviij. to gtt. clxiv., according to the age of the child. The dose is a teaspoonful every two hours. When the stomach is quieted we may have recourse to any of the remedies already mentioned, to restrain the action of the bowels ; of these, probably, the acetate of lead and opium, in small doses, propor- tionate to the age of the child, will be found the best ; and when these watery discharges are diminished or changed for those containing ENTERITIS. 519 feculent or bilious matters, the treatment will then be the same as for diarrhoea. When cholera infantum becomes more chronic we may have recourse to warm baths, frictions or blisters to the abdomen, anodyne injections, astringents, and a slight improvement in the diet. Some of the prepa- rations of iron may be tried. Eberle speaks highly of the tartrate, others of the persesquinitrate of iron. Sulphate of quinine is also very useful occasionally. Dr. Condie recommends powdered charcoal in conjunction with rhubarb, ipecacuanha, and hyoscyamus, when the discharges are acrid, offensive, and dark colored. In addition, as the disease appears to be produced by hot, impure air, and deficient ventilation, the child ought to be removed to a cooler and purer atmosphere ; and, as soon as the stomach will bear it, the diet must be improved in quality, and stimulants given in due proportion to the age and circumstances of the child. 750. The treatment of enteritis differs but little from that of gastritis detailed in the last chapter, except that, when it has been preceded by exhausting diarrhoea, we must be cautious not to push antiphlogistic remedies too far. If the pulse be pretty good, and the prostration not too great, we may apply leeches to the epigastrium, in number according to the age and strength of the infant, intensity of the disease, &c. ; and the bleed- ing should be stopped immediately, unless we superintend the operation ourselves, as Maunsell and Evanson suggest. It is easy to repeat the leeching, if necessary, but far from easy to remedy excessive loss of blood. Warm baths, when the child is not too weak, and fomentations to the abdomen, are most valuable ; or, what is less troublesome, a succession of nice, warm, soft poultices. I do not think the profession in these countries are fully aware of the great value of poultices in internal and deep-seated inflammations. Nothing can be more marked than the relief afforded, and their soothing effect upon children. Some degree of counter-irritation may also be necessary, either by means of mustard poultices, liniments, or blisters. Sinapisms or even blisters may be applied to the extremities with benefit. Internally calomel or gray powder will be very useful, if it can be given without increasing the irritation ; and if not, we may either use mercurial inunction, or dress the blister with mercurial ointment. Opium alone, or in combination with the above, or in the form of laudanum, pulv. cretse cum opio, or Dover's powder, will afford relief from the pain and gastric irritability, and will render tolerable other remedies. The diarrhoea may generally be arrested by some of the astringent remedies mentioned already — chalk, lead, kino, catechu, &c. ; and the diet must be carefully regulated. It is not a prime object to accumulate nourishment ; if this be given too soon the disease will rather be in- creased. Mucilaginous drinks, or milk, with very light, thin, farina- ceous food, appear to be the most suitable ; and when the disease is on the decline, then we may gradually give more nourishment, and wine if 520 ENTERITIS. necessary. Of course every possible exciting cause must be removed, and the gums lanced, if required. 751. Chronic diarrhoea requires a slight modification of the treat- ment already laid down. In addition to the calomel, chalk, ipecacuanha and hyoscyamus, recommended by Dr. Condie, the acetate of lead, with or without laudanum, the vegetable astringents, &c, we are advised to try spirits of turpentine, balsam copaiba, the persesquinitrate of iron, in doses of two or three drops of the liquor every two or three hours, in sugar and water, &c. One of the occasional symptoms I have already noticed, the prolapsus ani, demands a word as to its treatment. So far as it depends upon relaxation resulting from frequent discharges, the relief of the diarrhoea will cure it at the same time ; but it does often remain, because of the habit of sitting long at stool and forcing, which the child acquires during the course of the disease. Now, in order to remedy this effect- ually, all we have to do is to place a board, with a small perforation, across the chair or vessel the child uses, and to place the latter so that the child cannot touch the ground with its feet. So circumstanced, no excessive forcing can be used, and I have repeatedly found the plan successful. I am indebted for the suggestion to my friend Dr. Corrigan of this city. It will rarely, if ever, be necessary to have recourse to any surgical operation for its cure. If it persist, a little gall ointment, or a small astringent injection occasionally, will almost always be sufficient. I need hardly say that the gut is to be returned immediately each time it prolapses, by applying gentle pressure with one or two fingers, pre- viously oiled. Another very troublesome occurrence, as Dr. West has remarked, is the intertrigo occasioned by the contact of acrid fasces. Generally this results from want of due cleanliness, but I have seen it in children with an irritable skin in spite of the utmost care and watchfulness. The best remedy is careful sponging after each evacuation, and anointing the parts, when dried, with zinc ointment, zinc cream, or ointment of the acetate of lead. Dusting the neighboring parts with lapis calaminaris is also of great use in protecting them. 752. As regards the complications I need not say much, having already treated very fully of them; and I must refer the reader to the chapter on diseases of the mouth and pharynx. Bat I wish to impress most forcibly upon all, the importance of carefully watching for the first inroads of cerebral complications, and of promptly applying the very few suitable remedies at our command. It is not often that we can venture to apply leeches under these circumstances ; if the case will admit of it of course it should be done ; but if not, we must have re- course to counter-irritation to the scalp or to the extremities, and to calomel, if the stomach and bowels will bear it, or to mercurial inunc- tion or dressings. Notwithstanding the head symptoms, we are not to abstain from opiates, if the state of the bowels requires it, because the continuance of that irritation will be far more injurious to the brain than the small quantities of laudanum I have recommended. DYSENTERY. 521 Again, the head symptoms show themselves very often at the time when the constitution of the child has been so much weakened as to re- quire wine or other stimulants ; and although these are somewhat counter-indicated by the attack of the nervous system, I have found the child suffer more by their omission than by their continuance. I re- commend, therefore, that they should be continued, but with caution and watchfulness. 753. Secondary diarrhoea, with or without enteritis, requires no other modification of the treatment here specified than what results from the coincident treatment of the primary malady, and the state of constitu- tion induced by it. The diet I have mentioned should in every variety be bland, milky, and farinaceous ; very moderate also fti quantity, and repeated at dis- tant intervals, so as not to give the stomach too much to do at once. Fresh, pure air, and a change from town to the country, is of great value. Warm baths, to cleanse the skin, and promote its functions, absolute cleanliness, and suitable warm clothing, are quite necessary. I have seen most beneficial effects in chronic diarrhoea from a swathe of new flannel being worn round the abdomen next to the skin. CHAPTER XVII. DYSENTERY. — COLITIS. 754. In the last chapter I mentioned that inflammation of the small intestines was frequently accompanied by inflammation of the large intestines, constituting the entero-colitis of the French authors; nay more, that this compound affection was of more frequent occurrence than either element separately ; and some evidence of the morbid lesions was brought forward under the head of morbid anatomy. Rilliet and Barthez have given a table of these diseases, and of their conjunction numerically, and I shall quote it, in the hope of impressing upon my junior readers the difference between a written description of disease and clinical experience; how what is very clear and definite in the one is obscured by combinations and modifications in the other, which yet cannot be described on paper ; and how necessary it is in practice to bear in mind the relations of one disease to another, as well as the characters of each disease. The authors I have named met with forty-five cases of enteritis, and 113 cases of colitis, either erythematous, pseudo-membranous, ulcerous, or pustulous; ninety cases of follicular enteritis; sixty-four cases of follicular colitis; twenty-eight cases of softening of the small intestines ; and thirty-five cases of softening of the large intestines ; and these, occurring in 185 cases, were thus associated : 522 DYSENTERY. Enteritis alone, in 2 cases. Colitis alone ........... 32 " Entero-colitis alone 11 " Follicular enteritis alone 12 " Follicular colitis alone 3 " Follicular entero-colitis alone 10 " Enteritis and follicular enteritis 8 " Colitis and follicular colitis 12 " Enteritis and follicular entero-colitis 2 " Colitis and follicular enteritis ........ 17 " Colitis and follicular entero-colitis . . . . . . . 11 " Entero-colitis and follicular enteritis ...... 7 " Entero-colitis and follicular colitis 4 " Entero-colitis and follicular entero-colitis . . . . 7 . " Softening of the large intestines ....... 8 " Softening of the small and large intestines . . . . 10 " Enteritis and softening of the large intestines 1 case. Colitis and softening of the small intestines 2 cases. Colitis and softening of the large intestines ..... 1 case. Enteritis, colitis, and softening of the large intestines ... 2 cases. Softening of the small intestines and follicular enteritis ... 1 case. Softening of the large intestines and follicular colitis . . . 1 " Softening of the small intestines and follicular colitis . . 1 " Softening of the small intestines and follicular entero-colitis . . 1 " Softening of the large intestines and follicular enteritis ... 3 cases. Softening of the large intestines and follicular entero-colitis . . lease. Softening of the small and large intestines, and follicular enteritis . 2 cases. Softening of the small and large intestines, and follicular colitis . 2 " Softening of the small and large intestines, and follicular entero-colitis 3 " Colitis, softening of the small intestines, and follicular enteritis . 1 case. Colitis, softening of the small intestines, and follicular colitis . . 3 cases. Colitis, softening of the small intestines, and follicular entero-colitis 3 " Entero-colitis, softening of the large intestines, and follicular enteritis' 1 case. From this minute tabular view, it is evident that no arrangement or division of these affections can be based upon morbid anatomy; for we find in a great number of cases that lesions of the large and small intestines are more frequently conjoined than separate ; and that, there- fore, in making a distinction, we must rather be guided by the history and symptoms of the disease than by the result of post-mortem examina- tion. So far, however, this distinction is borne out, that we do, in fact, find, in a certain number of cases, that the disease of the small and large intestines existed separately, and that the latter cases were much more frequent than the former. 755. Without any wish, therefore, to make a clearer distinction than we find at the bedside, I have still thought it well to treat the irritation and inflammation of the small intestines separately in the last chapter ; and to complete the history of this complicated affection of the digestive tube, by treating of colitis, or, as it is usually termed, dysentery, in the present chapter; first, repeating that, as in the former disorder, when disease of the small intestines predominated, we found that the large intestines participated, to a certain extent; so in the present disease of the large intestines, we shall find that the small intestines are by no means in a state of integrity. Dysentery, then, consists in an inflammation of the large intestines chiefly, and may occur in children of any age; although it appears to be less frequent in infants than older children. 1 Mai. des Eufans, vol. i. p. 488. DYSENTERY. 523 It may present itself in either an acute or chronic form, and may be either primary or secondary. 756. I shall first notice Acute Primary Colitis. This may be developed in the course of ordinary entero-colitis by the diminution of the enteritis, and the consequent predominance of the inflammation of the large intestine, and the early symptoms will be those of which I spoke in the last chapter. Or it may commence by uneasiness, broken sleep, irritability, some increase of the regurgitation of milk, and diarrhoea of feculent matter. So far the attack appears one of simple diarrhoea, without fever, and with the mouth cool and moist. After a few days, however, the disease changes its character a good deal, the evacuations become more frequent, smaller, and with less fecu- lent matter, until they consist of little more than small quantities of mucus mixed with blood, or even of blood chiefly. They are preceded by pain and followed by tenesmus; indeed, it is difficult to induce the child to leave the chair, or to forbear extreme forcing. Occasionally masses of feculent matter are expelled. The abdomen swells, becomes hot, tympanitic, tense, and tender, and there is a corresponding degree of fever, with hot skin, quick pulse, and evening exacerbations. The child rapidly emaciates, his flesh feels flabby and soft, his face is dis- tressed and anxious, wrinkled, and with a look of age ; the eyes are dull, sunk, and with a dark circle around them. 757. If the disease be not arrested these symptoms increase. The abdomen becomes more distended, and very tender on pressure ; the child complains of severe pain, especially when the bowels are moved ; the discharges may preserve their ordinary character, or they may become dark-colored, acrid, and highly offensive. From the irritating nature of the evacuations the anus and surrounding parts become red, hot, painful, and excoriated. M. Bouchut observes, that " erythema of the thighs and buttocks exists in five-sixths of the cases of entero-colitis. It commences with the disease, and appears ordinarily some days previously. At first there is simple redness, with reddish papulae, more or less confluent, on the thighs, scrotum, or vulva, and on the inside of the limbs down to the ankles. The epidermis on these papulae becomes eroded, and superficial ulcerations, whose red and bleeding surface is on a level with the surrounding skin, are the result. These ulcerations spread and unite until they sometimes form an ulcer of considerable extent, and constitute in themselves a serious disease." 1 These ulcers are gradually covered with a false membrane, which becomes organized and covered with epidermis, as the process of healing makes progress. The erythematous redness which attacks the ankles and heels may also run on into ulceration. These accidents are by no means common in private practice, as M. Trousseau has shown that they are dependent upon a want of cleanliness, more likely to occur in a hospital. Redness and excoriation we do constantly see, however, and with all care it is difficult, if not impossible, to prevent it. At an advanced 1 Mai. des Nouveaux-nes, p. 221. 524 • DYSENTERY. stage of the disease we also not unfrequently find aphthous patches around the anus. Prolapse of the gut, also, is by no means uncommon. The fever continues; the pulse is quick; the heat of the surface un- equal; the extremities often cold; the thirst considerable; the mouth hot and dry, often attacked by aphthae, especially at the angles ; there is great depression of strength, and extreme emaciation. Colitis may terminate fatally at an early period, from the intensity of the disease, but more frequently it is protracted for several weeks, and the child sinks from exhaustion : or coma and other cerebral symp- toms supervene, and carry off the patient. The principal complications of dysentery are affections of the mouth, such as muguet, aphthae, cancrum oris, &c, and cerebral irritation or effusion, just as we found to be the case with diarrhoea and enteritis; and the observations I there made apply equally well to the present disease. 758. Chronic Dysentery presents nearly the same array of symptoms, but in a minor degree. Frequent discharges of mucus mixed with blood, occasionally of faecal matter; uneasiness and pain in the bowels, tenes- mus, more or less tension and tenderness of the abdomen; a dry mouth, thirst, no appetite, aphthae at the angles of the mouth and about the anus; great prostration, extreme emaciation, &c. We find cases occur as the partially successful result of treatment, or as an effort of the constitution to throw off the disease; but, after re- maining in a chronic state for some time, they very frequently prove fatal from exhaustion. 759. Secondary Dysentery is more frequent in the course of the eruptive fevers, and the characteristic symptoms show themselves from the sixth to the tenth day. There may probably be a diarrhoea for some days before, and then the discharges become sanguinolent, either black or red, and mixed with mucus. The evacuations are frequent, and accompanied with tenesmus. The abdomen is tense, tender and generally hot, and the constitutional symptoms very marked, — fever, dry, hot skin, anxious distressed countenance, sunken eyes, &c, but these may, of course, be partly owing to the primary affection. The following is the description of the disease, by M. Constant, in an epi- demic which occurred at the Hopital des Enfans: "The disease ordi- narily commenced by abdominal pains, accompanied by borborygmi and frequent desire to evacuate the bowels. The discharges were scanty, passed with great effort, and consisting at first of greenish or yellowish viscid mucus, soon replaced by whitish mucus mixed with blood, and lastly consisting of arterial blood, either pure or mixed with small quan- tities of stercoral matter, or the remains of membraniform concretions. At the same time there were griping pain, tenesmus, and pain in the rectum and anus; but this latter symptom was wanting in some cases. It was only a short time before death that we witnessed coldness of the extremities, failure of the pulse, and cadaveric expression of the face. In no case was there headache, singing in the ears, stupor, epistaxis, lenticular eruption (maculae), sudamina, or the sibilant rale in the chest, which so constantly occur in the course of severe fevers. The intellect DYSENTERY. 525 remained intact until the approach of death. In two cases only the tongue was dry and loaded." 1 More than half of the cases referred to by M. Constant died, and all Rilliet and Barthez's cases, after an interval of from four to fifteen days from the commencement of the diarrhoea, and from three to ten after the appearance of the dysenteric symptoms. 2 760. Morbid Anatomy. — In all cases there is evidence of inflamma- tion, often very intense, in the large intestines, and often also in the smaller. The mucous membrane is red, swollen, thickened, and of slight consistence, often very much softened, with small ecchymoses here and there. In the great majority of cases the mucous follicles are enlarged, and their orifices widened and ulcerated. M. Bouchut gives the following result of his observations on young infants: "The large intestine was aifected throughout in all cases, but the disease was chiefly confined to the mucous membrane. The intes- tine was ordinarily contracted, as it had been left by the spasm of the muscular coat, and the mucous membrane was of course thrown into a number of folds, the edges of which presented marks of inflammation. The color of the membrane varied from a pale rose to a bright scarlet, interrupted by the enlarged, whitish, prominent mucous crypts, de- pressed in the centre, and filled by a grayish fluid. At the edges of the folds erosion and ulceration occurred, of an irregular form, super- ficial and narrow, with red but not raised edges, and a surface of the same color as the surrounding tissue. Ulcerations were also found in the intervals of these folds, small, superficial, and round, hardly to be distinguished except by their inflamed borders, and probably occupying the mucous follicles. In those infants who died quickly the mucous membrane was of a marked thickness; but in cases which were pro- longed, with great emaciation, it was very thin, and, in some cases, scarcely discernible. It was generally softened, especially in those cases where the membrane was very red." The mucous follicles were always developed, with their orifices gene- rally dilated or ulcerated. The cellular membrane was somewhat thickened, and slightly harder than usual. The muscular tissue was unchanged. The mesenteric glands were occasionally enlarged, but unaltered in color or texture. 3 M. Constant has stated that in all his cases there was false membrane on the surface of the large intestine. In all, the mucous membrane was of a deep red color, thickened, rough, and unequal in its surface, and presenting different degrees of softening. Dr. Mayne states that he found an undue degree of vascularity of the peritonaeum, congestion of the absorbent glands, thickening and induration of the coats of the intestine, the mucous membrane varying in color from a bright red to green or purple, in some cases covered with a bran-like exudation, in others ulcerated. The ulcers were some- times small and isolated, in others superficial and extensive, and, in a 1 Gazette Me'dicale, 1836, p. 101. 2 Mai. des Enfans, vol. i. p. 530. 3 Mai. des Nouveaux-nes, p. 210. 526 DYSENTERY. third variety, large, irregular, ragged, and penetrating. The small in- testines were generally healthy; the liver was sometimes extremely con- gested. 1 761. Causes. — I do not know that either age or sex have much in- fluence in the production of the disease ; it occurs in both sexes indif- ferently, and at all ages, especially about the period of dentition. Atmospheric influence, however, is clearly traceable ; heat, moisture, and impure air seem to be the three principal elements. Thus we find it more frequent in the latter part of the summer and beginning of winter. The usual exciting causes of diarrhoea will give rise to it ; improper food, or an excessive quantity; cold, damp, deficient clothing, dentition, &c. Moreover in certain localities it is endemic ; foundling hospitals, fever houses, the densely populated and badly ventilated parts of towns, &c. Epidemics of dysentery are by no means unfrequent. I have alluded to the one described by Constant in the Hopital des Enfans in 1835. Dr. Cogswell described one which prevailed in the state of New York. 3 My friend, Dr. Mayne, has described an epidemic which prevailed in the South Dublin Union Poor-house between April, 1846, and August, 1848, during which 127 male children under ten years were attacked, and seventy-four died. The disease prevailed equally among the female children under Dr. Shannon. In a great many of the cases the disease occurred as a sequela of measles, proving rapidly fatal. Dysentery may supervene as a secondary affection upon diseases of the mouth, chronic diseases of the lungs and skin, and especially in the course of measles, scarlatina, and smallpox. 762. Diagnosis. — The only positive distinction between dysentery and diarrhoea, is the presence in the former of small muco-sanguineous evacuations with severe tenesmus. In general dysentery is much the more severe, with more suffering and decidedly more fever. 763. Prognosis. — Even as a primary disease the prognosis must of- ten be unfavorable, and still more when it supervenes upon a disease which has already exhausted the strength and constitution of the patient ; in fact, very few of the latter cases recover. In general it is very obstinate, not amenable to treatment, and unless seen early and treated promptly, it is very apt to wear out the patient, even when not of sufficient intensity to destroy life quickly. The most favorable symptom is the recurrence of faecal matter in the stools, the return of appetite, and the disappearance of fever. 764. Treatment. — Bearing in mind that there are in all cases evi- dences of inflammation of the large intestines, and that often very severe, we need not hesitate in primary dysentery to apply leeches along the track of the colon, in numbers proportioned to the child's strength and the severity of the attack. Some writers have recommended these ap- plications to the verge of the anus, but Dr. Condie objects to this, on account of the difficulty of stopping the leech-bites occasionally, and I quite agree with him. 1 Dublin Journal, May, 1844, p. 298. 2 New York Med. Repository, vol. ii. p. 127. DYSENTERY. 527 In secondary colitis the condition of the child generally precludes the possibility of applying leeches ; but for this, they would be equally suitable. In chronic dysentery they are rarely necessary. Bleeding from the arm has been advised when the child is strong, the attack severe, and the fever high ; the necessity of the case must of course determine its propriety. After the leeching nothing will be so comforting as a linseed-meal poultice applied hot, and renewed every hour. Fomentations and warm baths are also very beneficial. There is considerable difference of opinion as to the use of purga- tives, and the time for their administration. No doubt there is gene- rally an accumulation of faecal matter above the diseased portion of the intestines, which must be evacuated ; it is true also that the dis- charge of faecal matter is a first symptom of improvement; but I con- fess I prefer, as in diarrhoea, quieting the excessive irritation in some degree first, and then administering moderate purgatives at intervals. We may begin then by a starch and opium enema, or a mucilaginous or chalk mixture with laudanum, or acetate of lead and opium, or calo- mel, ipecacuanha, and hyoscyamus, or Dover's powder, in doses propor- tioned to the age of the child. One-third of a grain of calomel, as much ipecacuanha, and one-twelfth of a grain of opium, may be given every three or four hours, to a child of a year old; but if the stomach be irritable the ipecacuanha must be omitted. In the epidemic described by Dr. Mayne no medicine was so useful as mercury given early, in small doses rather than large ones, and con- tinued until the evacuations exhibited a beneficial change, or until saliva- tion occurred. Next to mercury, alkaline medicines were most useful ; the liquor potassae, or lime-water, with a small quantity of opium were found very soothing. Opium, in full doses, aggravated the disease ; purgatives were rarely useful ; the bitartrate of potassa in large doses failed ; turpentine was of little use, except in cases of relapse ; and ipecacuanha was perfectly ineffectual. 1 Medicated enemata, as a means of acting locally upon the intestines, are strongly advised by M. Trousseau and others. These may be com- posed of the acetate of lead, with or without laudanum, sulphate of zinc or copper, the ammonide of copper, &c. ; but the one M. Trous- seau prefers is the nitrate of silver, in the proportion of one or two grains to eight or ten ounces of water, once a day in mild cases, or twice a day when the attack is severe. It will be necessary first to clear out the bowels with a lavement of warm water, and then throw up the solution with the long tube and syringe. Dr. West has used gallic acid in an enema ; and in protracted cases, when the tenesmus was very distressing, one of black wash containing laudanum, or one containing two grains of sulphate of zinc. When the irritation is somewhat lessened we must proceed to evacuate the bowels, and I do not know a better means than castor oil diffused in mucilage, with a few drops of laudanum, as suggested by Dr. Stewart 1 Dublin Journal, May, 1840, p. 302, et seq. 528 DYSENTERY. and Dr. West. Dr. West's formula for an infant a year old is as fol- lows : — R.— 01. ricini, gj. Pulv. acacias, Qj. Syr. simp. gj. Tinct. opii, gutt. iv. Aquas flor. aurant. gvj. — M. A teaspoonful every four hours. Or we may give a few grains of rhubarb and magnesia. After the acute stage has somewhat passed, a succession of small blisters to the abdomen will be found of great service should the attack be prolonged; and we may also give some of the vegetable astringents recommended in diarrhoea, as being useful as tonics as well as in re- straining the discharges. " In an epidemic of dysentery that occurred among children in Wash- ington county, New York, an infusion of white oak bark, blackberry root, and yarrow, in milk, with the addition of sugar, was found, according to Dr. Cogswell, to be productive of the best effects." 1 The following is the formula employed : — R. — Cort. querci alb. Rad. rub. villos. aa ^ss. Fol. achill. milleflor. gij. Coque in lactis, gj. A dessertspoonful to be given frequently. In the epidemic of 1885, at Paris, the treatment consisted of local bloodletting, opiates by the mouth or rectum, and astringents. When these failed, or the disease became chronic, a large blister was applied to the abdomen. 2 Dr. J. Cummings, of Mass., U. S., speaks highly of tannin in dysen- tery. It may be given along with Dover's powder, or chalk powder, in doses of ^ to \ grain three times a day. 3 The treatment of chronic dysentery is but a modification of what I have now laid down : counter-irritation, enemata of lead and opium, of nitrate of silver, &c. ; calomel and ipecacuanha, with hyoscyamus or Dover's powder, warm baths, &c. Williams and others speak very highly of the persesquinitrate of iron, &c. Dr. Graves, in his excellent work, mentions that he has found the pernitrate of considerable use in chronic dysentery in adults ; I do not see why it should not be tried with children, though I am not aware of its having been given as yet. 4 765. The child should be warmly clothed with flannel next the skin, and should have plenty of fresh, pure air. The diet at first must be bland and simple ; mucilaginous fluids and milk and water may be given 1 Condie, Diseases of Children, p. 244. 2 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 533. 3 London Journal of Med., Nov., 1850, p. 1069. 4 Clinical Medicine, vol. ii. p. 226. DYSENTERY. 529 for drink, and for food, some farinaceous substances in very limited quantities. After a while, indeed, the diet must be improved, as it will be essen- tial to keep up the strength ; and it may be necessary to give wine or brandy. Dr. West observes : " As to the time when stimulants are to be given, or the quantity in which they are to be employed, no definite rule can be laid down. Each case must be treated for itself; and to be treated successfully it must be watched most closely. The necessity for stimulants may arise suddenly, or the need of their administration may be but temporary ; while the infant's state in the morning aifords, in cases of severe diarrhoea, no sure criterion to judge what its state will ,be at night. In general it is not until the active symptoms have begun to decline that stimulants are needed, nor even then are they required in the larger number of instances." " About half a drachm of brandy given every two or three hours to a child of a year old, in a quantity of a few drops at a time, mixed with the cold milk and water, or the thin arrowroot with which it is fed, will often have the effect of arrest- ing the sickness as well as of rallying the sunken energies of the system. No stimulant has appeared to answer the required ends better than brandy, and, when sufficiently diluted, children take it very readily. Sometimes, however, when it has been necessary to continue it for some time, it has seemed to occasion pain in the stomach, and even to nauseate the child, and in this case the compound tincture of bark, or the aro- matic spirits of ammonia, or the two together, may be substituted for it ; and there is seldom much difficulty in administering them, if they be mixed with milk and sufficiently sweetened." Again, " the support of the child's strength is a matter of no less importance in chronic dysentery than the suppression of the diarrhoea. The great weakness of the patient, and the manifest distaste for nou- rishment of all kind, often renders it necessary to continue the use of brandy for several days, or even for several weeks. For an infant not weaned, there can be no better food than that which is furnished by the breast of a healthy nurse. In the majority of cases, however, the child has been either in a great measure or altogether weaned before the affection came on, and consequently it is a less easy matter to sup- ply it with suitable food. Farinaceous articles, such as arrowroot, sago, &c. are less easily assimilated in early life than in adult age; and in cases of this kind they not unfrequently pass through the alimentary canal unchanged. Milk, too, does not always agree, and is sometimes ejected almost at once, unless it be given in a state of extreme dilution. Under these circumstances, we must not hesitate to give strong beef or veal tea in small quantities, but at short intervals, to the patient; for though it be true that the bowels are often excited to increased action, in cases of chronic diarrhoea or dysentery, by animal broths, yet this is a smaller hazard than that of the child dying for want of sufficient nourishment." 1 1 Diseases of Infancy and Childhood, pp. 398, 400. 34 530 HELMINTHIASIS, CHAPTER XVIII. HELMINTHIASIS.— INTESTINAL WORMS. 766. There is scarcely an attack to which children are liable, nay, scarcely a symptom, which has not been attributed to worms, or in some way or other connected with them ; and that not only by the people, but by medical authorities, with whom, indeed, popular prejudices gene- rally originate. Even at the present time, any disease Avhose nature is not very clear, any symptom of disorder of the digestive system, or of general nutrition, which is obscure, is solved by the magical abracada- bra of "worms ;" so that we are in some danger of being driven into the opposite extreme, and of supposing them not merely innoxious, but, with Roederer and Wagler, and Dr. Butter, rather advantageous. It may be as well, therefore, to commence this chapter by stating that while I neither deny the existence of worms, nor certain symptoms which are coincident with their presence, I very much doubt whether any such symptoms are caused by them. These symptoms may be a coincidence merely, or they may be the result of an irritation which gives rise to worms. Again, I do not believe in the existence of any symptoms pathognomonic of worms. Many such have been enumerated, but we may meet them all repeatedly without a trace of worms. I quite agree with my friend Dr. West, that the only proof of worms being present is seeing them. Having premised thus much, I shall first notice the varieties of worms which have been observed in the intestinal canal, referring my readers for more lengthened details to the elaborate researches of Bremser, Ru- dolphi, Bellingham, &c. 767. The ascaris lumbricoides occupies the small intestines princi- pally, and is found sometimes in great numbers, occasionally accumu- lated in the form of a ball. It is usually from three to twelve inches long, and from one to two or three lines in diameter. Its natural color is white, but it presents the color of the substances it swallows. It occa- sionally finds its way into the stomach, and may be discharged through the mouth or nostrils. The bothriocephalus latus, tsenia lata, or broad tape-worm, is thinner and wider than the common tape-worm, and very long, being often twenty feet long. Cases are on record of much greater length ; it is said to have been sixty, seventy, or even a hundred feet. Its color is a dirty white, though it becomes gray when put in spirits. It has a large head, with two lateral grooves, which Rudolphi conceives to be organs for the absorption of nourishment. It is an inhabitant of the small intestines, and is said to be very common in Poland, Russia, Switzer- land, and some parts of France. WORMS. 531 The taenia solium, or common tape-worm, is white and flat ; its ante- rior extremity long and slender, with a narrow neck and a minute head, armed with four suckers, between which the mouth is situated, sur- rounded by a circle of five hooks. The posterior extremity is round, and the joints that separate from it are called cucurbitani. It is found in the small intestines, where it may attain a great length. There may be several together, and occasionally other worms are found along with it, according to Rosen. It is not common in very young children, although now and then it has been found in the intestines of the foetus. Fortassin states that it occurs most frequently in persons engaged in preparing materials from fresh animal substances. The tricocephalus dispar, or long tliread-ivorm, is probably the most common, and is found in the upper portions of the large intestines. It is generally from an inch and a half to two inches in length; the anterior portion of its body is slender like a hair, and the rest much thicker. It is white, or colored by what it has swallowed. Its mouth is at the ca- pillary extremity, which is always adherent to the intestine. The sexes are in different individuals. The number is almost always small; very often only a single one is found. The oxyuris vermicularis, or ascaris, or thread-ivorm, is much smaller, being from one to four or five lines long, white, slender, and elastic, blunt at its anterior end, and with a rounded mouth. It is very com- mon in the large intestines of children, and especially in the rectum. It is generally found in considerable numbers, imbedded in mucus, and often in rounded masses. These are the chief intestinal worms : however, Dr. Dewees has named several others, as the distoma hepaticum, fluke, or fasciola, the scarabseus, or beetle grub, and the oestrus, or bois; and he alludes to worms or larvae introduced by accident, and producing spasmodic colic, with griping, and occasionally vomiting, or dejection of blood. 768. Symptoms. — Let us now examine the symptoms which are said to precede, accompany, and follow the appearance of worms. Indica- tions of gastro-intestinal disturbance generally precede the attack, such as disgust for food, loss of appetite, or voracious appetite, or perhaps each alternately ; hiccough, dribbling, fetid breath, nausea, acrid eruc- tations, sero-mucous vomitings, very acid ; borborygmi, umbilical colic, sometimes constipation ; at others, glairy or mucous stools, meteor- ism, &C. 1 These symptoms continue, and to them are added pallor and pufimess of the face, softness of the flesh, emaciation and weakness, a slight, tickling cough, headache, agitation, sleeplessness, dilatation of the pupils, itching of the nose, grinding of the teeth, creeping of the skin, and some degree of fever. The stomach and bowels are evidently disor- dered, the child complains of a good deal of pain, and of a troublesome itching about the anus. The urine may be turbid, yellowish, or whitish, like milk and water. Finally worms may be detected in the alvine dis- charges. M. Legendre has published an analysis of the symptoms produced by • Barrier, Mai. de l'Enfance, vol. ii. p. 207. 532 worms. tape-worm in 33 cases. Disorders of the cerebrospinal system occurred in 20 cases, swooning in 7, disturbed vision in 6, buzzing in the ears in 3, and a pricking or gnawing sensation at the epigastrium in 14 cases. 1 I may also refer my readers to the abstract of a paper by Prof. Wawzuch, which gives the result of very extensive experience. 2 Dr. Horner first noticed an cedematous swelling of the upper lip and lower part of the nose, which he regarded as very characteristic ; and Dr. Heberden thus sums up the symptoms from which worms may be suspected : " Headaches, torpor, vertigo, disturbed dreams, sleep broken off by fright and screaming, convulsions, feverishness, thirst, pallid hue, bad taste in the mouth, offensive breath, cough, difficult breathing, itch- ing of the nostrils, pain in the stomach, nausea, squeamishness, voracity, tenesmus, itching of the anus towards night, and dejection of films and mucus." Now, that we have evidence here of considerable disease of the mucous membrane, no one would question ; but upon which symptom could we safely rest our diagnosis of the existence of worms, except their pre-' sence ? Brera and others consider the face as characteristic ; sometimes pale, sometimes flushed, and sometimes of a leaden color, with a dark circle under the eyes, which are dull and inexpressive, with tumefied nares and upper lip, itching of the nose, and epistaxis. 3 According to M. Roman, the tongue has a pathognomonic character, consisting of small, prominent, isolated, rough, tubercular points, particularly at the edges. The breath is acid, or has a sickly odor, and the saliva is abundant. 4 M. Guersent mentions the glairy evacuations mixed with blood, and of a greenish-yellow color, with the abdomen sometimes tumefied, sometimes flat. 5 Others lay great stress upon the umbilical colic, or upon a feeling of constriction in the pharynx. Others, again, upon the acceleration and irregularity of the pulse, or upon the nervous symptoms. Now I do not mean to deny that such symptoms, and many others, may occur during an attack of worms, but I do say that we meet them all when no worms are present, and that upon them as evidence we can place little reliance, and as proofs they are worth nothing. I per- fectly agree with Rilliet and Barthez, who, after ample personal expe- rience and extensive research, remark: "The examination of our own facts, compared with those published by authors, has led us to the con- clusion that there is no other pathognomonic sign of the presence of worms but their expulsion." 6 When any are expelled it is presumable that there are more, although this is only probability, not proof. 7 769. Suppose we find the symptoms I have enumerated, or a suffi- cient number of them, including the decisive one of worms in the eva- cuations, are we quite sure that the symptoms are caused by the presence of worms ? That similar symptoms may arise from gastro- intestinal irritation we know, and may not the worms, when present, be 1 London Journ. of Med., Nov. 1850, p. 1073. 2 Ibid., p. 1074. 3 Page 162. 4 Ann. de la Soc. Med. Prat, de Montpellier, vol. xxii. p. 110. 6 Diet, de Med., vol. ii. p. 243. 6 Mai. des Enfans, vol. iii. p. 609. 7 Barrier, Mai. de l'Enfance. vol. ii. p. 206. worms. 533 an accidental and harmless complication, or may they not even be an effect of the previous condition of the mucous membrane ? It is a diffi- cult question, and one upon which it would be presumptuous to speak positively, but I am very much inclined to think that ordinarily worms give rise to very few symptoms at all, and that they may probably be the consequences of the preceding disorder of the intestinal canal. It is right, however, that I should notice some other very inportant effects of worms, or what have been supposed to be such. MM. Mon- diere 1 and Charcelay 2 have advocated the opinion that worms may perfo- rate the intestine during life ; and from having found them in the cavity of the peritoneum, Rilliet and Barthez seem to take the same view. It is opposed, however, by Rudolphi, Bremser, Scoutetten, Jules Cloquet, and Cruveilhier, who remarks that "the worms found in the cavity of the peritoneum, or in stercoral abscesses, did not arrive there by perforating the intestine, but because it had been perforated previously." 3 Worms have escaped from, or been discovered in abscesses of the abdominal parietes, and it has been supposed that the abscess was the result of the perforation and transit of the worms. M. Chailly gives an example of a case in a child of two years of age ; and M. Mondiere, who has collected and analyzed the facts on record, concludes that the abscess may occur in any part of the abdomen, but is more common near the umbilicus, or the inguinal canal, and that the symptom which marks the passage of the worm is a painful sensation of puncture in one particular spot, followed by a colorless swelling, which gradually sup- purates. M. Charcelay has published a case of fatal hemorrhage from the in- testine, in consequence of the division of a small artery by a worm as it perforated the intestine. Wedekind published an essay on the strangulated hernia occasioned by the accumulation of worms; and Rilliet and Barthez regard this sup- position as " not irrational," although their researches have not furnished them with an incontestible instance. Inflammation of the intestine is stated to have been the result of the accumulation of worms. Dr. Dewees mentions a case in which ninety-six worms, the shortest six inches, the longest ten, were discharged at once, forty-five of them in one mass. The child previously appeared " in great and constant agony." Again, intestinal worms have been discovered in other organs. MM. Guersent and Tonnelle relate cases of their discovery in the liver ; Hal- ler, Arronsohn, Bland, and Tonnelle', of their presence in the air-pas- sages, the results of which were sometimes serious or even fatal. They have also been found in the nasal canal, the frontal sinus, and the ears. Lastly, a series of nervous attacks have been attributed to them ; con- vulsions, chorea, pseudo-meningitis, meningitis, &c. As I have said, I cannot take upon myself to deny the explanation of these occurrences, but I am at liberty to confess that I am not satis- 1 L'Experience, June 25, 1838. 2 Recueil de la Soc. Med. d'Indre et Loire, 1839. a Diet, de Med. et Clin. Prat., vol. vii. p. 338. 534 worms. fied to attribute these effects to worms; there is too much of the "post hoc ergo propter hoc." 770. Causes. — It would be a useless waste of time and space to enter fully upon the qusestio vexata of the origin of worms ; I must refer such of my readers as are desirous of fully informing themselves upon the subject to the works I have already mentioned. It is sufficient for my purpose to say, that one party believe that they or their germs are de- rived from without, but that they undergo certain modifications within the intestinal canal ; the other party, at once the most numerous and most distinguished, that they are entirely formed within the body, whether by hereditary derivation or spontaneous generation. But what are the causes which favor their production ? Bremser thinks that their formation depends upon there being more digested than absorbed matter in the intestines, and that from this animalized matter vermin have formed. Cruveilhier admits that a superabundance of nutrient materials may have something to do with their production. It would appear that an hereditary predisposition to worms is trans- missible. The age at which they are most frequent is from three to ten years, although we meet with them much younger. Between these two periods M. Guersent observed them in one-twentieth of the children. They are also said to be more frequent with girls than boys, and in children of a lymphatic temperament. Worms are more prevalent in some countries and in some districts than in others; for example, in Savoy and Chambray, in France, throughout Holland and Switzerland, in certain parts of Germany and Russia. Mr. Marshall, Deputy Inspector of Hospitals, observes that Euro- peans and Africans are very much subject to worms in India. Mr. Annesley states that scarcely one in ten Hindoos is free from worms. Moreover, the different species of worms prevail in different localities, according to Bremser, Rudolphi, and others ; the bothriocephalus latus being more common in Switzerland, Poland, Russia, and some parts of France ; and in Egypt, Holland, Germany, and the greater part of France, the taenia solium ; the oxyuris and lumbricoides are more fre- quent in Great Britain, America, West Indies, and India. According to Bremser, worms prevail more in cities than in the coun- try, but Dr. Condie has not found this to be the case. "it would seem that cold, damp, low, unhealthy situations favor their production, and that they are more frequent during the spring and autumn than the other seasons. On this account we should expect that the children of the poor and wretched would be most afflicted by them, and this we find to be the case. Do worms occur as an epidemic ? It would appear so from the various accounts we have received. Worm fever is described by various authors, but it may, I think, be resolved into a gastro-enteric fever of the ordinary kind, complicated by a discharge of worms, whether essential or accidental, it would be hard to say. Roederer and Wagler found worms in the intestines of most of those who died of the epidemic mucous fever of Gottingen ; and in a similar worms. 535 fever which prevailed at Naples in 1836, Thibault detected worms very frequently. 771. Treatment. — Recollecting what I have said of the little value to be placed upon symptoms as indicative of worms, the reader will see the importance of ascertaining, as far as possible, by the only sure means, whether there be worms, before adopting any specific line of treatment. It would be worse than foolish to administer the more powerful reme- dies against worms in a case in which we have no proof of their ex- istence. But further, as we are not certain that the disorder which is undoubtedly present results from the presence of worms, I confess I much prefer trying to relieve the distress first, and then, if necessary, having recourse to means for destroying and expelling the worms. I am happy to have the support of Dr. Condie in this mode of practice. He states that " in any supposed verminous case, therefore, we would advise that all heating and irritating vermifuges be abstained from, and that our treatment be directed chiefly to restore the regular, healthy action of the digestive organs, and the strength and vigor of the body generally. We have been in the habit of pursuing this plan for a number of years, and have seldom been disappointed in promptly and effectually curing our patients, and have had but little necessity for resorting to either of the articles which strictly appertain to the class of anthelmintics. 1 With this view, the diet of the child should be carefully regulated ; not only must it be limited to plain food, but even that must be given in smaller quantities than usual, and at regular times. In many cases we must be as rigorous in diet as was recommended in the chapter on diarrhoaa. But if the irritation be not so great, in addition to bread and milk, rice, and arrowroot, we may allow a portion of animal food, chicken broth, beef-tea, chicken, or mutton chop. Vegetables, if used at all, must be so very moderately ; fruit and confectionery should be interdicted. Air, exercise, and warm bathing, come next in importance to the regulation of the diet, and within reasonable limits should be carefully and fully employed. But little medicine may be required. A few grains of hyd. c. magnesia, if the bowels are confined ; or hyd. c. creta, if free, may be taken two or three times a day. If there be diarrhoea, with much intestinal irritation, the remedies already recommended must be employed — counter-iritation, poultices, opiates, &c. If the bowels are steady, and the tongue pretty clean, I have seen good effects from the combination of a bitter tonic and an alkali ; for example, two grains of powdered columba root, with as much bicarbonate of soda, two or three times a day, for a child two years old. 772. But supposing that there are no symptoms of gastro-enteric irritation or inflammation, or that these have been subdued, and we are required to attempt the removal of the worms, "to what medicines should we have recourse ?" Anthelmintics have been divided into those which succeed by destroy- ing the vitality of worms, and those which merely remove them. 1 Diseases of Children, p. 254. 586 worms. Dewees and others divide them into, 1, those which act medicinally upon worms; 2, those which act mechanically ; 3, those which prevent the development of their ova or injure the young of the viviparous, or act beneficially upon the stomach and bowels. 1 Among the former we may include turpentine, which may be given to very young infants, if mixed with mucilage, milk, almond milk, &c, and sweetened. From five to thirty drops may be given three times a day, according to the age of the child. It is by no means a pleasant medicine, nor will children continue to take it willingly for any time, although they may consent to do so for a few days. It may also be given in the form of enema, combined with gruel or barley-water, and with great benefit, in the case of ascarides in the rectum. The dolichos pruriens or cowhage is highly recommended. It should be very carefully combined with honey or syrup, and a teaspoonful given for two or three mornings, before breakfast ; the last dose being followed by a purgative. Its operation seems completely mechanical, the minute hairs wounding and irritating the worms ; it is said to be chiefly useful against the ascarides and lumbrici. 2 The fueus helminthocorton is a favorite remedy with French physi- cians, and their opinion is confirmed by Dr. James Johnson of London, who recommends a strong decoction to be given as an enema. Dr. Eberle advises that an ounce of the helminthocorton, with a drachm of valerian, should be boiled in a pint of water until reduced to a gill, and a teaspoonful given three times a day. He considers it to be not merely an excellent vermifuge, but as very useful in that state of the alimentary canal which gives rise to worms, particularly when there is want of ap- petite and mucous diarrhoea. 3 " The oleum chenopodii is a remedy in considerable repute with American practitioners. We have employed it in some cases with con- siderable advantage, as follows : — "I£- — Olei chenopodii, gj. Sacch. alb. pur., gum acacise, aa 3Jss. M. Dein adde aq. menth. sativ. 31JSS. M. "A teaspoonful every three hours for two days in succession, to be followed then by a dose of castor oil." 4 Dr. Dewees considers the Spigelia Marilandica (Carolina pink) as the most efficacious remedy against lumbrici. He gave the infusion with sugar and milk, and in large doses, for three or four days — the last dose followed by a brisk cathartic. Bremser and Eberle speak highly of the following formula :— R. — Sem. santon., fol. tanaceti vulg., contus., ua §ss. Ead. valer. pulv. gij. Ead. jalap, pulv. £jss. Sulph. potass. gij, Oxymel scillse, q. s. ut fiat electuarium. A teaspoonful to be taken two or three times a day for sis or seven days. 1 Diseases of Children, p. 493. 2 Neligan, Medicines and their Uses, p. 20. 3 On Diseases of Children, p. 266. 4 Condie, Diseases of Children, p. 256. worms. 537 It is more effectual, however, when so given as to produce consistent evacuations rather than watery stools. The empyreumatic oil of Chabert is regarded by Bremser, Brera, and Rudolphi, as one of our best anthelmintics. From fifteen to twenty drops may be taken daily by children from two to seven years old. Dr. Vauvert states that flowers of sulphur taken in the morning be- fore eating is a most efficacious remedy. The Stannum granulatum is recommended by Alston, Patten, Brera, &c. Its modus operandi we cannot explain, but it occasions the worms to be evacuated. It may be given in doses of from half a drachm to two drachms twice a day, in treacle or syrup, with an occasional ca- thartic. 1 " Common salt," Dr. Condie observes, " is, perhaps, one of the best anthelmintics we possess ; it has often succeeded in the destruction of worms when other remedies have failed. It was a favorite remedy with Dr. Rush ; and, whenever we have been able to induce children to take it in a sufficient dose, we have never been disappointed in its effects. An ordinary sized teaspoonful, dissolved in a wineglassful of water, is the proper dose for a child of two or three years old." M. Peschier, of Geneva, has strongly recommended the tincture of the buds of the male fern (polipodium filix mas); and it is asserted by his brother that he cured 150 cases of lumbricoides, tricocephali, and taenia, in nine months. 2 Dr. Fosbrooke obtained great success also with this remedy. The dose is from one to ten drops, in pills, or on sugar. Dr. West speaks favorably of the decoction of the bark of the pome- granate root, in cases of taenia, with an occasional purgative. Many other vermifuge remedies have been highly lauded, such as tannin, garlic, tin filings, geoffroya inermis, any of which may be tried if those I have enumerated should fail. Each of these remedies, and many others, have been vaunted as of sovereign efficacy in worms ; and yet each will fail, owing, probably, as Dewees shows, to the one kind of worm being affected by one anthel- mintic, but not by others. Certainly, " that which shall detach and expel from the bowels lumbrici shall not stir the taenia solium." We must, therefore, endeavor to suit our medicine to the peculiar kind of worm. 3 773. The second class of anthelmintics includes all brisk cathartics — calomel, alone or in combination with jalap, scammony, or rhubarb ; castor oil, gamboge, and aloes, in the case of ascarides. A full dose may be given, and repeated after a day or two, and we shall seldom fail to discover a quantity of these little animals in the evacuations. In cases of ascarides, the greatest relief is often afforded by injec- tions, so as to wash out the rectum completely — the decoction of the fucus helminthocorton, turpentine in gruel or water, black wash, solution of common salt, aloes, or sulphate of iron, lime-water and milk, assa- foetida and milk, olive oil, sulphuret of potash, &c. 1 Dunglison, Diseases of Stomach and Bowels in Children, p. 60. 2 Edinb. Monthly Journal, June, 1852, p. 559. 3 Eberle, Diseases of Children, p. 264, et seq. 538 JAUNDICE. A bougie smeared with mercurial ointment, and passed into the rec- tum, is said to destroy these vermin very effectually. 774. After the worms, or a great portion of them, have been evacu- ated, the child will derive great benefit from the exhibition of some tonic. Marley recommends the infusion of columba or gentian, with infusion of rhubarb, and a little of the compound spirit of ammonia ; Dr. Stokes the tincture of aloes, with the sesquichloride of iron ; Dr. Rush, the carbonate of iron ; Dr. Dewees, equal parts of the carbonate of iron and common salt; M. Cruveilhier, the " wine of quinine" to lymphatic children. CHAPTER XIX. I. JAUNDICE. — II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. 775. I have included these subjects in one chapter, not because of any necessary or inseparable connection between them, but rather be- cause it seemed useless to make several chapters about diseases concern- ing which we know so little. I shall, therefore, first treat of jaundice in infants and children. I do not think it is by any means so rare as some authors have stated. If any one will take the trouble to watch an infant for a few days after birth, he will find the skin very red for a day or two, then it assumes a yellowish tinge, and finally becomes fair. The yellowish tinge varies in intensity up to a decided yellow, jaundice color. And in many cases I have seen infants continue suffering from this kind of jaundice for some days, and then, after suitable treatment, acquire their proper color. " In some instances, the skin of the infant will be marked by dull, yellow, irregular blotches (maculx hepaticse), more or less extensive, and sometimes occupying the greater part of the surface. The color of these blotches varies very much in intensity ; and in cases where there exists considerable derangement of the alimentary canal, they occa- sionally assume a very dark hue (melasina) ; in some instances they are accompanied with a prickly or tingling sensation. The disease appears to be most generally connected with derangement of the digestive organs ; the color of the skin being dependent upon a morbid secre- tion from the cutaneous vessels ; it has little or no affinity with jaun- dice." 1 In other cases, the infant is born jaundiced, the skin and conjunc- tivae quite yellow : these are not very common instances. Or, after acquiring a proper color, the child is attacked by jaundice from some of the causes to be noticed presently. 776. Symptoms. — The symptoms are so characteristic that we can- not easily mistake the disease. The skin is yellow, or greenish-yellow ; the conjunctivas the same color ; the urine and perspiration contain a 1 Condie, Diseases of Children, p. 698. JAUNDICE. 589 large quantity of bile, and stain the napkins and shirt of the child yellow. The face looks thin, wrinkled, and old ; the appetite is dimin- ished ; if very young, the infant sucks feebly, and does not seek after the breast. The discharges from the bowels may be dark-colored, if the meconium have not been entirely discharged ; afterwards they are generally whitish or grayish: in some few cases their color is natural. At the commencement of the disease the bowels are generally consti- pated ; but I have seen an attack ushered in by diarrhcea, which ordi- narily occurs after a few days. The tongue has a yellowish-white fur, especially towards the base, and the palate occasionally exhibits whitish patches, which resemble the false membrane of muguet. Vomiting occurs sometimes, even after a moderate meal, but it is by no means an invariable accompaniment. There is frequently some griping, which the child shows by sudden cries and retraction of the limbs. The spirits are generally depressed, and the child may be more irrita- ble than usual, but I have never seen delirium or convulsions result. Such are the ordinary symptoms of jaundice; in the greater num- ber of cases there is neither swelling nor tenderness of the abdomen or region of the liver, but, in some cases, M. Baumes mentions having found the hepatic region swollen and tense. 1 When the disease assumes a chronic character, it is attended by progressive emaciation, tumefaction of the abdomen, sometimes with oedema of the lower extremities, or effusion into the peritoneum. The tongue becomes dry, and of a dark brown color ; and at an advanced stage there are occasionally spots of purpura, or bleeding from the mucous membranes. Induration of the cellular tissue also sometimes, but rarely, complicates this affection. The disease may last from a few days to a fortnight, and then the skin acquires its proper color, the bowels become regular, and the appe- tite returns. But although, in general, it is a mild disorder, unattended by danger, we find that now and then it proves fatal. 777. Pathology. — It is not easy to explain the occurrence of jaun- dice in many cases. It may doubtless arise from some malformation or obstruction in the gall-duct, as first described, I believe, by Sir Henry Mark in his excellent essay, 2 and I am inclined to think that this is the most common cause with young infants. This obstruction may be caused by inspissated matter in the duct, or by inflammation of the mucous mem- brane extending from the duodenum, as may be the case when jaundice supervenes upon diarrhcea. Again, congestion and inflammation of the liver may give rise to jaundice, although hepatitis is not a frequent disease of childhood. The symptoms do not differ much from those already enumerated, except that in addition there is a degree of fulness and tenderness of the hepatic region. We must not forget how important a part the liver has played during 1 Traits de l'Icterus ou Jaunisse des Enfans de Naissance. 2 Dublin Hospital Reports, vol. iii. p. 292. 540 JAUNDICE. foetal life, and its undue size at birth ; this disproportionate activity previously, and the change to comparative quiescence after birth, may have something to do with the liability to the complaint. Lastly, jaundice may be caused by organic deterioration of the liver, though it is not always present, nor indeed are these diseases very frequent in childhood. 778. Causes. — Various exciting causes have been enumerated. M. Anthorn knew jaundice to occur after immersion in cold water. M. Levret conceives that the blood remaining in the umbilical vein, after it is tied, may become corrupted, and give rise to engorgement of the liver and jaundice. M. Andrieu attributes it to pressure of the hands of the nurse upon the head of the infant ; but these causes are not very probable, to say the least of them. The irritation caused by the first attempts at digestion, improper food, excess of food, cold, damp, &c, may doubtless give rise to it. Con- stipation, by causing an accumulation of bile in the intestines, and its absorption, may favor its production according to M. Baumes. Dr. West remarks that " the children in whom jaundice is most fre- quent and most intense, are the immature and the feeble ; while in none is it so often met with, or in such an intense degree, as in infants affected with induration of the cellular tissue, in Avhom the yellow color is often so deep as to be manifest in the serum infiltrated into their cellular tissue, or poured out into the cavities of the chest or abdomen. Inter- ruption of the function of the skin and great impairment of that of the lungs are, as you know, the grand characteristics of that affection, while in many instances of it, the foetal passages are still pervious, and the blood circulates in part through the channels which ought to have been closed from the time of birth. These facts seem to substantiate the opinion entertained by many writers of high authority, that the jaundice of children is not clue to any cause seated primarily in the liver, but rather to the defective respiration and the impaired perform- ance of the function of the skin, of which the hepatic disorder and consequent jaundice are but the effects. 1 I have known it occur near the termination of gastric fever, and its nature was evident from the previous intestinal disturbance, the subsi- dence of the pulse and heat of skin, although the icteric color of the skin and clay colored stools persisted for weeks. 779. Prognosis. — In those cases which proceed from mechanical ob- struction, from irritation extending from the duodenum, or from tempo- rary congestion of the liver, the prognosis upon the whole would be favorable if we could distinguish them ; after a little time, the disorder gradually subsides, and the infant is restored to health. Other cases, however, are not so fortunate, and these I apprehend to be chiefly those in which the liver is organically affected. The child be- comes emaciated and exhausted, the appetite is lost, the bowels are per- manently deranged, and the child is gradually worn out ; it may be carried off finally by an attack of convulsions. Dr. A. B. Campbell has related three fatal cases. In one case the 1 Diseases of Infancy and Childhood, p. 372. JAUNDICE. 541 gall-duct was obstructed by inspissated bile, and the other two by con- genital absence of the hepatic and cystic ducts. 1 The latter kind of cases are generally characterized by the occurrence of hemorrhage, generally from the umbilical cord, which can only be at most tempo- rarily arrested. 780. Treatment. — For the cases which arise from retention of the meconium and accumulation of bile in the intestines, nature has pro- vided a mode of cure in the purgative qualities of the early milk ; the bowels being cleared, the cause is removed and the child will recover. Or if necessary, we may aid this by a dose of purgative medicine, rhu- barb, castor oil, or what I have found even better, a single grain of calo- mel, repeated every day or every second day. If we have reason to suppose that there is irritation or inflammation of the duodenum, we must first endeavor to relieve that by fomenta- tions, poultices, counter-irritation, and internally by mucilaginous or chalk mixtures, with opium, the hyd. c. creta with Dover's powder, &c. When the diarrhoea or vomiting is relieved, then we may either continue the mercury with chalk, or have recourse to calomel, as the child may be able to bear it. Should there be enlargement and tenderness in the region of the liver, indicative of irritation or inflammation, it may be necessary to have recourse to a leech or two, followed by poultices, and afterwards to blis- ters, accompanied by the internal administration of calomel or the hyd. c. cret&, as the bowels may be able to bear it. After the bowels have been regulated, M. Baumes recommends the black oxide of iron, the tartrate of iron and potass, or some vegetable tonic. In the chronic form of the disease, Dr. Condie speaks favorably of turpentine, for the relief of the flatulent pains, in doses of from five to ten drops every three hours ; at the same time he gives hyoscyamus, ipecacuanha, and carbonate of soda, and applies a camphorated mercu- rial plaster over the right hypochondrium. He has also found benefit occasionally from the alkalies in combination with a weak infusion of hops or taraxacum. Considerable care should be taken of the diet, especially if there be much disturbance of the bowels. The nurse must be changed if there be any suspicion that her milk disagrees with the child ; and at a more advanced age, nothing but bland, unirritating food should be allowed. Milk, arrowroot, panada, &c, will be found most suitable until the disease subsides, and then we may have recourse to a more invigorat- ing diet. 781. Enlargement of the Liver, §c. — Comparatively little notice has been taken of enlargement of the liver in children ; they are not generally noticed in the systematic works, and I am chiefly indebted to a valuable monograph of my friend, Dr. Battersby, for the following details : 2 — Dr. Graves describes hypertrophy of the liver, as "that state in which 1 Northern Journal of Medicine, August, 1844. 2 Dublin Journal, May, 1849, p. 308. 542 JAUNDICE. there is an increase of size in the organ, with induration and imperfect secretion, but without any remarkable tenderness. This condition in children is accompanied with irritability of the digestive organs, fret- fulness, emaciation, loss of sleep, and impaired nutrition. It is only a form of general cachexy, connected with the scrofulous diathesis, affect- ing secretion and nutrition in general, and the digestive and biliary systems in particular." 1 Dr. West has seen cases of what " he believes to be hypertrophy of the liver. For the most part they were associated with very obvious indications of a scrofulous habit, but on one occasion only was there any serious disturbance of the general health, the child, in that instance, suffering from very severe diarrhoea, which had succeeded to a state of somewhat obstinate constipation." 2 Rilliet and Barthez mention enlargement of the liver when speaking of hepatitis, which they consider very rare, having only seen six cases of it : " It commences by a slight febrile movement, accompanied by increased thirst and loss of appetite. At the same time, or shortly afterwards, an icteric tint is perceived, limited at first to the conjunc- tivae, and slight, but soon becoming very marked. The liver then augments in volume, passes the ribs, extends to the epigastrium, and ascending in the hypochondrium, increases the dulness of that region. The tumor is ordinarily indolent, easily circumscribed when the abdo- men is soft and flexible, but is defined with difficulty when it is dis- tended. At the same time that the jaundice and tumefaction of the liver are manifest, the urine becomes changed and of the color of beer. The stools were few, liquid, and discolored. At the end of a variable time, the febrile movement diminishes and disappears ; thirst is no longer felt ; the appetite is recovered. The tumor of the liver, which has progressively diminished, still continues ; it, however, soon dis- appears. The icteric coloration is in part effaced ; the urine recovers its normal color, and at the end of twenty or thirty days all the morbid symptoms have disappeared." 3 Of Rilliet and Barthez's six cases, five recovered. 782. Dr. Battersby's cases, in some respects, resemble the foregoing description, although the history and results differ considerably. He met with sixteen cases, and out of eleven, six died, two of them of scarlatina ; four recovered, and one remained under treatment. As to the ages, one was under one year; four from one to two years; six from two to three years ; one from three to four years ; one from four to five years ; and three from six to seven years. As to the symptoms, Dr. Battersby observes: "In thirteen there was, in general, a slight febrile action, with tenderness on pressure over the liver ; in some the stools were uncolored, and the urine was deeply tinged. In ten, jaundice existed for some time ; in five, ascites or anasarca ; in one, phthisis ; in one, pompholix ; and one was affected with laryngismus stridulus. The children were generally languid, 1 Clinical Medicine, p. 566. 2 Diseases of Infancy and Childhood, p. 432. 3 Mai. des Enfans, vol. i. p. 578. JAUNDICE. 543 wasted, and had a dirty, jaundiced hue of countenance. The abdomen was much enlarged, its veins were distended, and the liver could be most distinctly felt extending, at various degrees of distance, from the ribs to the pelvis. In one case only I received intelligence of pain being felt in the right shoulder. Instead of the enlargement of the liver disappearing in twenty or thirty days, I have seen it after the con- tinuance of a year, one year and six months, two years, and even three years and a half." In one case clots of black blood were passed by stool and vomiting a week before death. But the most remarkable symptom, and one which, so far as I know, has not been noticed in children as a concomitant of disease of the liver, was a depraved appetite, or pica, as it is called. It was observed in seven of these cases of enlargement of the liver ; but whether the direct result of the disease, or the consequence of some condition of the sto- mach induced by the disease, it is not easy to say. "As a general rule," Dr. Battersby remarks : " this is one evidence of undue lactation, for of fourteen cases in which I noted it, the average duration of suckling was twenty months ; six of these cases were suckled two years and upwards ; and one of them weaned at one year, was continued at the breast for seven months during the utero-gestation of a succeeding child. I have remarked that these little children eat greedily of coals, cinders, ashes, lime off the walls, dirt, shoes, paper, and even their own ordure. Children affected with pica are very delicate and wasted, their complexion is sallow, anaemic, and waxy, the abdomen enlarged. The bowels are generally too free ; the stools are of all colors, green, yellow, black, or white." I have seen a case, however, in which this depraved appetite was ap- parently hereditary, and unconnected either with nursing or disorder of the stomach or liver. In two cases the hypertrophy of the liver originated in disease of the heart, and in another it was complicated with pleuritis and pericar- ditis. In the only post-mortem examination given by Dr. Battersby, the liver was greatly enlarged, red, and filled with blood, but unaltered in structure. 783. Treatment. — If we see the case early, and have reason to sup- pose the existence of active inflammation, or if, at a later period, there be much tenderness, the child will derive relief from the application of leeches in numbers proportioned to its strength. If it be too weak for leeches, or if the symptoms do not demand them, counter-irritation by blisters or liniments may be tried. A very good plan is to paint the abdomen with tincture of iodine over the region of the liver every morning. Internally, mercury is the best remedy. It must be given in such a form and dose as shall be tolerable to the bowels, and it will scarcely be advisable to push its use too far. The ioduret of iron acts very beneficially at a more advanced stage of the disease. It may be given in syrup, in doses of one-eighth of a grain, three times a day, to a child of two years old. 544 ENLARGEMENT OF THE SPLEEN. If the child be a year old it must be weaned immediately, and a good nourishing diet allowed ; if under a year, it will probably be advisable to change the nurse. 784. Enlargement of the Spleen. — This disease has hitherto been supposed to be peculiar to adults, but Dr. Battersby has observed seven cases of it, apparently the consequence of undue lactation. Of six of these cases, three died ; it is, therefore, a serious disease. Their ap- pearance agrees with the description given by Piorry : " When the spleen has been long affected the skin gets a dull aspect ; a grayish coloration presenting sufficiently well a light-colored Creole shade, but with color less warm and more ashy. It is the integuments of the face, especially, where this coloration is most remarkable: It is not the yel- low-ochrey color of icterus, nor yet the discoloration of chlorosis ; it is, a shade quite special, which has been very ridiculously called bluish icterus." 1 " The conjunctiva is bloodless, and the patients manifest a perfect indifference to everything around them. They have a sickly, pallid look, and the wasting of the body is not in proportion to the paleness. They are truly chlorotic ; they have invariably pica ; the bowels are generally irregular ; the abdomen is full. The patient's bulk will remain pretty good for a long time, although he will become blanched in a state of angemia. The blood is not proper in quality; it is deficient in fibrine, and likewise in red particles. The peritoneum sometimes becomes affected, and produces ascites, which renders the detection of the spleen difficult. The diagnosis is generally very easy, long before the spleen has attained a large size. The heart is unaffected in these cases. It has been said that the spleen is often hypertrophied in scro- fula and rickets; this, however, is by no means an established fact; and when there is tumefaction of this organ there is no peculiarity about it, and the other viscera, especially the liver, are simultaneously engaged." 2 Dr. West connects enlargement of the spleen with intermittent fever and malaria. "The only instance of it," he says, "which I have had an opportunity of observing was presented by a little girl six and a half years old, who had lived at Fernando Po from the age of two and a half years, having had dysentery at three years, and frequent attacks of fever subsequently. The enlargement of her spleen had first become apparent at five years of age ; and when I first saw her, a few weeks after her return from Africa, it had attained so considerable a size that her abdomen measured twenty-one and a half inches in circumference. The spleen in this case reached from under the ribs quite down into the pelvis, and forward as far as the mesial line of the abdomen. Inde- pendently of the patient's history, which, in a case of this kind, would be of itself sufficient to prevent an erroneous diagnosis, the relations of the swelling were characteristic ; for, although situated at the side of the abdomen, it did not extend backwards into the lumbar region, so as to fill it up completely, as an enlarged kidney would do, but a 1 Traite de Diagnostique et de Semeiologie, p. 287. 2 Dr. Battersby, Dublin Journal, May, 1844, p. 318. TABES MESENTERICA. 545 considerable interval existed between the posterior margin of the tumor and the vertebral column." 1 The diagnosis of the enlargement of the liver and spleen is almost always easy by an abdominal manipulation, the tumefaction on the right or left side being very characteristic, and the dull sound on percussion marking as clearly the limits of the tumor. I have seen such cases occasionally myself among the ill-fed, ill- clothed, and neglected children of the poor. In the better ranks, I do not think either disease frequent ; nor can I agree with Dr. West that the enlargement of the spleen is necessarily connected with intermittent fever, which is rare in Dublin. 785. Treatment. — The only treatment which Dr. Battersby has found of any use is weaning the child when oversuckled, and giving nourishing food ; sending it out freely into the open fresh air, and administering internally the ioduret of iron, and externally painting the abdomen with the tincture of iodine, or friction with the ointment of hydriodate of potass. CHAPTER XX. TABES MESENTERICA. 1. If the reader will take the trouble of referring to the chapter on pulmonary phthisis, he will find that the mesenteric glands were more frequently the seat of tubercular deposit than any other organ of the body, except the lungs and bronchial glands; that in one hundred cases, MM. Rilliet and Barthez found the mesenteric glands affected in forty- six. This tubercular deposition into the mesenteric glands is the disease which has been termed tabes mesenterica, although, as it is generally a complicated affection, the description is generally more or less uncer- tain, inasmuch as the symptoms essential to tubercle have not always been distinguished from those which result from the intestinal or peri- toneal irritation or inflammation. Among the children of the poor, it is by no means uncommon in these countries, though among the richer classes it is comparatively rare. Rilliet and Barthez found it in one-sixteenth of all the children. Out of 144 cases, twenty-seven were between the ages of one and two and a half, forty-one from three to five and a half, fifty-seven from six to ten and a half, and twenty-one from eleven to fifteen years of age. Of this number, ninety-three were boys and fifty-one girls. They further state that the younger the child is the slighter is the attack. Dr. Merriman speaks of it as occurring in infants at the breast as well as in older children ; but this I must believe to be rarely the case. From my own experience, I should say that it is most frequent 1 Diseases of Infancy and Childhood, p. 436. 35 546' TABES MESENTERICA. from three or four to eight or ten years of age. M. Barrier remarks that it is very common in phthisical children. 2. Symptoms. — Let me again observe that the symptoms which ac- company this disease are not referable simply to the condition of the glands, but arise from the intestinal disorder which so generally precedes and accompanies the affection, and from certain other more rare com- plications of the peritoneum, &c. In some cases, however, there is a singular absence of all indications of disease, the first discovery being made on examination after death, as, for example, in the case related by M. Bayle of a little girl who died from a burn, in apparently good health, but in whose mesentery was found a dozen tubercles of considerable size in a state of partial suppu- ration. Similar cases are mentioned by MM. Morgagni and Guersent, and probably most of us have found more or less deposition in these glands which had yet attracted no attention during life. In other cases, however, the symptoms not only excite suspicion, but are at length sufficiently well marked to enable us to determine the nature of the essential disease. Probably the earliest symptom which excites attention, is a failure in the health and healthy looks of the child : it is uneasy, pale, fretful, the appetite diminishes, the bowels are disturbed, and it loses flesh. For a time this may be all, and it is evident that the cause is disorder of the digestive system, and not necessarily tabes mesenterica.. However, sooner or later other symptoms are superadded, and the most significant is a dull, deep-seated pain about the centre of the abdomen increased by firm pressure, but which is not necessarily accompanied by tension or vomiting, nor does it resemble the tenderness of peritonitis. It may persist a long time without much change, and with no more peculiar characteristics, but, according to M. Guersent, it is most remarkable during spring and autumn, often diappearing during the heats of summer. 1 If the bowels be much disturbed, we may have some tympanitic enlargement of the abdomen ; at the same time in estimating this, all through the disease we must not forget that a child's abdomen is naturally somewhat prominent, and disproportionate. At this period we shall rarely find any fluid or solid enlargement. 3. As the disease advances, the symptoms all become aggravated, and the constitution deeply suffers. The appetite is variable, sometimes slight, in other cases almost voracious, with a desire for depraved food, as chalk, earth, &c. in some cases, but this I do not think so com- mon as in disease of the pancreas. The bowels are very irregular* sometimes constipated, at other times too frequently moved ; the dis- charges being frequently slate, or clay colored, or brown, and highly offensive. The pain in the abdomen continues, or even increases ; sometimes there is a tympanitic enlargement, in other cases, but more rarely, fluid may be detected. If the abdomen be tense, of course the tumefied mesenteric glands cannot be felt ; but if not, we may frequently ascer- tain their presence, especially if much deposition have taken place. 1 Diet, de M6d., in 30 vols., vol. vi. p. 444. TABES MESENTERIC!. 547 MM. Rilliet and Barthez remark upon this subject : " Although the tuberculous masses which occupied the glands were often very volumi- nous, we were far from being able always to appreciate them by the touch. There it was impossible to recognize these tumors when the tension of the abdomen was very considerable ; and in other cases in which it was less, a repeated and minute examination failed. There are, however, cases in which we could ascertain the presence of abdomi- nal tumors even though small, but then the abdomen was very flaccid, and extremely soft, allowing itself to be depressed even to the vertebral column. In other cases, modifications arising from meningitis, facili- tated the palpation of the abdomen, and permitted us to recognize the tumor in its cavity. In the case of a boy of five years, the abdomen was very unequal, knobby, projecting at the hypogastrium, depressed at the epigastrium, flaccid and soft. Immediately beneath the umbilicus we perceived a tumor which passed the median line on either side a finger's breadth and a half. This tumor was very hard, slightly move- able, and its tense edge rather sharp. The next day it appeared more superficial because of the sinking and softness of the abdominal parietes. The superior portion was very movable, but the deeper portion was less so. It appeared larger than on the preceding evening, probably be- cause we could circumscribe it more completely. On making the autopsy, the mesenteric glands formed a mass as large as the fist, com- posed of a number of tuberculous glands the size of a small egg. Some were entirely tuberculous, in others, tubercular matter occupied the centre, and the surrounding glandular tissue was enormously deve- loped." These distinguished observers further add, that " the abdominal tumors, resulting from tubercularization of the mesenteric glands, are always situated near the umbilicus ; they are more or less voluminous, but generally unequal on their surface; we can perceive that they are formed by the agglomeration of a number of tubercular masses. One might believe, a priori, that the fixity of the tumor was a constant cha- racteristic, but it is not always so ; sometimes, because the glands are not sufficiently enlarged to maintain the mesentery immovable against the vertebral column ; in other cases because the glands themselves do not change their place. But this apparent mobility, according as the ab- dominal parietes vary in tension according as the intestines are full or empty, affords us varying results, from an examination of the abdomen after a few days' interval." 1 Let me repeat the caution, that the disproportionate size of the abdo- men which is remarkable in rickety and scrofulous children, should not be mistaken for the enlargement from mesenteric disease. With this enlargement of the abdomen, there is a corresponding ema- ciation of every other part of the body ; the skin becomes loose and flaccid, its color changed to a dirty, sallow hue; the face is wrinkled and the fea- tures become sharper, so as to produce a very distressing expression of suffering. The pulse is permanently quick, but more rapid towards evening, 1 Mai. des Enfans, vol. iii. p. 443. 548 TABES MESENTERICA. ■when a kind of hectic fever sets in, lasting till near morning, and ter- minating in profuse sweat. The urine is scanty, and contains an excess of phosphates. Thus we have disorder of the stomach and bowels, increasing in amount and varying in character, deep seated pain in the centre of the abdomen, tumefaction of the abdomen by air or fluid, sometimes enlarge- ment of the mesenteric glands, and hectic fever. 4. But we may naturally inquire what are the mechanical or other effects of this enlargement and degeneration of the glands ? How far it offers an impediment to the circulation through the lymphatics and bloodvessels ? Sommering, and other authors, do not believe that the lymphatic circulation is injured at all, but that when the glands are entirely obstructed, it is completed by the anastomosing branches and the chyle thus conducted to the thoracic duct. Barrier, however, sug- gests, and I think reasonably, that the defective nutrition in tabes me- senterica may be owing partly to this state of the glands. I may add, that it may also be owing to the impediment in this situation that we sometimes find fluid effused into the peritonial cavity without evidence of inflammation. It does not appear that the mere pressure of the tumors ever pro- duces stoppage of the intestines, although M. Guersent mentions that he has known adhesions between the mesentery and the peritoneum produce strangulation, or even complete occlusion of the intestines. It sometimes happens that an adhesion is formed between the tuber- cular mass and the intestines, when the former suppurates, and Rilliet and Barthez mention that they have seen the commencement of perfo- ration of the intestine at this part. Others mention that through such a perforation the softened tubercle is discharged. We are told on the authority of Sir A. Cooper, of this tubercular matter making its escape by an abscess which burst at the umbilicus, and was afterwards cured by adhesive plaster. 1 When the diseased mass is very large, it is said to give rise not merely to ascites, but to anasarca of the lower extremities, from its pressure on the veins, especially at an advanced stage of the disease. Lastly, the patient is obnoxious to inflammation of the intestines, but more especially to chronic peritonitis, partial or general, with its train of symptoms to be noticed presently. I must not omit to mention also that as tubercles are seldom deposited in the mesentery alone we may have a complication of diseases, such as tubercular meningitis, bronchial and pulmonary phthisis, &c. &c. 2 The duration of the disease will depend very much upon the presence or absence of these complications. In many cases the disease may go on for months before we are quite certain of it, and the child may linger until fairly worn out by the hectic fever and want of nutri- tion; in other cases the occurrence of enteritis or peritonitis, acute or chronic, will hasten the fatal termination. 5. Morbid Anatomy. — The appearances found on dissection vary a good deal, according to the period of the disease, and even at the same period. 1 Coley, Diseases of Children, p. 223. 2 Rilliet and Barthez. TABES MESENTERICA. 549 At an early stage we may find the glands but little, if at all, enlarged, of an oblong shape, pale, of a natural color, and with no appearance of inflammation. On cutting them open, we discover tubercular matter, either in the form of small grains or in larger irregular masses, not mixed with nor adhering intimately to the proper tissue of the glands, but rather compressing it, and lying between it and the peritoneum. Again, the glands may be inflamed, and then they will present a dif- ferent appearance, the proper tissue will be found red, enlarged, and gorged with blood, more resisting to the scalpel than is natural, and increased in volume. The tubercular matter may assume the form of rounded or irregular grains, or we may find it, but more rarely, as patches, or irregular laminae which insensibly merge into the proper glandular structure. Whether the glands be inflamed or not, and whether the tubercular matter be deposited in their substance or only on the surface, it is some- times surrounded by a cyst, more or less distinct; in other cases the cellular tissue which surrounds it is gradually confounded with the glandular substance, and is partly in contact with the peritoneum, which serves to complete a kind of cyst. When this mesenteric disease is extreme and of long standing, M. Guersent observes that " the glands are often completely destroyed, or transformed into isolated or agglomerated masses of tubercle, of differ- ent sizes, from that of a pea to that of an egg, in which no trace of glandular structure can be detected. The tubercular matter is occa- sionally effused between the laminas of the mesentery, and then forms patches of greater or less extent, which have sometimes been mistaken for a kind of abscess when the tubercular matter was softened. True abscesses in this situation are very rare. " Mesenteric tubercles undergo all the stages of degeneration to which this morbid product is exposed. At first crude, they are of a dull white color, or opaline or yellowish. When the tubercular matter is scanty, and as it were infiltrated in the tissue of the gland, it is sometimes traversed by small, delicate capillary vessels, which subsequently dis- appear. In the latter stages we find every degree of softening, from a curdy pulp to fluid pus. It is rare, however, to have very fluid pus in mesenteric tubercles, either because it is partially absorbed or because the patients die before the last change has taken place. We find occa- sionally a dry and pasty matter, analogous to what we see in tuberculous bronchial glands. " At whatever stage the tubercles may have occurred, the peritoneum is almost always healthy, transparent, or slightly tinted with a pink color. In some few cases it is red, inflamed and adherent to the intes- tines." 1 M. Papavoine mentions a case in which the mesenteric glands were converted into greenish-yellow tubercles containing a limpid fluid of the same color in the centre. The same author saw in a scrofulous boy, the mesenteric glands enormously enlarged, with a central cavity, with un- equal parietes containing a deep red opaque fluid, analogous to bile. 2 1 Diet, de M6d., in 30 vols., vol. vi. p. 437. 2 Rilliet and Barthez, Mai. des Enfans, vol. iii. p. 407. 550 TABES MESENTERICA. M. Barrier mentions that the changes connected with the peritoneum are generally either tubercles, adhesions, or serous or sero-purulent effusion. 1 The mucous membrane of the intestine is not uncommonly red and inflamed, especially towards the end of the small intestine, where the mucous glands are most largely developed. In some cases we find small, round, superficial ulcerations and traces of former ulcers. But besides these small ulcerations, there are occasionally deeper ones involving all the coats of the intestine and piercing sometimes through the peritoneum. These larger ulcers are generally placed circularly and parallel to the transverse valves of the intestine. In appearance, they resemble very much the ulcers we find in the intestines of phthisical patients. They occur, according to M. Guersent, in more than half of the cases of tabes mesenterica. On the other hand, the mucous membrane is often perfectly healthy, even in cases where the glands are the seat of considerable tubercular deposition. If the child have suffered from chronic peritonitis, we shall of course find the usual morbid changes, and the same may be said of the other complications, but upon these I need not dwell as I have noticed them in detail elsewhere. 6. Diagnosis. — After a careful analysis of the symptoms of this disease, M. Guersent remarks, " it results from this discussion upon the physiological characteristics of tabes, that almost all the symptoms which have been hitherto assigned to this disease, do not really belong to it, but depend upon other affections of the intestinal canal with which it is often confounded, because they ordinarily accompany it. The only pathognomonic symptom, the only positive character by which tabes mesenterica can be recognized in its last stage, is feeling the tubercles by the touch : all others are more or less doubtful, and mark the dis- orders with which it is complicated." 2 Although it is true, to a certain extent, that many symptoms have been too lightly attributed to this disease which are not essentially con- nected with it, and also that but little stress can be laid upon any single symptom (except the one) taken alone ; yet I can hardly doubt that we may assume the presence of the disease with strong probability from the constitution of the patient, the history, the sequence, and combination of certain symptoms. 2. In the earlier stages, it may be quite impossible to decide whether the intestinal irritation is connected with tabes or depends upon chronic enteritis only, because the two diseases constantly coexist. M. Guer- sent mentions that in the former the diarrhoea and pain are increased by the slightest errors of diet, but not by movement, whereas in the me- senteric disease, the pain is augmented by pressure but not by flatulent distension or diarrhoea. Add to this a scrofulous constitution, perhaps the presence of tubercles in some other part, the persistence of the symptoms, notwithstanding appropriate treatment and unusual dulness 1 Mai. de l'Enfance, vol. ii. p. 331. 2 Diet, de MeU, in 30 vols., vol. vi. p. 447. TABES MESENTERICA. 551 on percussion around the umbilicus, and we have ground, I think, for suspecting very strongly the presence of this disorder. 3. The history of the disease will aid us in distinguishing it from chronic peritonitis in some cases, but no doubt a degree of obscurity will often remain, inasmuch as the two diseases may coexist. 4. At a more advanced stage when the tumors are perceptible, the diagnosis will of course be much more easy and certain, and yet some* confusion may arise between them and tubercles of the liver and kid- ney. The principal points of difference laid down by MM. Rilliet and Barthez are, 1, the seat of the latter tumors in one or other hypochon- drium ; 2, by the form of the tumor which terminates in a sharp edge; 3, by the possibility of pushing back these tumors under the ribs ; 4, by the increase of dulness in one or other hypochondrium ; and 5, by the absence of tension and distension of the abdomen. 1 Still, there are some cases in which the diagnostic is and will remain very obscure ; and I may say the same of the distinction between pan- creatic tumors and mesenteric disease. 7. Causes. — Whatever causes favor the development of scrofula, or tubercle generally, will no doubt aid powerfully in the production of mesenteric disease. When the general and local tendency to tubercu- lization exists, we can easily understand its being stimulated into activity by improper and insufficient food, dirty and badly ventilated dwellings, exposure to cold, insufficient clothing, &c. ; but we cannot tell why in one person the lungs are affected and in another the abdominal organs or the mesenteric glands. 8. Prognosis. — Nothing can be more serious than the prognosis in mesenteric disease, at an advanced stage, when the tumors can be felt. Almost all the cases prove fatal, either by gradual exhaustion or by the occurrence of some complication. At an early stage, patients recover from the intestinal disturbance, &c. ; but then the question arises whe- ther the disease was really tabes, and the answer in many cases is very doubtful. M. Barrier thus states his experience: " The prognosis of tubercular affections of the abdomen is at least as grave as that of tubercles of the thorax. In fact, the first rarely exist without the second, although the latter may occur without the former." "In some cases, abdominal phthisis runs its course with great rapidity, especially when the mesen- tery, the peritoneum, and the intestines are all affected ; but when these are singly affected, their course is slower." " That which proves fatal in many cases before the tubercles of the abdomen have completed their stages is the coincidence of tubercular affection of the thorax, head, &c, or certain local or general complications, as perforation of the intestine followed by acute peritonitis, meningitis, eruptive fevers, &c. There is no reason, however, to disbelieve in the possibility of a cure, or at least of rendering the malady stationary. The cure may take place, 1, by the softening and elimination of the tubercular matter; 2, by its trans- formation into cretaceous matter ; 3, by its absorption." 2 1 Mai des Enfans, vol. iii. p. 893. 2 Mai. de l'Enfance, vol. ii. p. 351. 552 TABES MESENTERICA. Rilliet and Barthez mention a case in which a portion of the tumor had been absorbed and the remainder had undergone the cretaceous transformation. 1 A similar case has been recorded by Dr. Carswell, who states that "the patient, who, when a child, had been affected with tabes mesenterica, and also with swelling of the cervical glands, some of which ulcerated, died, at the age of twenty-one, of inflammation of the uterus, seven days after delivery. Several of the mesenteric glands contained a dry cheesy matter, mixed with a chalky looking substance ; others were composed of a cretaceous substance ; and a tumor, as large as a hen's egg, included within the folds of the peritoneum, and which appeared to be the remains of a large agglomerated mass of glands, was filled with a substance resembling a mixture of putty and dried mortar, moistened with a small quantity of serosity." Unfortunately, all these modes of cure are rare, and I fear that the true explanation of the many cases of cure which have been recorded is to be found in the fact that the disease was really only chronic enteritis or gastro-intestinal irritation. 9. Treatment. — Very much will depend upon the state of the child and upon the stage of the disease. During the early stage, or when the intestinal irritation is the most prominent symptom, our efforts must be directed to quiet that, and to regulate the secretions and actions of the bowels. Some of the anodyne astringents I have mentioned, when speaking of diarrhoea, if the bowels are too free, with perhaps some counter-irritation to the surface, will often succeed. When the bowels are quiet, the secretions may be corrected by hyd. c. creta, combined either with rhubarb or columbo; and, as a change, I have seen much benefit from some bitter tonic, as columbo powder and an alkali. When the bowels are confined, mercurial purgatives are of great use ; and many authors lay great stress upon purgatives and emetics as a means of removing the disease. This may be the case in the earlier stages, but it may well be questioned whether they have this effect, if deposition have taken place. In some cases, when the abdomen was beginning to enlarge, after I had regulated the bowels, 1 found the iodide of iron of great use, in the proportion of one grain of the salt to an ounce of syrup ; a teaspoonful to be given three times a day, to a child three or four years old. It is doubtful in such cases whether the benefit does not altogether depend upon the action of the medicine upon the mucous membrane of the intestinal canal rather than upon the mesenteric glands. All British authorities are agreed, I think, upon the value of mercury at some period of the disease, although they differ as to the stage in which it is most serviceable. French writers, however, seem very doubtful. I have not myself had recourse to much mercury in the earlier stage of the disease, but Dr. Coley speaks well of its effects. He recommends a scruple of the ung. hyd. first to be rubbed ever the abdomen every 1 Mai. des Enfans, vol. iii. p. 421. TABES MESENTEKICA. 553 night for half an hour, and that the patient should take every night from two to four grains of Dover's powder, and three or four grains of hyd. c. creta. Every second or third morning, a dose of castor oil is to be given, or a grain of calomel and three or four of rhubarb, and this treatment must be continued for some time, unless the gums be touched. 1 Dr. Merriman advises calomel in large doses at first, and then smaller ones for a considerable time when the belly is enlarged, until some favorable change takes place in this particular. M. Wendt advises a combination of sulphur with calomel in the pro- portion of one part to twenty. A light bitter tonic has also been found very useful, either alone or in combination with an alkali. After the deposit of tubercular matter has fairly taken place, or after we believe it has done so, the principal remedies are said to be mercury, iron, iodine, acetate of potash, &c. &c. sulphur, iodine, or sea baths. The mercury may be given in form of calomel, blue pill, or hyd. c. creta, or we may have recourse to inunction, and the extent to which it should be carried will depend upon the condition of the child and the state of the bowels. Various preparations of iron have been recommended by different writers. The tincture or salt of steel or chalybeate waters are pre- pared by Dr. Munn ; others prefer the carbonate or the tincture of the muriate, &c. &c. The same may be said of iodine, some advise one form, some another ; the great point appears to be to guard against any injurious action upon the gastro-intestinal tube. I have found the iodide of iron in syrup apparently better than either element separately. Some prefer Lugol's solution in doses of three to six drops three times a day, or the hydriodate of potash in decoction of sarsaparilla, adding a minute dose of opium if the bowels be irritable, or suspending the medicine altogether. As an external application, Dr. Condie advises the iodide of lead (5ss to 3j of lard), or the ung. hydriod. potassse. 2 Or the abdomen may be rubbed or painted with the tincture. Ioduretted baths have been highly recommended ; they are formed by dissolving one grain of iodine and two of hydriodate of potash in a gallon of water. From the benefit derived from cod-liver oil in phthisis, we may natu- rally expect similar effects from it in mesenteric disease ; but although I have found it useful in some suspected cases, yet they have been too undecided and too few to enable me to speak positively, and I have not as yet seen any record of an adequate trial of the remedy by any one else. But as a general rule the success seems very limited; in many cases anything like active treatment is injurious, and the utmost we can effect is the palliation of the more distressing symptoms. Inasmuch as bad air, inferior or innutritious diet, and exposure have much to do with predisposing to or producing the disease, our attention 1 Diseases of Children, p. 226. ' 2 Diseases of Children, p. 627. 554 PERITONITIS. must be carefully directed to these points. Fresh pure air, well venti- lated comfortable apartments, and warm clothing, are all absolutely necessary. Bland, mild food must be selected until the fever and intestinal irri- tation subside. A mild diet is generally the best, or arrowroot with water or milk. Broths must be given with great caution, and generally speaking animal food is objectionable. Frequent washing portions of the body, warm or cold baths, will also be found very useful, both as prophylactic measures, and also as reme- dies if the disease be not too far advanced. The indications of treatment for the different complications will be found in the respective chapters. CHAPTER XXI. PERITONITIS. 786. Inflammation of the peritoneum is a rare, and, when acute, a very fatal disease among children, much less frequent than either pleurisy or pericarditis, and, if I might judge by my own experience, I should add than arachnitis ; but Rilliet and Barthez found it more so than the latter. In examining the bodies of children who have died from other diseases, it is by no means uncommon to find evidences of pleuritis or pericarditis which have been cured, but we scarcely ever find such traces in the peritoneum, from which I infer either that the disease is very rare, or that it carries off its victim. Rilliet and Barthez met with a dozen cases of acute peritonitis. In certain seasons it seems more common than in others. I met with three cases in one winter within a short time of each other, and judging from them, I suspect that cases that are put down as enteritis are as frequently peritonitis. M. Thore found that acute peritonitis existed in about six per cent. of all the infants who died at the Hospice des Enfans trouv^s. This affection has been but little noticed by writers upon diseases of children. Dr. Romberg, of Berlin, in 1833, published a valuable paper upon the subject. 1 Meissner 2 has entered pretty fully into the subject. Heyfelder, 3 and Malespini, 4 and Thore, 5 have published some interesting papers. It is noticed by Drs. Stewart and Condie. Peritonitis may be either acute or chronic, the latter occasionally being of a scrofulous character, and accompanied with the deposition of 1 Wochenschrift fur die ges. Heilkunde, 1833, Nos. 17, 18. 2 Ibid., vol. ii. p. 66. 3 Studien in Gebiete der Heilwissenschaft, 2, B. D. S. 190. 4 Archives G6n. de Med., 1840. s Archives Gen. de Med., Aug. Sept. 1846. PERITONITIS. 555 tubercular matter on the serous membrane. The disease may be either primary or secondary, but much more frequently the latter. It may occur before birth, as the researches of Dug&s, Billard, Simp- son, &c, have proved, and at any age subsequently. Of M. Thore's cases, thirty-five out of fifty-nine were less than a fortnight old, and none above ten weeks. 787. I. Acute Peritonitis. — The attack is generally somewhat sud- den, coming on either in the midst of health, or in the course of some other disease, and marked by severe abdominal pain, commencing, perhaps, at some one part, but quickly spreading over the entire abdomen, and greatly increased by any movement. In very young infants it is some- times not very well marked at first, but, with very few exceptions, it is always present. The pain rapidly becomes very acute, greatly increased upon pressure ; the abdomen becomes swollen, tense, and tender; some- times dull, sometimes resonant on percussion. After effusion has taken place it is always dull. This dulness and tension are general when the entire peritoneum is affected, but partial and local, when the peritonitis is circumscribed; and at the part affected we may feel a kind of tumor. Vomiting, which is so common a symptom in adults, is not general with children. Rilliet and Barthez met with it only in two cases. Constipa- tion also is very rare ; it is more common to find a diarrhoea, which is very distressing, as well on account of the pain which accompanies it, as from the efforts necessary, and the disturbance of the child after- wards. The pulse is small and very quick; the face has an expression of acute distress and great suffering ; the tongue is generally moist, but loaded ; sometimes clean, sometimes dry and loaded ; there is great thirst, and an entire loss of appetite. The skin is hot, and occasionally at the commencement there are rigors, but not always. The breathing is quick, high, and short, not from any thoracic affec- tion, but from the pain caused by the pressure of the descending dia- phragm in a fuller inspiration. After effusion has taken place, there may be a mechanical impediment to full and free respiration. The pain occasioned by any movement gives a sort of fixity to its position and to an intolerance of any change of posture. Dressing, changing napkins, nay, raising the arm even, will give rise to shrieks of agony so acute that a suspicion naturally arises of injury or of some affection of the parts, the moving of which gives so much pain. This symptom, so significant, should never fail to direct our attention to the peritoneum. 788. In unfavorable cases, these symptoms continue and increase, the pulse becomes insensible, the pain intense, the abdomen very large, the countenance extremely drawn, the anxiety very great, and death soon closes the scene. In more favorable cases, when the peritonitis is circumscribed, the symptoms diminish in intensity, the tumefaction becomes less and less painful, and finally disappears ; the pulse becomes slower, the thirst less, the fever subsides, and the digestive functions are restored ; or the symptoms, subsiding to a certain extent, may take on a chronic character. Another mode of termination occasionally occurs. Dr. West ob- 556 PERITONITIS. serves: 1 "The active symptoms diminish in intensity; the abdominal parietes grow thin at some spot, where a passage at length is formed, through which pus is discharged, and recovery sometimes slowly fol- lows ; the result of a process precisely analogous to that which nature has recourse to in pleurisy, when she brings about the evacuation of the fluid through an opening spontaneously formed in the parietes of the thorax. An instance of this mode of cure of peritonitis in a child seven years old was related by Dr. Aldis, at a meeting of the Medico-Chirur- gical Society, in November, 1846. 2 A few similar cases may be -found in medical journals; 3 and one has come under my own observation in the person of a little girl, whose history I formerly related, 4 as afford- ing an illustration of that rare affection, inflammation of the sinuses of the dura mater." The duration of the disease is very variable ; some cases have proved fatal in twenty-four hours ; others have continued for weeks. Rilliet and Barthez have given us the duration of nine cases : " In two, it terminated in one day ; in one, in three days ; in one, in five days ; in one, in twenty-six days ; in two, in twenty-six and twenty-seven days ; in two, in thirty-six and thirty-seven days. 5 There is no essential difference between the symptoms of primary and secondary peritonitis ; the former is, perhaps, more frequently cir- cumscribed, and the latter, supervening upon other serious affections, hardly permits a hope of cure. 789. Morbid Anatomy. — The serous membrane is generally found vascular and red, either partially or generally, and principally that portion of it which covers the intestines or the appendages. The sub- serous cellular membrane or the muscular coat may be infiltrated and softened, so as to be easily torn. In almost every case we find either liquid secretion poured out into the cavity, or false membranes. Some- times the fluid is serous, clear, abundant, and of a lemon color ; in other cases it is troubled, and mixed with albuminous flocculi ; or it may be purulent matter, thick, yellow, or greenish yellow. The quan- tity varies from a cupful to several pints. The purulent matter is generally found in the pelvis ; and according to the quantity, the fluid will distend the abdominal cavity more or less completely. False membranes generally coexist with effusion, slight,' thin, and elongated, or in the form of thin, soft, gelatinous layers, of a whitish or yellowish color, but seldom very firm or thick ; they unite the con- volutions of the intestines, more or less filling up the interstices, and, if the disease be prolonged, forming adhesions between different parts, and undergoing gradually the same sort of transformation we noticed in pleurisy. In one-third of M. Thore's cases, evidences of pleurisy were also dis- covered. 1 On Diseases of Infancy and Childhood, p. 416. 2 Medical Gazette, November, 1846. 3 Bernhardi in Preuss. Med. Zeitung, No. 10, 1842; and Beyer, Casper's Wochenschrift, 1842, No. 5. 4 Lecture vii. p. 81. 6 Mai. des Enfans, vol. i. p. 564. PERITONITIS. 557 790. Cannes. — Any of the ordinary exciting causes of inflammation may give rise to peritonitis, exposure to cold or wet, falls, blows, &c. Or it may be the consequence of a surgical operation, and occasion- ally it follows the perforation of the gall-bladder, the stomach, or intes- tines. Thus, Rilliet and Barthez state that in one case it was the re- sult of tapping ; in another, of a fall ; in a third, of the rupture of the gall-bladder ; in a fourth, of ulceration perforating the intestines. 1 Again, it may be a secondary attack, occurring in the course of other diseases, as ascites, typhoid fever, scarlatina, 2 or tubercles. In seventeen out of M. Thore's sixty-three cases, the peritonitis fol- lowed on erysipelas, and in four, on phlebitis of the umbilical vein. 791. Diagnosis.*— I. Acute peritonitis is more likely to be confounded with enteritis or entero-colitis than with any other affection ; in both thore is pain and tension of the abdomen, with vomiting and diarrhoea ; but in peritonitis the pain is far more intense, the tenderness far more acute: the aggravation of suffering by the least movement; the drawn, anxious face, the quick pulse, and the fluctuation in the abdo- men, are unlike the characteristics of enteritis. II. The localized peritonitis has some resemblance to the symptoms of abscess in the iliac fossa ; but the latter may be distinguished by the slowness with which the tumor is formed, its defined and limited seat, its progress, the slight degree of fever, and by its final evacuation, in- ternally or externally. 792. Prognosis. — Nothing can be more serious than the prognosis ; peritonitis following perforation is almost necessarily fatal. Secondary peritonitis is so grave an addition to any other disease, that we can hardly hope for the child to escape ; and the same may be said of general peritonitis; there is no more mortal disease. The only cases in which there is much chance of recovery, are those in which the inflam- mation is partial, limited to one spot, and moderate in degree. 793. Treatment. — The indications of cure are simple enough; the only difficulty is to fulfil them. We must first attempt to relieve the inflammation by antiphlogistic treatment ; and for this purpose, unless the child be greatly exhausted by previous disease, a number- of leeches, large in proportion to the age of the child, should be applied to the abdomen, or blood taken from the arm. Unless we can thus make an impression upon the disease at an early period, there will be little chance of success, and therefore we must act promptly and boldly. More moderation will be requisite when the disease is secondary and the child reduced, but still we must venture to leech, if we would hope to save the child, and to repeat the leeching according as the disease requires it and the patient will bear it. ■ After the leeches fall off, a warm, light poultice should be applied, and repeated every two hours, if the weight of it do not cause distress, in which case we must substitute frequent fomentations. Next to bleeding, the most important remedy is mercury, given so as 1 Mai. des Enfans, vol. i. p. 568. 2 Stewart, Diseases of Children, p. 263. 558 PERITONITIS. to affect the constitution, as indicated either by tenderness of the gums or mercurial diarrhoea. I have generally found frequent small doses of calomel better than larger ones, and in conjunction with mercurial in- unction more effective than alone. For example, to a child of two years old, half a grain of calomel, with a grain of the pulv. cretse c. opio, may be given every two or three hours, and at the same time the abdomen smeared thickly with ung. hyd. fort., over which the poultice may be applied, or the inside of the thighs rubbed with the ointment ; or we may adopt Sir B. Brodie's method, and apply a flannel bandage, smeared with the ointment, around the thighs or legs. But if diarrhoea be pre- sent, we may have to modify this plan, and either diminish the dose of calomel or increase the opium, or substitute for it the hyd. c. creta, or perhaps content ourselves with the external use of mercury only. Next to calomel, perhaps the most useful remedy we possess is opium in peritonitis, as Drs. Graves and Stokes have shown ; and although more caution will be necessary with children than with adults, yet the effects upon the disease are equally satisfactory. It may be given in combination with calomel or gray powder, if they can be borne, but if not, it may be continued alone, with benefit to the diarrhoea as well as the inflammation of the serous membrane. If there be obstinate constipation, of course purgatives must be given ; but Ave must take care that we do not ourselves render the exhibition of calomel impossible by exciting too much action of the bowels. In gene- ral, I much prefer trusting to the calomel acting sufficiently upon the bowels as well as upon the constitution. Moreover, if the peritonitis be the result of perforation of the intestine, it will be of great conse- quence to suspend the action of the bowels, and to cause constipation, so that instead of purgatives we must give opium and astringents. 794. But the remedies I have enumerated are not merely calculated to fulfil the first indication ; they meet the second, which is to remove the results of inflammation, at a more advanced period, by increasing absorption ; and the third, that of preventing the further escape of mat- ters from the intestines into the cavity of the peritoneum. I have said nothing as yet of blisters, because they are unsuitable at first ; but, after due leeching, when the first acuteness of the attack is over, and, at a later period, when effusion has taken place, they are highly useful; and I have found more benefit from small ones repeated than from large ones. Warm baths are occasionally beneficial, and always soothing, if the child be not too weak, The diet of the patient in primary peritonitis must be rigorously restricted ; a little milk and water or whey, and a little toast, will be sufficient. In secondary peritonitis, however, though it must be mode- rate, we must have some regard to the exhausted condition of the child, and must support the strength, in order that we may have a chance of curing the disease. In addition to milk in any form, therefore, we shall have to allow weak chicken broth or beef tea. 795. in. Chronic Peritonitis. — Slight allusions to this form of disease may be found in some of the writers on diseases of children, and more PERITONITIS. 559 details by Baron, 1 Abercrombie, 2 Gregory, 3 Billard, Rilliet and Barthez, Sir H. Marsh, West, &c. M. Billard gives a short notice of chronic peritonitis, and relates the following case: — " Josephine Perrine, set. ten months, of a good size, but thin and spare, had already cut the two incisor teeth of the lower jaw, when she was suddenly seized with dyspnoea. The child, usually lively, had become morose and fretful. She entered the infirmary on the 22d January, 1826. The abdomen was tympanitic, the respiration a little difficult, and was indistinctly heard at the upper part of the right side of the chest ; the tongue was dry, pulse small, skin burning ; she was affected with diarrhoea, consisting of green and mucous faeces. On the 23d, the diarrhoea became more light colored. On the 24th, the same general symptoms, but without fever ; tension of the abdomen, facies hippocratica, forehead wrinkled. On the 26th, deglutition difficult, retching whenever drinks were given, very feeble. The isthmus of the fauces appeared of a bright red. Death took place on the morning of the 27th. . "Post-mortem Examination. — Body considerably emaciated; gene- ral paleness of the integuments; nearly two ounces of yellow serosity were found in the abdomen. Numerous and firm adhesions existed be- tween the transverse portion of the colon and the great curvature of the stomach. Some of the convolutions of the small intestines were likewise adherent, but in a less solid manner. The mucous membrane of the stomach was of a pale rose color ; that of the small intestine8 was covered with red striae, and a number of slate-colored spots existed in the whole length of the colon, &c." 4 Sir Henry Marsh published some interesting cases of this disease in 1843, to which I had the honor to add some supplementary remarks, the substance of which is here reproduced. 5 I shall now shortly detail the first case, which occurred to myself, and for the diagnosis and successful treatment of which I am under obliga- tion to Sir H. Marsh. Mary , set. six, a healthy child, of delicate, fair complexion, fair hair, &c, about December, 1840, was observed to be somewhat unwell; she suffered from occasional attacks of diarrhoea, which, after a time, either subsided or were relieved by the usual remedies. Occasionally, she complained of shooting pains through the abdomen, coming on irre- gularly, and lasting but a short time, but not accompanied with tender- ness or swelling. Her appetite became delicate and fastidious, with some thirst. The pulse was scarcely quickened ; her countenance be- came pale, and she became thin. Matters continued in much the same state for about a month — occasionally attacks of pain and diarrhoea, with loss of appetite, &c. — but, after this time, I observed that the ab- domen became gradually swollen, with a distinct sense of fluctuation, 1 On Tubercles, &c, p. 131. 2 Diseases of the Abdominal Viscera, p. 191. 3 Med.-Chir. Trans., vol. ii. p. 259. 4 Mai. des. Enfans, and Trans., by Dr. Stewart, p. 354. 5 Dublin Journal, March, 1843, p. 1. 560 PERITONITIS. uneasiness on motion, but no pain on pressure. The pulse rose to 130, and there was a certain amount of fever, especially in the evening, with an occasional rigor. The emaciation had increased, and the other symp- toms continued much the same. By Sir H. Marsh's advice, hyd. c. creta, gr. ij, P. Jacob, gr. j, was given every four hours. The abdomen was well rubbed with ung. hyd. fort., and she took a warm bath at bedtime. This treatment was con- tinued a fortnight without any manifest improvement, and without the constitution being affected by the mercury. The transient pain, the swelling with fluctuation, the quick pulse, the fever, with exacerbations in the afternoon, and drowsiness, all continued. The appetite was rather improved. She had become by this time both thin and weak, was very unwilling to exert herself, and complained of abdominal uneasiness upon moving about. A blister was then applied to the upper part of the abdomen, and dressed with ung. hyd. ; frictions with a scruple of the same ointment were used twice a day, and the internal medicines omitted. Under this treatment she shortly began to amend. The pain re- turned less frequently, and at length ceased; the abdomen gradually though slowly diminished in size, until fluctuation was no longer per- ceptible ; the bowels became regular, the pulse tranquil, the fever dis- appeared ; in about six weeks from the commencement of the treatment she was convalescent. I have since seen several cases of the same kind which were benefited by similar treatment. 796. Chronic scrofulous peritonitis, with effusion, may follow acute inflammation, or it may occur without our being able to recognize any preceding acute stage, coming on so gradually, in fact, that we may not be aware of the nature of the disease until it is fully developed. As M. Duges observes, "there may be occasional pains, colics, irregular attacks of diarrhoea, emaciation, paleness, for weeks or even months before the disease is fully established." 1 From the earlier and more prominent symptoms being referable to the mucous membrane of the intestinal canal, the real affection may be overlooked, and the fatal results attributed to the diarrhoea. It may also be either primary or secondary, more frequently the latter. 797. Symptoms. — From what has already been said, it will be gathered that the mode of invasion varies widely. In one class of cases the patient labors under diarrhoea for a considerable time, with or with- out pain ; the appetite is pretty good, the temperature natural, and the pulse quiet ; but at length — it may be weeks or months — we hear com- plaints of a sensation of pricking, or of paroxysms of pain, and a feeling of tightness in the abdomen, which, upon examination, is found to be more or less swollen. In other cases there is a certain amount of pain from the beginning, occurring in paroxysms, with perfect intervals, and though at first limited to one part of the abdomen, yet by degrees spreading over and occupying the whole. 1 Diet, de M£d. et de Chir. Prat., toI. xii. p. 295. PEEITONITIS. 561 Again, as Dr. Abercrombie remarks, "in a very important modifi- cation of the disease there is no complaint of pain; the patient merely speaks of a feeling of distension, -with variable appetite and irregular bowels, and with these complaints becomes progressively emaciated. In many cases, indeed, the early symptoms are so slight that no attention is paid to them until the emaciated appearance of the patient excites alarm. The abdomen, on examination, is probably found tumid, and in some degree tender in various parts ; and, upon questioning the patient, it is found that there has been some degree of pain for weeks and months. In other cases there has been no actual pain, but a feeling of tenderness, which gives rise to uneasiness on pressure, or when any part of the dress is tight over the abdomen ; but in many cases the disease steals on to an advanced period without any complaint of tenderness or pain." 1 The observations of M. Andral 2 are confirmatory of Dr. Aber- crombie's remarks ; Dr. Gregory, however, states that tenderness on pressure is present from the commencement. 3 So much for the mode of invasion. Sooner or later, in the majority of cases, the patient complains of pain, occurring most frequently in paroxysms of varying intensity and duration, with intervals of complete relief; beginning in some one part of the abdomen, and gradually spread- ing over the entire. In the words of Dr. Gregory, " the attacks of acute pain occur in paroxysms at first, not oftener perhaps than once or twice in a day ; but, as the disease advances, they increase in frequency, and at the same time in violence. I have seen them happen as often as once in ten or fifteen minutes ; they do not last long, and immediately after an attack the child appears lively, as if nothing ailed it." 4 There is frequently, perhaps generally, a certain amount of tender- ness on pressure, especially at the part to which the pain is at first limited, though it is not very remarkable in many cases. The patient almost always complains of uneasiness on attempting to walk or stand, and in some cases finds it impossible to stand erect. After an uncertain interval, the patient complains of a feeling of dis- tension, and requires the dress to be left loose; and then, if an exami- nation be made, the abdomen will be found more or less swollen. Per- cussion generally yields a dull sound, but not always, for when the bowels are much disordered, they sometimes become tympanitic. Fluctuation is, I think, perceptible in all cases, if the examination be carefully made ; but it requires especial care with young children to guard against the action of the abdominal muscles, and the natural elasticity of the integuments. The best mode is to lay the child on its back, and accustom it for a short time to the presence of the hand upon the abdomen ; then, placing one hand, with the fingers separated, on one side, and percussing very gently with the other, the muscles will not be excited into action ; and, if fluctuation be perceptible -with the second or third finger, we may be certain of the presence of fluid; for 1 Diseases of the Abdominal Viscera, p. 192. 2 Mai. de 1' Abdomen, Clin. Med., vol. iii. p. 587. 3 Med.-Cbir. Trans., vol. ii. p. 263. 4 Ibid., vol. ii. p. 264. 36 562 PERITONITIS. the pressure of the forefinger upon the skin effectually arrests the vibra- tion which results from its elasticity. I have dwelt rather minutely upon the mode of examining the abdomen, because in many cases, from the paucity and obscurity of the symptoms, our diagnosis must chiefly depend upon the presence or absence of fluctuation. The enlargement of the abdomen is not always equable; in some eases, especially in the commencement, the umbilical region protrudes. As the effusion increases, the entire abdomen enlarges, loses its softness, and becomes tense and hard, though occasionally unequally so. The skin of the abdomen is hot and dry, and has the appearance of being stretched and diminished in thickness. In very chronic cases large blue veins are visible traversing the abdomen. When the mesenteric glands are diseased, it is possible in some cases to detect their enlarged condition, by making careful examination at an early period, before the abdomen is much distended. In some rare cases the intestinal canal preserves its integrity for a long time ; the tongue is pretty clean, the appetite much as usual, the bowels regular, or perhaps rather constipated ; but in the large majo- rity of cases, we find the tongue white, loaded, and flabby; more or less thirst; the appetite irregular and fastidious, sometimes increased, more frequently impaired or lost altogether; the bowels relaxed or con- stipated, perhaps alternately; the stools fetid and of a whity-brown or bluish color. " At first," says Dr. Gregory, " the stools are green, slimy, or fetid ; but when the disease has existed about six weeks or two months, they will be found to consist of a whitish or whitish-brown matter, of the consistence of thin pudding; nor do the evacuations differ more in quality than they do in quantity from those in health. The quantity passed by the child in twenty-four hours, and that with- out the aid of medicine, is often enormous ; and I have seen it taken notice of by the parents as greatly exceeding what the child could have taken in by the mouth." " This state of the bowels frequently con- tinues for six weeks or two months, the body of course wasting the whole time, until diarrhoea at length comes on, attended with peteehiae, which, in the course of three or four days, puts a period to the child's life." 1 When the effusion is considerable, the breathing may be rendered rapid and laborious, owing to the pressure upon the diaphragm. There may be another cause for the dyspnoea, however, for, as in one of Sir H. Marsh's cases, it sometimes happens that the serous membrane of the chest is affected, with effusion into its cavity. At first the pulse is scarcely altered ; but, as the disease advances, it increases in frequency, varying from 100 to 140, but is diminished in strength and fulness. The heat of skin is increased. In almost all cases, when the disease is fully established and the fever marked, there are distinct evening exacerbations of a hectic cha- racter, during which the pulse rises, the temperature augments, the face is flushed ; there is much thirst, and the urine is high colored, &c. After this state has continued an hour or two, it gradually subsides. 1 Med.-Chir. Trans., vol. ii. p. 265. PERITONITIS. 563 Generally speaking, throughout the course of the disease, the secre- tion of urine is diminished in quantity. It is hardly necessary to add, that so formidable and long-continued a disease is attended with great emaciation and exhaustion. As the disease progresses, the local symptoms are aggravated; the quick pulse and fever with exacerbations, more remarkable ; the weakness and incapability of exertion more extreme ; the patient, in short, is utterly worn out. 1 798. Terminations. — The course of the disease is generally very long ; it may be prolonged for several months, and then may terminate variously. I. In resolution. Under proper treatment the inflammation may be subdued, and the effusion absorbed, and this termination is the more practicable the less the mesenteric glands are affected. In such cases we find the unhealthy condition of the intestinal canal gradually cor- rected, the appetite return, and the fecal evacuations become natural ; the pulse diminishes in frequency, the fever and exacerbations cease. The last symptom remaining is the abdominal distension ; but this, too, gradually subsides until fluctuation can no longer be detected. These successful cases, however, are not the most common. II. In a circumscribed collection of the effused fluid and its final evacuation, with more or less subsidence of the original affection. Under such circumstances patients have been known to recover. Dr. Burns mentions a case of this kind ; 2 and Dr. Abercrombie states that the matter may make its way through the abdominal parietes or the inguinal ring. 3 An interesting case of this termination was related to the Surgical Society, by my friend, Dr. O'Reilly. Such cases, how- ever, are very rare. in. In death. The majority of cases terminate thus at different intervals from the commencement of the attack. Instead of diminish- ing, the symptoms progressively increase in intensity. The abdomen is very tense and tender, the fever high, the pulse very quick and feeble, the thirst considerable, the diarrhoea persistent, the exacerba- tions severe, the emaciation and exhaustion extreme. The countenance becomes sunken, the extremities cold, the surface covered with a clammy sweat, and occasionally dotted with petechise, and, at length, after a prolonged period of suffering, death closes the scene. In some cases the disease is brought to an earlier termination by ulceration and per- foration of the intestines, which convert the chronic peritonitis into aeute. 799. Morbid Anatomy. — Occasionally the vessels of the peritoneum are injected, though sparingly ; there is more or less serum effused into the abdominal cavity, with shreds of lymph floating therein. 4 The in- testines are more or less agglutinated together, and often thus assume the appearance of sacs of matter. Where there has been perforation of the intestines, we find fecal matter mixed up with the serum, and can 5 Burns's Midwifery, p. 811. 2 Midwifery, p. 811. 3 Diseases of the Abdominal Viscera, p. 195. * Burns's Midwifery, p. 811. Denis, Mai. des Enfans nouYeaux-ne"s, p. 119. 584 PERITONITIS. generally detect the communication with the intestine through which it has passed. The peritoneum itself is often thickened, and coated with a layer of lymph; sometimes it is studded with miliary tubercles, or has tubercular matter deposited upon it. In some cases the mucous mem- brane is intact, in others, ulceration has advanced to different stages. The mesenteric glands may be free from disease, or they may be en- larged, and contain tubercular matter. Dr. Abercrombie states as the result of his experience, that " on dis- section the bowels are generally found more or less extensively glued to each other, and to the parietes of the abdomen, and the omentum is often involved in the disease. There is sometimes ulceration of the mucous membrane, and not unfrequently the peritoneum is in many places much thickened, and studded with small tubercles ; in some cases again there is great thickening of all the coats of the intestines at particular parts. In many cases there are left amid the adhering por- tions of the intestines, cavities full of purulent matter, which is gene- rally of an unhealthy or scrofulous character. There is frequently disease of the mesenteric glands of the liver or lungs." 1 Dr. Gregory observes that, " on cutting through the parietes of the abdomen, all traces of abdominal cavity will be wanting. The mesen- tery, bowels, and peritoneum lining the parietes, will be found united together into one mass. The peritoneum, in all its duplicatures, appears thickened, and on cutting through the diseased mass, very large quanti- ties of scrofulous matter will be found. The mucous membrane of the bowels, particularly of the small intestines, appears ulcerated in various places, and at these points of ulceration the convolutions of the intes- tines communicate, so that instead of forming one line of canal, as they will continue to do even in advanced stages of chronic peritonitis, they constitute a mass of tubes communicating freely with each other, and with the thickened and ulcerated peritoneal membranes by innumerable openings. The matter which will be found both within and without the mucous membrane will be observed to correspond exactly with that which was passed during life by stool." 2 800. Causes. — Various exciting causes have been mentioned as giving rise to the disease, such as bad diet, cold, privations, excesses, dentition, constipation, &c, and doubtless with truth; but nevertheless, in the majority of cases, it will be extremely difficult to say exactly what is the exciting cause. In the cases which have fallen under my own ob- servation, it appeared to be the result of an extension of irritation from the intestinal mucous membrane. It also occurs as one of the sequelse of febrile diseases, such as scar- latina, measles, &c. It may be worth remarking, that none of the children in whom it occurred at an early age were born of mothers who had suffered from puerperal fever. 801. Diagnosis. — When pain and swelling of the abdomen, with fluc- tuation, are present, the diagnosis will be easy ; but in those cases in which there is no pain, and but slight tenderness, with little disorder of 1 Diseases of the Abdominal Viscera, p. 193. 2 Med.-Chir. Trans., vol. ii. p. 266. PERITONITIS. 565 the digestive organs, there may be great difficulty. Our principal guide is the enlargement of the abdomen, which ultimately always occurs, and the fluctuation, which, by a little care, may generally be perceived. When there is much dyspnoea, or when the diarrhoea is severe, we must be on our guard against supposing the disease limited to the chest or mucous membrane of the intestines. We know that both may be seri- ously involved, concurrently with the peritoneal membrane. The same may be said of the mesenteric glands ; they may also be diseased ; but when they are affected alone, we shall find neither the abdominal swell- ing (at least to the same extent) nor the fluctuation. 802. Prognosis. — The prognosis, in the majority of cases, is unfa- vorable. Where the peritoneum alone is affected, the patient has cer- tainly a chance of recovery; but if the mesenteric glands, or the mucous membrane of the intestines, or the pleura, be involved, the case will probably terminate unfavorably. 803. Treatment. — The treatment usually recommended is comprised in a few lines — short in proportion to its hopelessness. Leeches to the abdomen, fomentations, purgatives, of which calomel forms one of the ingredients, alteratives sometimes, tonics, chalybeates, absorbents, &c. Such is the catalogue usually given. The question, however, deserves a little more detail, inasmuch as a certain number of the cases are curable, if we are called in reasonably early. General bleeding, I believe I may say, is never required; but when the pain is distressing, especially if there be parts of the abdomen tender on pressure, we may afford relief by the application of a few leeches; to be repeated, if necessary. The abdomen should be fomented with a decoction of poppy heads, twice a day, or oftener, if the paroxysms of pain be frequent ; or a piece of lint wet with laudanum may be laid over the abdomen ; and every night, or every other night, the patient should take a warm bath. If the bowels be confined, a dose of castor oil, or Gregory's powder, must be given occasionally ; but if diarrhoea be present, it may gene- rally be checked by the pulv. cretse cum opio, or any other astringent combined with an anodyne. Dr. Gregory advises laudanum for this purpose. But our principal reliance is upon mercury, given so as to affect the gums, if possible. I believe that the credit of thus administering mer- cury in this disease is due to Sir Henry Marsh, as I have found no allu- sion to it in any authority. It may be exhibited internally or by inunc- tion ; in many cases the latter is preferable, as when diarrhoea occurs, the bowels are too irritable. A scruple of the strong ung. hyd. should be gently rubbed in over the abdomen, night and morning, and con- tinued until the gums are touched, or the disease shows signs of yielding to the treatment. Blisters to the abdomen are very useful ; they should be small, and applied successively to different parts, and dressed with the blue oint- ment. Should the disease give way, the moment the febrile action ceases will be the proper time to commence the use of tonics ; and the diet, 566 PERITONITIS. which up to this time should be bland and unstimulating, though nutri- tious, may consist of broths, meat, and a moderate quantity of wine or porter. During convalescence the patient must be confined to the house at first, and only by degrees allowed to take air and exercise. The cloth- ing should be warm, with flannel next the skin. At a more advanced period of convalescence a removal to the country will be of essential benefit. SECTION V. DISEASES OF THE SKIN. 804. My object in the present section is simply to give a brief sketch of those eruptions which occur most frequently in children. Although I agree with those who object to many points of the classification of Dr. Bateman, yet, in order to avoid confusion, I think it better to make use of his terminology, and, to a great extent, of his arrangement, specifying any points of difference as they arise. That the varieties of cutaneous eruptions are caused by the difference of the tissues involved, and the varying amount of inflammation, I fully believe, with perhaps one exception — and with regard to that the ques- tion can hardly be considered as settled. Commencing, therefore, with the slightest of these diseases, we shall consider successively the papular, squamous, vesicular, and pustular dis- eases in order. For fuller details I must refer my readers to the works quoted below. 1 CHAPTER I. STROPHULUS. — PRURIGO. — PITYRIASIS. — ROSEOLA. I. STROPHULUS, OR RED GUM. 805. This is ordinarily the earliest eruption to which infants are liable : it is very commonly seen a day or two after birth, and from time to time during the first year of infantile life. It appears to' arise from the irritability of the skin, and its sensibility to reflex irritations; thus, at an early period, it seems to be owing to the assumption of their proper functions by the stomach and intestinal canal ; at a later period, to some disorder of these organs, or to dentition, &c. Willan and Bateman have described five varieties : the strophulus 1 Willan on Diseases of the Skin. Bateman on Cutaneous Diseases. Britt, Abrege pratique sur les Maladies de la Peau, by Cazenave and Stredel. Lecons sur les Mai. de la Peau, par P. L. A. Cazenave. Eruptions of the Face, Head, and Hands, by Dr. Bur- gess. Portraits of the Diseases of the Scalp, by W. C. Dendy. On Diseases of the skin, by Dr. Neligan. 568 PRURIGO. intertlnctus " is characterized by papulae of a vivid red color, situated most commonly on the cheeks, forearms, and back of the hands, but sometimes universally diffused. They are usually distinct from each other, but are intermixed with red clots or stigmata, and often with larger red patches, which have no elevation. Occasionally a few small vesicles appear on the hands and feet, but these soon desiccate without breaking." 1 The other varieties are mere modifications of this one ; sometimes we find minute, hard, whitish, elevated specks mixed with it {strophulus albidus) ; or the eruption is more extensive and general, of a more vivid red, and sometimes in large, irregular patches (s. confertus) ; or it occurs in small circular patches or clusters of papulae, arising and exfo- liating on different parts of the body (s. volaticus); or it may consist of large papulae, with a smooth shining surface, without inflammation, around the bases (s. candidus). 806. Very little treatment is necessary, and no local applications beyond daily and careful ablution, or an occasional warm bath. In young infants, as the digestive system becomes used to the exercise of its functions, less and less cutaneous irritation of the skin is excited, and the disease subsides of itself. When it proceeds from morbid irritation of the bowels, however, it will be relieved by a few grains of gray powder, with rhubarb; or, if the bowels are too free, a little chalk mixture, with a drop or two of laudanum to the ounce. If the teeth are troublesome, and the gums swollen or inflamed, it will be necessary to lance them freely, so as to remove the distress. II. PRURIGO. 807. This disease is characterized by an eruption of papulae of the same color with the surrounding cuticle, accompanied with severe itch- ing. There is but one variety, the Prurigo ?nitis, which frequently affects young persons. It is " accompanied by soft, smooth papulae, somewhat larger and less acuminated than those of lichen, and seldom appearing red and inflamed, except from violent friction; hence an in- attentive observer may overlook the papulae altogether, more especially as a number of small, thin, black scabs are here and there conspicuous, and arrest his attention. These originate from the concretion of a little watery humor, mixed with blood, which oozes out when the tops of the papulae are removed by the violent rubbing or scratching which the severe itching demands. This constant friction also sometimes produces inflamed pustules, which are merely accidental, however, when they occur at an early period of the complaint. The itching is much aggra- vated both by sudden exposure to the air and by heat ; whence it is particularly distressing when the patient undresses himself, and often prevents sleep for several hours after he gets into bed." 2 1 Bateman on Cutaneous Diseases, p. 2. 2 Ibid., p. 15. PITYRIASIS. 569 It appears to be most frequent in spring or the beginning of summer, and certainly with children occasions great distress. It is quite distinct from scabies or itch, and yet, if neglected, it is quite possible that it may degenerate into that complaint. 808. Treatment. — The tepid bath, or frequent ablution 'with warm water, appears to be almost the only local remedy necessary, though at first the disease seems rather aggravated than relieved. I have found the addition of sulphuret of potash to the warm water afford great relief to the itching, but I think the most effectual remedy for it is the zinc cream, which consists of white wax 4 oz.; spermaceti 4 drachms; almond oil and distilled water 16 oz.; otto of roses one drachm, and oxide of zinc 16 drachms. The wax, spermaceti, and oil should be melted together in a water bath, and poured still hot into a mortar previousy heated, and the water added by degrees, whilst the mixture is assiduously beaten with a twig until it assumes a granulated appearance. The oxide of zinc finely powdered may then be added, and the otto of roses. I have given this formula in full, because I have found the cream afford great relief from the itching in all the eruptions of children in measles, scar- latina, &c. Internally Dr. Bateman recommends the use of sulphur, alone or combined with soda or nitre, and that this should be followed by the mineral acids. We must take care to regulate the bowels ; if they are not too free, the hyd. c. cretai, with rhubarb and a little carbonate of soda, will act kindly and beneficially. . II. PITYRIASIS. This eruption is characterized by irregular patches of thin scales, which exfoliate and reform, but which neither form crusts nor are ac- companied with excoriation. The first variety of Bateman [p. capitis) is that with which we have chiefly to do. It is observed on the head of many, if not most infants, in the form of dandriff, as it is called, and appears rather as an excess of cutaneous secretion than as a disease. It is most common on the top of the head, but it often extends to the forehead, where we may see a band of small whitish scales, easily re- moved by friction ; but on the top of the head and at the occiput the scales are larger, and, if neglected, rather resemble a large, dirty patch. Among the poor this state of the scalp is almost universal, and, I do not doubt, forms an appropriate preparation for more troublesome erup- tions in that region. Even with infants who are carefully tended, it requires patience and constant watching to prevent the formation of a layer of scaly secretion. Dr. Neligan remarks : " If we examine the condition of the scalp in pityriasis capitis, the surface is found to be closely covered with the imbricated scales, with small intervals here and there ; the skin of the unaffected parts presenting a smoother or more polished appearance than natural. On removing one of the scales we find that the spot on which it is seated is soft, and that another fine scale may be removed from it; and it is not until after the removal of several scales, each 570 ROSEOLA. finer than the preceding, that we arrive at the reddened and inflamed surface of the scalp, which is somewhat depressed." 1 The principal annoyance which it occasions is the itching ; and the efforts of the infant of course tend to increase the inflammation and irritation. 809. Treatment. — Daily and careful ablution of the head is neces- sary with all infants, and especially when this disposition to excessive secretion is manifest ; but I have certainly seen this disease aggravated by the frequency and profuse use of soap, which acts as an irritant to the tender skin of the infant. Very little, if any, soap should be used; if warm or cold water be not sufficient, oatmeal and water, or a little of the yelk of egg, may be employed ; and after the head is dry a small quantity of very thin oil may be applied ; or, if the skin appear red, a lotion of almond milk (Siv) and acetate of lead (gr. xij). For the ordinary dandriff, or for this disease, when it has so far sub- sided, I have found a lotion of two drachms of borax to a pint of water very useful. At a more advanced age soap may be used more freely, followed by the same oily or soothing applications, or an alkaline or spirituous lotion, according to circumstances. It will be generally advisable to remove the hair, or to keep it very short, and especially if its growth appear to have been injured. IV. ROSEOLA. 810. This eruption is a rose-colored efflorescence, not contagious, and without either wheals or papulse. Bateman describes seven varieties ; but we are principally concerned with two of them, the roseola autuni- nalis, which " occurs in children in the autumn, in distinct circular or oval patches, which gradually increase to about the size of a shilling, and are of a dark, damask-rose hue ; they appear chiefly on the arms, and continue about a week, sometimes terminating by desquamation : there is little itching, tingling, or constitutional affection connected with this efflorescence, and its decline seems to be expedited by the use of sulphuric acid internally :" and the roseola infantilis, which is a closer rash, with fewer interstices, sometimes disappearing after a few hours, or recurring and disappearing for days together, occupying some- times a limited space, in other cases being very general, and accompa- nied with smart though temporary febrile action. It appears to be the result of intestinal irritation, or of dentition, and it is not uncommon in the course of fevers. Previous to the eruption of smallpox, there is an eruption of roseola, and a similar one after vaccination ; but these are of trifling importance, and indeed I should hardly have mentioned roseola at all but for its resemblance to measles or scarlatina in some cases, but particularly to measles. I have no doubt but that some of the eases, in which it is supposed that measles or scarlatina has occurred twice in the same child, were in one instance cases of roseola. 1 Dublin Journal, August, 1848, p. 41. HERPES. 571 There is sometimes considerable febrile action before the eruption, and the eruption may present a striking resemblance to either of these diseases ; but in general the fever is infinitely less, and the eruption dies away much sooner. Moreover, there is less lachrymation and suffusion of the eyes, rarely any bronchitic affection or sore throat ; and, finally, it does not run through the family. 811. Treatment. — The removal of the irritation, caused by dentition or disordered stomach and bowels, is in general quite sufficient to cure the affection, which, in itself, is of no moment. CHAPTER II. HERPES. — ECZEMA. — RUPIA. I. HERPES. 812. We now pass on to a different class of diseases, in which the cuticle is not merely prominent, but in which it is separated from the cutis, and raised above the level of the surrounding parts by the effu- sion of serum. The characters of a vesicle, as distinguished from a pustule, are thus stated by Bateman: "It is a small orbicular elevation of the cuticle, containing lymph, which is sometimes clear and colorless, but often opaque and whitish, or pearl-colored. It is succeeded either by scurf or by a laminated scab." Of that form of disease which I shall first notice, herpes, Dr. Bate- man makes five varieties : H. phlyctenodes, H. zoster, H. arcuatus, II. labialis, and H. prseputialis: but as the majority of these affect children only incidentally, I shall enter into details concerning one species only, the herpes arcuatus or ringworm, which Dr. Neligan considers to be the true ringworm of the scalp. As we generally see it, it appears in small circular patches, with the vesicles best marked at the circum- ference; but this I believe to be because the disease, which commences by a single small vesicle, spreads concentrically, the centre healing whilst the circumference spreads and enlarges by successive crops of vesicles, producing in a short time the appearance of a ring. The vesi- cles are very minute, and in the course of a week form scabs, which fall off, leaving the cuticle underneath red for some time. Fresh vesicles may form, dry up, and the scabs fall; or the original circles may re- main red, and the cuticle throw off scales merely. Other circles meanwhile may form, and thus spread on the upper part of the body, the arms, chest, back, face, and scalp. There is no febrile disturbance attendant upon this eruption, nor any inconvenience beyond a disagreeable itching and tingling in the patches. 818. Dr. Bateman has noticed another form of herpes, "in which the whole area of the circles is covered with close-set vesicles, and the whole is surrounded by a circular inflamed border. The vesicles are of 572 ECZEMA. a considerable size, and filled with transparent lymph. The pain, heat, and irritation in the part are very distressing, and there is often a con- siderable constitutional disturbance accompanying the eruption. One cluster forms after another in rapid succession on the face, arms, and neck, and sometimes, on the day following, on the trunk and lower limbs. The pain, feverishness, and inquietude do not abate till the sixth day of the eruption, when the vesicles flatten, and the eruption subsides. On the ninth and tenth days a scabby crust begins to form on some, while others dry and exfoliate ; the whole disease terminating about the fifteenth day." Dr. Bateman seems to doubt whether herpetic ringworm is contagious, because the other herpetic eruptions are not. . M. Biett lays great stress upon its not being contagious, upon its vesicular character, and upon its not injuring the hair, as distinguish- ing it from porrigo scutulata. 1 Dr. Neligan has no doubt of its contagiousness; he regards it as com- pletely proved as that of smallpox. It certainly attacks more than one member of a family or school con- secutively, and in some cases I have thought was undoubtedly commu- nicated from one child to another. 814. Treatment. — The hair must be cut short, and if there be much irritation, soothing applications are to be applied; if not we may at once apply our special remedies. Strong astringent applications seem to be the best: the solution of the salts of iron, copper, zinc, or of borax, alum, &c, are very successful. The tincture of the muriate of iron I have found very useful: the tincture of iodine or nitrate of silver will cure it equally well. Common ink (which contains sulphate of iron, and galls) is a very favorite popular remedy. M. Biett speaks highly of lotions of carbonate of soda or potash; and his experience is confirmed by Dr. Neligan, who recommends the use of both ointment and lotion of these alkalies; and if a more stimu- lant treatment be necessary, a dilute citrine ointment. The stomach and bowels should be carefully regulated, and the skin kept in a state of great cleanliness. II. ECZEMA. 815. The varieties of eczema described by Dr. Bateman are not at all peculiar to children, and are not mentioned as attacking the scalp. But my friend, Dr. Neligan, has described a disease under the name eczema capitis, which is by no means uncommon. It is essentially a vesicular eruption, but in the different stages it presents varied appear- ances, because probably of the increase of the inflammation from rub- bing, scratching, &c, so that it often resembles the eczema impetigi- nodes of Willan and Bateman, an intermediate stage between a vesicular and pustular disease. 1 Mai. de la Peau, by Cazenave and Shedel, p. 110. ECZEMA. 578 The appearance of the eruption is preceded by itching, tingling, and heat; then the minute vesicles are seen crowded together in irregular patches, or scattered over a large surface. They usually appear first behind the ear, close to the edge of the scalp, from "whence they spread over the ear itself and the scalp. "The interspaces between the vesi- cles and the whole of the scalp, on which they are seated, is red and inflamed; in most cases the vesicles are so minute as to be scarcely recognizable, or at least are not seen by the physician, until they have burst, and given exit to a copious exudation of a serous fluid, by which the roots of the hair are cemented together. In the acute form of the disease the serous exudation continues for a long time, and is a most troublesome symptom : but in the chronic forms — and some cases assume a chronic character almost from the first — it rapidly dries into furfura- ceous scales, which are pushed forward by the hairs as they grow. With the progress of the affection, the appearance of the diseased surface varies much ; sometimes it is scarcely, if at all, elevated above the healthy parts, and is only to be recognized by the watery exudation which keeps the hairs in a constantly moist state. In other cases, the scalp is raw or excoriated, and secretes a thin whitish pus, which dries into grayish-brown scabs, presenting cracks or fissures through which the inflamed surface is seen. In a third form of the disease, the serous exudation dries rapidly into extremely thin membranous scales, which are readily removable by the slightest friction, but cause much itch- ing ; and a fourth variety is characterized by a repeated eruption of minute patches of vesicles, the patches rarely exceeding the size of a small bean, all on the scalp, which pass through the stages of eczema, as witnessed on other parts of the cuticular surface, and disappear in seven or eight days, but to be rapidly succeeded by a fresh outbreak of the disease." 1 So long as the surface of the cutis remains unbroken, the hair is un- injured ; but when the inflammation involves the roots of the hair, or ulceration of the cutis destroys them, the hair is either weakened in its growth or altogether obliterated. Eczema does not appear to be a contagious disease, nor can we name any special cause for it ; it may be connected with dentition or intes- tinal irritation like other eruptions. 816. Treatment. — I quite agree with Dr. Neligan that more harm than good is done by shaving the scalp, at least in the acute stage of any eruptive disorder. The hair should be cut very close with a pair of fine scissors, and kept very short ; this occasions no irritation, and affords sufficient facility for applying remedies, and for keeping the head clean. In no severe or acute case, however, should the head be washed with soap ; water alone, or oatmeal and water, will be sufficient. The local treatment will, in the first instance, depend upon the amount of inflammation : if this be great, the first object is to soothe and lessen it by emollient applications, such as poultices, fomentations, or the warm-water dressing. When the surface is less red and angry looking, we may try the alkaline applications recommended by Biett 1 Dublin Journal, August, 1848, p. 37. 574 rupia. and Neligan — the carbonates of soda or potash, either in the form of ointment or lotion. I would wish to impress upon my junior readers the fact that with some children greasy applications altogether disagree, and seem to aggravate the eruption, whilst, with the same children, the same remedies in the form of lotion will succeed perfectly ; and as this can be known only on trial, we should change the vehicle if we do not find it answer, before deciding against the remedy. Dr. Neligan forms the ointment of either carbonate by adding from twenty to thirty grains to an ounce of lard, and the lotion by dissolving half a drachm in a pint of rose-water or distilled water. The ointment is to be applied three times a day, and should be washed off every morning with the lotion : if the lotion only be used, it should be applied five or six times a day. The carbonate of soda is preferable when there is much inflam- mation, as being less irritating than the carbonate of potash. In all cases, Dr. Neligan keeps the child on milk diet during the entire period of treatment. Dr. Burgess recommends the alkaline lotions instead of any greasy applications, but as he regards eczema as a constitutional and not a local affection, he lays great stress upon "restoring the tone of the sys- tem by means of a course of mild tonics and alteratives." If the secre- tion be abundant, and the parts irritated, he advises barley water with sulphuric acid (half a drachm of the former to a pint of the latter), com- mencing with small doses, and taking a little water after each until the stomach is accustomed to the acidulated drink. If these remedies fail, then we may try alteratives, as sarsaparilla, and hydriodate of potash ; active purgatives if the patient be strong ; and lotions of the nitrate of silver, or the bichloride of mercury. In chronic cases, where some stimulant is required, a very dilute citrine ointment may be used. 1 • I have found singular benefit in all the moist eruptions, where the inflammation is not too great, from the use of black wash ; it dries the surface, and forms scabs, which must be carefully removed, in order that the lotion may get at the diseased surface. In some cases, a lotion of acetate of lead in almond-milk, or decoction of poppy-heads, is very soothing. The bowels must be regulated, and in some obstinate cases a few alternative doses of mercury may be advantageously given. M. Biett recommends acid drinks. III. RUPIA. 817. Dr. Bateman states that " rupia is characterized by an appear- ance of broad and flattish vesicles in different parts of the body, which do not become confluent ; they are slightly inflamed at the base, slow in their progress, and succeeded by an ill-conditioned discharge, which con- cretes into thin and superficial scabs, that are easily rubbed off and presently regenerated." 2 1 Dublin Journal, August, 1849, p. 45. 2 On Cutaneous Diseases, p. 243. RUPIA. 575 We are only concerned with one of his three varieties, however, the rupia escharotica, which appears to be identical with the disease de- scribed by Dr. Whitley Stokes, and others, under the name of pemphi- gus gangrenosum. Dr. Bateman says that " it affects only infants and young children when in a cachectic state, whether induced by previous diseases, especially the smallpox, or by imperfect feeding and clothing, &G. ; whence, among the poor, where it is commonly seen, it often ter- minates fatally. The vesicles generally occur on the loins, thighs, and lower extremities, and appear to contain a corrosive sanies ; many of them terminate with gangrenous eschars, which leave deep pits." 1 It is not stated by writers in general to be either a very frequent or fatal affection ; yet in Ireland it appears to be both in a very high de- gree, for I find in Dr. Wilde's Report that in ten years the mortality amounted to 17,779, in the proportion of 100 males to 78.93 females. The country people give it the significant names of "white blister," "eat- ing or mortifying hive," "burnt holes," and among them it appears to prevail as an epidemic occasionally. Dr. Whitley Stokes, who published a valuable paper upon this subject in 1808, states that " the causes of this malady are rather obscure, it seems exclusively confined to children. Dr. Spear observed that it was confined to children of three months and from that to five years, but it has been observed, near Dublin, in chil- dren of nine years old. It attacks the finest children in preference: the children of the poor more frequently than those of the affluent : those who live in damp situations seem more particularly subject to it than others. It appears to be infectious, though obscurely so in general, but in the year 1800 Dr. Spear observed it to spread epidemically." Bub. Med. | Phys. Essays, vol. i. 1808. MM. Cazenave and Shedel describe it as commencing with livid spots, slightly prominent, upon which the epidermis is soon elevated by the effusion of serum until they form large bullae, flat, and of irregular form, surrounded by a livid circle. These vesicles break, and expose irregu- lar ulcerations, varying in depth and extent, with red border and un- healthy surface. There is severe pain, much fever, sleeplessness, and, when the disease is extensive, death may occur in a week or two. In one or two cases which came under my care I was informed that the disease commenced by a vesicle filled with clear serum, which enlarged speedily, and the serum became opaque. The borders were slightly red. When I saw the case, the bullae had burst and exposed an irregular ulceration with defined edges slightly inflamed, and with a tolerably healthy surface. 818. Treatment. — It will be necessary to attempt to improve the general condition of the child, if we hope to cure the local disease. Cleanliness, comfortable clothing, pure air, and good diet, must be afforded. If there be much fever, of course the diet must be moderate but nourishing, and by degrees broth, beef-tea, or solid animal food, may be given. The local applications will consist, in the first instance, of caustics — ■ the nitrate of silver, the acid nitrate of mercury, dilute nitric or muri- 1 On Cutaneous Diseases, p, 244, 576 IMPETIGO. atic acid, &c. — so as to change the surface and arrest the ulceration, after which poultices may be applied. M. Biett has succeeded with the proto-ioduret and deuto-ioduret of mercury in the form of ointment ; a scruple of the former, and from twelve to fifteen grains of the latter, to an ounce of lard. CHAPTER III. IMPETIGO. — PORRIGO. I. IMPETIGO. 819. We now come to the consideration of pustular eruptions, and the one I shall first notice is one which occasionally assumes a vesicular appearance, although really pustular. Impetigo, moist or running tetter, is marked by small psydracious pustules, neither accompanied by fever, nor contagious, nor communicable by' inoculation. Dr. Bateman says that it chiefly occurs on the extremities, but it may also attack the head. In children it is very apt to appear in parts where there is much movement, such as the flexures of large joints, and is accompanied with intense itching. It may be excited by dentition, disorder of the stomach and bowels, &c, and is frequent in children of deteriorated constitutions. When it attacks the scalp it is preceded for a few days by feverish symptoms, and sometimes by vomiting ; the scalp is hot and tender, and with a slight redness where the eruption is about to appear. The pus- tules are psydracious, occurring singly or in groups, with inflamed bases. Each pustule contains thick, yellow, purulent matter, which is soon matured, and forms a greenish-yellow scab. This form Dr. Neligan considers to assume a chronic form but rarely; fresh pustules appearing in different parts of the scalp as the old ones heal. 820. " The second form of the disease is characterized by the erup- tion occurring in groups of pustules, but the individual pustules are also different in character, being of the variety which have been termed achores. Their appearance is attended with more decided symptoms of inflammation, both general and local, and the heat and itching are in many cases so severe that children tear the scalp, and prevent the dis- ease from presenting the truly pustular character of the first stage. The eruption usually commences on the forehead, involving at the same time some of the hairy scalp. The inflamed patches vary in size and form in different cases; in some extending in their longest measurement not more than from half an inch to one or two inches, while in others the greater part of the scalp is involved from the very commencement. In nearly every instance the skin bordering on the scalp is more or less engaged in the disease, and it often appears at the same time in the ears or on some part of the face. The pustules are not so large as when they occur singly; their coats are apparently thinner, and the pus which IMPETIGO. 577 they contain is not so consistent, and is of a richer yellow color. They usually become confluent before they burst, and the resulting greenish- yellow (when chronic, greenish-brown) scab is consequently much more extensive. When the eruption has continued for any length of time, large quantities of bright yellow pus are secreted beneath the greenish crusts, which separate in cracks, to give exit to the matter, exhibiting beneath the highly inflamed raw surface of the scalp, from which the pus is secreted." 1 The disease does not appear to be contagious ; it chiefly occurs in infancy and childhood, and may last for years, if neglected. It con- stitutes the crusta lactea of authors. I cannot agree with Dr. Neligan that the hair is unaltered; it is not so rapidly or so completely destroyed as by porrigo, but, if the disease be of long standing, the roots of the hair are injured, and its growth checked ; it becomes thin and poor-looking. In this, as in other severe eruptions of the scalp, the glands at the sides and back of the neck, below the hair, are apt to be enlarged and tender, but they rarely suppurate. Small abscesses sometimes form at the nape of the neck, close to the roots of the hair. I have no doubt that occasionally a brisk eruption on the head may prove a salutary counter-irritation, and hence I suppose has arisen the popular objection to curing them. But I do not conceive that there is any danger if due care be taken, and I am quite sure that many evils follow their long continuance. Sore eyes or ears, otorrhoea, glandular swellings, &c. may, I believe, often trace their origin to a chronic erup- tion neglected. 821. Treatment. — From the amount of inflammation present, our first applications must be of a soothing character. After cutting the hair as short as possible with a pair of scissors, a poultice of bread and milk, or linseed meal, may be applied over the inflamed parts, or they may be frequently fomented with the decoction of poppy-heads. At the same time, if the child can well bear it, a brisk purgative should be given, and the child put upon low diet, or confined to milk, as Dr. Neligan recommends. With children who are in bad health, or whose constitution has been impaired, we must use caution as to purgatives, and it may be desirable to allow a more generous diet. When the redness is diminished, and the irritation is calmed, we may use a lotion of the sugar of lead, black wash, or the alkaline lotion recently described, with the alkaline ointment. This treatment, with cleanliness and pure air, will soon effect a change in the aspect of the disease, unless the child be teething, and then, although dentition did not cause the disease, it may be kept up for some time, until the teeth are cut. Even lancing the gums, which should always be done, will not always immediately relieve the irritation. 1 Dublin Journal, August, 1848, p. 39, 37 578 PORRIGO. IT. PORRIGO, OR SCALD HEAD. By Bateman and the older writers, porrigo has been regarded as a pustular disease, the result of inflammation. Comparatively recent researches with the microscope, however, seem to have established the fact of two varieties, at least, being of vegetable origin, and not the result of inflammation. We are indebted to the investigations of Schon- lein, Gruby, Bennett, Corrigan, Miiller, Lebert, Robin, &c, for the amount of our present knowledge. But it follows, if this view be the true one, that some of the varieties usually included under porrigo must either be made a separate order, or included among the impetiginous eruptions, leaving the porrigo scutulata and porrigo favosa (or perhaps the p. favosa alone) as an order of vegetable productions of the scalp, the result of constitutional causes chiefly, and not of inflammation. Dr. Bateman describes six varieties, the -porrigo larvalis, or crusta lactea, the porrigo purpurans, the porrigo deealvans, the porrigo lupi- nosa, the porrigo scutulata, or ringworm of the scalp, and the porrigo favosa. They differ in the size of the pustules, and the form of the crusts or scabs. 822. The porrigo larvalis u commonly appears first on the forehead and cheeks, in an eruption of numerous minute and whitish achores, which are crowded together oh a red surface. These pustules soon break, and discharge a viscid fluid, which concretes into thin yellowish or greenish scabs. As the pustular patches spread, the discharge is renewed, and continues also from beneath the scabs, increasing their thickness and extent, until the forehead, cheeks, and even the whole face become enveloped as by a mask (whence the epithet larvalis), the eyelids and nose alone remaining exempt from the incrustation. The eruption is liable, however, t'o considerable variation in its course, the discharge being sometimes profuse, and the surface red and excoriated, and at other times scarcely perceptible, so that the surface remains covered with a dry and brown scab. When the scab ultimately falls off, and ceases to be renewed, a red, elevated, and tender cuticle, marked with deep lines, and exfoliating, is left behind." Other parts of the body may be attacked, and the irritation occasions loss of sleep, and much distress to young infants. The description I have quoted from Bateman resembles that of impetigo, already given by Br. Neli- gan, and it would often be difficult to decide whether the eruption was impetigo or porrigo larvalis, unless we confine the genus porrigo to the porrigo scutulata and favosa. The treatment recommended for impetigo is well suited to the present species. THE PORRIGO SCUTULATA, OR RINGWORM OF THE SCALP, 823. Has given rise to great difference of opinion as to whether it is a pustular or vesicular disease, and whether the pustules or vesicles are at all essential to the disease. Willan, Bateman, Biett, and the older writers, class it among the former ; some of the French writers, espe- PORRIGO. 579 cially M. Cazenave, among the vesicular. Dr. Neligan considers herpes to be the true ringworm ; and Dr. Burgess 1 regards this form as the result of abnormal irritation of the bulbs of the hair. When such emi- nent dermatologists differ, I cannot expect to be able to decide. I can scarcely doubt, after the examination I have made, that there is a form of ringworm, the element of which is a vesicle, but this does not prove that a pustular eruption may not assume this character. Dr. Burgess's description differs equally from that given by Bateman and that by Neligan. Dr. Bateman states that "it commences with clusters of small light yellow pustules, which soon break and form those scabs over each patch, which, if neglected, become thick and hard by accumulation. If the scabs are removed, however, the surface of the patches is left red and shining, but studded with slight elevated points or papulse, on some of which minute globules of pus again appear in a few days. By these repetitions of the eruptions of achores, the incrustations become thicker, and the areas of the patches extend, often becoming confluent, if the progress of the disease be unimpeded, so as to affect the whole head. As the patches extend, the hair covering them becomes lighter in its color, and sometimes breaks off short ; and as the process of pustula- tion and scabbing is repeated, the roots of the hair are destroyed, and at length there remains uninjured only a narrow border of hair round the head." 2 Dr. Burgess, one of the most recent writers on the subject, thus de- scribes the disease: "We have seldom an opportunity of seeing ring- worm in the early stage, for the patient, even, is not aware of its presence for some time after its development, and the first indication is a trifling degree of itching in the parts, which is relieved by the dis- lodgement of a thin scruff' in the act of scratching. It is this circum- stance which first directs attention to the disease. If examined now, there will be found neither heat, redness, nor moisture on the morbid surface, but a thin layer of furfuraceous matter, of an oval or circular form surrounding the hair, either singly or in small groups. These cir- cular patches are always few in number and limited in extent ; fre- quently there is only a single diseased spot to be found on the head, which, if observed early, will be found to extend from a small point or nucleus by its periphery, until the spot attains a certain size of limited circumference, when it ceases to extend, and within these limits the dis- ease passes through its various phases. The skin is dry, uneven, and covered with rough eminences, insensible to the eye and to the touch, which give it the appearance of the prickly condition of skin called 'cutis anserina.' These mammillary projections are enlarged and dis- eased hair follicles, propelled by the hair in its growth from beneath the level of the skin; and if we endeavor to pull the hair, it will not be detached from the root, but break on a level with, or a short distance from, the mouth of the follicle. The hair that grows on the morbid surface, after it has arrived at the condition described, does not attain any length, but breaks spontaneously at a short distance from the skin, 1 Eruptions of the Face, Head, and Hands, p. 176. 2 Oa Cutaneous Diseases, p. 169. 580 POKRIGO. leaving an exposed patch of the scalp, which always maintains a circu- lar, disk-like form. The ends of the broken hairs are jagged, disco- lored, twisted, and not unlike the filaments of flax and tow. If the disease has not been arrested at this stage, the furfuraceous, scaly mat- ter will become agglomerated, and form dry, thick, dirty, yellow-looking scabs or incrustations, thicker at their circumference than towards the centre. It is the irritation produced by these scabs, but more particu- larly by the action of the nails in scratching or trying to dislodge them, that produces the pustules, and subsequently the discharge of the con- tents around the original disease, which deceived Willan, and induced him to place ringworm amongst the pustular eruptions of the scalp. He mistook an incidental or superinduced lesion for the element of the dis- ease, which is totally different." 1 Whether Dr. Burgess is right in considering these pustules as acci- dental, produced by the cause he mentions, may be doubted, I think; nor is this inconsistent with his view of the nature of the disease, which he regards as "the result of a vitiated or abnormal nutrition in the organs which secrete the hair, analogous to scrofulous degenerations which occur in other structures of the body. The seat of the disease is not in the hair but in the organs which secrete it ; and the vegetable productions so minutely described by Gruby, of the existence of which there can be no doubt, is a secondary product, and not the disease itself." Let us now see what has been observed of this "vegetable para- site." M. Gruby remarks : " On examining attentively with the micro- scope this grayish-white powder which is seen on the morbid surface, you will be surprised to find that it is composed of a number of crypto- gamia. On submitting the hairs which grow on this surface to the same method of examination, we shall observe a great quantity of these cryp- togames embracing the cylinder of the hair on all sides, and forming round it a perfect vegetable sheath, which accompanies the hair for a short distance after its exit from the follicles. The structure of the hair becomes less transparent ; the fibrous portion is interspersed with extremely minute granular molecules, which separate the fibres from each other in part or wholly, the size of which is estimated at the five- thousandth part of an inch in diameter, and the shaft of the hair is dis- tinctly enlarged or hypertrophied. The cryptogame surrounding the hairs at their bases, by contact with the adjoining hairs, involves them in the same morbid condition, altering the texture gradually, until they break off short, and thus expose a circular patch of partial baldness. These vegetable parasites are produced with surprising rapidity. On issuing from the follicle, the hairs become grayish for a certain distance, and in eight days break at the line where the cryptogame surrounds them. The hairs which are most enlarged resist for a longer period, and, according as they rise above the level of the skin, are attacked by the parasitic fungus. They are often surrounded at their base by a quantity of cryptogamia sufficient to form a small, grayish elevation. It is these accumulations which have been mistaken for pustules, vesi- cles, and the secretion of the sebaceous follicles." 1 Eruptions of the Head, Face, and Hands, p. 177. PORRIGO. 581 According to M. Robin, 1 the seat of this vegetable (trichophyton ton- surans) is in the interior of the roots of the hair, and he has described another (microsperon audonini) which is seated round the roots of the hair like a cylinder. In the midst of such varying opinions, all that seems agreed upon as to the disease is, the presence of circular or oval spots of, at first, a furfuraceous secretion, upon which ultimately something like pustules, at least, appears ; that the hair is at first injured, and then falls ; that in all probability the disease involves the follicle ; and that the secre- tion is of the nature of a vegetable parasite. The disease is also highly contagious, and, according to Gruby, it is transmitted by means of the furfuraceous powder, or cryptogame. Approximation of the head, or wearing the same cap, hat, or bonnet, will communicate the disease to another person hitherto free. I have seen spots of ringworm produced on different exposed parts of the body of a person employed in dressing the head of a child in whom this scurf was very profuse, which so far confirms M. Gruby's opinion. This affection is sufficiently common in children from three years old, and often proves very obstinate, lasting several years. Those of a feeble and flabby habit, the ill-fed, ill-clothed, and uncleanly, who live in unwholesome habitations, are the most exposed to it ; but it may be communicated to those in health and of good constitutions. 824. Treatment. — So long as the spots exhibit much redness, our ap- plications must be adapted to soothe; poultices, emollient fomentations, &c. will be most suitable. The hair must be clipped as short as pos- sible, which is much better than shaving, though more tedious, and requiring more frequent repetition. When the inflammation is subdued, or the disease has become chronic, we may proceed with more direct attempts to act upon the diseased portion. "In the more irritative states, the milder ointments, such as those prepared with the cocculus Indicus, with the submuriate of mer- cury, the oxide of zinc, the superacetate of lead, or with opium or tobacco, should be employed; or sedative lotions, such as decoctions or infusions of poppy-heads, or of tobacco may be substituted. When there is an acrimonious discharge, the zinc and saturnine lotions, with the milder mercurial ones, such as the ung. hyd. praacip. albi, or the oint- ment of calomel, or a lotion of lime-water with calomel, are advantage- ous. According to the different degrees of inertness which ensue, various well-known stimulants must be resorted to, and may be diluted or strengthened, or combined, according to the circumstances. The mercurial ointments, as the ung. hyd. pnecip., ung. hyd. nitrico-oxydi, and especially of the hyd. nitrat., are often effectual remedies ; and those prepared with sulphur, tar, hellebore, and turpentine, the ung. elerni, &c, separately or in combination, occasionally succeed, as well as preparations of mustard, black pepper, capsicum, galls, rue, and other acrid vegetable substances. Lotions containing the sulphates of zinc and copper, or the oxymuriate of mercury in solution, are likewise occasionally beneficial." 2 1 Des Vegetaux qui croissent sur l'Homme, &c. 2 Bateman on Cutaneous Diseases, p. 172. 582 PGRRIGO. M. Biett was in the habit of using the sulphuret of potash, the iodide of sulphur, or solutions of the sulphate of copper, zinc, nitrate of silver, corrosive sublimate, &c, with success. M. Cazenave recommends an ointment of one part of pitch to two of citrine ointment, and another with a scruple of tannin to an ounce of lard, as the most effectual ointments in this disease. Dr. Burgess speaks highly of a "lotion of the bicyanuret of mercury, in the proportion of one or two grains to the ounce, according to the amount of stimulus required, which will be found more serviceable than these, or even the solution of the bichloride of mercury, so commonly used in this eruption and in favus." If the latter be used, lint soaked in it should be applied to the parts, and covered with thin gutta-percha or oil-skin ; but the former is to be laid on with a camel's-hair pencil. " The local remedy, however, which I have found most effectual in the treatment of this obstinate complaint is the vapor of iodine and sulphur, conveyed directly to the morbid patch through a caoutchouc tube, from any simple apparatus for igniting the compound, the patient lying in the horizontal position during the application of the vapor. It will stimulate the parts greatly if applied for twenty minutes, and the dis- eased surface, which was previously dry and pale, will appear slightly red arid bedewed with moisture. The following formula will be strong enough to commence with, which may be afterwards increased according to circumstances : — R.— Sulphur sjiij. Iodiui, gr. xij to gr. xxiv. To be divided into sis powders — one to be applied three times a day." 1 M. Bazin first removed the hair by an ointment of lime and carbon- ate of soda, of each one part, lard thirty parts ; and then a solution of bichloride of mercury (1 part to 250 of water), or an ointment of the acetate of copper. Dr. Parker has recommended a solution of pernitrate of mercury (1 part to 30 or 40 of water), or an ointment of sulphate of copper (1 part), alum (3 parts), and lard (20 or 30 parts). 2 Dr. Jenner has successfully employed sulphurous acid. 3 The local applications I have found most useful, after the redness had subsided, are the black wash, diluted citrine ointment, ointment of the acetate of lead or oxide of zinc, or hydriodate of potass, and when chronic and obstinate, nitrate of silver or tincture of iodine — the latter particularly. The patches should be painted with it every second or third day. 825. But local treatment will not be sufficient; we must carefully remove any irritation, such as that from dentition or disordered bowels, and regulate the state of the stomach and bowels; after which in badly nourished, lymphatic, or scrofulous children we must endeavor to raise the tone of the system by good diet and tonics, either mineral or vege- , ' Eruptions of the Head, Face, and Hands, p. 182. 2 Brit, and For. Med. Rev., Oct. 1853, p. 418. 3 Med. Times and Gazette, Aug. 1853. POKRIGO. 583 table, or the mineral acids. Dr. Burgess recommends the citrate of iron in infusion of quassia, or a bitter infusion -with the hydriodate of potass. Much time is generally required, and great care before this obstinate disease is cured, and if the treatment be suspended too soon, before the surface of the patches is smooth, pale, and free from scurf, a relapse is almost sure to take place. I think that when the disease has been so far subdued that nothing marks its having existed but the bald spots and a slight excess of furfuraceous scales, I have derived much benefit from a weak ointment of hydriodate of potass; and at this stage oint- ments seem more useful than lotions. The hair must be kept quite short until some time after the disease is cured, and when there is no longer danger of much irritation, it may be well to have the entire head shaved once or twice ; it strengthens the growth of the hair on the bald spots, and secures an even length over the head. When it is allowed to grow, a little very thin oil of almonds may be used occasionally ; the common hair-oils are far too thick, and only neutralize all efforts at cleanliness. The head should be washed occasionally, but nothing can be more injurious both to the tender scalp and hair than the liberal use of soap. By far the best substitute is a portion of the yolk of an egg ; if it be well washed off with fresh water, it leaves the scalp perfectly clean and pale, and the hair soft and silky. PORRIGO FAVOSA. 826. Notwithstanding the opinions of Willan, Bateman, Alibert, Biett, and others, of the pustular character of porrigo favosa, it seems clearly established now that this variety at least is of vegetable nature. It is true that Dr. Mahon considers it a morbid secretion of the sebaceous glands, and Drs. Bennett and Burgess and M. Erichsen as a tubercular disease; but the researches of Schonlein, Gruby, Remak, Corrigan, Robin, &c, seem to have pretty well set the question at rest. The confusion as to the nature of the disease may have partly arisen, as Dr. Corrigan suggests, from the presence of two species of eruption on the scalp at the same time. He considers the disease as essentially pustular, but that the growth upon the skin is a vegetable parasite, and he describes the growth from the beginning. If the scalp be shaved and the scabs removed, we may soon observe the whole process of repro- duction. "Within some days, a few, often not more than three or four, very minute pustules will show themselves, scattered far asunder over the red surface ; they are not raised above the surface, and they seem like dots of transparent amber-colored matter bedded in the skin. In twenty-four hours after, they become solid, depressed in the centre, and of a pale yellow color, very often with a hair in the centre of each. They then rapidly increase in number and size." 1 These crusts consti- tute the vegetable parasite, underneath which the skin is red but un- 1 Dublin Hosp. Gazette, Aug. 15, 1846, p. 2. 584 porrigo. broken, and not secreting matter. Dr. Corrigan has established the fact that the appearance of the matter under the microscope is distinct- ive of this variety. In the first stage, it neither gives rise to heat of the scalp nor itch- ing; it commences generally at the edge of the scalp, and from thence spreads rapidly over the head, very often occupying nearly the entire surface of the scalp. The eruption is occasionally, but more rarely, seen on different parts of the body. "The appearance of this eruption is so peculiar and so distinct from all the other eruptive diseases of the scalp that it cannot possibly be mistaken for any of them. It first appears in the form of small, yellow, dry spots, about the size of a pin's head, of a bright yellow color, seated on the surface of the skin, which is depressed slightly by them ; each spot is distinct, hemispherical, slightly concave or cup-shaped on its free surface, and convex beneath, where it is adherent to the skin. On removing the small diseased mass, that portion of the scalp on which it was seated is found to be somewhat depressed, smooth, and shining. A single crust of the disease, or favus, as it has been termed from its honeycomb appearance, is often traversed by one or sometimes by two hairs, which appear to grow as it were from its very centre or most depressed portion. This has given rise to the notion that the disease is one of the bulbs of the hair ; but the fact of its appearance on other parts of the body which are quite free from hair is a sufficient refutation of this opinion. The eruption spreads by additions to the outer edge or circumference of each crust, which thus retains its hemispherical cha- racter, until it attains a diameter of two or three lines, or sometimes more. In a case which I have had recently under my care in hospital, some of the favi which were seated on the back of the trunk were fully half an inch in diameter; on the head, however, they rarely exceed the size above mentioned. The adjacent favi, as they increase, unite with each other, and form large irregularly shaped masses, in which the original circular form of the individual crust is lost; the centre also of each is changed in appearance, and, instead of the cup-shaped depres- sion, the entire surface is covered with alternate elevations and depres- sions, or, so to speak, ridges and furrows, concentrically arranged. The eruption thus increasing, the whole of the scalp — often, too, the fore- head, neck, and parts of the trunk — become encased in one large yellow crust, at the edges of which some favi, of the peculiar characteristic appearance, are invariably to be seen. The crusts of porrigo are of a pale sulphur-yellow color; they are hard and dry, and break with short fracture, exhibiting within a mealy powder, of a paler yellow than the external surface. They may generally be removed with facility from the scalp ; but they bring away with them a thin layer of epidermis, which is firmly adherent to their under surface, through which small projections may be seen with a moderate lens, sometimes with the naked eye. These projections or processes pass into the dermis beneath, and when the crusts are torn forcibly away, blood issues through the small orifices into which they were inserted. From the very commencement of the eruption of porrigo the hair becomes altered ; much of it falls out, and the straggling hairs that remain are thin, broken, weak, whitish. PORRIGO. 585 and readily removable with the crusts of the disease, in which they are firmly imbedded. When this affection has continued for any length of time, bald patches are left after cure, on which the hair does not again grow ; and even when it has been cured at an earlier stage, the hair never regains its proper character, being weak, thin, and of a pale, whitish-yellow color. As the disease advances, much irritation of the scalp is produced ; small pustules form here and there in spots as yet unaffected with the eruption ; the tingling and heat are so unbearable as to compel the patient to tear the surface with his nails, even to such a degree as to cause ulceration ; innumerable pediculi are engendered ; the favous crusts emit an abominable odor, resembling that of urine ; and a copious offensive discharge is secreted by the pustules and ulcer- ated spots — in short, an individual affected with this disease in its aggravated form becomes a loathsome and disgusting object." 1 In some parts of the inflamed surface, ulceration occurs, spreading irregularly, and becoming very troublesome. The great irritation of the scalp is extended along the lymphatics, and the glands around the neck become enlarged and tender ; they sometimes, but rarely, suppurate. M. Biett observes that it is rare that any internal organ becomes inflamed. 827. With regard to the character and appearance of this vegetable favus, Dr. Neligan gives the following extract from M. Robin: "Re- duced to powder and placed under the microscope, it presents a mix- ture, 1, Of tortuous, branching tubes, without partitions, empty, or containing a few molecular granules {mycelium); 2, Straight or crooked, but not tortuous tubes, sometimes, but rarely, branched, containing gra- nules, or small rounded cellules, or elongated cellules, placed end to end, so as to represent partitioned tubes, with or without jointed articu- lations [receptacles or sporangia in various states of development ?); 3, Finally, sporules, free, or united into bead-like strings. The myce- lium is very abundant near the inner surface of the external layer, to which it adheres. The spongy, friable mass of the centre of each favus is principally formed of the sporules and the different tubes containing mycelium already described {sporangia or receptacles ?). We often find mixed with them mycelium tubes, but in small quantity. All these ele- ments pass insensibly into each other; empty tubes {myceliuiii); tubes containing small round corpuscles ; tubes with corpuscles as large as the smaller sporules ; sporules placed end to end so as to resemble a hollow partitioned cylinder, with a tendency to separate at the joints ; and free sporules. Bennett has given a good drawing of this arrange- ment." 2 828. That porrigo favosa is a contagious disease, we have proof in the experience of ages ; and that it can be propagated by inoculation has been shown by Remak and Bennett, although Gruby and others failed. They failed, as Neligan observes, because, in addition to the mycelia by which it is propagated, they wanted the proper soil, i. e. the 1 Neligan; Dublin Journal, August, 1848, p. 52. 2 Des Vegetaux qui croissent sur l'Homme et sur les Anhnaux divans, 1847, p. 8. 586 PORRIGO. state of constitution produced by filth, close air, bad feeding, and insuf- ficient clothing. It is a very rare disease in Ireland, as Dr. Corrigan observes, and almost never met with in persons of a respectable station. " Can it be," Dr. Corrigan asks, " that, like the cow-pox, it is a disease propagated from some inferior animal, perhaps the mouse, on which Dr. Bennett has discovered the same parasitic plant as in porrigo ? while the disease in the human subject, as if to strengthen the supposition, gives out so strongly the odor of the mouse, that it forms a well-marked diagnostic sign of the disease ? and that to favor its production, poverty or sickli- ness must have reduced the living body to a state fit to constitute a nidus for a parasitic plant ; as in parasitic growths, the more feeble or more sickly the animal is, the more will such growths develop them- selves." 829. Treatment. — Our first object is the removal of the crusts and the diminution of the inflammation, and this will be best attained by the application of poultices for twenty-four hours, which should be changed as often as they become dry. The hair should be cut as close as pos- sible previously, but not shaved at this period. Dr. Bateman recommends the application of the ung. zinci, or the ung. hydr. prsecip. albi, mixed with the former, or with a saturnine ointment, or "the ointment of the nitrate of mercury, diluted with about equal parts of simple cerate, and of the ceratum plumbi superacetatis," varying the proportions of the ung. cerge according to the degree of inflammation. M. Biett speaks most favorably of alkaline or sulphurous applications, or acid lotions. The subcarbonate of soda or potash, in form of oint- ment at first, and afterwards more diluted as a lotion ; or the following lotion, which is much used at St. Louis : — R. — Potass, sulphuret. gij. Sapon. alb. gijss. Alcohol, rect. 3J. Aquse calcis, gvij. — M. Muriatic or nitric acid much diluted, sulphurous douches; or, if more powerful applications are needed, solutions of sulphate of zinc or cop- per, nitrate of silver, or corrosive sublimate, may be tried. M. Biett has also found benefit from the use of the iodide of sulphur, applied by gentle friction in the form of an ointment, containing from a scruple to half a drachm, to an ounce of lard. 1 Dr. Corrigan speaks highly of the oxymuriate of mercury, which he employed because of its power of destroying the sporules of cryptogamic plants. " I have used it," he says, "in the form of ointment in the proportion of five grains in very fine powder to an ounce of ung. cetacei. I have used it in the proportion of ten grains to the ounce, but it some- times gives pain in this large proportion. A small portion of the oint- ment is rubbed in on the part affected every day. It has not salivated in any instance in which I have employed it ; its action in the first of these cases was peculiarly satisfactory," &c. 1 Cazenave and Shedel, Mai. de la Peau, p. 244. PORRIGO. 587 M. Mahon lias a depilatory which removes the hairs very completely. M. Chevalier believes it to be chiefly composed of lime and carbonate of potash. The carbonate of potash, the lotion recommended by Biett and Neligan, of which I have already spoken, will answer this purpose very well. Dr. Neligan's method is as follows : " As soon as the poultice is re- moved, the head is well washed with the stronger carbonate of potash lotion, and slightly brushed with a soft hair-brush, or a roll of lint ; the scalp is then covered with the carbonate of potash ointment, spread on lint, and over it a closely fitting oil-silk cap is placed ; the ointment is renewed twice daily. By the use of these applications the crusts of the eruption are generally completely removed in from two to three days. The carbonate of potash ointment is at the expiration of this time replaced by one containing the iodide of lead, in the proportion of half a drachm of the iodide to an ounce of prepared lard ; the head is to be still washed every morning with the carbonate of potash lotion. In some cases it will be found that the iodide of lead ointment excites a certain degree of inflammation of the surface of the scalp after it has been used for some days ; when such occurs, it should not be applied for a day or two, and the lotion alone employed three or four times daily. After this first attack of inflammation disappears, I have not seen it again recur, although the use of the ointment had been persisted in for months. The strength of this ointment should be increased after a fortnight, if the disease again appears, even to double that above indicated." After this treatment or any other has been continued for some time, it should be suspended for a time, to see if the disease will recur, or if it be really cured. If it reappear we must again have recourse to the external applications, as well as to the internal remedies. Professor Hebra, of Vienna, directs his attention first to the destruc- tion of the plant, and then to the prevention of its reproduction: "With this view he orders the hair to be cut close, and, after the favous crusts are softened by a sufficient quantity of oil, the head should be enveloped in warm fomentations, composed of a melange of soap and bran, which are to be continued until the incrustations covering the scalp begin to swell, and detach themselves from their bases. After removing these softened crusts with a spatula, the brush and comb should be used, and the scalp examined carefully (which will be found very red, bleeding easily, and the seat of several excoriations), so as to ascertain if there is still any favous matter remaining; for it is necessary to remove the seeds of the disease from the epidermic cells and hair follicles, in order to prevent their reproduction. To attain both these objects, M. Hebra strongly recommends lotions of the deuto-chloruret of mercury, of the nitrate of silver, or of arsenic, and the ointment of the iodide of lead, as very efficacious remedies. He also sometimes employs ointments of the cocculus indicus, of quicklime, of the carbonate of potash, the citrine ointment, and the dilute mineral acids. He has then succeeded more rapidly in completing the cure by the following method than by any other: the favous matter being removed from the scalp, the dilute acetic acid should be rubbed over the morbid parts until they bleed slightly ; when this occurs, the acid is to be omitted, and an alcoholic solution of 588 PORRIGO. iodine applied in its stead, and continued for several weeks, until the parasite ceases to be produced." 1 Dr. Burgess speaks favourably of alkaline lotions and iodide of sulphur, as recommended by M. Biett, but he prefers the vapor of iodine and sulphur to all other remedies. I have found the nitrate of silver and caustic tincture of iodine very useful after the removal of the crusts and hairs. 830. But external applications alone will not be sufficient. In almost all cases the disease is a constitutional one, and must be met by consti- tutional remedies. After due care in the removal of all irritation from teething, or gastro-intestinal disturbance, and a careful regulation of the stomach and bowels, we must afford the child the relief of cleanli- ness, pure air, and a more invigorating diet, at the same time avoiding crude vegetables and fruits, and all stimulating substances. Milk pud- dings, broths, and plain animal food, may be given, according to cir- cumstances. Dr. Neligan confines the patient entirely to a milk diet. The medicines recommended by Bateman are alterative doses of mer- curials, " especially when the biliary secretions are defective, the abdo- men tumid, or the mesenteric glands enlarged." Small doses of calomel, either alone or with soda, and some testaceous powder, or, if the bowels are irritable, the hyd. c. creta. If the patient be of a squalid habit, or the glandular affections severe, bark and chalybeates, or the muriate of barytes combined with the former, will be of service. Dr. Neligan speaks most highly of the iodide of arsenic, which he says may be safely given to the youngest child, " its effects being, of course, duly watched." "The dose of this preparation is, for an aclult, from one-tenth to one-fourth of a grain, very gradually increased ; for a child six years old, one-fifteenth of a grain ; and for a younger child, from one-eighteenth to one-twentieth of a grain. It is best given to adults in the form of a pill, made with dry manna and a little mucilage ; to a child it is best administered in the form of powder, its minute division being perfected by means of a little white sugar or aromatic powder. When the system is saturated with this medicine, we usually find that some constitutional symptoms, such as acute headache, dryness of the throat, &c, are manifested; but, in some cases, I have given it in full doses for many weeks without any manifestation of its effects further than those produced on the disease for which it was adminis- tered. When, however, it gives rise to the symptoms above mentioned, its use should be intermitted for some days, and an active purgative administered." 2 When the condition of the child is deteriorated and the nutrition feeble much benefit is derived from the use of the cod-liver oil. It will not only aid in the cure, but may prevent the evil consequences of a long- continued eruption of whatever nature. Dr. Hess has occasionally found it act with remarkable benefit. 1 Burgess on Eruptions of the Face, Head, and Hands, p. 195. 2 Dublin Journal, August, 1848, p. 56. SECTION VI. ERUPTIVE FEVERS. CHAPTER I. MEASLES. — RUBEOLA. — MORBILLI. 831. Measles consists essentially in an exanthematous eruption of the skin and mucous membranes, of a circular or crescentic form on the skin, preceded and accompanied by fever, running a defined course, occurring epidemically or propagated by infection, and generally attack- ing a person but once during a lifetime. It is much more common among infants and children than among adults, and among the latter than with old people; and, without going so deep as some writers have done, the explanation seems to me natural and easy. The disease is by no means uncommon; it is often epidemic, and always contagious or infectious ; and of course a child takes it the first time it is exposed to its influence, which must happen before it is many years or perhaps many months old. The reason that fewer adults than children take it is simply that the majority of adults had it when children. Some dispute has arisen as to the antiquity of measles, some authors contending that they were known to the ancients ; but Gruner 1 and Sprengel have shown that they appeared about the same time as small- pox. The earliest account we possess is by Rhazes ; Avicenna has also described this disease, and distinguished it from smallpox, with which it has been often confounded even in comparatively modern times. The distinction was first clearly made by Forestius (1597), Schenck (1600), Riverius (1655), and especially by Sydenham (1676), and Hoff- mann (1718). It has been confounded with scarlatina so recently as in the writings of Morton and Watson ; indeed, as Dr. George Burrowes has remarked, the distinction between the two diseases was not thoroughly established until Dr. Withering's Essay on Scarlet Fever, in 1793, and Dr. Willan's Treatise on Cutaneous Diseases, were published. 832. Some notion of the frequency and fatality of measles may be gathered from the fact stated by Dr. Gregory, that, on an average of five years, nearly 6 per cent, of the mortality of London is due to mea- sles and scarlatina. According to the Fifth Report of the Registrar- 1 Var. Antiq. ab. Arab, solum repetend., sects 7, 14, 17. 590 MEASLES. General, 81 per cent, of this mortality occurs in children under five years old, and 97 per cent, in children under ten years old. In his admirable Report upon the Table of Deaths, appended to the Census of Ireland taken in 1841, Mr. Wilde states that in the ten years preceding, the deaths from measles amount to 30.739, in the proportion of 100 males to 96.12 females. " Compared with all diseases ; the deaths from this cause amount to 1 in 38.62, and with all the epidemic affections to 1 in 12.4, being the sixth most fatal disease of this class. With the exception of the year 1840, when 4.491 deaths from this cause are returned, measles have presented the most remarkable uniformity throughout the entire period. The age at which the disease has proved most fatal was from birth to the end of the first year, when the sexes were 100 males to 86.74 females ; from the first to the end of the fourth year, 100 to 100.04 ; from the fourth to the fifteenth, as 100 to 100.57 ; from the fifteenth to the thirtieth, 100 to 138.76 ; and after 30, as 100 to 161.81." 1 Now, as we know that a large proportion of those attacked by the disease recover, we may infer, from these tables of mortality, the very great frequency of measles. 833. SymjJtoms. — After exposure to the epidemic influence or to contagion, an interval elapses before the child exhibits any symptoms of the disease. This period of incubation, as it has been termed, may vary from a few days to two or three weeks. In the majority of the cases inoculated by Dr. Home, the fever showed itself in about the seventh day. M. Bouchut, in an epidemic in the Hopital Necker, found this period range from twelve to thirty days after exposure. 2 Dr. Panure, who had opportunities for unusually accurate observations, found the period from exposure to contagion to the appearance of the eruption to be either thirteen or fourteen days. 3 As a general rule it will, I think, be found that the fever commences from the fifth to the eighth day. The course of the disease, after the fever has set in, may be divided into the period of invasion, of eruption, and of decline, and each of these may be successively described. 834. Period of Invasion. — The earliest symptom is a sense of weari- ness, and a chilliness increasing to a rigor, and followed by febrile heat of skin and quick pulse, increasing in intensity for some hours. Or the child may at once awake in the midst of high fever, with dry skin, flushed face, a very quick pulse, thirst, &c, in which there is occasion- ally some little remission at the appearance of the eruption. The face soon becomes flushed, the eyes injected, suffused, sensitive to light, and with incessant lachrymation ; the eyelids are swollen, and the child is constantly rubbing them and the nose, in consequence of the incessant itching and tingling. The nasal mucous membrane is red, congested, and so irritable, that the contact of air occasions perpetual sneezing. Sometimes epistaxis 1 Report upon the Tables of Deaths, &c, p. 13. 2 Mai. des Enfans nouveaux-nes, p. 487. 3 Mode of Propagation of Measles, by Dr. Panure, of Copenhagen, Edinb. Monthly Jour- nal of Medicine, June, 1851, p. 589. MEASLES. 591 occurs, and there is always more or less of a thin, acrid secretion at first, which afterwards becomes thicker, and finally muco-puriform. The bronchial mucous membrane is equally affected; from the begin- ning there is a hoarse, rough cough, dry and laryngeal, and which comes on in kinks. It is certainly very characteristic, but I doubt whether we could decide upon the nature of the attack by this symptom alone. Heberden and Peter Frank met with cases in which the cough did not appear till after the eruption. These symptoms do not come on gradu- ally, but commonly appear at the very outset of the disease all together. Other symptoms occur during this period, but without any regular order. M. Heim 1 has noticed a peculiar smell, which he compares to recent goose-quills, and which lasts five or six days ; Home compares it to that of smallpox ; and Heyfelder thinks that it is stronger in the morning than in the evening, and when many patients are together. I have certainly noticed a peculiar heavy smell, which appeared to be owing to increased cutaneous secretion, but I have not noticed its increase in the morning. On the other hand, Guersent, Gondie, Billiet and Barthez have not perceived it. MM. Blache and Guersent mention that they have frequently ob- served a punctated rose color of the vault of the palate to precede the eruption of measles, quite distinct from the redness observed in scarla- tina, as had been previously remarked by Heim and Marc d'Espine. 2 Nausea and vomiting occasionally occur during this period ; but, in general, the gastro-intestinal mucous membrane seems less affected than the pulmonary. The lymphatic glands of the neck, and along the margin of the eyelids, are not unfrequently enlarged. The urine is generally scanty, of a deep color, very acid, and of in- creased density. The urea, chlorides, and sulphates, are frequently increased, with a small proportion of albumen. 3 835. The symptoms I have enumerated are generally present, but they may be differently grouped, sometimes the nervous symptoms pre- dominate, and we may have delirium, stupor, or convulsions ; in other cases, the pulmonary or gastro-intestinal may be more marked, as will be shown by great dyspnoea, and frequent cough ; or by vomiting and purging. Moreover, if the attack of measles occur in the course of another disease, these precursory symptoms will generally be much less marked. They occupy ordinarily from two to four days; seventy-two hours according to Dr. Gregory; but, in some cases, Blache and Guersent have known them prolonged for seven, eleven, or even fifteen days. Rilliet and Barthez have given the result of their observations in forty cases of normal measles: in one case there were no precursory symp- toms ; in one, they lasted a few hours; in eight, one day; in eleven, two days; in seven, three days; in eight, four days; in two, five days; and in two, seven days. 4 Dr. Panure observed the catarrhal symptoms in the majority of cases from two to four days before the eruption, but in sqme they occurred four or six days, and in others six or eight days previously. 1 Hufeland's Journal, 1812. 2 Diet, de M