> > i< a ^'> ■>:vy> ^ > > ^ 1- >3 3 D > 3 i> 1 i ->> » ■^ J> » D 1 ^ > y ^ :> ) ■^ > ) -^ > ■^ > >]> -^ ) > ) ^ LIBRAir^-4)F CONGRESS. Sheir -.MrA- UNITED STATES OF AMEllICA. | > i ? -> ^ J y I PRACTICAL TREATISE DISEASES OF CHILDREN, PRACTICAL TREATISE DISEASES OF CHILDREN BY / J. FORSYTH MEIGS, M.D., tK THE PHYSICIANS TO THE PENNSYLVANIA HOSPITAL; CONSULTING PUY'SICIAN TO TlIK children's hospital; fellow of the COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, OF THE PATHOLOGICAL SOCIETY, OF THE OBSTETRICAL SOCIETY, ETC. ETC. WILLIAM PEPPER, A.M., M.D., \ PRDFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; PHYSICIAN TO THE rNIVERSITY, TO THE PHILADELPHIA, AND TO THE CHILDREN'S HOSPITALS; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; P^ESIDKNT OF THE PATHOLOGICAL >f>CIETY ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; HONORARY MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW JER.SEY, OF THE OBSTETRICAL SOCIETY, ETC. ETC. i^th Edition, REVISED AXD ENLARGED. PHILADELPHIA: LINDSAY & BLAKISTON 18 7 7. <7r 4I' ^ ^ Kntered according to Act of Congress, in the year 1877, By LINDSAY & BLAKISTON, In the Office of the Librarian of Congress, at Washington, D. C. ■«lii.l;.M.\.N .^ (O., PRINTERS, PHILADELPHIA. ^ TO GEORGE B. WOOD, M.D., LL.D., Prttident of the College of Physicians of Philadelphia ; Emeritus Professor of the Theory and Practice of Medicine in the Unix'crsity of Pennsylvania : late one of the Physicians to the Pennsylvania Hospital, etc. etc. A TIUDUTE OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS AND EMINENT PRIVATE VIRTUES, AND AS A MA1:K of (iRATITUDE FOR HIS VALUABLE INSTRUCTIONS, BY THE A U T li O R S, J. Forsyth Meigs, William Pepper. PREFACE TO THE SIXTH EDITION In preparing the present edition for the press, attention has been devotee! rather to the careful revision of the text than to the addition of new articles. A few have, however, been added, as upon Xiglit Terrors, and on Epidemic Cerebro-spinal Meningitis; while others have l>een rewritten, as in the case of the article on Cerebral Con- gestion. Wherever our own views have undergone modification since the publication of the last edition, it has been carefully noted ; and the attempt has been made to incorporate whatever is most important and trustworthy among the recent additions to our knowdedge of children's diseases. It is hoped that the thorough revision wliich lias thus l>een giv^en may entitle the present edition to as favorable a reception as has been accorded to its predecessors. Philadelphia, .January, 1877. PREFACE TO THE FIFTH EDITION Owing to the comparatively short time which has elapsed since the appearance of the last edition of this work, it has not been thought necess;iry to introduce any extensive changes in many parts of the text. All of it has, however, been subjected to careful revision, and such modifications made as were called for by changes in our own views, or by the results of the recent researches of others. In addition to this, several important articles have been almost entirely rewritten ; among which may be mentioned that on the Diseases of the Heart ; on Pro- gressive Muscular Sclerosis ; on the treatment of Scarlet Fever, and of Measles; on Variola, and on the Vaccine Disease. Some of the articles which seem appropriate in a systematic work on the diseases of children, but which were unavoidably omitted in the last edition, have been supplied. Among these will be found arti- cles on Pulmonary Emphysema, Pneumothorax, Affections of the Ton- sils, Retropharyngeal Abscess, Malarial Fevers, and Scrofula. To obviate the increase in the size of the work necessitated by these addi- tions, most of the illustrative cases, the number of which has been con- siderably increased, have been placed in smaller, type, and in many places the former text has been condensed. Despite these changes, however, an increase of ninety pages has resulted from the large amount of new matter added. On the whole, it is felt that the hope may rea- sonably be entertained that the work in its present form will prove of more practical utility than heretofore, and will continue to serve the purjxjse, which has actuated its authors, of facilitating the study and treatment of this interesting and important class of diseases. PiiiLADBLPHiA, January, 1874. TABLE OF CO]S^TENTS, PAGE Preface to the Sixth Edition vii Preface to the Fifth Edition ix Introductory Essay. 17 CLASS I. DISEASES OF THE RESPIRATORY ORGANS. CHAPTER I. diseases of the upper AIR-PASSAGES. Article I. Cor}-za. SECTIOX I. SECTIOX II. diseases of the larynx. General Remarks, Article I. Simple lar}-ngitis without spasm, " II. Spasmodic simple laryngitis, . III. Pseudo-membranous lar3-ngitis, 51 59 »i7 83 CHAPTER II. diseases of the lungs and pleura. General Re3£arks, Article I. Atelectasis pulraonum. " II. Pneumonia '' III. Bronchitis, . IV. Emphysema, V. Pleurisy, VI. Pneumothorax. • VII. Ilooping-cougli 129 130 153 IIK) 213 226 XU TABLE OF CONTENTS. CLASS 11. DISEASES OF THE CIRCULATORY ORGANS. PAGE x\.RTiCLE I. Cj^anosis, 276 " II. Diseases of the heart, 284 CLASS IIL DISEASES OF THE DIGE":»TIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH AND THROAT. Article I. Shnple or erythematous stomatitis, 296 II. Aphthse, 297 '-'■ III. Ulcerative or ulcero-inembranous stomatitis, . . . 300 " ly. Gangrene of the mouth, 304 V. Thrush, 315 " YI. Aflfections of the tonsils, 342 " yil. Simple or erythematous pharyngitis, .... 346 ** VIII. Retropharyngeal abscess, . 351 CHAPTER II. diseases of the stomach and intestines. General Remarks, 353 SECTION I. functional diseases or mild catarrh of the stomach and intestines. Article I. Indigestion, 353 " II. Simple diarrhoea, 364 sectio:n" II. diseases of the stomach and intestines, attended with appre- ciable ANATOMICAL ALTERATIONS. Article I. Gastritis, 374 " II. Entero-coiitis, or inflammatory diarrhoea, . . . 380 TABLE OF CONTENTS. Xlll Article III. Cholera infantum "• IX. Dysentery '' V. Diseases of the ca'cuni and appendix ccvci, VI. Intussusception, PAOF. 416 436 441 456 CLASS IV. DISEASES OF THE N37.V0US SYSTEM. Gen-eral Kkmarks, Article I. Tubercular meniniiiti; II. Simple meningitis, III. Cerebral congestion, . IV. Cerebral hemorrhage, V. Chronic hjdrocephalus, VI. General convulsions or eclampsia VII. Larynirismus stridulus. VIII. IX. X. XI. Contraction with rigidity. Tetanus, .... Chorea, . . . . , Atrophic infantile paralysis, XII. Facial paralysis, XIII. Progressive muscular sclerosis muscular paralysis, XrV. XiLrht terrors. . pseudo-hypertrophic 472 473 503 510 513 522 532 550 567 576 584 609 626 628 639 CLASS V. GENERAL DISEASES— CONSTITUTIONAL AND ZYMOTIC. IXTRODUfTORY REMARK.S, . Article I. Rheumatism, II. Diphtheria. III. Mumps, IV. Malarial fever, V. Epidemic cerebro-spinal meningitis, VI. Scarlet fever, or scarlatina, ■ VII. Mea.Hles, or rubeola, or morbilli, ■ VIII. Small-pox, or variol I IX. Vaccine disea.«e, X. Varicella, XI. Typhoid fever 645 ('45 651 6S5 689 61 c; 7< )J :•;} 7s7 809 >Jl XIV TABLE OF CONTENTS. CLASS VI. CACHECTIC DISEASES. PAGE Article I. Scrofula, 842 " II. Tuberculosis, 848 " III. Kickets, 863 " ly. Congenital syphilis, 875 CLASS VI L DISEASES OF THE SKIN. INTRODUCTOIIY REMARKS, 882 CHAPTER I. RASHES. Article I. Erythema, 883 " II. Erysipelas, 888 " III. Roseola, 896 " ly. Urticaria, . . . . . . . . . .899 CHAPTER II. VESICLES. Article I. Eczematous affections, . ... . . . . 903 " II. Herpes, 918 " III. Scabies, 923 CHAPTER III. BULL^. Article I. Pemphigus or Pompholyx, 928 " II. Rupia, . 930 CHAPTER IV. PUSTULES. Article I. Ecthyma, 933 TABLE OF CONTENTS. XV CHAPTER V. PAPULES. PACE Article I. Strophulus, 936 TI. Lichen, 937 •• III. Prurigo, 939 CHAPTER VI. Sfiuamre. . ' 940 CHAPTER VII. DISEASES yOT CLASSIFIED AMONG THE PRECEDING. SECTION I. parasitic diseases of the skin. General Remarks, 942 Article I. Favus, 946 II. Tinea, 953 III. Alopecia areata, .... . . 958 SECTION II. Article I. Sclerema, 960 CLASS VI 1 1. WORMS IN THE ALIMENTARY CANAL. General Remarks 905 Article I. Ascari.s lumbricoides, 909 *' II. Ascaris vermiculari.s, 981 A PRACTICAL TREATISE OK THE DISEASES OF CHILDREN, INTRODUCTORY ESSAY. •% ON THE CLINICAL EXAMINATION OF CHILDREN. The clinical examination of children, and particularly of young infants, cannot be successfully practiced upon the same method as that habitually made use of in the case of adults. The truth of this statemeut will be readily assented to by all who have had much experience in the treatment of the diseases of the two ages, by those who will reflect for a moment on the great differences in the expressions of the various organs in early and adult life, and by those who are acquainted with the opinions of distin- guished writers upon children's diseases. It is proper and useful, there- fore, to preface a practical work on the diseases of children, with a sketch or plan of the best method to be pursued in forming a diagnosis of these diseases, and with remarks upon the physiological characters which dis- tinguish the organization of early life from that of maturity. The difficulties that beset the path of the practitioner in his clinical ex- amination of children are so great that he who has not been prepared by preliminary study to surmount these obstacles, will find it a most uncer- tain and dubious t^usk to unravel the history and nature of any case that may be set before him. The helpless silence of the infant, — the wilful silence, or the loose and inconsistent answers of the older child, which lead astray the mind rather than guide it to true results, — the agitation and fright produced by the examination, rendering it impossible at times to ascertain the real state of the different functions of the economy, — and, lastly, the difficulty of obtaining accurate and reliable accounts of the his- tory of the case from the attendants, all combine to make the duty of the physician most perplexing, and, unless he be gifted with a large share of patient and philosophic calmness, most irksome and trying to the temper. 2 18 INTRODUCTORY ESSAY. So great, iudeed, are the difficulties encountered by some practitioners who enter upon this branch of the practice of medicine without proper prelim- iujirv preparation, that they never overcome them ; but, to use the words of Dr. West, " grow satisfied with their ignorance, and will then, with the greatest gravity, assure you that the attempt to understand these affections is useless." That it is possible, however, to overcome, in great measure, these obstacles, and to arrive at a correct diagnosis in nearly all cases, is quite as true as that these obstacles really exist. But, in order to do this, the physician must first be aware that difficulties exist, and must have formed in his mind some plan or method by which to surmount or elude them. Before proceeding to show what is the best method of examining or ex- ploring disease in children, we must state that our remarks apply chiefly to infants and very young subjects ; for, after the age of eight and ten years, the physical and intellectual development have progressed to such a point as to render the method of diagnosis nearly the same as that em- ployed in adults. The chief causes which render the diagnosis of disease in young chil- dren difficult, are the absence of the faculty of speech, and the violent agitation generally caused by the examination, which prevents a proper appreciation of the state of certain organs and functions. It is easy to understand how much our means of diagnosis are restricted by the absence of the faculty of speech. How many symptoms are there in the case of adults with which we become acquainted only through the patient's own account of his sensations ; and, consequently of how many must we be deprived in children by the absence of this account. It might, indeed, at first view, seem impossible to detect the nature of the sickness without the assistance of this means, so greatly do we depend upon it in our examination of adults. Nevertheless, we shall find ourselves enabled, by an attentive consideration of other resources in the child, by a close study of its physiognomical expression, its decubitus, the nature of its cry, and by the most rigidly careful physical examination, to form our conclu- sions with almost as great a degree of precision as in older patients. The other causes of difficulty, — the violent disturbance, both physical and moral, of the child, its fright, agitation, and cries, — constitute, when they are present in a high degree, much greater embarrassments than the want of speech. To overcome these, the physician must use all his skill, tact, and patience ; for, unless they can be avoided by art, or overcome by soothing and gentle persuasion, he can learn but little that will be of essential service to him in making up his opinion. He can neither read the countenance of the little patient, nor judge by its attitudes or decu- bitus of the state of the various organs, whether internal or external ; he will be unable to ascertain the rate, force, or regularity of the circulatory or respiratory functions ; he cannot, to any useful purpose, examine the abdomen, to learn whether it be tender on pressure, or whether its con- tained organs be in their natural condition as to size and ppsition ; and, lastly, he will find that the physical exploration of the lungs and heart, by auscultation and percussion, yield him at best only imperfect results. METHOD OF DIAGNOSIS. 19 To avoid the difficulties just detailed, it is always useful, if uot abso- lutely uecessary, to couduct certain portious of the examiuatiou whilst the child is calm and quiet, and certain othei-s whilst it is disturbed and agitated. This distinction of the examination into two periods, or stages, is one of the utmost importance in a practical point of view, and should never be forgotten by the physician during his clinical observation of the various symptoms the patient may present. By the period of calm is meant a condition of total quiescence, in which the child is undisturbed either by internal or external causes of irritation. This condition is best found in the state of sleep. If this cannot be ob- tained, the one most nearly approaching to it is that which exists during the act of nursing, or which follows that act. Suckling is usually followed, even in the sick child, by a condition of drowsiness or by a gentle and languid :^lumber, during which it will allow a careful examination upon many points without agitation. If possible, therefore, the physician should always see the child when asleep, and if the mother or nurse propose, on the occasion of his visit, to hurry upstairs to prepare the child, or to bring it down into the parlor or lower room, he should ask, as a favor, that he may see it asleep. If, in spite of having just been nursed, the child be awake and fretting, and when, also, it is more advanced in age, we should endeavor, by the attraction of toys, by gentle and soothing words and manners, by fondling, or by having it carried about the room, to get it quiet. Before proceeding to a consideration of the particular means by which we are to judge of the state of health or sickness of young subjects, it is proper to call attention to the great importance of a careful examination of the attendant's, in regard to the history of the case, previous to and between the medical visits. In the instance of children, their inability to describe their own symptoms compels us to depend entirely upon the mother or nurse for all detail of the case previous to our first visit, and for all ac- counts of what may have happened between two subsequent ones. It is, therefore, extremely important that this part of the examination should be conducted with every care and caution. Very much that is useful may be learned from it, if it be well managed. A great deal of skill and art are required in putting the questions, and in sifting the evidence thus collected. We should always bear in mind the character of the persons questioned. Much depends upon their education, and much more on their natural powers of observation, and manner of relating what they may have seen. The degree of credence to be attached to their answers must rest u\h)ii their probable intelligence. Nurses and mothers will often give accounts of their charges which must be received with large allowance, and even in some few instances with disbelief. We would, however, in this place, most earnestly caution the young practitioner of medicine to be very careful not to misbelieve, or even mistrust, without well-poised reasons, the account of a sick child given by a mother; for though a foolish, weak woman will often give a false or exaggerated statement of the symptoms of her child, an observant and intelligent, and sometimes a foolish and weak ono, when guided by maternal instinct, will detect variations from the healthful con- 20 INTRODUCTORY ESSAY. dition of the child, which may entirely escape the search of the most acute and rigorous medical observer. A mother may perceive a change in the expression of the face, in the manner of the muscular movements, in the temper or conduct of her child, which shall fail to attract the attention of the practitioner ; or it may be that the symptom which has caused the parent to take alarm occurs only during the absence of the physician. The medical attendant ought, for these reasons, to listen patiently and kindly to whatever the mother or nurse may have to say, and if unable to detect immediately what they assert they have seen, let him not determine at once that there has been a mistake, that their anxiety has deceived them ; but let him examine the patient yet again, and more carefully, or let him pay another visit to learn whether the symptom or symptoms continue, or have occurred again. Our own rule, in a doubtful case, is to listen with religious attention to the mother, and unless she be far beneath the average of human intelligence, our opinion as to the fact of some deviation from the ordinary health of the child is considerably influenced by what she tells us. The inquiry in regard to the history of the case, previous to the first visit of the physician, should bear particularly upon the causes of the sickness, its precise moment and mode of attack, and its course and symptoms up to the present time. The most important points to be considered in connection with these objects, are the health of the parents, including their ordinary health, or their habitual diseases, the causes and periods of their death, if they are not living, and the state of health of the- child at the moment of birth and since. The hygienic conditions in w^hich the patient has been placed ought always to be investigated ; the place of habitation ; the kind of house, and whether a large well-ventilated room, or a small, narrow, and close one ; the clothing ; the food ; and lastly, whether the infant has been suckled, or brought up on artificial diet. The state of the health just anterior to the attack ought always to be examined into. Has it been good and strong, or feeble and delicate? If delicate, what diseases? If the approach of any of the eruptive fevers be suspected from the character of the symptoms, the question as to whether the child has previously had measles or scarlet fever, or has been vaccinated or had variola, should always be asked. It is next necessary to fix as accurately as possible, the precise period of the onset of the sickness. If the question, " When was the child taken sick?" be asked, as it usually is, the answer will be, "Oh, several days ago," or, " I don't recollect exactly—I think yesterday, or the day before," or some such loose answer. The best way to learn the exact period in a recent case, is to go back, day by day, or else to inquire as to some par- ticular day. We may ask, was the child quite well day before yesterday ; was it well last Sunday ? did it play and amuse itself? was it as gay and good-tempered as usual yesterday, or the day before, or the day before that? Did it sleep well night before last, or the night before that? A sick child never scarcely sleeps well at night, and very often we may learn by close inquiry into this particular, the exact time at which the attack began. In this way, by forcing the attendant to tax her memory, and to DIAGNOSIS OF ANTECEDENTS. 21 go minutely over the events of the several days previous, we shall nearly always succeed in fixing very precisely the moment of onset. Having determined these points, we should proceed to inquire in regard to the course of the disease prior to the first visit. This is to be done only by patient and repeated questioning. The questions must be so framed as to elicit free and unbiassed answers. They should be general, and not leading. Lastly, we are to inquire into the treatment of the case up to the present time. It is best that all these interrogatories should be made previous to see- ing the child, in some other room than the nursery, in order to avoid the risk of alarming the child by the presence, during an unnecessary length of time, of a stranger. If, however, the child be well acquainted with the physician, it matters not where the inquiries are made. Having now obtained from the attendants all the information they can give in regard to the history and nature of the case, the physician must proceed to the personal examination of the patient, in order to determine, by his own observation, the exact nature of the sickness, and the treat- ment it may require. The most important points to be attended to during the clinical exam- iDatioD,are the countenance or faciei, noting its expression, coloration, the presence or absence of furrows and wrinkles from pain, from emaciation, or from disordered muscular action, the appearances presented by the nasal orifices, and especially by the alse nasi, and the characters exhibited by the mouth ; the sleep ; the cry ; the state of embonpoint or emaciation ; the condition of the skin as to coloration, temperature, moisture or dryness, the presence of swellings of any kind, such as those produced by dropsy or by aflfections of the joints, and the existence of eruptions ; the pulse ; impulse of the heart ; the respiration ; the signs furnished by the state of the mouth and throat, and by the disposition towards and power of suck- ing, or by the manner in which drinks are taken ; and lastly, the state of the abdomen. The O'UXTenan'ce. — The countenance of a young and healthy infant, who is sleeping or perfectly quiet, wears no expression except that of com- fort and content. It is composed and still ; no movement disturbs its in- nocent tranquillity, unices, perhaps, some gentle smile light it up from time to time, when we might well believe the happy superstition of the fond mother, who will tell us that angels are whispering it. In sickness, even when slight, the countenance .«oon loses this expressionless character. In all acute disorders the alteration is very great, such indeed as to strike the most careless and inexperienced observer. The features become contracted, furrow.s and wrinkles appear about the forehead, the nostrils are dilated, or pincheosition that of being held in the nurse's arms, with the front of the chest placed against her chest, and the head hanging over her shoulder. When the dyspno?a is so severe as to produce, by slow degrees, a partial asphyxia and consequent dulness of perceptivity, the child becomes so- porous or comatose, and lies usually upon the back, as in diseases attended with prostration of strength. In pleurisy and peritonitis the decubitus is usually dorsal, and the child dislikes to be moved or nursed often crying violently when touched or dis- turbed. In intestinal inflammations the young patient is usually excessively rest- less at first, and very fretful, unless the attack be grave and threatening, when it often lies still for a time from the prostration of strength which attends violent attacks, but becomes restless, turns and twists in the bed, cries out, and agitates the lower extremities at each evacuation of the bowels. In the early period of cerebral inflammation there is generally excessive restlessness, and great irritability of all the senses and temper, but as the case goes on, and passes into the stage of coma, the child becomes still and quiet, assuming very often the decubitus called by the French ''en ch'ien de fusil;' that is to say, on the side, with the inferior extremities strongly flexed, and the arms drawn close to, or crossed over the thorax. This posi- tion is especially characteristic of the latter stages of tubercular menin- gitis. Extreme restlessness, constant tossing upon the bed, or incessant chang- ing from the arms to the bed, or from bed to bed, is a very bad sign. We have observed it in several different affections ; especially in obstinate pneu- monia, in longrcon tinned intestinal disorders, and in the secondary inflam- mations of measles and scarlet fever. Amongst the gestures most deserving of attention are the sudden starts, attended with cries, which indicate the occurrence of some painful sensa- tion, as that of colic, of stitch in the side in pneumonia and pleurisy, and sometimes of shooting pain in the head. The fre(pient carrying of the hand to the head, or to the ear, ought not to pass unnoticed, as this is often indicative of headache or earache. So also of the constant application of the hand to the mouth, or the introduction of the fingers into tiiat cavity, which often occurs when the child is suffering the od(jntalgic pain of den- tition. Nor should the physician ever neglect to observe any peculiar and especially any automatic movements of the limbs, and particularly of the fingers or toes. Nature often heralds the approach of a convulsive seiz- ure by certain peculiar muscular movements. The thumbs are drawn into 30 INTRODUCTORY ESSAY. the palms of the hand, and the fingers clasped over them ; or the toes are strongly bent towards the sole of the foot, or rigidly extended ; sometimes the fingers are for an instant convulsively extended upon the hand and drawn widely apart from each other; or lastly, the muscular movements, instead of being easy, steady, and natural, are badly co-ordinated ; they are irregular, uncertain, and tremulous. This latter character, tremulous- ne.s>^ and uncertainty, we have often noticed. The occurrence of paralysis will often be unperceived for some length of time by an inattentive observer. It is to be discovered by the failure of the child to move one limb, whilst the others are more or less agitated, or by taking hold of the limb, and comparing the total want of resistance in it, with a certain stiffness and opposition to movement almost invari- ably present in the healthful condition. The state of the cutaneous surface is always important, and ought to be carefully and systematically examined. The points most requiring to be noted are its temperature, dryness or moisture, coloration, and the presence of eruptions or swellings. By the temperature, and dryness or moisture, taken in connection with the rate of circulation, we must judge as to the existence of fever. The inferences to be drawn from the condition of the surface in these respects are the same in children as in adults, and they need therefore no particular consideration in this place. The coloration of the skin, on the contrary, owing to its great suscepti- bility to change in certain affections, becomes, in the diseases of early life, of very considerable importance in diagnosis, and deserves therefore some special remarks. The physician should be aware, in the first place, that the color of a new- born infant is some shade of red, varying from a deep brick-red tint, to one of a much lighter hue. The red appearance fades aways usually in about four or five days, and leaves the surface of a yellowish-white, or in some instances of a decidedly yellow color. The yellow color is sometimes 80 marked as to impose very readily upon an inexperienced person the idea that it must depend on an affection of the liver, or, in other words, that it conrititutes a true jaundice. In a very large majority of cases, however, the conjunctiva retains its natural white tint, the digestive functions go on with perfect regularity, there is no fever, and indeed no marks of de- cided disorder of the health, so that the icterode hue cannot depend, under these circumstances, on any serious lesion of the liver or its append- ages, and it is manifestly wrong to regard the case as one of disease, or as requiring any treatment. Besides the yellow color just described, the cutaneous surface in chil- dren, and particularly in those under three or four years of age, very often exhibits different shades of a bluish color, which need some atten- tion. When the whole skin assumes a decidedly blue tint, the case is one of cyanosis or morbus cccruleus, depending on some malformation or dis- ease of the heart or lungs. In severe cases of this kind, the blue color deepens into a purple or even blackish hue. If this appearance last more than a very few days, there can be little doubt that it depends on some malformation or disease of the heart. ALTERATION OF COLOR. 31 It is quite coramou to observe iu new-born and very young infants, a bluish tint of the hands and feet, and of the parts around the mouth, whilst the rest of the body is pale. These appearances depend usually on some obstruction to the pulmonary circulation, as that caused by ate- lectasis pulmouum, bronchitis, or pneumonia, and they increase, diminish, or disapi>ear, according to the course of the causative malady. In older chiklren, the blue color of the skin is rarely of any considerable intensity, unless the condition has existed from birth, or soon after ; but it is not at all UDCoramon to meet with faint, but quite perceptible shades of that color, depending on the asphyxiated state which occurs in croup, capillary bron- chitis, pneumonia, and sometimes in laryngismus stridulus. It is hardly necessiiry to add, that a very slight blueness of the fingers and toes is sometimes observed in the cold stage of intermittents. Occasionally we meet with an excessive harshness, aridity, and scurvi- ness, or with a wrinkled appearance of the skin, especially upon the ab- domen and thorax. This symptom, when strongly marked, is usually attended with enlargement of the superficial veins of that part, and is then very striking even to a careless observer. It accompanies very gen- erally the abdominal tuberculosis of children, and should not pass unob- served. Though generally indicative of tubercular peritonitis, or of tuber- culosis of the mesenteric glands, it is not always so, since in a case that occurred to one of us, and in which it was perfectly well marked, a post- mortem examination showed it to have been caused by a chronic peritoni- tis, resulting from inflammation and suppuration of the mesenteric glands entirely independent of tubercular disease. The peritonitis had given rise to extensive adhesions amongst the intestines, and the pus had found its way by a tortuous sinus between the intestines into the vagina, through which it was discharged externally. There is one other alteration in the color of the skin which is deserving of notice in a practical point of view. It is an excessive pallor, occurring sometimes in diseases which obstruct the respiratory function. We have been most struck with it in the capillary bronchitis, or suffocative catarrh, of youDg children, and in membranous croup. The whole surface assumes a dead white hue, which seems to depend on a total want of blood in the cutaneous capillaries. The nose is white, the ears become white and di- aphanous, and the only relief the eye meets with in gazing upon what seems an almost alabaster countenance, is the still pink or bluish lips, the dark eyebrows and eyes, and perhaps a somewhat leaden tint of the cir- cumference of the mouth and of the forehead. In strongly marked cases the whole surface, even of the fingers and toes, exhibits this white or blanched appearance. When this condition has lasted for several hours, or a day or two, the hands and feet sometimes assume a bluish look, which may last until death occurs, or until the attack approaches a favorable termination. This condition of the surface, when occurring in cases at- tende it f-an he gained from his statements, and the latter the one liiaiiicHl by M. Roger, in infants from one to seven days old {l)r In Tnn- perature chez les EnfaiUs, Paris, 1844). The physician ought, however, to be aware of the fact that, though the above is the average rate of the cir- culation at the age mentione^i.Z 29.2 29 72 18 . 30.4 29.2 29 82 23 . 80.5 29.8 29 81 16 . 306 29.4 29.83 23 . 30.3 29.1 29 75 17 . 30.4 29.3 29.82 22 . 30.4 29.0 29.72 11 . 30.0 29.4 29 70 8 . 29.9 29 6 29.75 2 era the thirtieth to the thirty-sixth hour after birth ure is observed. Then a fall takes place, which 38 INTRODUCTORY ESSAY. reaches its maximum at four days after birth (average maximum 29.68° R.). Again, between the fifth and eighth days, a new elevation of tem- perature occurs ; but this new elevation is less in degree than that pre- viously noted. The average maximum was 29.83" R. Some differences were found in the results, according as the children, were large and heavy, or the reverse. Large and well-developed children had a slightly higher temperature than those less robust. Thus the average temperature in the early part of the day was, in children weighing eight pounds and upwards, 29.84° R.; but, in children weighing less than this, the average was 29.65° R. The evening observa- tions, again, gave an average for the heavy children of 29.94°; for the others, of 29.77° R. Resj^ecting the temperature at different times of the day', observations showed that, from the second to the ninth day, there was an average elevation of temperature, from morning to evening, amounting to .11° R. ; the average morning temperature being 29.75° R. ; the average evening temperature, 29.86° R. This interesting subject has been further examined in regard to older children, by Mr. Finlayson (^Proc. of Manchester Med. Soc., in Brit. Med. Jour., Jan. 16, 1869, p. 59). His results are based on two hundred and eighty-one observations on eighteen different children, of ages varying from twenty months to ten and a half years, a ud are as follows : 1. The daily range of temperature is greater in the healthy child than that recorded in healthy adults — amounting to 2° F. 2. There is invariably a fall of temperature in the evening, amounting to 1, 2, or 3 degrees. 3. This fall may take place before sleep begins. 4. The greatest fall is usually between 7 and 9 p.m. (at least under the conditions of life in hospital). 5. The minimum temperature is usually observed at or before 2 a.m. 6. Between 2 and 4 a.m. the temperature usually begins to rise, such rise being independent of food being taken. 7. The fluctuations between breakfast and tea-time, are usually trifling in amount. 8. There seems to be no very definite relationship between the frequency of the pulse and respirations, and the amount of temperature ; the former being subject to many disturbing influences. RespiPwAtion ; its Rate and General Characters. — The respira- tion, like the pulse, to be examined with any advantage to the explorer, must be investigated whilst the child is still and quiet. In the young in- fant it should be done during sleep, as it is only then that we can find the breathing uninfluenced by disturbing causes other than those connected with deranged health. In the older child, the play of whose functions is more steady and regular, and less readily jarred by trivial causes, this part of the clinical exploration may be made during the waking state ; but, still, it must be done whilst the patient is quiet and tranquil, else the results obtained will necessarily be less certain and reliable than under the oppo- site state of things. RESPIRATION, ITS RATE, ETC. 39 The respiration ought always to be counted bv tlie watch, if possible, especially bv the young practitioner. This is the only mode in which a perfectly accurate idea of the frequency of the respiration is to be obtained. It sometimes happens that a greatly increased rate of the breathing will pass unnoticed by the physician, from the fact that it continues to be reg- ular and without effort. We have known children to breathe eighty times in the minute, without presenting any appearance of labor or effort in the act; without cough, and without the least wheezing or sound to be heard at a short distance from the patient. Under these circumstances, the great rapidity of the respiration might very well pass unnoticed, especially by inexperienced practitionei^ ; and, be it remarked, this would be particularly apt to happen were the attention of the physician addressed to some other part of the economy than the thorax, as the seat of the sickness. For instance, in latent pneumonia, when this simulates meningitis, or when it is conjoined with gastro-iutestinal symptoms, the failure to note a greatly increased rate of the breathing might very well occur. In many cases of secondary pneumonia, it might also take place. In children, who have been long sick with diseases that debilitate and impoverish the health, a sudden aggravation of the symptoms dependent on collapse of the lung, might be misunderstood and falsely explained, for the want of this pre- caution. It is therefore a good and useful rule, for the young practitioner always to count the respiration, when he has to do with a case presenting the least obscurity of diagnosis, since this simple habit may guide him to the real seat of disease, which else he might mistake. The rate of the respiration in children is very different at different ages, a circumstance that should always be recollected in the examination of their diseases. The average frequency of the breathing in new-born children and during the first week of life, is thirty-nine, according to M. Roger. It may rise, however, upon very slight disturbances, to fifty, sixty, or even eighty, while it is not at all unusual to find it at twenty-five or thirty in perfectly healthy infants during sleep. Between the ages of two months and two years the average is about thirty-five. Between two and six years, the average is eighteen during sleep and twenty-three during the waking state ; from six to twelve years, the average during sleep is eighteen, and in the waking state twenty-three; from twelve to fifteen years, it is eigliteen in the former, and in the latter twenty. It wmH be observed, therefore, that after the age of two years, the rate of the respiration is nearly the same throughout the remainder of the period of childhood ; it changes so little, indeed, that the same average will answer for all practical purposes through- out that period. The other characters of the respiration require some attention on the part of the practitioner. In the first place, the diaphragm plays a more important part in the process in the child than in tlie adult. In the young infant, indeed, the function is carried on almost wholly by the action of that muscle, so that the respiration is correctly described by the technical term of abdominal. The walls of the chest are almost motionless. On this account the rate and character."* of the breathing can be best studied in young children, by examining the abdomen, the movements of which 40 INTRODUCTORY ESSAY. being strong and marked, are much more easily seized by the eye than are thoso of the thorax. During })eriect quiescence, and especially during sleep, the breathing of a young child is soft, regular, though less so than in the adult, and per- fectly noiseless ; it is necessary to place the ear close to the face or chest of tlie child, and to listen attentively, in order to hear it. It the young child, and especially the young infant, the breathing is, in the waking state, very different from that of the adult. It is short, irregular, uneven, and marked by occasional pauses, followed by a hurry and precipitation of the movements. These peculiarities in the respiration of the infant appear to depend on the weakness and imperfect action of the muscular apparatus at that early age, which causes the various movements of the body to be hesitating and uncertain, and without that steadiness and even- ness which arc characteristic of matured strength. After the age of two years, these irregular and tumultuous movements cease, and the breathing becomes more regular and even, like that of adults. In the inflammatory affections of the lungs, — pneumonia, bronchitis, and pleurisy, — the respiration is almost invariably accelerated. In exten- sive pneumonia, and in capillary bronchitis, it becomes very rapid, rising to eighty or one hundred in the minute. In pleurisy and simple ordinary bnHichitis, it seldom becomes so frequent, not exceeding, usually, forty or fifty. In severe pneumonia, the rhythm of the movement sometimes be- comes inverted : the pause occurs at the termination of the inspiration instead of the expiration. The patient makes first a violent and labored expiration, bringing into a kind of convulsive action all the expiratory muscles of respiration; instantly after the expiration follows a rapid and full inspiration; then occurs a momentary pause, and again the respira- tory act begins with the labored expiratory effort. This kind of respiration is a very unfavorable symptom, as it is indicative of a most dangerous oppression. It is particularly apt to occur in infants, and very young chil- dren. It has been called expiratory respiration. Tiie respiration, though almost invariably accelerated in pulmonary in- flammations, sometimes retains its normal rate, or even falls below that rate. This occurs, we believe, only under one condition of things : when the forces of the constitution have been sapped by previous disease, or ex- hausted by the long continuance of the thoracic inflammation. It is there- fore met with in cases of secondary inflammations, and in those of the chronic form. The respiration is very much increased in frequency as a general rule in Atelectasis Pulmonum, or collapse of the lungs. When, therefore, a young child who has been exposed to the causes of this disease (feeble- ness at birth, exhausting disease, or debilitating hygienic conditions), is su explore the whole chest, and this ought to be done in all obscure cases. But when the child is sick and suffering, when it is irritated and exasperated by the presence of a stranger, or by coercion, and still more, when it is weak and exhausted by long or violent illness, it becomes of the greatest importance to shorten, as much as possible, the time occupied in the examination. For these reasons, it is well to be aware of the fixct that, in nearly all inflammatory diseases of the lungs, the morbid changes aff*ect first and most .severely the posterior surfaces of those organs. Tliis is thought to depend on the fact that the child passes so large a portion of it-J time in the recumbent position as to cause the fluids of the body to gravitate towards the df'i)endent parts of the lungs, and thus to deter- mine the beginnings of inflammatory action in that direction. Certain it Is, be the explanation what it may, that it is rare to find the anterior surface of the lungs afl^ected either with bronchitis, pneumonia, or pleu- risy, the posterior surface remaining healthy. When, therefore, upon auscultation and percussion, no signs of disease are met with over the dorsum of the thorax, we may feel pretty well satisfied that the lungs are healthy. Nevertheless, in all doubtful cases, the examination ought to be extended to the whole chest, in order to make what was, before this ha-s been done, only a strong probability, a certainty. Whenever, also, it is important to ascertain the precise amount of disease in any serious or long-continued sickness, the front as well as the back part of the chest must be examined. The rej*piratonj sounds are not of the same character precisely in the child as in the adult, and of this the physician ought to be aware. In children the vesicular murmur is stronger than in the adult, so that it as- sumes somewhat of a blowing or bronchial sound. It was in consequence of this peculiarity that Laennec gave it the name of puerile respiration, which, though a mark of health in early life, is, at the period of matu- rity, an indication of a morbid change in some portion of the pulmonary parenchyma. It ought to be remarked, however, that in infants under two, and particularly in those under one year, the vesicular murmur is, in ordinary respiration, weaker than in adults ; owing, no doubt, to the fact that the inspirations are short and imperfect, not distending the lungs to their full capacity. When, however, from any cause, a sigh, a sudden disturbance, or the act of crying, a full and complete inspiration takes place, so as to dilate thoroughly the pulmonary structure, the murmur becomes at once loud and strong, or, in other words, puerile, as in older children. The murmurs of inspiration and expiration bear the same relation to each other as in the adult ; the expiration being much shorter and feebler than the inspiration, though, at the same time, it, like the inspiration, is louder than in the adult. In some instances, however, and especially over the posterior, inferior, and lateral regions of the thorax, no sound whatever is heard during the accomplishment of the expiration. This absence of sound during expiration is the more apt to be met with in proportion as the child is younger. When a young child is made to breathe forcibly and rapidly, the res- piratory sounds assume certain characters, even in perfect health, which might mislead an inexperienced observer. The inspiration is short, loud, and hard, so as to assume somewhat of a blowing character, resembling not a little the sound of bronchial respiration. At the same time, the ex- piration becomes louder also, and longer, which two circumstances, rude or even blowing inspiration, with loud and somewhat prolonged expira- tion, may very well deceive a young or careless practitioner. The respiration is most clear and characteristic over the anterior lateral, and posterior inferior regions of the thorax. Over the origin of the larger bronchia, that is to say, in the interscapular region, the respiration is very strong, so as to resemble very closely bronchial blowing. Here, also, the expiration is often very marked; it is sometimes heard as long, or even longer than the inspiration. Over the scapulas, the sound of respiration is always feebler than elsewhere, except in the pr?ecordial region from the interposition of the scapulas and of thick muscles between the ear and the lung. Percussion yields a much louder and more sonorous sound in children over two years of age than in adults, — a circumstance always occurring coincidently with the presence of puerile respiration, and dependent on the fact that the function of respiration is, at that age, very active, and the lungs therefore filled to their utmost capacity with air. In infants under two years of age, the sonorousness varies to a considerable extent in the same child. When the respiration is, as it usually is, gentle and easy, the inspirations being rather feeble and incomplete, the amount of air con- EXAMINATION OF THE ABDOMEN. 45 tained in the lungs will be somewhat deficient in comparison with what their cells might contain, and the sound yielded upon percussion will neces- sarily be rather dull and insonorous. When, on the contrary, the respira- tory process is quick, active, and energetic, from any cause, so as to give rise to the auscultatory phenomenon called puerile respiration, the percus- sion will be loudly sonorous, as it is in the later periods of childhood, owing to the thorough dilatation of all the air-cells, and the consequent presence in the thoracic cavity of a large amount of air. The sonorousness of the thorax is different in different parts in children, as in adults. In front, the percussion is most sonorous from just beneath the clavicle on the right side down to one or two inches below the nipple, where it gradually becomes dull, owing to the position of the liver. On the left side the sonorousness is modified by the presence of the heart in the manner already mentioned. Below the precordial region we again have pulmonary resonance down to the sixth or seventh ribs, below which is heard the tympanitic sound of the stomach. Behind, the sound is very dull above the spine of the scapula, and con- siderably so over the scapula beneath its spine. Over the interscapular space it is clear and strong, and more so in the lower than in the upper half. Beneath the inferior angle of the scapula, likewise, it is clear and full, until we approach the inferior margin of the thorax, where it is dulled, even above the lower edge of the lungs, by the presence beneath of the liver on one side and of the spleen on the other. Over the right side the dulnesd begins a little higher than over the left, in consequence of the greater bulk of the liver than of the spleen. The lateral regions are very resonant in their upper portions, but become dull as we approach the liver on the right side and the spleen on the left. On the left side the pulmonary sound is often entirely eclipsed by a tym- panitic rcMjnance occasioned by the presence of gas in the stomach. In practicing percussion in children it is necessary to strike gently, be- caus(\ from the great natural sonorousness of the chest in early life, any con>iderable force would bring out so much sound as to prevent the recog- nition of a degree of dulness which might readily be perceived by the use of more gentle blows. It is necessary always to compare the two sides to- gether, as in adults, since this often leads to the detection of a degree of imflaired resonance which might l>e otherwi-ne inappreciable. Yet, and the physician ought to be well aware of this, the comparison of the two sides is not quite so useful in young as in mature subjects, because of the fact that the diseases in which the differential comparison is most impor- tant, pneumonia and pleurisy, are more frequently double than in adults. It becomes, for the same reason, very important to compare the upper and lower portions of the thorax behind, since we may assure ourselves of the existence of dulness below, of which we were before doubtful, by the fact that the sound is less sonf»rous in that region than above; which is, as already stated, the yery opposite of the healthy condition. ExA.MiNATioN OF THE Abdomen. — It is ofteo Very important to ascer- tain, by palpation, the form, size, and degree of tension of the abdomen, the preaence or absence of effusions within its cavity, and the condition of 46 INTRODUCTORY ESSAY. the organs which it contains ; to learn by percussion the degree of reso- nance which it affords ; and, lastly, to find by pressure whether it be un- naturally tender to the touch or not. By a careful inquiry into these various points, and a proper comparison between them and the rational symptoms presented by the patient, we shall be able to discover the exis- tence of tumors, of hypertrophied organs, of unusual developments of gas in the intestines, of dropsical effusions, of enlarged and hardened mesenteric glands, of gurgling, and of soreness on pressure caused by inflammation of some of the contents of the cavity. The examination should be made, if possible, whilst the child is still and composed. It is best, therefore, to perform it before auscultation and percussion, in children who are old enough or amiable enough to be willingly quiet, since the length of the examination of the thorax often wearies out their patience, and they refuse to submit to further inspection ; whilst, in infants and in children who ob- stinately resist the examination, it matters little at what particular period it is attempted, since it must be done at last in the midst of cries and gen- eral agitation. It is, at all times, a difficult and not very useful examina- tion, unless the patient consents to it freely and without fear. It is very necessary, therefore, to resort to every means to obtain this quiet consent. In children over a year old, this condition is to be obtained only during deep sleep, during the act of nursing, or, when the patient is awake, by so pleasing and attracting its attention by toys, by soothing voice and man- ners, as to cause it to forget what is passing. The reasons why the exam- ination is useless, unless made during a state of calm, are very obvious. In the first place, the contractions of the abdominal muscles give to the walls of the abdomen such a degree of hardness and rigidity, that it is impossible to learn anything in regard to the state of the parts within, except merely what can be learned by percussion ; and, in the second place, no acuteness of perception will enable us to distinguish between the cries of anger and fright, and those that may proceed from pain occasioned by pressure. M. Valleix recommends a plan in the case of young infants, by which tenderness on pressure may very generally be recognized. It is as fol- lows : He carries the child, carefully sustained in the arms, suddenly before a bright light, either that which pours in at a large window during day- light, or that of a bright artificial light at night. The infant, whose great- est pleasure consists in gazing at a bright light, almost always ceases to scream and becomes perfectly quiet while thus attracted. Seizing this opportunity, the physician should pass his hand under the clothes, and applying it directly over the cutaneous surface, he may first learn, by a rapid palpation, the general characters of the abdomen, and then ascertain by sudden and decided pressure whether it be abnormally sensitive. If the pressure gives pain, the infant will cry out at the moment, while, at the same time, a sudden contraction of the countenance will assist to show the perception of some painful sensation. Should the infant, on the con- trary, continue to gaze fixedly at the light, without noticing the manoeu- vres of the physician it is fair to conclude that there is no inflammatory tenderness present. n EXAMINATION OF THE MOUTH AND THROAT. 47 Examination of the Mouth and Fauces. — In all obscure attacks of sickness occurring in young children, and even in those who have at- tained to the faculty of speech, the physician ought to be most careful to inspect the condition of the mouth and fauces, since not a few cases of fever which seem at first view inexplicable, are at once made plain by this simple exploration. We were once called to see a child three years of age, who had been sick three days with fever, thought by intelligent and educated parents to depend on gastric derangement. A single look into the throat showed it to be completely clogged up with pseudo-membranous exudation, whilst a slight hiss in the inspiration, and a husky voice, de- clared that the same fatal product was just entering the larynx. The time for successful action had slipped by ; the patient died two days after in the agonies of slow croup. On another occasion we were called to take charge of two children in one family who had been ailing several days with fever- ish symptoms, loss of appetite, languor, and some complaint of sore throat. In both we found the fauces covered with plastic deposit, and both died a few days after of membranous croup. Some yeai*s ago we attended a child between five and six years old, for a period of four days, with irregular fever, some vomiting, total anorexia, languor, indisposition to play, and rare complaints of pain in the chin and neck, that were not mentioned to us by the attendants, so that all the time we had the idea that the attack was one of gastric embarrassment. Greatly to our amazement and con- sternation, the mother informed us on the fifth day that she had seen something white in the throat, and upon examination we found both ton- sils covered with whitish exudation. Happily the exudation was still con- fined to these glands, and we were able by appropriate treatment to pre- vent its further extension. In croup, also, in whatever form it may make its attack, the fauces ought to be closely watched, in order to know by the presence or absence of false membrane, the probability or improbability of the case being one of the membranous kind. In scarlatina and measles, especially in the former, the throat ought to be examined each day, to ascertain its precise condition, and particularly to learn whether there be present any disposi- tion to membranous, ulcerative, or gangrenous angina. In young infants, also, the mouth requires a thorough examination from time to time in all their ailments, and especially in their digestive diseases, since they are liable to thrush, to aphthie, and, in chronic and debilitating maladies, to gangraena oris. In teething children the act of dentition re- quires that the mouth should be inspected occasionally in order to ascer- tain the state of that process, and to detect the existence of the form of stomatitis called ulcerative, which generally occurs between the ages of one and five or six years. The mouth can be readily examined by pressing upon the chin with force sufficient to cause the child to separate the jaws. In the young in- fant this very generally produces crying, during which the mouth is w idely opened, and the state of the cheeks, lips, gums, and tongue can be per* fectly well seen. In an older child, who refuses to open the mouth, or to INTRODUCTORY ESSAY. keep it open, the haudle of a smooth silver spoon is the best instrument to ein})Uiy by which to effect our purpose. The throat cannot be well seen at any age, except by depressing the base of the tongue, which is best done by means of a spoon-handle, as above directed. When a child refuses obstinately to open the mouth, and resists with violent struggles, it should be taken on the lap of a strong assistant, with the back of its trunk resting against the chest of the assistant, whose arms should restrain, by being crossed over the body and limbs of the child, its more vehement movements. Another assistant must hold the head of the child steady, whilst the physician obliges it to open the mouth, either by closing the nostrils with the fingers, or by slowly and gently, but firmly, insinuating the handle of the spoon between the teeth. After the spoon has once been passed over the tongue there is seldom any difficulty in obtaining a good view of the fauces. The introduction of the finger into the mouth is of some use as a diag- nostic means in the case of infants. It informs us of the temperature of that cavity, of the state of its secretions, and consequently, of its dryness or humidity, and of the disposition and ability of the infant to suck. When an infant is in goed health, it will almost always seize the finger, when this is placed in the mouth, and suck vigorously for some instants. It will do the same when it is only ailing with some slight malady, and in the early stage of more dangerous diseases. But, in severe and threat- ening illness, the infant either refuses to suck upon the finger at all, or does so only for an instant. When the mouth is irritated or inflamed, as in the various forms of stomatitis, the child will open the mouth and cry, and make no attempt whatever at suction. In stupor, and especially in coma, but little attention is paid to the finger, the infant being generally unconscious of its presence. By watching the child when put to the breast, we may acquire nearly the same information as that just referred to, except that the child would naturally make a greater eflfort to seize the nipple than the finger, and would therefore nurse, even though the act of so doing were painful, under circumstances in which it might refuse to grasp the finger at all. The refusal to nurse, or the nursing but little at a time, may depend on other causes, however, than sore mouth. It often depends on some angi- nose inflammation. When this is the case, it may be suspected from the peculiar gulping manner in which the child swallows, and from the fact that swallowing often causes fits of coughing. It is caused also by dysp- nea. An infant laboring under severe oppression from pneumonia, bron- chitis, or any other cause, never sucks well and steadily, but rather by fits and starts. The nipple is seized often with avidity, and two or three swallows are made in quick succession ; then follows a pause to regain the breath, and then again the effort of deglutition. In a few cases at- tended with very great dyspnoea that we have seen, the patients have been able to swallow only once or twice without pausing, and even then with very great diflficulty. Manner of Taking Drinks. — The remarks just made as to the in- ferences to be drawn from the manner in which the infant sucks, will VOMITING AND THE DISCHARGES BY STOOL. 49 apply also to the mode in which both iufauts and older children drink. A vounjx child drinks continuously, without stopping to breathe. If, how- ever, it have any disorder which accelerates the respiration, it will, after drinking a few raouthfuls, cease, jerk its head away from the cup or spoon, breathe irregularly and hurriedly, and cough. These symptoms ought to call attention to the respiratory organs. So, if a child, whose breathing is not oppressed, nevertheless drinks with difficulty, slowly, at intervals, and apparently with pain, there is reason to suspect some impediment in the pharynx, and the fauces ought thereupon to be care- fully examined. We may learn also from the manner of drinking whether the child is thirsty or not. When it drinks often and with avidity, and yet has a dry mouth, it is evident that there is very great thirst. Vomiting and the Discharges by Stool. — The physician should never think his examination of a sick child concluded until he has in- quired as to the occurrence of vomiting, and as to the state of the dis- charges by stool. Not only, indeed, should he inquire as to these symp- toms, but he ought by all means to inspect pei*sonally the appearance of the matters ejected. This is especially important in regard to the dejec- tions, since no description of a mother or nurse, however intelligent, can impart to the physician the precise and accurate idea of the state of those discharges which even a very rapid inspection would give him. Vomiting is of very frequent occurrence in infancy and childhood. Owing to the fact that the stomach is much less curved in its shape than Id the adult, and that the oesophagus enters the organ close to its left ex- tremity, vomiting and regurgitation take place with great readiness, and are, therefore, very common symptoms in the diseases of early life. The young practitioner must beware lest he regard all kinds of vomit- ing in the infant as the result of disease. The nursing child is very apt to vomit, even when in the most perfect health, especially if it be suckled at an abundant breast. This kind of vomiting, however, may be readily distinguished from that which depends on some morbid state of the health, by the circumstance of the infant's ejecting nothing but the milk which it has swallowed, either just as it was drawn from the mother, or slightly curdled, and by the fact that it suffers no inconvenience what- ever from the act, — neither any violent effort, languor, paleness, nor faint- Dess. And yet we have known a young practitioner to prescribe antacids and absorbents to correct this kind of vomiting, which is most plainly an act of nature kindly intended to rid the infant of any excess of food it may have imbil)ed. In older children also, vomiting not unfrequently occurs as a conse- quence of overdistension of the stomach with food. When, therefore, after vomiting, a child seems relieved and comfortable, when any un- plea^'ant symptoms that may have existed prior to it moderate or disap- pear afterwards, it is fair to conclude that the act has been beneficial, and wrong to regard it as the .signal of a necessity for giving medicine, or for regarding the child as a patient, except insomuch as to watch lest it 4 50 INTRODUCTORY ESSAY. be sick as an after-consequence of having had the digestive power over- tasked. Frequently repeated vomiting, attended with retching and effort, and with paleness and exhaustion, or with fever, always indicates some con- siderable derangement of the health. It is impossible to ascertain the precise cause of such vomiting, except by a proper consideration and com- parison of all the symptoms the child may present. The cause may be in the stomach itself, consisting of an inflamed state of the organ, or it may be a simple indigestion without any inflammatory condition what- ever ; it may be that the cause lies in the intestine, being some inflam- mation, functional disease, or obstruction of that part; it may be pneu- monia or pleurisy ; it may be the approach of some of the eruptive fevers ; or last, and most serious of all, the cause may be some commencing lesion of the brain, which, though as yet determining no proper cerebral symp- toms, shall perhaps be destined, by its inevitable progress, to end the patient's life. The detection of the particular causative condition, in any of these forms of vomiting, can be arrived at only by a careful study of the whole constitution of the patient, both through the rational symptoms that may be present, and by a thorough inspection of the different systems of the body by means of the physical methods of diagnosis. The rule to examine with his own eyes the napkins or cloths of the child, ought never to be forgotten by the practitioner, when there is any reason to suppose that the alimentary functions are at all deranged. The number of the stools in the twenty-four hours ought also to be ascertained, not loosely and carelessly, but precisely and with certainty. Without a close attention to these two precautions, it is impossible for the physician to obtain really useful and exact notions in regard to the nature of the dis- order he is called upon to treat, or to judge of the degree of severity of the attack. We shall not attempt to consider in this place either the various unnat- ural appearances of the matters vomited, or ejected by stool, the amount of those substances, or the frequency with which the discharges take place, since these various circumstances can be treated of in the manner they require, only when we come to study separately the diseases of which they form a part. We shall here conclude our remarks upon the methods to be pursued in the clinical exploration of the diseases of children. We have only to add the wish that those who shall honor them with their perusal, may find them of some real assistance in their subsequent studies of the affections of early life. They are intended, of course, chiefly for the student and young prac- titioner ; but we cannot help hoping that they may possibly prove useful to some who have spent a longer time in the profession, but who have never, perchance, given any particular attention to the best modes of investigating the diseases of infants and children. CLASS I. DISEASES OF THE KESPIRATORY ORGANS. CHAPTER I. DISEASES OF THE UPPER AIR-PASSAGES. SECTION I. DISEASES OF THE NASAL PASSAGES. ARTICLE I. CORYZA. Defixition; Synonyms; Forms; Frequency. — Cory za is inflamma- tion of the mucous membrane lining the nasal passages. It is called in common language, cold in the head, or snuffles. We shall describe three forms of the disease, — the simple or mild, the severe, and the chronic. The severe form includes purulent and pseudo- membranous cor}'za. Simple coryza is very common at all ages ; it occurs frequently as a distinct disorder, but still more frequently in connection with laryngitis, bronchitis, pneumonia, measles, scarlet fever, etc. The seTere form of coryza is that which was called by Underwood coryza ma- ligna, or morbid snuffles, and which, as he stated, is very different from and far more serious than what is usually called snuftles. Purulent and pseudo-membranous cor}'za rarely occur idiopathically, but are almost invariably connected with angina or other disea.ses. The affections upon which they are most frequently dependent are diph- theria, measles, and scarlet fever. A full account of this complication will be found in the chapters devoted to these various affections. Chronic coryza occurs most frequently in connection with scrofula or hereditary syphilis. It also results from the persistence of the purulent form which has originated in the course of some specific fever. Causes. — The only clearly evident cause of simple primary coryza, iu most cases, is chilling of the body. Insufficient dress, — a very common error in this country, — too low a temperature of the nursery, and exposure to bad weather, may often be discovered to have been the causes of the attack. 52 CORYZA. As already stated, acute purulent coryza usually occurs in connection with some general disorder, though we have occasionally met with it as an independent affection, for which no satisfactory cause could be assigned. The cases of MM. Rilliet and Barthez coincided generally with primary or secondary purulent or pseudo-membranous angina. From the account given by Underwood of coryza maligna, there can be little doubt that it was epidemic when observed by himself and Denman. The latter author states that in connection with the coryza there was a general fulness of the throat and neck externally ; that the tonsils were tumefied, and of a dark- red color, with ash-colored specks, and in some cases, with extensive ul- cerations ; and that some of the children swallowed with difficulty : all of which symptoms clearly point to severe concomitant angina. There can therefore be little doubt but that in reality these were cases of nasal diph- theria. Anatomical Lesions. — The Schneiderian mucous membrane is found reddened uniformly, or in points, rough, thickened, and sometimes softened. When pseudo-membrane is present, it exists either in fragments, or lines the whole extent of the nasal passages, and is mixed with mucus or muco- purulent fluid, in greater or less quantity. Symptoms. — The symptoms of simple coryza are sneezing, dryness of the nose at first, soon followed by discharge, which is very small in quan- tity in the beginning, and more abundant afterwards, and more or less disturbance of the respiration. It is only in young infants that this form of coryza is a disorder of any consequence in itself In older children it never injures the health by its own action ; it is of importance merely as the sign that a cold has been taken, and ought to be regarded as a hint given by nature of the necessity of guarding the child more carefully in future. But, in infants at the breast, and very young children, it assumes much greater importance from the very considerable obstacle it opposes to the act of respiration. At this early age, in fact, coryza becomes a serious and even dangerous disease. If primary, it causes great distress and dis- turbance to the child, interrupting its sleep, interfering with the act of nursing, and, in some instances, so impeding the function of respiration, as to bring on slight, and more rarely, dangerous asphyctic symptoms. It may, undoubtedly, occasion in weak and debilitated children, more or less extensive collapse of the lungs, an accident which will explain the imperfect performance of the hematosic function in some cases, where the only evident disease is this apparently insignificant one of coryza. Wheil simple coryza exists in connection with bronchitis and pneu- monia, it adds to the severity of those diseases. In children over three or four years old, and particularly in those who are vigorous, it seldom gives any serious trouble. But in young infants, and in weakly children of any age, its influence upon the symptoms is often very marked. The effort to breathe through the nasal passages, when they are partially or wholly occluded by the inflammatory swelling of their lining mucous membrane, or by abundant and viscid secretions, fatigues, and wears away the strength of the child, exhausts its energies, and renders it less able to resist the pressure of the sickness. But not only this ; — as in SYMPTOMS OP THE SEVERE FORM. 63 primary coryzii, the entrance of air into the lungs is impeded, and the hematosic function is thereby interfered with, while at the same time, the existence of an obstacle to the full inspiratory movement, in addition to that which exists in the lungs themselves from bronchial or pneumonic disease, cannot but assist in the production of that collapse of the pul- monary tissue, which has been found of late years to coincide so often with the bronchitis and pneumonia of young children, and especially with the former. The reiison why coryza causes so much difficulty in young children is, that they persist in the eilbrt to breathe through the nose in spite of the obstruction of the nasal passages. They seem to do this instinctively, not, apparently, having the power to carry on the act of respiration through the mouth, or but for short periods only at a time. The constant strug- gle to force the air through the nose, and the necessarily smaller quantity that reaches the lungs, are undoubtedly the two chief causes of the symp- toms above described as occurring in the coryza of children. Severe Coryza begins with sneezing and stoppage of the nostrils, soon after which the discharge, which is the pathognomonic symptom of the disease, makes its appearance. This consists of serous or mucous fluid in greater or less abundance, usually of a yellowish color, and which, at first thin and without odor, becomes afterwards thicker and often purulent, with a peculiar, unpleasant, but not fetid odor. In other cases, on the contrary, and especially when the pseudo-membranous exudation is present, the discharge is thin, and often contains small granular particles, which seem to be the detritus of the false membrane, while at other times it is ichorous or even bloody. When false membrane is present, it can often be seen, upon examination of the nostrils in a strong light, to cover the mucous membrane in the form of thin adherent layers of a yellowish- white color. The ahe nasi, and sometimes the whole extremity of the nose, are red and swelled, and the skin, which is tense and shining, pre- sents an erysipelatous appearance. The upper lip is generally reddened, irritated, swelled, and sometimes excoriated, by the nasal secretion. The re*]nraiion i.s generally difficult, nasal, and snoring. When the Da.erfect suspensions of a few days, during the same length of time. Both these cases occurred in hearty boys, one in the second, and the other in the third year of life, and yet both were vigorous and healthy children, as time has shown. In many other instances, we have known it last two, three, and four weeks, proving all that time most troublesome and rebellious to treat- ment. During the day, the child generally seems perfectly well, or at most merely a little pale and languid, and be coughs but moderately, but 64 SIMPLE LARYNGITIS WITHOUT SPASM. as soon as night comes on and especially when he is put to bed, the cough begins and goes on for hours, as stated above, unless some remedy, and particularly some opiate, be given to check it. It is most annoying to the practitioner, for he finds that his usual remedies act merely as palliatives. They check and modify, perhaps overcome it for a time, but the next change in the weather, and especially the least exposure to cold and damp, start it afresh, and he has to resort again to the same round of treatment to subdue it. To the members of the family also it gives great anxiety. At first, they fear it must run into croup, which, however, it very seldom does, and then, finding how difficult it is of cure, and how often it recurs, they can scarcely be persuaded that it does not depend on some serious disease of the lungs. The principal cause of this form of chronic laryngeal irritation is, so far as we have been able to ascertain, an unusual susceptibility of the laryn- geal mucous membrane, sometimes the result of a congenital idiosyncrasy, and at other times the result of influences coming into action after birth, and especially of improper dress. We have generally met with it in chil- dren dressed upon the hardening system so much in vogue with many of our most highly educated citizens. The low frock, leaving the neck and upper half of the chest exposed to the air, the bare arms and bare legs, persevered in through our cold autumns, winters, and springs, have certainly, in most cases, been the cause of this troublesome and chronic cough. ' Our experience since the publication of the last edition fully confirms the truth of these remarks upon the style of clothing just referred to. We certainly do not see so many cases of obstinate laryngeal cough as we for- merly did, for the simple reason that but few of the families we take care of, adhere to the old-fashioned system of leaving their children half naked. The duration of the disease varies according to its form and the circum- stances under which it occurs. When primary, it lasts usually from a few days to one or two weeks, but when it becomes chronic, as we have known to happen in a good many instances, it has lasted from two to four or six weeks, and even two or three months. The duration of secondary cases depends, of course, upon that of the disease during which they occur. Diagnosis. — The diagnosis of simple laryngitis is very easy. The hoarseness of the cry, voice, and cough, the redness of the mucous mem- brane of the pharynx, and the absence of general symptoms, will distin- guish it from any other affection. In somewhat severer cases of this form, in which the cough is more frequent and harassing, the general symptoms more strongly marked, and the respiration somewhat hurried and op- pressed, the attack may at first view present the appearances of bronchitis or pneumonia. The absence of the physical signs of these affections will show at once, by negative evidence, the true nature of the case. In some cases in which there is little or no hoarseness of the voice or cough, the symptoms strongly resemble the early stage of hooping-cough. We have met with five instances in which it was difficult not to believe, for two and three weeks, that the attack was really one of that disease. In one of these the resemblance was so close, that for several days there TREATMENT. 65 was a distinct hoop during the fit of coughing, with vomiting at the close of the paroxysm. The grounds for deciding that the case alhided to was not one of pertussis, were, that the attacks came on like laryngitis, after measles, and that the paroxysms occurred only at night. In the other cases a correct diagnosis was arrived at only by attention to the state of the fauces, which are almost always more or less inflamed and thickened in laryngitis, whilst they are not so in pertussis, and by watching the prog- ress of the sickness. Prognosis. — The prognosis is always favorable in the mild form of the disease. We have never met with a fatal case. Treatment. — The treatment of the milder cases of this form of laryn- gitis ought to he very simple. Children under four or five years old ought to be confined for the first few days to the house, unless the weather be dry and not intensely cold. In mild weather they may be sent out for a short time in the middle of the day. When the patient is five or over, he may continue to go out through the day, unless the weather be very bad. Much must depend upon the peculiarities of the child's own constitution. These can only be learned by observation on the part of the mother. Some children bear going out with such attacks perfectly well ; others, if sent out with this simple laryngitis, are almost certain to have spasmodic croup or bronchitis more or less severely. When there is any febrile movement in the case, no matter how slight, the child ought to be kept quiet, and confined to the house. Attention to this point, therefore, careful manage- ment of the clothing, slight reduction of the diet if there be any fever, a warm foot-bath at night of simple water, or of water containing a little mustard, the application of some slightly stimulating liniment to the front of the neck and throat twice a day, and the occasional internal adminis- tration of some gentle expectorant and anodyne dose, constitute all that is necessary in the great majority of cases of this kind. The best internal remedies are a few drops of syrup of ipecacuanha, with paregoric, lauda- num, or solution of morphia given every evening as the child is put to bed, or occasionally through the day also, if the cough is troublesome. A com- bination of syrup of seneka with that of ipecacuanha, will often be found ver>' serviceable. The treatment of the chronic laryngeal cough, unattended by fever or any severe constitutional symptoms, described above, requires some special remarks. In the first place, we have to state we have seldom succeeded in curing it until we had obtained from the parents their consent (often obtained with great difficulty) to a proper dress for the child. Expector- ants, nauseants, opiates, antispasmodics, counter-irritants, and local aj)pli- cations, have nearly always failed to procure more than temporary alhvia- tion, until the child has been dressed warmly. We have cured, on several occasions, this kind of cough, after many ineffectual trials with the above remedies, only by insisting upon a mode of dress which covers the neck, arms, and lower extremities. A merino or soft flannel shirt, with long sleeves and high neck, long merino stockings, and thick muslin or canton- flannel drawers, have done more in such cases to eflTect a cure than all other means. This style of dress has removed the cause, the constant 6 66 SIMPLE LARYNGITIS WITHOUT SPASM. chilling of the body, and then the usual therapeutic measures will, no doubt, assist in overcoming the local changes which constitute the disease. The best therapeutic measures to be adopted in such cases are the appli- cation, once a day, of a solution of nitrate of silver, of from five to twenty grains to the ounce, low down into the pharynx and chink of the glottis, by means of a small sponge-mop on a bent whalebone. After several ap- plications have been made daily, they should be made only once in two or three days. The strength of the solution is to be determined by the con- dition of the pharyngeal mucous membrane, as we may assume this to mark, in seme measure, the state of the contiguous tissue of the glottis. When the mucous membrane of the fauces is covered with large, pro- tuberant follicles, when the tissue between the follicles is thickened, re- laxed, spongy-looking, and when the color of the membrane is dark- red, the stronger solutions are the best ; when, on the contrary, the mucous membrane is not roughened or thickened materially, when the follicles are small, when the color of the tissues is bright-red, it is best to use only the five-grain, or even a weaker solution. The most useful internal treatment in our hands has been the exhibition, three times a day, of one of the fol- lowing mixtures, preferring that with antimony for a vigorous child, and that without antimony for one less robust. R. — Potass. Carbonat., • . . • BJ. Vin. Antiipon., . . f^^ss. vel j. Tinct. Opii, . gtt. xxiv, vel xlviij Syrup. Simp., . . . . . fSh Aq. Cinnamom., . . . f^ij— M. Ft. Mistura. R. — Potass. Carbonat., . • . BJ. Tinct. Opii, . gtt. xxiv, vel xlviij Syrup. Senegffi, . • . . f^ij- Syrup. Tolutani, • . . f^vj. Aq. Fluvial, . . . f^ij— M. Ft. Mistura. One of the most troublesome cases of cough we ever met with, occurred a few years since in a fine, intelligent, but not robust boy, four years old. He was seized with a hard, obstinate cough, which, in a few days, became really terrible from its almost incessant repetition for many hours at a time. The cough was dry, tickling, choking, repeated with nearly every breath, and so incessant as to drive the parents — and we may add the doctor — almost frantic. The little fellow at last found out, instinctively, that, by placing himself on the front of the body on two pillows, with the chin hanging over the edge of the upper one, he coughed less frequently, and with less violence, than in any other position. Discovering that the uvula was very much lengthened from relaxation and elongation of its mucous membrane, we touched the lower, sharp extremity with the lunar caustic stick twice a day. At the same time the following mixture, which we had often used to control general nervous irritability in children, was pre- SPASMODIC SIMPLE LARYNGITIS. 67 scribed ; and this, with the lunar caustic application, finally controlled the cough. It was as follows: R.— Vin. Antimonii, gtt. xlviij. Ext. Valeriana? FL, Tr. Opii Camph., aa, f^ij. Syrup Simp.. ^,^=^^- Aqua? f5J— ^'^• S. A teaspoonful every hour or two when the fits of coughing set in. After a few days, when the irritability of the fauces was somewhat subdued, the elongated portion of the mucous membrane of the uvula was cut off close to the muscle, and there was no renewal of the cough afterwards. When the cough is very harassing at night, from two to four drops of laudanum, with from ten to twenty drops of syrup of ipecacuanha, or two grains of Dover's powder, given once or twice in the evening, have answered better than any other means. When the patient presents an anemical ap- pearance, or other symptoms marking a general deterioration of the health, iron, and especially the syrup of the iodide of iron, given three times a day, has assisted in removing the cough, and especially in lessening the extreme susceptibility of the system to changes of the weather. The diet ought to be light, but strengthening. Good fresh meat, with simple nutritious vege- tables for dinner, and bread and milk morning and evening, constitute the most proper diet. In bad weather, during the cold seasons of the year, the child should be confined to the house. ARTICLE II. SPASMODIC SIMPLE LARYNGITIS, OR SPASMODIC OR FALSE CROUP. Defixitiox ; Synonyms ; Frequency ; Forms. — Spasmodic laryngitis is a disease of the larynx almost peculiar to children, consisting of simple catarrhal inflammation, without pseudo-membranous exudation, of the mucous membrane of that organ, attended with sj)a.^modic contraction of the glottis, or laryngismus, occasioning violent attacks of threatened suffo- cation. It is the disease commonly called in this country croup, or, by those who make the distinction between it and pseudo-membranous laryngitis or true croup, spasmodic croup. It is known also by the names of false or pseudo- croup. We prefer the term spasmodic laryngitis, because it is expressive of the essential characters of the disea.*e. It is the .stridulous laryngitis of MM. Guersent and Valleix ; the stridulous angina of M. Bretonneau ; the acute a.'^thma of infancy of Millar ; and the spasmodic croup of Wichmann, Michaelis, and Double. It is not the lar}'ngismus stridulus described by 68 SPASMODIC SIMPLE LARYNGITIS. the English authors, Kerr, Ley, and Marsh, which is the same as the thymic or Kopp's asthma of the Germans, and spasm of the glottis of the French. It is called by Dr. Wood, in his work on the practice of medi- cine, catarrhal croup. Spasmodic laryngitis is one of the most frequent of the diseases which occur during childhood in this country. It is so common in this city, that almost all mothers who have had any experience in sickness, keep some remedy for it in their houses, which they are in the habit of resorting to upon their own judgment. During the last 20 years we have had under our charge 109 cases of the disease, of which we have kept an accurate record, and at least 100 other cases, of which we have no written account. Of the 109 cases, 86 were of the mild, and 23 of the severe form. We shall describe two forms or degrees of this disease, the mild and the severe. Without this distinction it would be impossible to give an accurate account of the disorder, since the two forms differ so much in aspect as to render them almost as much unlike as though they were two distinct af- fections. Moreover, the mild form differs so widely from membranous or true croup in its course and symptomatology, that the distinction between the two is readily made out, whilst the severe form, on the contrary, resem- bles true croup so much as to demand often very nice powers of observation to distinguish them, and yet the distinction is one of vast consequence to the patient, since the prognosis and treatment are widely different in the two diseases. Predisposing Causes. — The disease is much more common at some ages than others. It occurs most frequently during the period of the first dentition, being more common in the second year of life, which is the time of greatest activity of the first dentition, than at any other age, though it is often met with also in the third and fourth years. In the fifth year it still occurs occasionally, in the sixth and seventh it becomes rare, and after the seventh we have seen it but a few times. Of 106 cases of the disease that we have attended, in which the age was noted, 8 occurred in the first year of life, 33 in the second, 22 in the third, 26 in the fourth, 12 in the fifth, 2 in the sixth, 2 in the seventh, and 1 in the eighth. It is said to be more frequent in boys than girls, and this seems borne out by our own experience, since of 106 cases, 62 occurred in boys, and 44 in girls. Spasmodic croup occurs usually as a sporadic disease, but is said by some authors to prevail at times as an epidemic. We have never had any reason to suppose that it was strictly an epidemic like membranous croup, which appears to a considerable extent in some years, and in others is scarcely seen. We believe rather that the unusual prevalence of spasmodic laryn- gitis at certain periods, in comparison with others, depends on the fact that certain states of the weather or season predispose or excite to it in a greater degree than usual, and thus occasion a large number of children to be attacked with it. It is generally believed to be hereditary in certain families, and of this ANATOMICAL LESIONS. 69 we ourselves have uo doubt. We are acquainted with one family in this city, in which the children for three generations were extremely liable to it; with another, in which the grandmother and grandchildren were fre- quently attacked ; and with a third, in which the father and children showed the same predisposition in the most marked manner. The idea is, moreover, entertained by many people in this community. The natural constitution of the child does not seem to have much influ- ence upon the liability to the disease; it occurs indiflerently in the weak and strong. We have no doubt, however, that there are certain transient conditions of the health which do aff*ect the liability to it, since it has long been remarked that disturbances of the digestive functions frequently invite it, and since we have often ourselves found it most apt to attack those who are liable to it, when they happen to be laboring under bilious disorders or indigestions. It is most common during cold weather. Exciting Causes; Cold. — By far the most frequent exciting cause is the action of cold ; either the passage from a warm into a cold atmosphere, or prolonged exposure to cold and damp. It has been known on several occasions to follow long-continued crying, doubtless from inflammatory action set up in the larynx, as a consequence of the excessive determina- tion of blood to that part during the act of crying. We were assured, some time since, by a very intelligent woman, that her little daughter had, at the age of two years, a well-marked attack of croup, after a severe and long-continued fit of crying from some contrariety. Anatomical Lesions. — Mild cases of spasmodic laryngitis are so rarely fatal, as to leave us in some doubt as to the character of the ana- tomical lesions, or whether there are indeed any perceptible alterations of the tissues. We have never ourselves met with a fatal case of tliis form, and are therefore unable to give any personal account of the condition of the lani'nx, though we have never doubted, from the nature of the symp- toms, the hoarseness, the dry cough, which afterwards becomes loose, and the whole aspect of the disease, that the anatomical condition of the af- fected organ must be one of slight inflammatory hyper?emia. In some cases, however, that have been examined, a little mucus in the larynx, and slight redness have been found, while in others no change has been detected. Dr. Wood (Trent, on the Prac. of Med., vol. i, p. 779) accounts for this absence of morbid appearances in the following plausible manner: "In some rare instances, no signs of disease are discovered in the mucous mem- brane, and the patient has probably died of spasm, consequent upon high vascular irritation or congestion, the marks of which disappear with life." Cases of severe spasmodic croup have not unfrequently proved fatal, and the anatomical alterations of this form of the disea.sc have therefore been well ascertainerl. These alterations consist of either simple ratarrlial inflammation of the laryngeal murous membrane, or of inflammation attended with ulceration. When the inflammation is simple, the mem- brane is changed in color, either uniformly or in spots, to a deep rose or dark-refl tint. This may be the only alteration, or the tissues may be found also softene^l, or roughened and thickened. When the redness, (liirk- ening, and softening, are all present, these appearances are usually confined 70 SPASMODIC SIMPLE LARYNGITIS. to certain parts, and particularly to the epiglottis and vocal cords, but when redness alone is present, it generally affects the whole of the larynx, and may extend to the trachea. To the alterations just described are sometimes added, as was stated above, ulcerations. These are commonly small, few in number, of a linear shape, and are usually seated upon the vocal cords. They are so slight as to escape observation, unless carefully looked for. Symptoms; Duration. — The invasion of the mild foiTu of spasmodic croup is generally very sudden, for though it is often, probably in a large majority of cases, preceded for a few hours or a day or two by slight coryza, hoarseness, and cough, these symptoms are seldom noticed at the time, and the child is not supposed to be sick until seized with the paroxysm of suffo- cation, which is pathognomonic of the disease. This occurs in much the larger number of cases during the night, and very generally wakes the child from sleep. Of sixty-four cases observed by ourselves, in which the time of the attack was noted, it occurred in the night in sixty-two, whilst in two it came on in the afternooon. The period of the night at which it takes place is very irregular, but it is much more apt to be before than after midnight, as is shown by the fact that of forty-two cases in which this cir- cumstance was. ascertained, the attack was before midnight in thirty, and after in twelve. This agrees very closely with the statement of MM. Killiet and Barthez, that it has been observed most frequently at eleven in the 'evening. The duration of the paroxysms varies considerably, and depends a good deal upon the treatment employed. They may last from a few minutes to several hours, but are seldom shorter than from half an hour to an hour. The number of the attacks also varies. In some cases there is but one, though very generally there are several; When the attack occurs early in the night, it is very apt to recur again towards morning, and, unless means of prevention are used, on the following night also, and even, though this happens much more rarely, on the third night. As a general rule, the first attack is the most severe. When the paroxysm comes on, the child is wakened from sleep by the sudden occurrence of symptoms apparently of the most alarming and dangerous character. These consist of loud, sonorous, and barking cough ; of prolonged and labored inspiration, accompanied by a shrill and piercing sound, to which the term stridulous is applied ; of rapid and irregular respiration, amounting often to violent dyspnoea, or seemingly impending suffocation ; the child, alarmed and terrified at its condition, and at the fright of those around, its countenance expressive of the utmost anxiety, cries violently between the attacks of coughing, and begs to be taken on the lap, or sits up or tosses itself upon the bed, struggling apparently with the disease, which seems for the moment to threaten its very existence. The voice and cry are hoarse, and sometimes almost extinguished during the height of the paroxysms, but become distinctly audible, and often nearly natural, in the intervals between them ; differing in this respect from pseudo- membranous croup, in which they remain permanently hoarse or whisper- ing. We have never heard, in this disease, the whispering voice and the short smothered cough of true croup. The face, head, and neck, are at 1 SYMPTOMS. 71 first deeply flushed, aud as the paroxysm becomes more violent, assume a dark livid tint, which atterwanls passes into a deadly paleness, if the attack be long continued. These changes in the coloration depend upon the arrest of the respiratory function and a consequent partial asphyxia. The pulse is frequent during the paroxysm, and the skin sometimes heated. After a longer or shorter period, generally from half an hour to an hour, the res- piration becomes more tranquil ; the stridulous sound disappears entirely, unless the child be disturbed and made to cry, when it again becomes dis- tinct ; the cough is less frequent and less boisterous, and the child generally falls asleep. The attack is very apt to recur towards morning, as has been stated, and if not then, the following night. The patient often seems per- fectly well the day after the first paroxysm, with the exception, perhaps, of slight cough. This is no reason, however, for supposing that the dis- ease will not return in the course of the second night, which is almost sure to hapi^en, unless measures be taken to prevent it. The cough generally continues for a day or two, but soon loses the peculiar character expressed by the term croupal ; it becomes less frequent and more loose, and the child is commonly well again in two or three days. Sometimes, however, the cough lasts for several days, becoming gradually less frequent, until at last it ceases entirely. There is very little fever in mild cases, for though the pulse is accele- rated and the skin warm during the paroxysm, these symptoms disappear very soon after that is over. In more severe cases, on the contrary, there may be considerable fever, the pulse becoming frequent aud full, and the skin hot. The febrile movement is most apt to occur after the first parox- ysm, as a consequence, apparently, of the slight catarrh which remains after the attack. In the few fatal cases on record, the paroxysms have generally become more frequent and more violent by degrees, and death has occurred from suffoc-ation. In other instances, death has been the result of prostration, which itself ha.s probably depended on imperfect hematosis. Recurrences of the disease are very common, children sometimes having several attacks in a single winter. This is not the case in true croup. We have known but two children to have a second attack of that disease. The $evereform of spasmodic laryngitis may begin as such or result from an aggravation of the mild form ; or the case may commence as one of simple laryngitis without spasm of the glottis, and as the intensity and extent of the laryngeal inflammation increase, it may assume all the fea- tures of the form under consideration. Whatever be the mode of onset of the case, this form of the disease sets in with hoarse, frecjuent cough, difficult respiration, restlessness, and more or less violent fever, symptoms which almost always become severe for the first time at night, and usually between early evening and midnight; though, in some few cases, they make their first appearance during daylight, and this is very much more apt to happen in this than in the mild form of spasmodic croup. During the night the symptoms increase in severity ; the respiration is frequent and difficult, and, after a time, attended with the stridulous sound in in- spiration aud expiration caused by narrowing of the glottis ; the cough is 72 SPASMODIC SIMPLE LARYNGITIS. hoarse, dry, and croupal, and unattended with expectoration ; the voice becomes hoarse, and fever sets in, the pulse becoming full and frequent, the skin hot and dry, and the face flushed. These symptoms persist, with greater or less severity, throughout the night, while from time to time, they increase to such an extent as to seem to threaten suffocation, resem- bling then exactly the paroxysms described as occurring in the mild form of the disease. They usually subside, however, very decidedly towards morning, the breathing becoming easier, the stridulous sound less loud, or ceasing altogether, the fever diminishing, and the patient becoming in all respects much more comfortable. This amelioration of the child's con- dition often continues until the after-part of the day or till evening, when the same train of symptoms reappears. In other cases the disease scarcely subsides at all for two, three, or four days, but continues throughout the day and night to exhibit the same symptoms as have been described above. In cases of this kind, which are not rare, the disease assumes many of the alarming and dangerous characters of pseudo-membranous laryngitis or true croup, and it becomes very difficult often to distinguish between the two. If no favorable change take place, the dyspnoea be- comes so violent as to threaten suffocation ; the cough is rare and short ; the voice is reduced to a mere whisper ; the pulse becomes small, extremely rapid and thready ; the countenance, at first livid and congested, assumes a pale, cadaveric appearance ; the features are contracted ; the child be- comes comatose or delirious, and death occurs from slow asphyxia, or sometimes in an attack of general convulsions. In favorable cases, on the contrary, the dyspnoea, and especially the stridulous sound, diminish ; the cough becomes loose, less hoarse, and loses its croupal character ; expectoration of mucous sputa takes place in older children, whilst in younger, the loose gurgling sound produced by the dis- charge of the sputa into the fauces, is heard at the termination of each cough; the voice becomes clearer and stronger; the fever diminishes; the child regains its spirits and disposition to be amused ; and soon all dan- gerous symptoms have disappeared, and the recovery is established. In nearly all the cases that have come under our observation, we have found, upon examining the fauces, more or less decided inflammation of the tonsils, soft palate, and pharynx. The duration of the severe form of spasmodic croup depends on the vio- lence of the attack, and on the mode of treatment. When the treatment is begun with from an early period, the disease is much sooner overcome than when allowed to run on for some time without remedies. In cases of moderate severity, the violence of the symptoms usually subsides after thirty-six or forty-eight hours. In more violent cases, on the contrary, the symptoms seldom subside definitively before the third, fourth, and not unfrequently the fifth day. In no case that has come under our observa- tion, has the disease continued to present dangerous symptoms after the fifth day, unless, as not unfrequently happens, the inflammation spreads to the bronchia or tissue of the lungs, producing bronchitis or pneumonia. But even after the signs of severe laryngeal inflammation have disap- peared, there almost always remains for several days longer, some cough II I NATURE OF THE DISEASE. 73 and hiiskiness of the voice, marking that the mucous membrane of the larynx has not yet regained completely its healthy condition. The disease is said to have proved tatal in twenty-four hours. Nature of the Disease. — Authors hold very different opinions as to the nature of spasmodic laryngitis. By Underwood, Dewees, and Eberle, it is confounded with membranous laryngitis, they making no distinction between false or catarrhal, and true or membranous croup. Dr. Cheyne (Cyclop. P}'act. Med., Art. Croup) treats of the two affections as one and the same disease, differing only in their degree of violence. Dr. Copland (Diet, of Pract. Med., Art. Croup) describes spasmodic croup as a variety or modification of true or membranous croup. He supposes that the modi- fications of true croup are attributable to " the particular part of the air- passages chiefly aftected, to the temperament and habit of body of the patient, and the intensity of the causes." It seems to us, however, that these views as to the nature of the two diseases are not correct, and we are induced by personal observation to regard them as distinct affections, which may, in the great majority of cases, be distinguished from each other at a very early stage, by a careful observer. The comparative fatality of the two diseases alone is sufficient to establish a wide difference between them. Thus, of 35 cases of the pseudo-membranous form that we have seen, 16 died ; while of considerably more than 200 cases of the spasmodic form that we have seen, not one has been fatal. M. Guersent states that of ten cases of the former disease, scarcely two escape ; while of upwards of a hundred of the latter that he has seen, not a single one was fatal. {Diet. de Med., t. ix, p. 365.) The different effects of treatment in the two affections also point to a wide difference in their nature. True croup is almost inevitably fatal, un- less attacked at an early period by energetic remedies, while the mild spas- modic form seldom resists the exhibition of an emetic, a warm bath, or of nauseating doses of ipecacuanha or antimony ; and the severe form, though of a most threatening appearance, almost always yields to the proper em- ployment of very moderate local depletion, aided by the use of expector- ants, emetics, opiates, and correct hygienic means. When we add to these circumstances, the differences in the anatomical alterations in the two dis- eases, the difference in the mode of invasion, in the cough, voice, cry, fever, duration of the attack, and state of the constitution, all of which will be carefully described in the remarks on diagnosis, we do not see how we can resist the conclusion that they are two distinct disorders, and not, as was formerly generally asserted by English writers, degrees or modifications of the same. We believe, therefore, that mild spasmodic laryngitis is a disease con- sisting in slight catarrhal inflammation of the mucous membrane of the lar}'nx, attended with violent spasmodic contraction of that organ, or, as that condition has been called of late, laryngismus. The spasm of the laryngeal sphincter seems to be the result of a disordered action of the exfito-motor innervation of the part, the irritiint, which is j)roductive of the morbid innervation, being, in all probability, the inflammation of the lar}'ngeal mucous membrane, which has been already stated to constitute 74 SPASMODIC SIMPLE LARYNGITIS. one element of the malady. The nervous element predominates in the early part of the attack, but towards the conclusion, the spasmodic symptoms disappear entirely, and we have left only those which depend on the local tissue-changes. In severe cases of the disease we have the same element of laryngeal spasm, or laryngismus, coincident with, and produced by, a much more in- tense and dangerous inflammation of the mucous membrane of the part than exists in the mild form. Diagnosis. — Unquestionably the disease with which spasmodic laryn- gitis is most likely to be confounded is pseudo-membranous laryngitis, or true croup. There is very little difficulty, however, in distinguishing the mild form of spasmodic croup from true croup, whilst in regard to the severe form, it may be safely stated, that the distinction cannot, in some cases, be made with positive certainty, except by watching the course of the sickness. Mild cases of spasmodic croup may be distinguished from membranous croup by a comparison of the different symptoms as they arise. The most important of these are : the invasion, in one sudden and almost invariably in the evening or night, in the other slow and creeping, the paroxysm first occurring indifferently day or night ; the cough, in one hoarse and boister- ous, in the other hoarse and frequent at first, but rare and smothered to- wards the end ; the voice, in one hoarse, but never scarcely whispering, and if so, only during the height of the paroxysm, in the other hoarse at first, and soon permanently whispering or entirely lost ; the cry, in one hoarse and stridulous only at the moment of the paroxysm, in the other per- mianently so ; the respiration, in one stridulous and difficult only during the paroxysm, and in the interval perfectly natural, in the other, at first natu- ral, becoming by degrees permanently stridulous, and attended by the most violent dyspnoea, with remarkable prolongation of the expiration, and even with recession of the base of the thorax in inspiration ; the fever, in one very slight and generally observed only during the nocturnal paroxysm, in the other much more considerable and permanent ; and lastly, the duration, in one seldom more than two or three days, in the other rarely less than six, and very often eight or ten days. M. Trousseau states that the hoarse- sounding croupal cough is not a sign of the presence of exudation in the larynx, but rather of its absence ; but, " when the cough, croupal at first, becomes less and less frequent, and ends with being nearly insonorous with suffocation, there is true croup, that is to say, with plastic exudation in the larynx." This is precisely our own experience. The rare, insonorous cough of M. Trousseau is the condition which we have expressed by the term smothered. In order to render the diagnosis still clearer, we add the following table, which is altered from one given by MM. Rilliet and Barthez : MILD SrASMODIC LARYNGITIS. PSEUDO-MEMBRANOUS LARYNGITIS. Begins with coryza and hoarse cough, In epidemic form, begins as pseudo- or more frequently with a sudden attack membranous angina. In sporadic form, of suffocation in the night. Eauces natu- invasion of slight hoarseness for a day DIAGNOSIS. 75 MILD SPASMODIC LARYNGITIS. PSEUDO-MEMBRANOUS I. ARYiTGITIS. ral, or merely slisjht redness, as in simple or two. There is fever, inoroaso of the angina. hoarseness, with hoarse, croupal coui;h ; in most of the cases, pharvniroal exu- dation, and a little later, paroxysms of suffocation. Afterthe paroxysm, thechildseems well, The fever continues; stridulous res- the fevfr disappears, or is very slight, piration ; prolonged and difficult expi- Voice natural, or only slightly hoarse ; not ration; recession of base of thorax whispering. during inspiration ; cough hoarse and smothered ; voice hoarse and wliisper- inir. If the paroxysm returns, it is during the The dyspnoea and suffocation increase; following ni^ht, and it is less severe; the the voice and cough are smothered or hoarseness disappears ; the cough becomes extinguished; stridulous respiration loose and catarrhal. persists. Duration seldom more than three days. Duration seldom less than five or six days. The hoarseness continues for several weeks. Very rarely fatal. Fatal in the majority of the cases. The only real difficulty in the diagnosis is the distinction between the grave form and pseudo-membranous laryngitis or true croup unconnected with angina ; and this, it would appear from all evidence, cannot in some cases be made with absolute certainty. The only certain and indubitable sign by which to distinguish them is the presence of false membranes in the ex|>ectoration. The existence of this symptom is proof positive of pseudo-membranous disease, but its absence is no proof that the case must be one of simple inflammation ; for, even though the membrane has been exuded in large quantities within the larynx, it is not always thrown off by the effort of coughing or vomiting. To show the difficulty of the diag- nosis, we will cite the case quoted by M. Valleix {loc. cit., t. i, p. 211) from M. Hache, of a child supposed to be laboring under true croup, who was sent to the Children's Hospital in Paris, in order to have the operation of trachtN)tomy performed. The ab.sence of false membrane in the expecto- ration, and a slight remainder of clearness in the voice, occasioned the 9US|>en8ion of the operation. The child died, and no pseudo membrane whatever was found in the larynx. The only lesions were moderate red- ness of the mucous membrane, without tumefaction, and without narrow- ing of the glottis; so that the fatal termination must be a.scribed to spas- modic constriction of the glottis, or to tumefaction of that part, which had di.«appeared after death. Nevertheles"*, though the diagnosis is difficult, it can almost always be made out with certainty by attention to the following points. The pseudo- membranous form of the di.sca.se is usually preceded or accompanied by the presence of false membranes in the fauces, which is not the case in spasmodic simple laryngitis; the symptoms of invasion of the former dis- ease are less acute than those of the latter, the fever being less violent, and the restlessness and irritability less marked, than is usual in the simple affection, in which the general symptoms are decided fVom the first. The hoarseness of the voice and cough follow a different course in the two dis- 76 SPASMODIC SIMPLE LARYNGITIS. eases ; the progress of these symptoms being slow and gradual in the mem- branous, and much more rapid in the severe spasmodic form. The fever is marked throughout the attack in the severe spasmodic disease, whilst in the other form it seldom reaches a high degree of intensity. Lastly, the presence of portions of false membrane in the expectoration, in connection with the laryngeal symptoms, affords positive evidence of the existence of true croup. Of the characters just enumerated as likely to aid us in distinguishing between severe spasmodic and true or membranous croup, we wish to call the reader's attention in greater detail to two, — the condition of the voice, and the stridulous respiration. The former is, we have no doubt, much the most important single symptom. In membranous croup, the voice begins by being hoarse, but soon becomes weak, so that after the disease has lasted three or four days, it changes from hoarse to whispering; it be- comes, in fact, suppressed. In severe spasmodic croup, the voice is hoarse at first, and becomes more so as the disease goes on, but it very rarely be- comes whispering as in true croup, but almost always retains a good vol- ume, so that when urged the child can speak out loudly. Now this is never the case in the membranous disease, for, as the fibrinous exudation is deposited on the vocal cords and in the ventricles of the larynx, it sus- pends almost entirely the functions of those parts, and the voice is more or less completely suppressed. The remarks just made in regard to the voice will apply also to the cry, which should be carefully studied in young infants. The second very important symptom is the stridor. This is, as might be expected, more marked in all its features in true than in false croup, since in the former it depends on a permanent and considerable obstacle to the passage of the air through the larynx. That tube is, in fact, com- pletely coated over upon its internal surface, with a more or less thick false membrane, which reduces, materially its calibre, and impedes to a greater extent the passage of air, than does the mere inflammatory tur- gescence and swelling of the mucous membrane of the organ in severe spasmodic croup. On this account, therefore, the stridor in the respira- tion is louder, shriller, more persistent, more marked in the expiration, and attended with greater effort of the respiratory muscles to overcome the obstacle to the passage of the air in membranous than in severe spas- modic croup. We may add that there is something very peculiar in the cough in true croup. When the membrane has come to cover the in- terior of the larynx, the cough is very distinctive ; it has a sound which we can describe only by saying that it always reminds us of the sneezing of a young kitten. This we have never heard in catarrhal croup, no matter how severe. To conclude, there is in membranous croup a slow, steady, and unre- lenting progression of the symptoms, which is not observed in the spas- modic disease. From hour to hour, from day to day, we can perceive, so to speak, from the gradual and steady march of the disease, that a foreign body in the form of a fibrinous moulding is being spread slowly over the cavity of the larynx. In severe spasmodic croup, on the contrary, the TREATMENT. 77 course of the symptoms is less regular ; paroxysms of suftbcatiou occur as in true croup, but when these are over, the child is ofteu quite comfort- able ; the symptoms imiicatiug a much less cousiderable permaueut me- chanical obstruction than in the other affection. Spasmodic laryngitis has been mistaken also for laryngismus stridulus. The manner in which it is to be distinguished, will be described in the article on that disease. Prck»nosis. — Spasmodic catarrhal laryngitis is very rarely a fatal dis- ease. Of its two forms, there can be no doubt that the severe is much more dangerous thau the mild, since in the former the patient labors under acute intlammation of the larynx, as well as under spasm of that organ ; whilst, in the latter, the amount of inflammation is so very slight as to be of little or no consequence, were it not associated WMth the laryn- gismus, which gives to the disorder its most characteristic features. Of 109 cases of the disease of which we have kept an accurate record, Done proved fatal, though 23 of these were of the grave form. We may state, also, that we have seen at least 100 more cases, of which we have no written account, in none of which was there a fatal termination. We have, therefore, never seen a case of croup without false membrane prove fatal. That it does sometimes end unfavorably, however, cannot for a moment be questioned. There are various examples of the kind scattered through the medical journals. M^NI. Rilliet and Barthez quote, in proof of this, two cases from the work of Jurine, in one of which an autopsy was made, and no false membrane discovered. Copland {loc. cit.) re- marks, that in the few cases of the more purely spasmodic forms that he has had an opportunity of examining, an adhesive glairy fluid, with patches of vascularity on the epiglottis and larynx, and a similar fluid in the large bronchi, were the only alterations observed. Great imminence of danger in any case is shown by a high intensity of the gtridulous sound, especially as heard in the expiration ; by great severity of the dyspncea or suffocation ; by permanently whispering voice; by lividity or extreme paleness of the face; by smallness and rapidity of the pulse; by coldness of the extremities ; and by delirium or convul- sions. Treatmext. — M. Guersent (loc. ciL, pp. 367, 368) states that demul- cent and mucilaginous drinks, with stimulating hand-baths and foot- baths, are the principal means that ought to be employed in the treat- ment of spa.«modic laryngitis, or pseudo-croup. He proscribes the use of emetio; and leeches as unnecessary in most cases, and is of opinion that they have come into general use, in the management of the disease, in consequence of its having been generally confounded with true croup. In a paper on croup, by the late Dr. Charles D. Meigs (^ff.'d. Exam., vol. i, p. 308;, may be found the following statement in regard to the spas- modic variety: "The croup sound often ceases entirely, and never returns afler the exhibition of a small quantity of ipecacuanha, or any other emetic substance, even when no emcisis is prcxluced." He says in another place, that " a foot-bath with mustard, and an emetic of ipecacuanha, is in general all thnt is nfffs-ary for the cure." 78 SPASMODIC SIMPLE LARYNGITIS. In giving our own experience in regard to the treatment of this disease, we shall speak first exclusively of the mild, and then of the severe form, since the measures proper and necessary in the one, are very dijfferent from those called for in the other. Treatment of the Mild Form — Emetics. — The great majority of cases will recover perfectly well under the use of emetics employed alone, or in combination with warm baths and revulsives. Of late years we have often succeeded in warding off the slight attack, where there has been good reason to expect it, by the administration of an opiate with syrup of ipecacuanha, at bedtime (early in the evening). At two years of age, three or four drops of laudanum, with ten to twenty drops (ac- cording to the gastric susceptibility) of syrup of ipecacuanha; at three or four years, five drops of laudanum with twenty of the ipecacuanha, are about the proper doses. Even when the child has had one attack early in the night, the use of the opiate is most successful, after vomiting, in preventing the usual return towards morning. If the physician is not called until the day after the first attack, this treatment is excellent in the evening of the second day. In cases attended with violent dyspnoea, hoarse cough, and loud stridulous respiration, the emetic should be given until it produces a full effect. In milder cases, in which there is merely loud croupal cough, with an occasional stridulous sound, nauseating doses alone will generally suffice. The most suitable emetic is, as a general rule, ipecacuanha. The best preparation for children is the syrup, of which from twenty to thirty drops may be given to those two years of age, to be repeated every ten or twenty minutes until vomiting is produced, or until the paroxysm is relieved. In very sudden cases, the Syrupus Scillse Compositus, which is more active in its effects in consequence of the tartar emetic which it contains, might be preferable ; about twenty drops of this may be given, and repeated every ten or fifteen minutes, until vomiting or the resolution of the paroxysm is obtained ; but, in its employment, care should always be observed not to continue it for too long a time, lest it produce the injurious effects of tartar emetic. Of late years we have almost entirely abandoned the use of this latter emetic, as we succeed per- fectly well with the ipecacuanha, and dislike more and more the antimo- nial preparation in children. When the dyspnoea is very urgent, or when other means fail to produce emesis, we have found nothing so efl^ectual as powdered alum, in doses of a teaspoonful mixed with honey or molasses. (See Treatment of Pseudo-membranous Laryngitis.) A simple and good method of treating the paroxysm is that recom- mended by Dr. Charles D. Meigs, in the paper referred to. It is to direct a small teaspoonful of powdered ipecacuanha to be diffused in a wine- glassful of water, of which mixture doses of a teaspoonful are to be given every ten, fifteen, or twenty minutes, according to the urgency of the symptoms. This is a plan of treatment often resorted to by parents in this community, where the disease is so common and so well understood, that there are few mothers who have several children, and who have had some little experience, who do not know how to treat a nocturnal attack of mild spasmodic laryngitis. I I TREATMENT. 79 A very simple and efficient mode of treating tlie paroxysm, which was first recommended by Graves, consists in gently pressing a sponge soaked in warm water under the chin and to the front of the neck. This may be repeated every ten or fifteen minutes, and under its influence the croupy sympioms will often promptly subside without the use of an emetic. After the paroxysm is relieved, it is a good plan to direct five or ten drops of the ipecacuanha syrup to be given every two or three hours during the following day; or, if the child seems perfectly well in the morning, we may begin with these doses in the middle of the day, and continue them until bedtime. By this method, the recurrence of the paroxysm during the second night may, we think, often be prevented, and the cough is ren- dered free and loose much sooner than when the disorder is left to pursue its natural course. Moreover, the child ought to be kept in the house dur- ing the next two or three days, or until the cough is thoroughly loose and easy. If the child be at all a delicate one, or one in whom the disorder is prone to be obstinate, there is no plan so good as to make it sit or lie quietly in bed, sufficiently covered, with a large abundance of playthings, or with a kind nurse to read to and amuse it for two or three days. Baths. — The warm bath is a very prompt and useful remedy in the dis- ease. In all very violent cases, it ought to be resorted to immediately. It should be used also whenever the emetic fails to relieve the urgency of the symptoms, and in cases attendant with much disturbance of the circula- tion. The temperature of the water ought to be about 95° Fahrenheit, when the child is first immersed, to be raised gradually by the addition of hot water, to 100° or 102°. The child may remain in the bath from ten to twenty minutes. B€vnL'*ive-!<. — The only revulsives that it can be necessary to employ are mustard foot-baths or mustard poultices applied to the interscapular space ; and even these are often needless if the emetic be given. Blisters, which are recommended by some of the French writers, can only be proper in rare cases of the grave form. Purgatives are required when constipation is present, or when there is so much fever on the second or third day, as to show a considerable amount of lar}'ngeal inflammation. Under the latter circumstances .some mild remeiiy of this class may be resorted to with a view to its evacuant efil^ct. We have never had occasion to employ any of the mercurials^ and believe them to be unnecessar)'. Opium is exceedingly beneficial when the emetic, nauseant, or warm bath has failed to relieve entirely, and when a troublesome croupal cough continues after the spasm has been overcome. Laudanum, paregoric, or solution of morphia, in combination with syrup of ipecacuanha or Dover's powder alone, are the most suitable preparations. It is a very good plan to give the child a moderately full dose of the opiate, with ipecacuanha, after the violence of the paroxysm has subsided. It puts the child to sleep, promotes perspiration, softens the cough, and tends to prevent the return of the spasm. Repeated once or twice early in the second night after the first attack, we believe it often assists materially to avert the recurring nocturnal paroxysm. 80 SPASMODIC SIMPLE LARYNGITIS. Treatment of the Severe Form. — This form of spasmodic laryn- gitis requires more active measures than the mild form of the disease. In some of the former editions of this work, bloodletting was recom- mended when the disorder occurred in robust and vigorous children, and a record was given of the employment of venesection in seven out of twenty-three cases, all of which recovered. Since that report we have learned that depletion is less necessary than we formerly supposed, and, as we can still say that we have never yet seen a fatal case of spasmodic croup, either simple or severe, it is fair to conclude that the disease can be safely managed without a resort to this more violent measure. Still, it is but proper to state, that should a case occur to us in a strong and healthy child, in which the breathing should become so much obstructed as to cause deep and alarming venous stasis, and in which these symptoms re- sisted the more simple means we now employ, we should not hesitate again, as in former years, to employ a venesection to the extent of four ounces at the age of four or five years, or a leeching to the same amount. Our favorite remedies of late years have been emetics, opiates, salines, and the sulphurated antimony of the recent Pharmacopoeia. When the patient is a vigorous child, and over a year old, we generally employ the following combination : R. — Antimon. Sulphurat., Pulv. Doveri, . Sacch. Alb., M. et div. in chart, xij. gr. J. gr. iij. gr. xij. i Of these powders one may be given every two, three, or four hours, care being taken to suspend the antimony when it produces any of the peculiar distress or general prostration to be described in the article on pneumonia. In such a case, we use one of the following combinations : Or .—Potass. Citrat., . • . . . 3J- Syrup Ipecacuanhae, . . . . . fgij- Tr. Opii Deodorat., . . . . . gtt. xij. Syrup Simp., .... f^ij. Aq, . f^iss.— M. Dose for a child two years old, a teaspoon ful every two hours. . — Aramonife Muriatis, gr. xxiv. Ammonii Bromidi, 3J- Syrup Ipecacuanhae, fgiss. Syrup Zingiberis, . fk'js^^- Aquae, .... f^iss. Ft. sol. Dose for a child two years old, a teaspoonful every four hours. In older children, both the potash and opiate may be doubled. In all these cases an emetic ought to be given once, or two or three times in twenty-four hours, when the dyspnoea and stridor become very severe ; and in about an hour after its operation, the saline dose should be resumed. Of course, if decided drowsiness supervene from the opiate, the doses must TREATMENT. 81 be given at longer intervals. The emetic treatment is not so essential as in true croup, where it is so useful in causing the rejection of the false mem- brane which obstructs the larynx. Yet it is exceedingly useful, and often indispensable, in assisting to expel the viscid mucus secreted within the larynx, and in relaxing, for a time at least, the spasmodic constriction of the glottis, which plays a most important part in the production of the distre^iug dyspnwa and suffocation of the disease. They act probably also by lessening immeiiiately, or through their action on the circulatory and nervous systems, the inflammation of the larynx. For their choice and mode of administration, the reader is referred to the article on true croup. Purgatives are required merely to keep the bowels soluble ; they should be repeated as may be neces^sary throughout the disease. If the bowels are moved every day or every other day spontaneously, there is no use in giving them at all. The most suitable are castor oil, rhubarb, or magnesia, in small doses ; or an enema may be given from time to time if the child does not resist its application. Expectorants are useful after the violence of the disease has been mod- erated by more energetic remedies. They may consist of small doses of ipecacuanha, of antimonial wine and sweet spirits of nitre, of decoction of seneka, snakeroot, or of the citrate or carbonate of potash. Opiates are necessary, and are serviceable, as has already been stated, in calming excessive restlessness, and in allaying the violence of the suffo- cative attacks, which depend, in good part, on spasm of the glottis. The most suitable are Dover's powder or some other preparation of opium, or small doses of belladonna, or hyoscyamus. Belladonna would seem, from its power to relax the sphincters, and from ita excellent effects in hooping-cough, to be indicated in this disease, but we have succeeded so well with opium that we have not often used bella- donna. Probably a combination of the two would be found beneficial. A warm bath at 97° or 98°, employed once or twice a day, and continued for a period of ten or fifteen minutes, often assists greatly in lessening the sufferings of the child, in calming restlessness, and in moderating the heat of skin, and violence of the circulation, when the latter symptoms are strongly marked. The same effects may often be obtained by the use of counter- irritants, as sinapisms, mustard poultices, mustard foot-baths, etc. Blisters are of doubtful propriety in any cases. Hygienic Tkeatmknt.— In either form of the disease the child should be placed for the time in a warm room, and warmly clothed. If old enough, it ought to be kept as much as possible in bed during the paroxysm. If so young as to prefer the lap of the nurse, it should be clothed in a long loose wrapper in addition to its usual night-dress. It is very important to confine the child during the whole term of the acute period in the bed, if it is over three or four years old, and in the crib or lap if it be younger. Even after the cessation of the acute condition, it ought to be kept in the house for a few days, in order to make sure of the convalescence. The diet must be simple and of easy digestion, so long as there is any disposi- tion to recurrence of the disease. It may consist of preparations of milk, 6 82 SPASMODIC SIMPLE LARYNGITIS. of bread, rice, or of thin chicken or mutton water. Meat and most vege- tables had better be avoided until the convalescence is fairly established. Prophylactic Treatment. — It is certain that much may be done by a wise attention to physical education, to prevent attacks of the disease in children who show a liability to it. We would strongly recommend, with this view, attention to the following advice given by M. Guersent, who says (Jog. cit., p. 381) : " It is possible, to a certain extent, to prevent attacks of pseudo-croup, if we fortify the constitutions of children, by exposing them well-clothed to a dry and elastic atmosphere, particularly if they can be kept in constant movement. But of all the precautions which have been found unquestionably advantageous, that which seems most useful is to make them sleep in well-ventilated, dry, carefully closed chambers, having a southern exposure, and always without fire. We have several times been convinced of the utility of this habit in families the children of which were subject to this kind of catarrh." There can be no doubt that the style of dress used for children in this country, must occasion many and repeated attacks of croup which might just as well have been avoided. The custom is to dress children between the ages of one and four or five years, in such a way as to expose to the air the whole of the neck and the upper half of the thorax (for the dresses are made so low and loose at the shoulders, as to leave the upper part of the chest virtually uncovered). The arms are left bare, as are also the legs from the knee, or above the knee, to the ankle, so that very nearly half of the cutaneous surface is without covering, and this too, in the very same rooms and temperature in which sit the parents with the body and limbs warmly clothed to resist our climate, at all seasons changeable and uncer- tain, and, in the winter, very cold. We are perfectly well convinced that this faulty and unreasonable system of dress, which is chosen because it is the fashion, or in order to harden the child, who, however, invariably puts on warm clothing when it comes to years of discretion, will explain in part the enormously greater frequency in children than in adults, of the various diseases of the air-passages and lungs produced by cold. One of the most important means of prevention, therefore, is the adop- tion of a suitable dress. In winter this should consist of one that shall cover the body completely. If the child be at all delicate, it ought to wear next to the skin a woollen jacket with long sleeves, and covering the chest to the neck. Over this should be put a long-sleeved stout muslin dress, or one of some light woollen material, made in the same style. In young children, the stockings ought to be of wool, and should reach to the knees ; in older ones, they may be shorter, but the legs should be covered ■with drawers made of canton flannel, of thick cotton stuff, or of light woollen flannel. To show the influence of dress. Dr. Eberle mentions the fact that in the country, and especially amongst the Germans, who cover the neck and breast, croup is a very rare disease. During a practice of six years amongst that class of people, he met with only one case of the disease. When the liability to the disease continues after the completion of the first dentition, we have found the daily use of the cold bath, in connection NATURE AND RELATIONS. 83 always with warm clothing, most useful in preventing the attacks. The bath must be commenced with in the summer, and persevered in through the following winter. The water, after the cold weather begins, should be drawn in the evening, allowed to stand all night in a room in which there is a fire tlirough the day, and made use of on the following day. Prepared in this way, we have found the water in the morning at a temperature of between 50^ and 60° F. The child ought to be kept in the water only half a minute or a minute, then well rubbed, and dressed immediately. When the child is pale, weak, and feeble, and unable to bear exposure to the outer air, it may generally be restored to much better health by careful attention to diet, and by the steady and long-continued use of some tonic remedy. The diet ought to consist of bread and milk, and of meat and the simpler vegetables, as potatoes and rice. The tonics most generally suitable are quinine or iron. Of the quinine a grain may be given in pill or solution, twice or three times a day ; while at dinner or lunch, or at both, the child should be made to drink from a dessert to a tablespoonful of port wine, mixed with water. This method ought to be steadily persevered in for from three to six weeks or longer. If quinine be objectionable for any reason, iron must be substituted. The best prep- arations are the iodide or the metallic iron. ARTICLE III. PSEUDO-MEMBRANOUS LARYNGITIS, OR MEMBRANOUS OR TRUE CROUP. Definition and Synonyms. — Pseudo-membranous laryngitis is an acute inflammation of the mucous membrane of the larynx, attended with the exudation of false membrane. It ia the croup of the French writers, while, in this country, it is called by the various names of slow, creeping, true, membranous or iuflamma- tor}'. The terra given above seems most suitable, as expressive of the real nature and seat of the disease, and we shall, therefore, make use of it in contradistinction to that of spasmodic laryngitis or spasmodic or false croup, which is a much more common and less dangerous affection. Natike and Relations. — Since the publication of our last edition, the questions of the es-sential nature of membranous croup and its rela- tions with diphtheria have been actively discussed, and it has appeared that there are marked differences in the opinions held by the best authori- ties. In the present state of the discussion, it is iniproper to attempt any dogmatic assertions on the points at issue, but it seems desirable to restate fully the views we have long held and the considerations on which they are based. By many authorities, true croup is regarded as an ifliopathic primary inflammation, presenting the unusual result of pscudo -membra- nous exudation, and differing thus from diphtheritic crou]), which is a 84 PSEUDO-MEMBRANOUS LARYNGITIS. mere complication in the course of a constitutional disease, depending upon the extension of the false membrane from the fauces into the larynx. The considerations upon which this distinction is based may be briefly stated as follows : that true croup is a disease peculiar to childhood, and that many of its peculiarities are to be explained by reference to the de- velopment of the larynx at that period ; that it is a local disease and not connected with any special alteration of the blood crasis ; that it is not contagious ; that it nearly always commences in the larynx, and, though it may pass downwards into the trachea, never passes upwards into the pharynx ; and finally, that it does not present the complications of diph- theria, such as albuminuria and pseudo-membranous exudation on abraded surfaces, nor its characteristic paralytic sequelae. So far as the mere anatomical conditions are concerned, it is generally conceded that there is no essential difference between primary croup and pseudo-membranous croup occurring in the course of diphtheria. The attempt was made by M. Isambert to base a distinction between the two affections upon the ulcerated condition of the mucous membrane of the larynx in diphtheritic croup, but West has met with similar ulceration in cases of primary croup, though somewhat less frequently than in the sec- ondary diphtheritic form. It has also been attempted to establish a distinction between the morbid process in croup and in diphtheria upon the greater intensity of the lesion in the latter case, associated with more swelling, a more intense congestion of the mucous membrane ; but from careful observation of the numerous grades of severity of the diphtheritic process, we are convinced that this difference in degree is not constant, and cannot be made the basis of a radical division of the two affections. It appears moreover that there is no essential chemical or histological difference between the pseudo-mem- branes formed in the two conditions. But further, our personal experience constrains us to state that the dif- ferences between the two forms of membranous croup above enumerated, have not seemed to us sufficiently marked and constant to positively estab- lish their essential diversity ; and that it is our decided opinion that the vast majority, of the cases usually termed pseudo-membranous laryngitis are in reality instances of primary laryngeal diphtheria, in which the con- stitutional symptoms are not grave, and where the faucial deposit has been very slight and perhaps even overlooked. We are led to this conviction especially by the repeated observation of cases in private practice, where we have been summoned upon the first symptoms of indisposition, and have found a trifling amount of membran- ous exudation on the fauces, which, in a day or two, had disappeared, while the symptoms of croup supervened. In one of the most recent works on General Pathology, Wagner, who inclines to believe in the distinction be- tween the two affections, says (p. 266), " in the greater number of fatal cases of laryngeal croup, diphtheritic exudation is found on the soft pal- ate." Apart from their sporadic occurrence, we confess that we are altogether unable to detect any difference between such cases and the cases of so-called NATURE AND RELATIONS. 85 primary laryngeal diphtheria, frequently met with in epidemics of diph- theria, where the angina is but trifliug, and is rapidly followed by pseudo- membranous formation in the larynx. It is true that the primary sporadic form of croup we are now discussing occurs more exclusively in children than does the more fully developed form of diphtheria ; but it must be remembered that in childhood there seems to be a peculiar tendency for the larynx to become involved in the course of diphtheria, and also that a comparatively trifliug amount of membranous exudation in a child's larynx will produce grave symptoms of obstruction. It is true that in membranous croup there is but little enlargement of the lymphatic glands, but when the anatomical conditions of the larynx is borne in mind it will be understood why there should be but little lym- phatic implication, while, when the pharynx with its very rich lymphatic supply is affected, enlargement of the glands is a prominent symptom from an early date. We may here merely allude to the query whether this latter fact may be concerned at all in more frequent constitutional infec- tion which follows pharyngeal diphtheria. It is also true that these sporadic cases are rarely attended with albu- minuria or followed by paralytic sequelce ; but when we consider the re- markable variations in the frequency of these conditions in different epi- demics of diphtheria, it is not inconsistent that they should be usually absent in mild sporadic cases. In regard to the difference in the contagiousness of croup and diph- theria we would merely remark, that it is undoubted that in cases where the virulence of the disease is marked, and where its infectious or conta- gious character is most pronounced, the pseudo-membrane is most likely to appear first in the pharynx, and to be extensive and persistent. On the other hand, in ca:?es where the infectious character is but slightly devel- oped, and the symptoms mild, the membrane either remains limited to the pharynx where it speedily disappears, constituting the mild cases of diph- theria which we frequently meet with, usually in a sporadic form. Or, in a certain proportion of these cases, the pharyngeal deposit having been slight and often overlooked, the larynx is invaded and the symptoms of membranous croup appear. It is but natural, if this suggestion be entitled to any weight, that there should be found a considerable diflference in the degree of contagiousne^ of croup and of grave infectious diphtheria. However, we have recently met with two separate instances where among children of a family, one was seized with membranous croup presenting the symptoms and course described in the sporadic idiopathic form, while one or more of the others were affected with pharyngeal diphtheria. As we have above stated this question must be regarded as still under discussion and un.settled. We are by no means prepared to assert the identity of croup and diphtheria in all case,**, but have merely desired to state the considerations which incline us to regard them as closely allied, and as probably being different forms of one great pathological process. As it is not our intention, therefore, to deny the possibility of pseudo- membranous larj'ngitis occurring as a purely primary idiopathic affJection, 86 PSEUDO-MEMBRANOUS LARYNGITIS. we have consequently treated of it as a special disease, apart from the brief notice of it we have given in the article on diphtheria. But the considerations which we wish to impress deeply upon the mind of the reader are, that in the vast majority of cases of true croup careful examination of the throat at an early period of the attack will show the presence of exudation on the tonsils or pharynx ; and that, consequently, whenever a child is taken sick with even the most trifling croupy symp- toms, the throat should be immediately and repeatedly examined, and, if any membranous exudation be detected, the case should be regarded as probably one of membranous croup, a most guarded prognosis accordingly given, and the most careful treatment immediately instituted. Frequency. — The mortality from this disease is in all years consider- able, as will be seen from the subjoined table: Mortality Mortality Total Mortality Years. from Croup. from Diphtheria. less Stillborn. 1846, . - . Ill . . . . 5,944 1847, . 121 . 6,881 1848, . 177 . . 7,268 1849, . 130 . 8,989 1850, . 151 . 8,034 1851, . 180 . 8,374 1852, . 208 . 9,745 1853, . 303 . 9,184 1854, . 304 . 11,280 1855, . 265 . 9,906 1856, . 268 . 11,720 1857, . 256 10,331 1858, . 292 10,162 1859, . 312 9,084 1860, . 354 307 10,849 1861, . 304 602 13,838 1862, . 258 825 14,386 1863, . 443 434 15,045 1864, . 455 357 16,794 1865, . 350 260 . 16,453 1866, . 239 192 16,005 1867, . 185 118 13,153 1868, . 206 118 13,949 1869, . 237 182 13,428 1870, . 316 172 15,317 1871, . . . . 264 145 15,485 1872, . 296 150 18,987 1873, . 200 110 .. . 15,224 1874, . 199 179 16,238 1875, . 428 656 .. . 17,805 It is difficult to estimate the number of deaths due to this affection since diphtheria has made its appearance in the mortality lists of the city, as many cases of diphtheritic croup have unquestionably been returned as mere pseudo-membranous laryngitis. True croup is, however, rare in comparison with false croup, since while we have seen but 35 cases of pseudo-membranous laryngitis, we have met PREDISPOSING CAUSES. 87 'with upwards of 200 of the catarrhal form. In the following remarks, and in those on the causes of croup, we refer the reader also to the table in the article on diphtheria, showing the comparative monthly and annual mortalities from these two diseases. From a glance at the accompanying table, it will be seen that since the prevalence of diphtheria, the mortality from croup has not increased dis- proportionately to the increase in general mortality. ^loreover, no change whatever has occurred in the type of this disease during the past ten years, for the experience of one of us for a number of years before the terra diph- theria came into use and appeared in the mortality returns of this city, enables us to attest the fact that pseudo-membranous laryngitis, both of the primary and of the more grave diphtheritic form, occurred then pre- cisely as it does now. Predisposing Causes — Age. — The disease is far most frequent between the close of the fii-st and fifth years. Thus of 2136 fatal cases reported in this city during the seven years from 1862-68, 301 were under 1 year of age; 571 between 1 and 2 years; 951 between 2 and" 5 years; or 1522 be- tween 1 and 5 years; and 236 between 5 and 10 years; leaving but 77 cases as occurring after the latter period of life. Of the 35 cases that we have seen, 28 occurred between 2 and 7 years of age, while of the remaining 7, 1 occurred at the age of 18 months, 1 at that of 19 months, 1 at 7^ years, 2 at 11 years, and 1 each at 11^ and 12i years. Sex cannot be said to exercise any decided influence upon the frequency of the disease. Thus of the above 2136 cases, 1115 occurred in males, 1021 in feraala-s. CoNSTiTiTioN. — A feeble and delicate constitution is thought by some to be a powerful predisposing cause, but this is at least very doubtful. Of the 35 cases referred to, of which we have preserved notes, 26 oc- curred in healthy vigorous children, while the remaining 9 occurred in children who, though neither very weak nor very sickly, presented a rather delicate appearance. Season exerts a very jwwerful influence upon the development of croup. Thus the mortality from it attains its maximum during the months of November, December, and January, during which quarter about four times as many deaths occur from croup as during the months of June, July, and August. It is, however, comparatively frequent from October to March inclusive. The relation between the mortality from croup and the temperature appears to be a definite and quite constant one, since, as will be seen by referrinjr to the table in the article on diphtheria, with the single excep- tion of February, the mean monthly teniperature and the mean monthly mortality from croup rise and fall together throughout the entire year. The ez4;iting causes are but little understood. The only ones which seem to have been ascertained with any certainty, are the application of irritating agents to the laryngeal mucous membrane, and exposure to cold, and even these are questioned by the most accurate observers. In none of the cases that we have seen could the exciting cause be even suspected. 8S PSEUDO-MEMBRANOUS LARYNGITIS. It seems probable, therefore, that the existence of at least some predispos- ing constitutional condition may be assumed. Second Attacks of membranous croup, though rare, are mentioned as occurring by several authors; and, in our remarks on tracheotomy, we quote from Millard an allusion to five cases, in each of which the operation was twice successfully performed for successive attacks of this disease. We have ourselves met with two instances in which second attacks oc- curred. One was a girl, who had her first attack at the age of llj years, and her second at the age of 12^, and recovered from both without the operation. The second patient was a boy, who had his first attack, a very severe one, but from which he recovered without tracheotomy, at the age of 5 J years ; and his second attack, which is fully detailed at the end of the article on tracheotomy (Case 1), at the age of 7J years. Anatomical Lesions. — The false membrane may cover the whole mucous membrane of the larynx, and extend into the pharynx, trachea, and bronchia ; or it may be confined to the larynx, either forming a com- plete lining to the cavity of that organ, or consisting merely of patches of various sizes, with intervals of mucous membrane destitute of ex- udation. It is, in the first place, important, to ascertain the proportion of cases in which the deposit extends into the bronchia, and those in which it re- mains limited to the larynx, or larynx and trachea, as the determination of this point has some bearing upon the question of the propriety of the operation of tracheotomy. It appears from a table given by M. Guersent (Did. de Medecine, t. ix, p. 346), containing the results of cases collected by M. Hussenot from various sources, and of autopsies made by M. Bre- tonneau, numbering in all 171, that in 78 the membrane did not extend beyond the trachea, and that in 42 it invaded the bronchia, and in 30 the condition of the bronchia was not mentioned ; and in 21 there were no false membranes; so that of 120 cases, in which the extent of the false membrane was accurately noted, it was confined to the larynx and trachea in 78, and extended into the bronchia only in 42 ; or in about one-third of the cases. This proportion is the same that Millard gives {De la Tracheotomie dans le cas de Croup, These de Paris, 1858), in his masterly memoir upon croup, after an analysis of a large series of cases. Our own experience, based upon 15 cases in which we ascertained with exactitude (by autopsy or by tracheotomy) the extent of the membrane, would indi- cate that it passed into the bronchia in a larger proportion of cases ; since in 7 of these 15 cases the exudation extended beyond the trachea. It is to be borne in mind, however, that the cases upon which these calculations are based have very frequently resulted fatally, and presented extensive formation of pseudo-membrane in the bronchia ; and it is probable that it really exists there in other instances, but to a much less extent, so that recovery takes place, and renders it impossible to determine accurately the extent of the exudation. The proportion of cases in which the pharynx is'implicated is also im- portant, since it affects the diagnosis of the disease, and indeed bears upon ANATOMICAL LESIONS. 89 the question of the identity or non-identity of pseudo-membranous laryn- gitis and diphtheritic croup. In considering the statements of authoi-s upon this subject it is evident that much of the diversity in their opinions depends upon the fact, that they are not in reality all referring exclusively to this particular affec- tion. Thus the assertion of M. Guersent (Diet, de Mai., t. ix, p. 339), that in nineteen-twentieths of the cases the exudation begins in the phar- ynx, is evidently to be explained on the supposition that this distin- guished practitioner had been observing a series of cases of diphtheria in which the exudation had extended into the larynx. MM, Rilliet and Barthez, on the other hand, state that a majority of the cases observed by themselves, and of those of M. Hache also, commenced in the larynx. Dr. We^t also report-s 11 cases of idiopathic croup, in only two of which was there any formation of false membrane upon the velum and tonsils. In 31 cai^es observed by ourselves, in which the condition of the throat was recorded, the croup followed membranous angina in 21 cases ; in 5 the disease began in the larynx, but was attended later with small deposits upon the tonsils ; and in 5 only was there no deposit on the throat at any time. The fauces and pharynx do not present any constant alterations in cases of croup. Frequently, however, the mucous membrane is red and swollen, and there may be patches of membranous exudation upon the tonsils, velum, half-arches, or on the pharynx. These patches are usually thin, whitish, and may not persist more than 24 to 48 hours, disappearing and being succeeded by similar formations in some other part of the throat. We believe indeed that such patches of exudation will be found in a large proportion of cases during the first two or three days of the attack; and that they are not more frequently observed, chiefly because the symp- toms are usually so slight during this stage, that either no medical attend- ant is summoned, or his attention is not attracted to the throat. The most important and characteristic morbid appearances are, however, to be found below the glotti.s, and consist in the presence of pseudo-mem- braooufl exudation, and of certain alterations in the respiratory mucous membrane. The false membrane may be limited to the larynx, or to the larynx and trachea ; or it may extend over these parts and into the branches of the bronchi, even to the third and fourth division. In the larynx, trachea, and even the primitive bronchi, it may appear merely as patches of various sizes, with intervening .«paces of vascular mucous membrane; but in the gmaller air-passages it usually takes the form of complete tubes lining the broDchus. Jo some cases, such tubular casts may be formed continuously from the larynx down to the minute bronchioles, completely lining the air-passages. It is undoubted, that in the more sthenic idiopathic form of membranous laryngitis, the membrane is more apt to extend deeply into the ramificatioas of the bronchi, than when it occurs as a complication of diphtheria. The false membrane is commonly of a yellowish-white color, and from a fifth of a line to a line in thickne,*s. Its consistence is generally con- 90 PSEUDO-MEMBRANOUS LARYNGITIS. siderable, and it is usually somewhat elastic ; indeed the more white and fibrous varieties possess a degree of firnmess and toughness that renders it difficult to tear the membrane, or teaze it out with needles. It is an al- most invariable rule, that the membrane lining the upper part of the air- passages is more white and firm than that found in the smaller bronchi ; so that it frequently happens, that, on drawing out the firm white tubular membrane lining the larynx, trachea, and primary bronchi, it is seen to terminate in branches which grow progressively softer, more yellow and purulent, as they become smaller and smaller. The free surface of the pseudo-membrane is usually covered with puri- form mucus, while the attached surface is adherent with various degrees of force to the mucous membrane beneath. The strength and closeness of these adhesions are often proportionate to the firmness and toughness of the false membrane itself. In the larynx and trachea it is often necessary to employ a good deal of force to separate the exudation from the mucous membrane, and innumerable little fibres are seen passing from one to the other, as though they were processes of exudation dipping into the minute orifices of the mucous follicles. On the other hand, the adhesion between the exudation and mucous membrane is rarely close in the smaller bron- chi, or in cases where the pseudo-membrane in the larynx and trachea is less firm and consistent. These false membranes consist, according to Hasse, mainly of fibrin blended with mucus in various proportions. {Path Anat, Syden. Soc. ed., p. 278.) On microscopic examination, they present a more or less close fibrous basis, consisting of interwoven fine fibrils, with imbedded cells in varying number ; these cells presenting the ordinary appearances of exu- dation-corpuscles, being round, granular, and containing from one to three small nuclei. The action of various chemical reagents upon them will be found detailed in the article on diphtheria. The mucous membrane beneath the exudation presents various shades of redness, or it is purplish, or even ecchymosed and blackish. It is also swollen, and may be slightly softened or friable, and has a dull excoriated appearance, though actual ulceration very rarely exists. West mentions the occurrence of small aphthous ulcers about the edges of the rimi glotti- dis and the arytenoid cartilages, as a frequent lesion in idiopathic croup; but the same lesion has been observed in the diphtheritic form of the dis- ease. There is also vascularity, though usually to a less marked degree, of the bronchial mucous membrane at the points where no exudation exists. The lungs present some abnormal condition in the great majority of cases. Bronchitis and pneumonia are frequent complications of the dis- ease ; and in addition there is often collapse of larger or smaller portions of lung-tissue from occlusion of some bronchus by the pseudo-membrane. In other instances, or frequently in conjunction with collapse of portions of the lungs,' the violent respiratory efforts induce either vesicular or even interstitial emphysema, especially of the anterior borders of the lungs. The morbid appearances found in cases where the croup has followed SYMPTOMS. 91 diphtheritic angina, will be fully described under the head of this latter disease. In the secondary croup of measles, the appearances are very similar to those observed in primary case^, while in that of scarlet fever the ex- udation differs in being less consistent and less uniformly spread over the diseased part. In the last-named malady, the membrane is thinner and less adherent, and, in some cases, purif«)rm, soft, and of a grayish color. It is usually poor in fibrin, and prone to decomposition. The mucous membrane is generally discolored and softened. Symptoms. — In the majority of cases, the development of the symptoms characteristic of croup, is preceded for a few days by the ordinary symp- toms of catarrh and slight sore throat. The child is feverish and drowsy ; there is cough, which may possess a slight croupy character at some period of the twenty-four hours, but more frequently seems like an ordinary catarrhal cough ; coryza is very rarely present, but there is slight soreness behind the angles of the jaws, and the fiiuces are seen to be reddened, and probably small, thin patches of pseudo-membrane may be visible on the tonsils or fauces. This early stage lasts a variable time, usually from one to three or four days, and is more or less gradually succeeded by the symptoms indicative of laryngeal obstruction. When, on the other hand, the disease begins in the larynx, the invasion is marked by hoarseness of the voice, and hoarse, croupal cough, which often continue for one, two, or three days, until the disease has made con- siderable progress, before the parents deem it necessary to send for a physician. In a case that came under the observation of one of ourselves, the child was playing about the room at a time when he had hoarse, whis- pering voice, and cough, and stridulous respiration. In another we were not called until the evening of the third day, though the child had had stridulous cough and respiration for two nights ; but, as he always seemed better in the morning, it was not thought necessary to send for a j)hysician until after he had become violently ill. In a third case there was hoarse- ness of the voice and slight croupal cough during the afternoon of one day and the ensuing night, and the next morning fully devehjped croup, with fibrinous patches on each tonsil. These symptoms are not generally accompanied by fever at first. The appetite is usually unimpaired, the thirst scarcely augmented, and the child, though somewhat dull and languid, is disposed to be amused at times. In other and severer cases, on the contrary, the disease becomes aggravated much more rapidly, and may soon lead to a fatal termination. The change of the voice is the first symptom observed in the cases which begin in the larynx. It has always been described to us as hoarse, like that which is heard in an ordinary cold. As the disease progresses, the voice becomes more and more hoarse and difficult, until at length it is reduced to a mere whisper. The degree of the hoarseness varies, however, to a ver>' great degree in the same case, the diversities depending probably upon the amount of the spasm of the larynx at the moment, and upon the state of the exudation. We have several times observed the voice to be- come much stronger and clearer after the operation of an emetic, in con- 92 PSEUDO-MEMBRANOUS LARYNGITIS. sequence, no doubt, of its relaxing effect upon the glottis. The cough is peculiar. At first slightly hoarse, it becomes, as the case goes on, very hoarse and hollow, and then short and smothered. It is variable in fre- quency, and is apt to occur in paroxysms, which are often very troublesome from their frequent recurrence. Towards the termination of the disease in fatal cases, or whenever the case is very severe, it is altogether different in character from what it was at the beginning, becoming short, instanta- neous, and smothered, so that it might very well be called whispering. As the disease progresses, it is accompanied by stridulous respiration, in which a hoarse, rough, hissing, or crowing sound is produced by the rush of the air through the constricted larynx. This sound is usually heard at first only during forced inspirations, and is therefore noticed first during the long inspiration which precedes coughing. Next it is heard during the violent respiratory movements which accompany the act of crying ; and as the larynx becomes more and more clogged with the exudation, it occurs during both inspiration and expiration, in every act of respiration, and is so loud as to be heard over the whole room, or even in adjoining rooms. The respiration is natural in the early part of the attack, but as the voice and cough assume their characteristic features, and the stridulous sound is established, it becomes more frequent, rising to 28, 32, 40, and 48 in the minute. At first easy and natural, it becomes, during the height of the symptoms, and especially in fatal cases, the most frightful dyspnoea we have seen in any disease. Every movement of inspiration requires the whole force of the inspiratory muscles to lift the walls of the chest, and enable the air to find its way through the narrow and obstructed glottis ; each expiration, instead of being short and easy, as in health, and in nearly all other diseased conditions, requires a slow and laborious contrac- tion of the expiratory muscles to expel from the lungs the air which they contain, and which hisses through the larynx with a sound nearly as loud as that produced during inspiration. The dyspnoea just described is for the most part constant, but exhibits paroxysmal aggravations from time to time. When a paroxysm of dyspnoea occurs, the expression of the child is that of the most terrible anxiety, or of the wildest terror. In some instances, the face becomes deeply red, then blue, livid, and finally pale and white, and for a moment life may seem extinct. In other cases, in which the dysp- noea is constant, the face is of a dusky red color, tfie expression anxious and haggard, and the child either lies on its side with the head thrown far backwards in a state of somnolence, or constantly changes its position from restlessness without noticing anything around it. Jacobi (Amer. Jour, of Obstet, May, 1868, pp. 13-65) lays particular stress upon the fact that in membranous croup the dyspnoea exists both in inspiration and expiration, whereas in spasmodic catarrhal croup it is chiefly present in inspiration, and is due, he thinks, to paralysis of the crico-arytenoid muscles from oedema and infiltration, so that the vocal cords are brought into contact during inspiration. There is one further peculiarity about the dyspnoea in membranous croup AUSCULTATION. 03 to which we would direct especial notice, since we regard it as of the utmost importance. This consists in the occurrence, in certain cases, of a deep sulcus around the base of the chest, and of recession of the lower part of the sternum and the epigastrium during the act of inspiration. These phenomena are, perhaps, partly due to the violent action of the diaphragm, but undoubtedly their chief cause is the atmospheric pressure, which acts here, as it has been clearly shown by Jenner to act also in rickets to produce the deformities of the thorax characteristic of that dis- ease. The normal relation which exists between the firmness and resist- ance of the thoracic walls, the power and rapidity of contraction of the diaphragm, the elasticity of the lungs, and the size of the orifice of the larynx, is here disturbed by the greater or less degree of occlusion of the larynx by membranous exudation. The calibre of the larynx being thus diminished, so that air enters the lungs but slowly, and the diaphragm contracting violently, there will necessarily be recession of the softer parts of the chest-walls at each inspiration. The persistence of these phenomena during inspiration for even a short time is, we believe, in the highest degree characteristic of the presence of false membranes in the larynx ; and when, despite the use of emetics, this form of respiration continues, it constitutes one of the strongest indica- tions for the performance of tracheotomy. There is no expectoration early in the disease, or it consists of yellowish viscous mucus. At a later period there is usually expectoration of false membrane, sometimes in the form of a complete tube, or, much more fre- quently, of small, irregular fragments, mixed with mucus, or with the matters ejected from the stomach by vomiting. To detect the membrane, the substances expectorated or vomited ought to be placed in water, when the former detaches itself from the mucus and other matters, and is easily recognized. It is not voided in all cases in which it is known to be present in the larynx. Thus of the 3-5 cases observed by ourselves, it was expelled by vomiting or coughing in 12; in 21 none was rejected, though its presence in each case was proved by the character of the symptoms and by its existence in the fauce?, by autopsy, or by the operation of tracheotomy ; in one there was expectoration of mas.>ie8 of viscid, yellowish fibrin, though none of membrane; and in one there was no positive evidence of its existence. M. V'alleix (Guide du Mid. Prat., t. i, p. 330) states that of 51 cases, in which the symptoms were very carefully observed, no traces of the exudation could be discoverefl either in the expectoration or in the matters rejected by vomiting in 26, though itij existence was proved by post-mortem exami- nation. AusKTLTATioN. — In the severe ca.«es of true croup that have come under our notice, auscultation has been of little or no aid. In fact, the chest-sounds have been, in most cases, so completely masked by the loud shrillne^ of the laryngeal stridor, that we have been unable to judge with any satisfaction to ourselves of the condition of the lungs. It has been impossible to determine whether the inability to detect natural respiratory murmur def)ended on thf .«iniall vojiinu; of air that found its way through 94 PSEUDO-MEM*BRANOUS LARYNGITIS. the obstructed larynx, or on the fact that all sound was masked by the stridor. This is particularly unfortunate, since, were it not for this cir- cumstance, we might be able to judge by auscultation of the extent to which the bronchia have been invaded by the false membrane, — a matter very important to determine when the question of tracheotomy comes to be mooted in any case. In cases in which the laryngeal obstruction is not very great, and the stridulous sound consequently less loud, we may auscult the chest to some profit. The vesicular murmur is then either natural, or altered according to the state of the lung. But though such has been our own experience in regard to auscultation in croup, MM. Barth and Koger {Trait. Prat, d' Auscultation , 2eme ed., pp. 255 and 261) describe, as a sign of croup with floating false membrane, a kind of vibrating murmur, or tremblotement, as though a movable mem- branous veil were agitated by the respired air, and which can be heard when the stethoscope is applied over the larynx or trachea. If this sound be heard only in the larynx, and not in the trachea and bronchia, it indi- cates the plastic exudation to be of small extent, and likely to be rejected by expectoration, and the prognosis is favorable. In the other case, on the contrary, it shows the disease to be of considerable extent, and the prognosis becomes much more serious. This question will be found referred to more fully in our remarks on the indications for the operation of tracheotomy. There is a sWght febrile movement at the onset, or a day or two after the appearance of the earliest symptoms. When the disease is fully estab- lished, the fever becomes violent. The pulse rises to 130, 140, 160, or even higher ; it is generally regular and strong at first, but as the case pro- gresses, becomes small, feeble, and very rapid. In one of the paroxysms that we witnessed, it became so rapid that it could not be counted, and at last ceased to beat at either wrist for a few instants. The heat and dry- ness of the skin are very moderate at first, but increase as the disease reaches its maximum, to diminish afterwards gradually, and in fatal cases, to be replaced by coldness, with copious clammy perspirations. The strength is not diminished at first, but as the disease progresses, becomes more or less so in proportion to the violence and duration of the case. The digestive organs are but little disturbed by the influence of the disease, with the exception of diminution or loss of appetite, and moderate thirst, during the violent period. Spontaneous vomiting or diarrhoea are rare, though both sometimes occur. The tongue is moist, and generally cov- ered with yellowish-white fur. Pain in front of the larynx has been noticed by several authors. We have ourselves observed it in but one case. Tumefaction of the submaxillary glands, which is a frequent symptom of pseudo-membranous angina, ought always to be sought for, and when present lends additional support to the diagnosis. The mode of recovery in favorable cases is different in different instances. In some it is sudden, taking place rapidly and steadily after the expecto- ration of a tubular-shaped membrane. The rejection of the deposit in MODE OF RECOVERY — DURAtlON — DIAGNOSIS. 95 this form is, however, a rare event, and is not always followed by recovery. We have seen in this city three distinct tubnles of false membrane, which were thrown from the larynx of the same chihl at intervals of two days each. The first was the largest, and came evidently from the whole length of the larynx and trachea ; the second was somewhat shorter, and the third not more than half so long as the first. The child was greatly re- lieved for some hours on each occasion of the rejection of a tubule, but then became more oppressed as the exudation again collected. It sank from exhaustion after the third came away. As a general rule, the recovery is slow and gradual. After free vomit- ing, after the expectoration of fragments of false membrane mixed with mucus, or, as happened to ourselves in two cases, after the expectoration of masses of tough yellowish fibrin, or, lastly, after the rejection of mucoid and frothy sputa only, the symptoms gradually ameliorate ; the stridulous respiration slowly subsides, and at last disappears; the cough, which was short, hoarse, and smothered, becomes louder, stronger, less hoarse, and what is still more favorable, loose ; the aphonia moderates, but very slowly; the fever disappears; appetite and gayety' return ; and, after a variable length of time, the child enters into full convalescence. The hoai*seness of voice very generally continues for several days after all the other symp- toms have lost their dangerous character, and sometimes lasts for weeks. In one case the voice was still weak and hoarse on the tenth day, and in another during the seventh week. {See a paper on Croup, by J. F. Meigs, M.D., Am. Med. Jour. Med. ScL, April, 1847.) Duration. — Death has been known to occur on the first, second, and third days, but such cases are rare. The duration of the disease may be stated at from three to thirteen days, as its most common term. Tlie cases seen by ourselves lasted from five to fourteen days. Diagnosis. — There can be no difliculty in recognizing the presence of pseudo-membranous laryngitis, when the development of the symptoms of lar}-ngeal obstruction has been preceded for several days by angina, with or without membranous exudation, and hoarseness of voice and cough. For the relation which exists between such cases and diphtheritic croup, the reader is referred to the remarks at the begiuniug of this article on the nature of croup, and to the remarks made under the head of diagnosis in the article on diphtheria. When, however, the disease begins in the larynx, and especially when there is no exudation whatever in the fauces, the diagnosis becomes more embarrassing, .«ince under these circumstances there are two other larvn- geal affections with which true croup maybe confounded, to wit: false croup or spasmodic catarrhal laryngiti.^, and laryngismus stridulus. The mode of distinguishing between these different disorders has been carefully described in the remarks on diagnosis, under the head of the former dis- ease. We wish in this place merely to call the attention of the reader, and particularly of the young practitioner, to the extreme importance of the differential diagnosis between the disease now under consideration, and false or spasmodic croup, since the former is one of the most dangerous and frightful disorders to which children are subject, demanding vigorous 96 PSEUDO-MEMBRANOUS LARYNGITIS. and active treatment from the start, at which period only is medical treat- ment likely to be successful ; whilst the latter, though of a much more threatening aspect at the beginning, is in fact a mild and safe disease in comparison, and one rarely requiring other than very simple treatment. In this connection we would urge again the extreme importance of a careful examination of the throat in every case where there are even the most trifling croupy symptoms present, since if menibranous exudation be present either on the pharynx or tonsils, there is great danger that the laryngeal symptoms are due to an extension of the false membrane. Prognosis. — Pseudo-membranous laryngitis is a very fatal disease. In its sporadic form it is decidedly less dangerous than when it occurs in the course of epidemic diphtheria, owing to an extension of the exudation from the fauces into the larynx ; but it still ought, at all times and in all shapes, to arouse the utmost caution of the practitioner. MM. Rilliet and Barthez state that its common termination is in death. M. Valleix says that, " to speak in general terms, it is fatal when not treated energetically." M. Guersent {loe. cit, p. 365), after a careful con- sideration of the statements of various authors, says: "In fact, true croup is one of the most dangerous of all diseases ; it is generally fatal." He adds that he has seen at least 100 cases of spasmodic croup without a single death, while of 10 children attacked with true croup, it is scarcely possible to save two. We have ourselves seen upwards of 200 cases of spasmodic or false croup, all of which without exception recovered, while of the 35 cases of true croup, of which we have preserved careful notes, 16 died. The danger is great in proportion as the child is younger and more feeble, and in proportion to the rapidity of the case and the degree of the dyspnoea. The most unfavorable symptoms are : loud stridulous sound, heard both in the inspiration and expiration ; laborious, and prolonged expiration ; recession of the base of the thorax during inspiration ; whis- pering voice or complete aphonia ; congestion of the face and neck ; som- nolence ; weak, rapid, and irregular pulse ; cold extremities ; and cold, clammy perspirations. The favorable symptoms are: expectoration of false membranes ; diminution of the stridulous respiration ; the change from whispering to hoarseness or to clearness of the voice ; looseness of the cough ; moderation of the fever ; improvement of the temper and moral state ; and amelioration of the general condition. The case should not, however, be abandoned as hopeless until life is ac- tually extinct. An instance has been elsewhere put on record by one of us (see paper by Dr. J. F. Meigs, loc. cit.) of the recovery of a child after momentary suspension of animation from asphyxia on two occasions, though these attacks were followed by a dreadful illness of two days. , Treatment. — We are desirous, at the beginning of our remarks upon the treatment of this disease, to express the opinion, that none is likely to succeed, unless it be applied early in the case, and by this we mean, in the course of the first, or at the latest, second day. And not only should it be commenced early, but the most active remedies ought to be applied at this period, in their full force. The very moment there is good reason TREATMENT — BLOODLETTING. 97 to suppose that a case will prove to be oue of membraDOUs croup, the most energetic means ought to be brought to bear upon it, and if this be done from the first, or even second day, we cannot but hope that a considerably- larger proportion of recoveries may take place than has heretofore been thought possible. In the study of the treatment, it will be ne^cessary to rely chiefly upon the works that have been published since the distinction between the two forms of croup has been correctly drawn, for it is impossible to place much de}>endence on the assertions of previous writers, inasmuch as their opinions in regard to the eftect;s of treatment must have been formed from indiscriminate experience in two very opposite maladies. It is only nec- essary to recollect the enormous difference in the mortality of the two affections, as shown by our own experience and the statistics quoted from Guersent, to be convinced that the success of any plan of treatment in the one, is no fair argument for its probable success in the other. The most important objects to be held in view in the treatment, are the following: to prevent, if this be at all possible, the formation of false membrane; after its production, to cause its dissolution, or render it less adherent; to pro- voke its expectoration; to prevent its reproduction after it is once expelled; to subdue the inflammatory diathesis which exists ; to allay the painful symptoms; and in every way to support the system. Bloodletting. — Some authors still award to bloodletting a high place in importance amongst the medical means in our possession, and it was for- merly regarded by many in this country as an indispensable agent in the cure. Moreover, there are not a few who believe that, when promptly and boldly resorted to, it will seldom fail in arresting the disease. The more careful and extended study which this question has received during the past few years, however, has led many observers to doubt the efficacy of venesection in arresting the course of this inflammation, or pre- venting the formation of membranous exudation. In those cases where croup supervenes in the course of epidemic diph- theria, there can be no doubt that bloodletting is entirely contraindicated; and the same remark may be made of those sporadic cases of pseudo-mem- branous laryngitis, where the onset of the disease is slow, and its course gradual, and unattended by high febrile reaction. Indeed, the more wide experience we have ourselves had in the treatment of this disease during late years, has convinced us that bloodletting is, to say the least, unneces- san*', excepting perhaps in cases where the disease occurs suddenly in vigorous children, and is attended at an early period of the attack by violent febrile action and especially marked suff(jcative symptoms. Under such circumstances, and such only, it may be advisable to resort to a moderate general venesection, principally for the mechanical relief thus afforded to the acute and intense venous stasis caused by the obstructed respiration. For all the other indir-ations, however, for which bleeding was formerly recommended in croup, namely, for the reduction of the fever and inflam- mation, and for the arrest of the exudative process, we prefer resorting to the other remedies hereafter mentioned. 7 98 PSEUDO-MEMBRANOUS LARYNGITIS. Emetics. — Emetics are recommended by all writers, and are generally acknowledged to be amongst the most, if not the most, efficient of all the means employed. M. Valleix (op. cit, i. i, p. 358) has demonstrated their importance more fully than any other writer. He states that of fifty-three cases of the disease, tartar emetic and ipecacuanha were chiefly relied on in thirty-one, of which fifteen were cured ; whilst of the twenty-two others, in which they were parsimoniously given, but a single one recovered. He gives other facts in regard to these cases which are highly interesting and important. Thus, of the thirty-one cases treated with powerful emetics, false membrane was rejected during the efforts of vomiting in twenty-six ; and of these, fifteen, or nearly three-fifths, recovered. In the five others of the thirty-one, on the contrary, no membrane was expelled, and they all terminated fatally. Again, of the twenty-two cases in which emetics formed but a secondary part of the treatment, two rejected false mem- brane, and of these one recovered ; while of the twenty others in which no false membrane was expelled, not one escaped. Our own experience in regard to emetics has been as follows : They were administered frequently and in full doses in thirteen of the twenty- one cases which began with angina, of which we have preserved notes ; in six they w^ere employed to a moderate extent, and in two not at all. Of the thirteen cases in which they were freely administered, eleven recovered ; but, as in one of these life was saved only by tracheotomy, the success can- not be attributed to the emetics. Of the eight cases in which the emetic plan was not pushed, all but one ended fatally. False membuane was re- jected in eight out of the thirteen cases above referred to. In one of the eight cases the quantity rejected was very small, and this was the case in which the child was ultimately saved only by operation. Of thirteen cases in which the disease began in the larynx, emetics were energetically used, and frequently employed, in eight. Of the eight, five recovered. In four of the eight cases, fragments of false membrane were rejected, and in a fifth, a mass of viscid, yellowish fibrin (this case was marked as one of unquestionable membranous croup by patches of false membrane on the tonsils). Of these five, four recovered. In three of the eight, no false membrane was rejected, and of these two died. In five of the thirteen cases they were not freely used, being employed in two only as a secondary means ; in one other only at the very termination of the attack, as we were not called to the case until the tenth day, the patient having been under homoeopathic treatment before ; and in the remaining two cases they were not employed at all. Tracheotomy was performed in four of these five cases, but in only one was a successful result obtained. It is indeed true that there were peculiarities about the age and the type of the disease in the above groups of cases which may modify to some extent the conclusions which seem inevitable ; but the statements and facts above given are quite sufficient to show that emetics exert a most powerful and beneficial influence on the disease, and that they ought, therefore, to form a principal and essential part of the treatment. The emetics generally employed in Europe and this country are tartar emetic and ipecacuanha, which are given in the usual doses to produce i TREATMENT — EMETICS. 99 full vomitiug. We would, however, strongly discouuteuanee the employ- ment of tartar emetic as an emetic, under any circumstances, in children; and, at least in the disease under consideration, we do not like ipecacuanha as an emetic so well as one which, so far as we know, was fii-st recom- mended by the late Dr. Charles D. Meigs. We refer to the Alumcn of the Pharmaco|xiMa. In an article published by him in the Medical Examiner (vol. i, p. 414, 1838), he says he has been " accustomed to make use of an emetic, which, so far as I can learn, is very little employed, but which, from the certainty and the speediness of its operation, ought to be more generally admitted into the list of available medicines for this particular case at least. I have been familiar with its effects for more than twenty years, and my con6dence in them increases rather than diminishes by time." He adds, " I think that I have never given more than two doses without causing very full vomiting ; but I have often given large quantities of antimonial wine and ipecacuanha, without succeeding in exciting the efforts of the stomach." The alum is given in powder, in the dose of a teaspoouful, mixed in honey or syrup, or in syrup of ipecacuanha, to be repeated every ten or fifteen minutes until it operates. It is not generally necessary to give a second dose, as one operates in the majority of cases very soon after being taken. We have known it to fail to produce vomiting only in two in- stances, both of which were fatal cases. In one the disease had gone so far before we were called, that no remedy had any effect upon the stomach. In the other, it was administered several times with full success, but lost its effect at last, as had happened also in regard to antimony and ipecacu- anha. The reasons for which we prefer alum to antimony, or ipecacuanha alone, are the following: Antimony, when resorted to as frequently in the disease as we are of opinion that emetics ought to be, is too violent in its action ; it prostrates many children to a dangerous degree, and is, we fear, in some cases, itself one cause of death. It acts injuriously upon the gastro-intestinal mucous membrane when used in large quantities and for any considerable length of time. Again, it is very apt to lose its effect, and to fail to produce sickness. Ipecacuanha is a nuich safer remedy than tartar emetic, but its operation is often too mild, and it not unfrequently fails to produce any effect after it has been used several times. The ad- vantages of the alum are that it is certain and rapid in its action, and that it operates without producing exhaustion or prostration beyond that which always follows the mere act of vomiting. It does not tend like antimony, and in a less degree ipecacuanha, to produce adynamia of the nervous system ; an effect which, in some constitutions or states of the con- stitution, or when it has been exhibited frequently, is often attended with injurious or even dangerous consequences. We have given alum in the dose above mentioned every four or five hours, for two and three days, without observing any bad effects to result from it. The alum was given in all the cases that we have seen, in which eraetio were used, and was usually the only one employed when it was found to produce full vomit- ing. In one of the cases accompanied by violent angina, ipecacuanha 100 PSEUDO-MEMBRANOUS LARYNGITIS. was substituted because of its smaller bulk. We have already said that it failed to produce vomiting only in two instances. It was the emetic employed in the nine cases in which fragments of false membrane were rejected, and in that in which the yellow viscid fibrin was expelled. Al- though it did not occasion the rejection of membrane in the other cases, it operated most speedily and efficiently. Sulphate of copper has been highly recommended by several writers for its emetic operation, and, by some of the German physicians, as exerting a specific influence upon the disease in addition to its emetic effect. As an emetic, it may be given to a child two or three years old, in the dose of from half a grain to a grain every fifteen minutes, until it operates. To obtain its specific action it is continued afterwards in doses of a quarter of a grain every two hours. We have also employed, with very good results, sulphate of zinc dis- solved in syrup of ipecacuanha, in the proportion of 2 or 4 grains to the fluid ounce. Of this, a teaspoonful may be given to a child two or three years old, and repeated every fifteen minutes until it operates. This com- bination appears, like that of alum and ipecacuanha, to possess the double advantage of mild action without the production of any subsequent de- pression. In the third edition of this work we referred to the use of the yellow sulphate of mercury (Hydrargyri Sulphas Flava) as an emetic in croup, as recommended by Dr. Hubbard, of Maine. Our own experience with this remedy has been limited, and not very decided. In the American Journal of Obstetrics, for May, 1870, Dr. Fordyce Barker, of New York, speaks in the highest terms of praise of its emetic effects in this disease. He always commences the treatment by a dose of from three to five grains, according to the age of the child, which may be repeated if it do not act, which he states very rarely occurs, in fifteen minutes. This he follows up with the use of veratrum viride, and states that the treatment has been' successful in every case of true croup in which he has employed it. Un- doubtedly this high testimony in its behalf justifies a further trial of tur- peth mineral in croup, though we confess to a suspicion that not a few of the cases in whose incipient stage he has administered this drug so success- fully would have proved to be instances of the severe catarrhal and not of the true membranous form. We conclude these protracted remarks upon emetics with the statement that from what we have read, and from personal experience, we are in- duced to regard them as the most important remedies we have to oppose to this fearful malady. The emetic, whatever it may be, ought to be given three or four times in the twenty-four hours, and in severe cases, once in every four or five hours. The exact periods and frequency of the admin- istration must be determined by the stage and urgency of the symptoms, and by the constitution and present strength of the patient. Mercury. — This powerful drug was first employed freely in the treat- ment of membranous croup in America, and has subsequently been exten- sively used by English and European physicians. Calomel is the prep- aration almost always preferred, and many authors still recommend the LOCAL TREATMENT. 101 administration of this remedy, in larger or smaller doses, iu the earliest stage of the attack. During late years, our increased dislike of the administration of mer- cury to children in large and frequently repeated doses, and the constant observation that even its free use does not appear to arrest the course of true croup, or prevent the formation of membranous exudation, have led us to abandon entirely its employment in this disease. At the same time we believe there has been found, iu the free admin- istration of the alkalies, an agency far less injurious than mercury, and equally powerful, if not more so, iu promoting the separation and discharge of the exudation, and preventing its reproduction. The internal remedies, then, upon which, after emetics, we rely most surely, are various alkaline salts, the use of which iu large doses, has been of late years highly recommended, both at home and abroad. Those which we are most in the habit of employing are the chlorate and citrate of potash, which should be given in full and frequently repeated doses, as, for example, two or three grains every two hours to a child of four years old. We are also in the habit of combining with the chlorate of potash, tincture of the chloride of iron, in doses of three to five drops, at the same age. Anthpasmodics are undoubtedly useful in some cases, when there is much laryngeal spasm. Opium is, however, the best remedy that can be employed for this con- dition, since it constitutes an important element in the treatment, by allevi- ating pain and restlessness, at the same time that it relieves the laryngis- mus, and thus diminishes the asphyctic symptoms. AVe would consequently recommend the use of some of the preparations of opium, as the tinct. opii deodorata, in such doses and at such intervals as will maintain a gentle opiate impression. In this, as in many other diseases of children, it is better not to prescribe the opium in combination with the other remedies that may be administered, but to either give it separately, or better still, to add it to the dose of the other medicines at the time of administration, 80 that the amount of the dose of opium and the frequency of its repeti- tion may be modified constantlv in accordance with the condition of the child. Revulsives often prove useful in allaying restlessness, and moderating the violence of the suffocative attacks. Sinapisms and mustard poultices, applied upon various parts of the cutaneous surface, and mustard foot- baths, are amongst the best. The warm bath is often highly beneficial in the same way. We do not think it desirable ever to employ blisters in this disease. Lkx'AL Treatment. — In those cases, and, as we have seen, they consti- tute the large majority of all cases of true croup, where the exudation appears in the fauces or on the tonsils before it involves the larynx, local applications to the throat are undoubtedly of importance. The objects of such applications are here, as in diphtheritic angina, to promote the separation of the false membrane, and to prevent its repro- duction. To fulfil thf first f)f thf'sc indifations, manv authorities rccom- 102 PSEUDO-MEMBRANOUS LARYNGITIS. mend astringent and caustic applications, which cause the pseudo-mem- brane to contract and shrink, and thus tend to promote its separation ; while others direct the use of those agents which exert a solvent action upon the exudation. In the former class, the most advisable are, alum ; tannic acid ; solu- tions of nitrate of silver ; the astringent salts of iron, especially the tinc- ture of the chloride and the perchloride; dilute mineral acids and carbolic acid. Of these applications, those which we prefer are a solution of nitrate of silver, in the proportion of 5 to 20 grains to f ^j of distilled water ; and tincture of the chloride of iron, in the proportion of f3ss. to fjij, to the f 5j of water. The second group comprises chiefly solutions of various salines, as the carbonate of potash, bicarbonate of soda, chlorate of potash ; and lime- water. If any of the astringent or caustic solutions are employed, we would rec- ommend their application only to the patches of exudation in the fauces, since we regard it as highly doubtful whether they actually possess the power of preventing the formation of membranous exudation when ap- plied to the surrounding mucous membrane. Still more should we doubt the efiicacy or advantage of introducing such solutions, and especially the more powerful ones, into the larynx ; either by pressing a soft sponge sat- urated with the solution upon the chink of the glottis, or by passing the sponge directly into the cavity of the larynx, as recommended by Dr. Horace Green. {Observ. on the Path, of Croup, etc., New York, 1852.) The practicability of this proceeding is undoubted, and a certain number of cases are on record in which it seems to have been used with success ; but we have never resorted to the treatment ourselves. In cases occurring in older children, who can be induced to inhale the vapor from an atomizer, or to allow a hand-ball atomizer to be used, the various astringent and solvent solutions above mentioned can be applied most satisfactorily in this manner ; and, when this is practicable, we would prefer the use of lime-water or one of the alkaline solutions. We attach so much importance to this remedy, and have found it to be followed by so much relief and comfort that we are in the habit of direct- ing the inhalation of vapor of lime-water for five or ten minutes at least every two hours. In order to obtain the advantage which undoubtedly follows the inhala- tion merely of the watery vapor, we are in the habit of causing the child to inhale the vapor from slaking lime for a few minutes in every hour, by covering the patient's body with a thick cloth, and holding a vessel con- taining the slaking lime a short distance below his mouth under the cover- ing. It is doubtful, however, whether any appreciable amount of lime is carried up by the vapor so as to give the additional advantage of its sol- vent action upon the exudation. The reader is referred for more detailed discussion of this question of local applications in the treatment of croup, to the remarks upon treatment in the article on diphtheria. I HYGIENIC TREATMENT — TRACHEOTOMY. 103 Hygienic Treatment. — The child ought to be warmly clothed, and confiued to bed. The temperature of the room should be kept equable, and about 70° F. ; the air should also be frequently changed, so as to pre- serve it constantly pure and fresh. Owing to the loss of appetite and the pain caused by deglutition, it is often very difficult to induce the little patients to take food, so that this important element in the management of the case requires the utmost tact and attention. During the early part of the attack, the food should con- sist of light animal broths, beef tea, and preparations of milk. Later in the case, when the violence of the febrile action subsides, or if any symp- toms of exhaustion and prostration appear, a small amount of wine and water, of wine whey, or of weak milk punch, should be given. Ice, given in small pieces to be held in the mouth, should be used very freely, a.s it relieves the parching thirst and at the same time appears to act favorably upon the inflamed mucous membrane. Summary of the Treatment. — The general plan of treating this dis- ease should, therefore, in our opinion, be somewhat as follows : The child should be confined strictly to bed. The food should be light, digestible, but nourishing, and, upon the earliest approach of exhaustion, a stimulus should be administered. In the early part of the attack, we should advise the use of revulsives, with mild counter-irritants ; topical applications to the fauces if there is any membranous exudation visible, and the internal administration of citrate of potash, with ipecac and small doses of opium, or of chlorate of potash with tr. ferri chloridi. So soon as the symptoms positively indicate the presence of false membrane in the larynx, we should resort to emetics, as directed in our remarks upon those remedies. During the whole treatment we should also recommend frequent inhalations of the vapor of lime-water or some other alkaline solution. And finally, after employing these means faithfully but without securing the discharge of the false membrane, while, on the other hand, the symptoms of laryngeal obstruction steadily progress, and the respiration grows more and more difficult, we must consider the propriety of resorting to the operation of tracheotomy, a proceeding which, as will be seen from the ensuing remarks, we approve of under the above circumstances. Tracheotomy. — The operation of tracheotomy would be apt to suggest itself to a medical man, on his witnessing the closing symptoms of croup, as the very means most likely to aflford to the patient relief from the dread- ful sufferings under which he labors, and as a possible rescue from impend- ing death. It has accordingly been often resorted to in different parts of the world, at various .stages of the di.sease, but with results that have led to ver}' different conclusions. In England, for example, the operation was almost universally con- demned and abandoned about ten years ago ; and in a former edition of this work, we presented the unfavorable opinions of the most eminent English authorities. It was a matter of very great surprise, at that time, that the results of the operation in the hands of Engli.sh surgeons should differ so widely from those obtained by the French physicians in similar cases. And, sm 104 PSEUDO-MEMBRANOUS LARYNGITIS. there was no good ground for believing that sufficient difference existed between the croup of Paris and Loudon, to explain the difference of suc- cess in the two cities, it is probable that the great disparity resulted, in part, from the operation being performed in France at an earlier stage of the disease, and in part also from the more careful after-treatment which the patients received. Within the past few years, however, the operation has been more favor- ably regarded by English surgeons, and the statistics published show that the proportion of success now obtained does not fall far short of that claimed by French operators. Thus in a paper read before the Eoyal Med.-Chir. Soc, in 1857, by Dr. Fuller, it is stated that up to that time 22 cases of tracheotomy in croup had been recorded in England, and that life had been saved in 8 of these, or in 1 out of every 2f cases. In the statistical report of English Hospitals from 1854-59, it appears that the operation had been performed in 15 cases with 4 recoveries, or 1 in every 3| cases. Still further, from the statistics published by indi- vidual operators in England, since 1858, though it is not to be presumed that we have met with all the cases recorded, it appears that tracheotomy has been resorted to in 63 cases, with successful results in 24, showing a success of 1 in 2f . When it is borne in mind also, that in each of these instances the opera- tion was postponed to the last suffocative stage, and that without exception the operators believe that the proportion of success would have been in- creased by its somewhat earlier performance, it becomes evident that tracheotomy has acquired a fair position in England among the legitimate operations of surgery. It is thus advocated by Fergusson in the last edition of his Practical Surgery; and Dr. West, in 1859, speaks of it in these terms: "In spite of the unfavorable issue of the few cases in which I have either directed or sanctioned the performance of tracheotomy in croup, I am so far from being opposed to the operation, that my chief anxiety is to make out the indications which may justify me in having more timely recourse to it in future." In Germany, also, the operation, if not generally practiced, is regarded as fully justifiable, and recommended and successfully performed by many of the most eminent authorities. The statistics of the results there obtained, borrowed from Fock ^ and Voss,^ show that of 50 cases operated on in the last stage, 24 terminated favorably, giving a success of 1 in 2yL^ or 48 per cent. Steiner has also recently published {Jahrh. /. Kinderheilk., No. 1, 1868) the results of the operation in 52 cases (33 boys and 19 girls), which show a recovery of 18, or 34.6 per cent, of those operated upon ; and in an article upon diphtheria and tracheotomy by Giiterbock {Arch. d. Heilhunde, 1867, No. 6) 100 cases, operated on in Berlin, are reported, with 33 cures. 1 Keport on Tracheotomy. Brit, and For. Med.-Chir. Kev., July, 1860, from Deutsche Klinik, 1860. ' New York Journal of Medicine, January, 1860. TRACHEOTOMY — STATISTICS. 105 It is, however, in France that the operation first obtained, and has since firmly held, the position of a proper and legitimate method of treatment under certain circumstances of the disease. M. Bretonneaii, of Tours, was the first who practiced it with sufficient success in France to give it some vogue. Since that time, it has been recommended and performed by many dit!erent surgeons and physicians in that country, and particularly, as is well known, by M. Trousseau, who has been undoubtedly the most ardent and persevering, as well as the most experienced advocate of the operation. In one of his later publications upon this subject {Arch. Gen. de Med.y Mars, 1855, p. 259\ he thus boldly advocates it : " For ray part, I am quite determined not to allow myself to be discouraged, but to preach trache- otomy with the greater conviction in proportion as its success increases, and did this proportion remain what it was ten years since, I should still proclaim the necessity of the operation, nor cease to say that it becomes a duty, a duty as imperative as the ligature of the carotid artery after a wound of that vessel, though death follows the operation as often, certainly, as recovery." M. Guersent {Did. de Med., t. ix, p. 376) recommends the operation when the usual therapeutical methods have failed, "as the only means that offers a remaining chance." He adds (p. 377) that he is certain it does not add to the danger of the disease. MM. Rilliet and Barthez (Mai. des Etifants, 2^me ed., t. i, p. 337) say that " the utility of tracheotomy in the treatment of croup cannot at this day be denied ; numerous cases of children snatched from a certain and imminent death, reply victoriously to any doubts that may be raised as to the truth of this assertion." The authors of the Comp. de Med. Prat. (t. ii, p. 587) remark that of late years, " the successful operation.s have been numerous enough to dispel the unfor- tunate prejudices which tracheotomy has hitherto inspired." M. Yalleix {Guide du Med. Prat., t. i, p. 388) says that the number of recoveries are " now too numerous to allow any one to think of opposing the operation except by statistics." MM. Hardy and Behier {Trait, de Path. Int., 1850, t. ii, p. 496;, in speaking of the contest in regard to the propriety of the operation, say, "But the question seems now to be definitely settled ; the operation has succeeded in fact in a little more than one-fourth of the cases io which it has been performed, and, in presence of these results, it may be said to become the duty of the physician to have recourse to it whenever, notwithstanding an appropriate treatment, the general and local symptoms indicate the extension of the false membrane." M. Bouchut (Trait, des Mai. de^i XouL-nes, 2c*me ed., p. 316 j says, that when medical means have failed, and the disea.se has produced a " state lending towards asphyxia, in which an attack of suffocation might cause the death of the child, there should be no hesitation ; a new route must be artificially opened to the external air; tracheotomy must be performed." At the time mrjst of the above expressions were writen, a comp)aratively small number of operations had been placed U[>on record in France, but they were quite sufficiently numerous to show conclusively that, if the operation were carefully performed, and the after-treatment skilfully con- ducted, from 25 to 33 per cent, of the cases would recover. This excellent 106 PSEUDO-MEMBRANOUS LARYNGITIS. result is to be in great part attributed to the improvements introduced by Trousseau, and subsequently by other operators, both in the mode of per- forming the operation, and in the after-treatment of the cases. Since the publication of the last edition of this work the operation has continued to be so frequently performed in France, that we cannot find space to quote the results obtained by individual operators. The aggregate of their reports, however, as collected by Koger and See, Chaillou, Barthez, etc., yield a result of about one recovery in four in a series of over 500 cases. The proportion of recoveries has varied considerably in different years in accordance with the type of the epidemic ; in some years, as 1858, falling as low as 1 in 6.9 (124 operations, and but 18 recoveries), while in other years it has risen even higher than 1 in 3. It is further to be remembered that these French statistics are chiefly derived from the reports of the Hopital des Enfants in Paris, and refer, therefore, to a poor class of patients, who have in many instances been subjected to improper and debilitating treatment before reaching the hos- pital, and who are exposed to unfavorable hygienic conditions while in the institution. When these unfavorable circumstances are allowed their full weight, it must be conceded that the operation of tracheotomy has achieved a considerable share of success in France, and has fully justified the elo- quent and enthusiastic advocacy of Trousseau. In America, tracheotomy has been resorted to but rarely until within the past few years. The statistics which have been lately published, how- ever, fully sufiice to show that, in the hands of American physicians, it has been very nearly, if not altogether, as successful as it has abroad. Dr. H. H. Smith ( Oper. Surg., 2d ed., vol. i, p. 473) gives the results of 26 operations performed in this country, of which 9 recovered. Dr. Gay {Boston Med. and Surg. Jour., Jan. 27, 1859, et al.) reports 13 operations, with 7 cures and 6 deaths ; and other operators in Boston have performed the operation in all 15 times, with 7 cures and 8 deaths. But by far the most extensive statistics have recently been published by Dr. A. Jacobi, of New York (Amer. Jour, of Obstet, May, 1868, pp. 13 to 65), derived exclusively from the practice of physicians in that city. The following table shows the results obtained : Operator, Jacobi, L. Vo?s, E. Krackowizer, . W. Von Eoth, . Total, In this city the operation has been as yet but seldom resorted to, and with but moderate success, owing to the fact that in nearly every instance it has been postponed until the child was almost moribund. The follow- ing table embraces certainly the great majority of the operations that have been performed ; for a knowledge of which we are to a great extent in- Percentage No. of cases. No. of cures. success. 67 13 . 19^ 43 10 . 23^ 55 . 16 29 48 . 11 23 — . 213 60 23^ I TRACHEOTOMY STATISTICS. 107 debted to the courtesy of the operators, since but few of them have as yet been placed on record : Xanie of operator. No. of cases. Xo. of cures. Physick, 2 Goddard, . 2 Pajje, . 1 J. Paneoast, 6 3 R. J. Levi?, . 14 2 T. H. Baohe, 1 A. Hewson, . 1 H. Lenox Hodge, . 9 2 J. H. Packard, . 3 T. J Morton, 3 2 GfK>dman, 3 1 Drysdale, . 9 3 Total, . . 54 . 13 or 5 13 or 24.07 per cent. Finally, to sum up the statistics given above, although even this aggre- gate does not include by any means all recorded cases, Jacobi states (loe. cit.), that out of 1024 operations of tracheotomy, performed in various parts of the world, but principally in Europe, 220 or 21.48 per cent, re- covered. It is evident, therefore, that wherever this operation has been practiced in tru^ croup, a considerable proportion of cures has been effected; but in order to form a clear opinion as to the real merits of the operation, it is necessary to have some idea as to the number of subjects that might have recovered without a resort to it. This is ver}' easily arrived at in this country, since we believe that it is never performed here except as a last resort, when the patient is manifestly in great danger of death, or absolutely moribund. In regard to the French operations, it is not so clear whether some of the patients, who recovered after the operation, might not have been so fortunate without it, particularly as M. Trou.sseau formerly recommended that it should be performed so soon as we can be certain that the larynx contains false membrane.*. But then it is generally understood that he was not called to many of the cases upon which he operated until all other means had failed, and the child had fallen into an apparently hopeless condition. To elucidate this matter, we shall quote the statements made by M. Valleix, one of the most accurate and impartial of writers. M. Valleix (foe. cit., p. 388-9) tells us that he collected together 54 cases of undeniable, well-marked true croup, treated without the operation, and found that 17 had been cured. Then, examining what had occurred in regard to the operation, he found, as M. Brichetcau had done before, that nearly 1 in 3 had recovered, a success almost precisely the same a«* had taken place in the ca«es treated by meambert, . . . •• 16 «• I Barthez, ..." 13 Archambault, . . ♦* 13 . . " 18 Roc.r. . " 19 Maslieurat Lagemand, *' 23 In adult-, (Ml iML' other hand, tracheoiomy m cruup i.- lo.'^s sucecs-ful tlian in children, probably because, a-s Trous.seau suggests, the form and size of the larynx allow the pseudo-membrane to extend deeply into the broucliia before producing the symptoms of croup. There is another condition which, it is thought by many, ought to con- stitute an insuperable bar to the operation, and the possible exi.-tence of which, in any case, is one of the moat iierious objections that has been 112 PSEUDO-MEMBRANOUS LARYNGITIS. brought against its performance. The condition to which we allude is the presence of pseudo-membranous exudation in the bronchia. The existence of this condition must greatly lessen the chances of a suc- cessful operation, but that it renders success impossible, as has been sup- posed, cannot be admitted. MM. Rilliet and Barthez {op. cit., 2eme ed., t. i, p. 338) say: "It has been said that one contraindication was the pres- ence of false membrane in the bronchia. But, besides the fact that the symptoms denoting its presence are uncertain, we cannot see in this a posi- tive objection to the operation. Recovery has been known to occur, in effect, after the rejection of bronchial false membranes, and we were our- selves witnesses of a remarkable example of this kind. And is there any better mode of facilitating the escape of foreign bodies than by opening to them a passage below the larynx ? Under such circumstances, we must expect to be sure, a greater mortality than under more favorable conditions. This opinion is, moreover, that of M. Bretonneau." Numerous cases are indeed on record, and we have ourselves met with such, where, after the operation, large membranous casts of the trachea and bronchia, which could certainly never have escaped through the larynx, have been dis- charged through the tracheal opening, and their escape followed by com- plete recovery. It appears evident, therefore, that if in such cases, when death is even more surely imminent than in those instances when the exudation does not extend below the larynx, tracheotomy affords even a very slight additional chance of recovery, it should be performed despite the fact that the child will in all probability die. But, apart from this consideration, it must be borne in mind that statis- tics prove that the false membrane extends below the larynx in about one- third of all cases, and still further, that there are no means by which we can with certainty determine in any individual case whether such exten- sion has taken place or not. It was at one time thought that auscultation might afford the desired information, but more careful observation has shown that it is not to be depended upon. As already said, in most cases the laryngeal stridor is so loud as to mask all chest-sounds, and, even when this does not happen, we have frequently observed that no definite and reliable information is to be gained from physical examination. The following cases may be quoted, out of the number on record, besides several that we have ourselves seen, as proving this statement. MM. De La Berge and Monneret {Comp. de Med. Prat., t. ii, p. 587) mention a case in which they could. not believe that the bronchia contained false membranes, as the vesicular murmur was extremely pure and was heard everywhere ; and yet, during the operation, a false membrane was drawn out, which represented the trachea and the division of the principal bronchia. The child died in 15 hours. The late Prof. William Pepper, of this city, reported 2 fatal cases {Sum- mary of Trans. Coll. Phys., vol. iii. No. iii, p. 106), in one of which "dis- tinct vesicular murmur could be heard throughout the lungs, marked only occasionally by sibilant and sonorous rales," a few hours before tracheot- omy was performed. The child died 20 hours after the operation, and TRACHEOTOMY — CONTRAINDICATIONS. 113 the exudation was found to implicate the larynx, trachea, the large bron- chia, and even some of the smaller ramifications. In the other case, the state of the respiration was carefully examined the day before death, and not the least respiratory murmur could be heard over any part of the chest, and yet, in this instance, the exudation was confined strictly to the larynx; not a vestige of false membrane was to be found either in the trachea or bronchia. Iii a case recently attended by us, where tracheotomy had been per- formed, so that all laryngeal stridor was absent, auscultation, eight hours before death, revealed quite strong respiratory murmur, much obscured by snoring bronchial rales. The autero-lateral parts of the chest were alone ausculted. Death occurred somewhat suddenly from the lodgment of a very large tubular membrane from the left bronchus in the trachea ; and at the autopsy there was a tubular membrane found extending throughout the trachea, and through the right bronchus to its third divisions. The left lung was collapsed and congested ; the right one distended and em- physematous. Since, then, we can learn little or nothing from auscultation, or any other means, as to the presence of false membrane in the bronchia, the question becomes one of expediency, so far as this contraindication is concerned., whether to leave two-thirds of the patients, many of whom could certainly be saved by the operation, to perish without an eflfort to save them, because one-third viwst probably die ; or to perform the operation, with very little prospect of success in one-third, for the sake of the chance of saving many of the remaining two-thirds who must otherwise perish. The presence of pneumonia is also universally recognized as greatly les- sening the chances of recovery after tracheotomy. It must be borne in mind, in regard to this point, that pneumonia is frequently overlooked, and indeed that it frequently cannot be recognized on account of the loud tracheal rales which hide all auscultatory sounds; while, on the other hand, it^ presence may be simulated by the occurrence of collapse of some portion of the lung, owing to occlusion of the bronchus leading to it. Millard suggests that the degree of dyspnoea may be of service as indi- cating the presence or absence of pneumonic complication. Thus he has found that in croup not thus complicated the rate of respiration is from 32 to 48, while, when pneumonia is present, it rises above 50. It is probable, also, that by a careful study of the temperature, the occurrence of pneu- monia may be suspected by a marked elevation of several degrees. Pneu- monia of one lung is not, according to Guersent, a contraindication, nor is even double pneumonia regarded by some operators as absolutely inter- dicting the operation, though at the same time we are not aware of a single instance in which it has been successfully performed where this condition was unquestionably present. Another condition in which tracheotomy is thought by many to be con- traindicated, is when membranous croup occurs as a secondary affection, during the course of some constitutional disease other than diphtheria, as, for instance, scarlatina, measles, or pertussis. Such cases were regarded even by Trousseau as absolutely unfit for operative treatment. Still, that 8 114 PSEUDO-MEMBRANOUS LARYNGITIS. this contraindication, although of the greatest weight, does not entirely forbid tracheotomy, is shown by a case of croup following scarlatina, in which Dr. Voss operated, and the child survived 31 days, the tracheal wound being nearly closed. Millard, also, in his excellent essay on tracheot- omy {De la Tracheotomie dans le Cas de Croup, Paris, 1858), records 3 cases of croup secondary to measles, successfully treated by operation. He re- gards croup occurring in the course of pertussis as far less unfavorable, since the violent cough favors the expectoration of the false membranes. There remains, finally, one condition to be indicated in which the ope- ration is, in the almost unanimous opinion of authorities upon this question, absolutely contraindicated. We refer to the cases of profound general diphtheritic infection, where the danger of the child depends upon the constitutional disease, even more than upon the laryngeal obstruction, where the blood is gravely altered, and the well-known tendency exists to the formation of pseudo-membranes upon all abrasions or wounds, so that in all probability the operation would merely serve to invite the Extension of the exudation. Trousseau opposes the operation under such conditions, in the following words : " If the diphtheritic infection have profoundly attacked the con- stitution ; if the skin, and especially the nasal passages, are occupied by the specific inflammation ; if a frequent pulse, delirium, and prostration show the system to be deeply poisoned, and if the danger is rather from the general condition than from the local lesion of the larynx and trachea, the operation ought never to be attempted, for it is invariably followed by death." Even under this most unfavorable of all conditions, however, there are not wanting some operators of wide experience, who still recommend the operation : thus Jacobi (loc. cit.) asserts, that whenever the indication of suffocative dyspnoea, steadily increasing and not relieved by emetics, ex- ists, he would operate despite any complications, general diphtheria, or anything else, and uses this powerful language : " Seeing a person sus- pended by the neck and being strangled, we should hardly investigate the propriety of cutting the rope from the point of view that the sufferer might be or is affected at the same time with tuberculosis, cancer, or dia- betes." After a careful review of the entire question, we believe that the facts upon record justify the following conclusions : that the condition of success which excels all others is the predominance of the characters of asphyxia; that when these are so marked that death is imminent, the operation is justifiable despite any complications which may coexist, save perhaps the presence of grave general diphtheritic infection ; and finally that, when no such contraindication is present, and the dyspnoea is continuous and in- creasing despite all other treatment, the operation is positively indicated, and it becomes the duty of the practitioner to recommend its performance, and, if the decision be intrusted to him, to unhesitatingly assume the re- sponsibility of operating. We have already indicated with sufficient clearness the influence which the age of the patient, the period of the disease, and the character of the TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 115 epidemic exert upon the results of tracheotomy. But we would again al- lude to the marked manuer iu which the result is modified by the charac. ter of the previous treatment, and to the fact that its success is very much interfered with by the earlier employment of any debilitating measures, such as were, until lately, but too frequently adopted. We have more than once been asked by the parents of children, upon whom tracheotomy was about to be performed, or who had actually un- dergone it, what influence would be exerted by the eflJects of the operation, should it be successful, upon a subsequent attack of croup ; and since, as has already been seen from the cases quoted by us from our own experi- ence, second attacks of croup are not very rare, it is interesting to know, that so far the statistics which bear upon this question tend to show that a previous attack of croup cured by tracheotomy is a favorable condition for its performance in a subsequent attack. Thus of 5 cases, collected by Millard, in which the operation was performed for the second time, every one recovered. The second operation was uniformly found much easier, on account of the cicatrix of the former incision serving as a guide, and also on account of the slight amount of the hicmorrhage. Mode of Performing the Operation. — Tracheotomy being an oper- ation which all physicians, whether experienced or not in the use of surgi- cal instruments, are liable to be called upon to perform at a moment's Dotice, no apology is needed for the introduction here of the details of its performance. The following account is in great part borrowed from the pages of that most experienced tracheotomist, Trousseau,^ and from a very complete and practical discussion of the operation by F. Howard Marsh, Esq.' The child should be carefully wrapped up, so as to avoid all exposure to cold ; and if an anaesthetic is to be employed, should be allowed to sit or lie in any position he may choose during its administration, as the con- strained position necessary during the operation tends to increase the diffi- culty of breathing. He should then be placed upon a table, furnished with a thin mattress, and a folded pillow or roll of cloth should be placed under the shoulders and back of the neck, so as to put the skin of the throat upon the stretch, and render the trachea prominent. If the opera- tion is performed during the day, the table should be drawn close to the window, and the patient's face directed toward it, so that a full light may fall upon the throat; if, however, it be at night, and there is not suflicient gaslight, a special as.«istant must be intrusted with the duty of holding the candles or lamp. An assistant is also needed to stand behind the patient and hold the head securely ; and another, whose duty shall be to draw aside the successive layers of tissue and the bloodvessels with a hook, and to .«ponge the wound from time to time. The instruments needed are a sharp-pointed, slightly curved bistoury ; a blunt-pointed bistoury ; two flexible hooks ; a dilator to stretch the inci- sion in the trachea so as to favor the introduction of the canula, and made * Clin. Med., 2ime ed., torn, i, p. 414 ft seq. « St. Barth. Ho«p. Rep., vol. iii, p. 831 ct seq. 116 PSEUDO-MEMBRANOUS LARYNGITIS. like a pair of curved dressing forceps, with a little spur projecting back- ward, so as to catch in the tissues and prevent its displacement ; and finally a cauula. The size and form of this canula are matters of great impor- tance ; and of late years several marked improvements have been effected in them. The calibre of the canula should, as first clearly directed by Trousseau, be as large as possible without interfering with its easy intro- duction into the trachea, and its curve should be that of a quarter of a circle. In regard to this very important question of the size of the canula, we are indebted to Mr. Marsh {loc. cit.) for a series of observations, which appear to indicate that a tube somewhat smaller than that recommended by Trousseau, Fuller, and others, may be equally eflScient and yet less irritating. By a series of careful measurements of the respective diam- eters of the trachea and cricoid cartilage, he established the fact that the latter diameter is almost invariably less than that of the trachea, to an extent varying from ^^gth to 4''ottis of an inch. If, therefore, as his meas- urements show, the diameters of the trachea are as follows : during the first two years of life, ^jo'ths of an inch ; in the third year, :jQths ; in the fourth and to the seventh, ^Jths ; in the eighth and ninth, :^f ths ; and in the tenth, ^Jths ; it will be seen that a canula having a diameter of /gths of an inch will answer for children between the ages of 1 and 4 years ; one of ^ths for children between 5 and 8 years ; and one of | |ths for children between 9 and 12 years old. It may be added, that after the 12th year the diameters of the cricoid cartilage and trachea increase so rapidly, that the canula now usually made for adults, with a diameter of ^fths of an inch, is rather small for children between 14 and 16 years old. The length of the canula should be sufficient to cause it to reach from i to 1 inch below the inferior angle of the wound in the trachea. The canula must also be double, the outer tube having a broad collar in front, with holes through which the band which passes around the neck and secures the canula in position, may be passed and tied. It should also be furnished with a key, which plays easily in a notch on the upper part of the inner tube. This inner tube must so fit the larger one, as to be readily removed and replaced, being secured in position by the little key above mentioned. In some canulas a still further improvement is introduced, by having the outer tube and collar merely yoked together by means of two arches on the collar, which receive small outjutting bars at the sides of the upper extremity of the outer tube, so that this can shift its position according to any pressure it may receive. There is also a canula recommended by Fuller, called the "bivalve canula," the outer portion of which is not a tube, but consists of two nar- row lateral blades, which are easily compressed by the finger and thumb into the form of a thin wedge, and expand again when the pressure is removed. This instrument supersedes the need of any dilator, and has the great advantage of being readily introduced. It is evident, however, .that it must produce much more irritation while in position than a tubular TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 117 cauiila, and in addition, ^Yhen the inner tube has been removed, as is fre- quently required, its reintroduction causes pain and irritation, from the constriction of the mucous membrane which has bulged inward between the blades of the outer portion. Mr. Marsh, therefore, advises that when there is any difficulty in introducing the canula at the time of the opera- tion, a Fuller's tube should be used, but that this should be exchanged on the second day for one whose outer portion is tubular. Although it is almost the universal practice to introduce a canula at the time of operation, its use has been objected to by several good author- ities, as apt to cause inflammation and ulceration of the trachea, and to favor the development of pulmonary complications; and several plans have been suggested for the separation of the edges of the tracheal wound. Thus Mr. Adams, of the London Hospital, recommends the introduction of a strong metallic wire speculum, such as are frequently used in opera- tions on the eyes, and Dr. Pancoast, of this city, employs a pair of blunt leaden hooks. In addition to the instruments already enumerated, some operators, following the practice of the Dublin surgeons, use a hook or tenaculum to fix the trachea, whije the incision is being made through its rings. This proceeding has certain advantages, especially when it is designed to excise a portion of the trachea, or in case of venous haemorrhage, as the trachea can be raised above the pool of effused blood and speedily opened, which will usually check the bleediuo^. It is also of service in vouno: children, because the trachea is then so pliable and yielding, that, unless the hook be used, its anterior wall may be easily driven in front of the point of the scalpel, till it is nearly or quite in contact with the posterior, in which ca«e the latter also may be wounded. Trousseau, Millard, and others, however, strongly object to this practice, believing it to be danger- ous to so fix the trachea and oppose the movements connected with the performance of the function of respiration which is already so much im- paired. Our own observation would go to show that, while the advantages to be gained from fixing the trachea are undoubted, especially in young children, the dangers have been somewhat exaggerated. It has been recommended by several high authorities — Lawrence, Car- michael, G. H. Porter, Brainard, Fergusson — to excise a small piece of the walls of the trachea. By some this has been adopted with the view of dispensing with the use of a canula, but it is claimed that, even when one is employed, this practice renders its introduction more easy ; that the tube fits the oval opening thus made much more accurately than a mere slit, produces less pressure upon the edges, and consequently is not so apt to cause caries of the tracheal rings. It seems never to be 'followed by narrowing of the trachea after the canula has been removed, as might be apprehended. This practice is followed by Dr. Pancoast, of this city, who, in the case he describes, excised an elliptical piece about one-third of an inch long and two-tenths of an inch broad, from the front part of the third, fourth, and fifth rings of the trachea. As already said, he does not emph)y either a canula or dilator, but holds apart the edges of the wound made in the 118 PSEUDO-MEMBRANOUS LARYNGITIS. soft parts over the trachea by means of a piece of thick leaden wire, bent so as to form hooks at either end. The wire is of such a length as to fit accurately around the neck when the hooked ends are placed within the edges of the incision, and thus keep up just sufficient traction in opposite directions to maintain the wound open. In regard to the operation itself, almost all who have had much experi- ence in it direct that it must be performed with great deliberation and care. The incision through the skin should be made precisely in the median line of the neck, and should extend from the cricoid cartilage to a little above the sternum. The slight white fibrous line which marks the inter- space between the sterno-hyoid and sterno-thyroid muscles should then be followed as a guide for the next incision, and the muscular masses drawn aside by hooks. The trachea is now exposed with the isthmus of the thyroid gland, and, occasionally, large thyroidean veins lying upon it, and great care must be observed to avoid wounding these on account of the troublesome haemor- rhage which is apt to follow. A still further reason for this caution is the occasional existence of an anomalous distribution of arteries, by which a branch of considerable size, or even the innominate artery itself, passes over the trachea directly in the course of the wound. Any bloodvessels may be drawn aside by hooks, and the isthmus of the thyroid gland may either be treated in the same way, or if it cannot be drawn away far enough to allow a sufficient incision of the trachea, may be ligated in two places and divided between (Brainard, of Chicago), although, when possi- ble, this had better be avoided. The trachea, having been thus carefully exposed, should be punctured just below the cricoid cartilage, and the probe-pointed bistoury being introduced, and its edge guarded by the nail of the index finger of the left hand, the opening should be enlarged down- wards to the extent of two or three tracheal rings. It usually occurs that there is some haemorrhage during these incisions ; but if it be venous and moderate in amount, the opening of the trachea should not be deferred, as the re-establishment of respiration will usually speedily check it. So soon as the trachea is incised, the dilator should be instantly intro- duced with the blades closed; and so soon as in position these should be moderately opened. Air now enters readily, and there is a discharge of mucus, fragments of false membrane, and blood, through the opening. The canula should then be introduced upon the dilator as a guide, its en- trance being evinced by the increased facility of respiration, and the es- cape of mucus and blood through its calibre. A guard of india-rubber or a disk of waxed cloth should then be placed between the guard of the ex- ternal tube and the skin, to prevent any irritation or chafing, and the canula may be fastened in position by a tape passed around the neck. Should blood bubble up by the side of the canula, as Geraldes observes, the wound in the trachea has been made too large, so that the blood gains entrance during inspiration, and a larger canula should be at once substi- tuted. AFTER-TREATMENT. 119 It occasionally happens, as in a case related by Trousseau, that the trachea is lined by a false membrane, which is partly detached and pressed forward by the end of the canula, so that it completely occludes the open- ing, and thus even increases the asphyxia. When this occurs, the canula should be withdrawn, and an attempt made to seize the false membrane with forceps and withdraw it. When the operation has been a laborious one, emphysema of the neck may be met with, sometimes extending to a considerable distance, and causing great disfigurement or even seriously complicating the course of the case. It results from a want of parallelism between the cutaneous and tracheal wounds, or from marked disproportion between the size of the tracheal wound and that of the canula, or, as occasionally may happen, from the escape of the canula from the tracheal wound. It has also hap- pened that the inflamed and thickened mucous membrane is stretched over and driven before the point of the scalpel, and so escapes a sufiicient divi- sion. It has not been customary to use anaesthetics in the performance of trach- eotomy. Fock, however, advises the use of chloroform, and states that he has never, even in extreme dyspna?a, found any ill effects to result from its employment. At first the dyspnea is increased by the inhalation, but anaesthesia is speedily established, and then the breathing becomes much calmer than before. Dr. Voss, who has also employed it, reports equally favorably of its effects; and Mr. Marsh, who has seen it administered in at least twenty cases, believes that, when carefully and slowly given, it is most beneficial. It must be remembered, however, that, owing to the as- phyxia, the sensibility of the child is usually much blunted, so that, even without anresthesia, the operation has appeared to us to cause but little pain, and has bpen borne by the little patients with scarcely any struggling. After-Treatment. — Immediately after the successful performance of the operation, and the satisfactory adjustment of the canula, an almost in- credible change occurs in all the symptoms of the patient. The wild rest- lessness of the little sufferer, with the agonized, appealing glances at those surrounding the bedside, and the frantic clutching at the throat as though to tear it open to admit air, the lividity of the surface, the noisy, hissing stridor of the respiration, all vanish as though by magic. Very frequently the child falls into a placid sleep, the skin and lips regain their normal color, and the breathing becomes regular, full, and nearly as silent as in health. This calm is not, however, to be of long duration ; there are fright- ful dangers still to be undergone, from which nothing but the most assidu- ous care and skilful treatment can enable the patient to escape with life. It may, in fact, be asserted that the much greater proportion of success which has of late years attended this oix'ration, is to.be attributed chiefly to the more judicious after-treatment which patients receive. Indeed, Trousseau has mostly truly said, with regard to the importiince of this por- tion of the management of the cases, that tracheotomy, badly performed, but well treated aflerward.s, will end favorably io a third of all cases; whereas, tracheotomy excellently executed, but badly treated afterwards, will almost invariably be followed by a fatal termination. 120 PSEUDO-MEMBRANOUS LARYNGHTIS. It might, consequeotly, have been added to the contraindications already enumerated, that, unless we can secure constant and skilful attendance upon the case after the performance of the operation, there can be but little hope of obtaining a favorable result. Wherever it is in any way possible, the constant presence, by day and night, of a physician or student of medicine, should be secured for four or five days after the operation. When this is utterly impossible, all of those engaged in nursing the case should be carefully instructed how to act in the event of any emergency, so that the child shall never be without the presence of some one competent and ready to render the prompt assistance which is frequently necessary to avert instant death. The details of the attention necessary will be given a little further on. One of the first points to which careful attention must be paid, is to give to the air to be inspired through the canula as much as possible the tem- perature and degree of moisture that the air attains by its normal passage through the mouth and nose. Various means have been recommended to secure this object ; thus a piece of loose coarse sponge, wetted with tepid water, and enveloped in a piece of gauze, may be applied over the canula ; or, as directed by Trousseau, " the neck of the child may be surrounded by a cravat of knitted wool, or a large piece of muslin or gauze, so that the patient expires into this thick tissue, and inspires the air impregnated by the warm watery vapor which the expiration has just furnished." This is the only means adopted by Trousseau ; but we may, in addition, by the aid of a spirit-lamp, keep shallow dishes of water evaporating in the room, and at the same time employ a thermometer to regulate the tem- perature of the chamber, which should be uniformly kept at from 70° to 72° F., though the air should be changed frequently, so that it may be pure and fresh. By careful attendance to this clear but long-neglected indication, we not only prevent the rapid drying of the mucus in the canula and trachea, but, as Trousseau asserts, avoid to a great extent the occurrence of pneu- monia or bronchitis as sequelae of the operation. In regard to the treatment of the wound itself, we have already alluded to the advantage of placing a piece of lint spread with cerate, or a caout- chouc ring, beneath the collar of the canula to prevent any irritation of the skin. No sutures should be introduced into the skin incision, as the efforts during coughing will soon tear them out. Trousseau strongly ad- vises that the edges of the wound should be cauterized daily for the first three or four days, with solid nitrate of silver, in order to prevent the for- mation of diphtheritic deposit. It very soon becomes necessary, despite every care to render the inspired air moist, to cleanse the inner tube of the coating of viscid, partly dried mucus which collects on its interior, and to eflTect this, the inner tube should be removed as frequently as is necessary. The frequency with which this withdrawal is required varies in different cases, but it may be stated as a general rule, that it should be performed from four to twelve times in twenty-four hours. When the tube is clear, the respiration is almost noiseless, and hence the II I AFTER-TREATMENT. 121 siiperventiou of Doisy breathing is usually the indication of some obstruc- tion in the inner tube, which should immediately be withdrawn and cleaned. The drying of the mucus in its interior may be partially prevented by dropping, every half hour, a few minims of tepid water into the mouth of the canula, and by smearing the inner surface of the tube with pure glyc- erin, every two or three hours. Some yeai*s ago,^ Barthez reeommended instillations of tepid solutions of chlorate of soda through the canula after tracheotomy, in the hope of effecting the softening of the false membranes, and their more rapid and complete expulsion. Although he was inclined to attribute a beneficial effect to the practice at the time, it appears to have since fallen into disfavor even with its originator. We have ourselves employed lime-water in several cases, and always with obvious relief. We were induced to use it from its well-known sol- vent action upon pseudo-membranous exudation, and have generally em- ployed it by atomizing warm lime-water through the canula every few hours, or so often as the breathing becomes noisy and labored, despite the removal and cleaning of the inner tube, from the collection of viscid mucus or pseudo-membrane below the end of the canula. The atomization has been continued for a moment or two, and has usually excited cough, while at the same time it softened the viscid mucus and enabled the child to reject it through the tube. So great, indeed, is the relief at times thus afforded, that in one case the little patient asked frequently that the use of the atomizer should be repeated. In all probability it does good, partly by its mechanical action in exciting cough, partly by the softening effect of the watery spray, but partly also, we are inclined to believe, by the action of the lime upon the mucus and pseudo-membranes. We are also in the habit of directing that the child shall breathe, for a few minutes in every hour, the steam from slaking lime, though in all probability this does not contain an appreciable amount of the lime itself. Recently Dr. Bocker of Berlin {Deutsche Klhiik, July 8, 1876) has re- ported the very favorable results he has obtained by means of frequently repeated inhalations, after tracheotomy, of the spray of lime-water solution, of chlorate of potash, or dilute lactic acid. Dr. Burrer, who has adopted the same practice, reports eight cases in which these frequent inhalations formed part of the after-treatment; of these eight cases only two died, while of ten cases, tracheotomies performed by the same operator before his adoption of this mode of treatment, seven were fatal. It occasionally happens, however, that the breathing becomes noisy and obstructed and remains so even after the withdrawal of the inner tube, and the use of the atomizer. The cause of the obstruction then probably consists in the presence near the end of the canula, either of a collection of dried mucus or of a piece of false membrane too large to escape through the canula. If, under thase circumstances, an access of dyspnoea should ensue, the strings securing the canula should be instantly cut and the outer tube withdrawn. If this be followed by the rejection of false membrane and a return of quiet respiration, the canula may be returned ; but if there 1 Bull. G^n. de Tb6r., May 30, 1858. 122 PSEUDO-MEMBRANOUS LARYNGITIS. is reason to fear that the trachea contains false membranes too large to escape through the tube, it is better to allow it to remain out permanently. Millard {loc. cit.) recommends that the external tube should always be removed at the end of twenty-four hours after the operation, when the track of the wound is usually patulous, being lined by plastic lymph, and after waiting a few minutes for the rejection of false membranes and cauterizing the wound, be again introduced. In those cases which progress favorably, it soon becomes necessary to decide at what date the canula shall be finally removed. It is evident that this should be accomplished so soon as possible, as the tube acts the part of a more or less irritating foreign body in the neighborhood of delicate and imp^n-tant structures, and yet it is only in rare cases that the patient can endure its removal before the sixth or seventh day. At the end of the fifth day, therefore, the experiment may be tried of plugging the mouth of the canula with a little roll of wool, to learn in what degree the larynx has become patulous. Should the child be unable to take a single respiration, the experiment may be deferred for several days, but should breathing be performed through the mouth for several minutes, the measure may be repeated daily, in order to gradually accus- tom the larynx to a resumption of its function. About the seventh or eighth day the tube may be removed for an hour or two ; and, if its abstraction be well borne, it may be finally withdrawn the following day, and the wound closed by bringing its edges together with adhesive plaster. It is very necessary to observe the caution, that the canula must never be removed unless some one competent to replace it is at hand. It occasionally happens, however, that the larynx remains impervious for a much longer time, and cases are recorded in which it has been impossible to remove the canula for fifteen, twenty-five, forty- four (Trousseau), or even one hundred and twenty-six (Fock) days ; or even for months or years. The causes which thus delay the period at which the tube can be removed, are summed up by Mr. Marsh (loo. cit.), as follows : 1. Obstruction of the larynx by false membranes, which have been known to linger in its cavity for at least fourteen days after the operation. 2. A chronic inflammation and thickening of the mucous membrane of the larynx, which may remain after the acute disease has passed off". 3. A narrowing or complete obliteration of the passage of the larynx, by the growth of granulations above and around the canula. 4. An impairment or complete loss of those functions of the muscles of the larynx which regulate the admission of air through the rima glot- tidis. 5. Adhesions of the opposed surfaces of the vocal cords. After the removal of the tube, the wound heals, either by contracting from the circumference toward the centre, when air escapes until the very last day ; or the tracheal wound first closes, and the cicatrization then ad- vances externally. The average time occupied by this process of cicatri- zation, is about one mouth, though it may be completed in two weeks or be protracted for two months. I GENERAL TREATMENT. 123 Among the results which have been known to follow the prolonged stay of the cauula in the trachea, are necrosis of the tracheal cartilages, and ulceration about the wound, or of the trachea around the cai^uhi, which, in several cases, has been followed by fatal haemorrhage. Suppuration among the deeper structures of the neck, even extending into the anterior mediastinum, has been noticed in a few instances, when the deepseated tis- sues of the neck had been much disturbed. General Treatment. — Having carefully discussed the management of the canula and the treatment of the tracheal wound, it remains to say a few words in regard to the general treatment of the patient after the operation. The most essential point to be secured is, unquestionably, the proper alimentation of the child. It is, however, frequently very difficult to in- duce it to partake even of the most tempting food. We should endeavor to persuade it to take, as before the operation, nourishing animal broths, beef tea, milk, custard, chocolate, wine-whey, or weak milk-punch. If, however, these are refused, and the child expresses a desire for any other digestible article of food — as the breast-meat of fowl, finely minced, or the soft portions of oysters, or eggs — the taste should be gratified. Occasionally ice cream will be taken willingly, when other food is refused ; or, when both wine-whey and milk-punch are rejected, iced wine and water, or brandy and water will be relished. Unfortunately, however, it not rarely happens that, owing partly to the soreness of the throat and partly, undoubtedly, to the pain caused by the canula during the movements of the trachea in deglu- tition, the little patient utterly refuses to swallow more than a mere sip of iced water. Under such circumstances, so serious a complication is abstinence, that Trousseau recommends that it should be forced to take a little food. " Do not fear," he says, " to employ intimidation. In such cases I have often — assuming an apparent severity, the expression of which I have exaggerated — forced the child to eat, and so have prepared the way for a recovery, which, without this, seemed to me impossible." Even by this means, however, it may be impossible to secure the ad- ministration of a sufficient amount of nourishment, and we would then advise the use of nutritious enemata, consisting either of the yolk of one egg, beaten up in an ounce of milk, or of one ounce of beef tea, and given about every four hours. If they appear to irritate the rectum, and are not retained, one or two drops of laudanum may be added to each enema. In comparatively rare casas there exists, in adsitive difficulty in swallowing liquids. This results from the inaction of the vocal cords and epiglottis, whicii allow the fluid to pass through the glottis into the trachea and bronchia, causing violent cough and escaping through the artificial opening. The child is ho alarmed by this that it sometimes refuses all nourishment, and can only be supported by nutritious enemata. Under these circumstances, Trousseau advisees that all liquid aliment should be interdicted, and that the food of the child should consist of very thick sf)up, vermicelli boiled in milk or broth, hard eggs, eggs \er\ much cooked in milk, and rare-cooked meat, in rather largo 124: PSEUDO-MEMBRANOUS LARYNaiTIS. morsels. If the thirst becomes ardent, he allows pure cold water, taking care to give it either some length of time after, or immediately before, the meals, in order to avoid vomiting. This difficulty in swallowing rarely begins until three or four days after the operation, and does not usually last beyond the tenth or twelfth day. Sometimes, as M. Archambault has suggested, the child is enabled to swallow with ease by closing the cauula with the finger at the moment of deglutition, but at other times this fails entirely. In many cases the difficulty in inducing the child to swallow, after the operation, is so great that all medication must be suspended, excepting the administration of small doses of opium, by the mouth or by enema, which we would advise to be continued. Whenever it is practicable to give remedies, however — without inter- fering with the ability and willingness to take food — it is very important to bear in mind that despite the very great relief which the operation may have afforded, it has by no means put a stop to the disease, but has simply afforded the system another chance to overcome and cast off the constitu- tional affection. Of course, the use of emetics must be suspended, and so if, on any theo- retical ground, any depressing remedies have been employed, they should be discontinued. But we should recommend under such circumstances, that the use of the combination of chlorate of potash, tincture of chloride of iron, and sulphate of quinia, should be persisted in. We subjoin the histories of two cases of true croup, which have lately occurred in our practice, and which will serve to illustrate clinically the remarks that we have made upon this disease. In both cases tracheotomy was performed by Dr. H. Lenox Hodge, in one instance with complete success, but in the other with a fatal result. The first and successful case was under the care of Dr. R. Boiling, of Chestnut Hill, and was seen in consultation by Dr. J. F. Meigs, and, sub- sequently to the performance of the operation by Dr. Hodge, by Drs. Edward Rhoads and William Pepper. The second case was visited by both of us from the first ; and was at- tended, after the performance of the operation by Dr. Hodge, with the most zealous and skilful care, by Drs. Wharton Sinkler and M. Longstreth. Angina with Membranous Exudation on Tonsils — Membranous Lai^yngitis : Tracheotomy at end of second day — Complete Recovery. Case 1, F. W., set. 7^ years, a delicate child, who at the age of 4 years had suffered from a severe attack of true croup, from which he recovered without the operation. On December 23d, 1868, he was noticed to have the symptoms of an ordinary cold in the head, with slight sore throat, some dysphagia, and larj'ngeal cough ; he was visited and prescribed for by Dr. E. Boiling. On December 24th the cough persisted, and there was slight coryza and redness of fauces, but without any membranous deposit or any croupy symptoms. He was ordered small doses of Kermes mineral, Dover's powder, and nitrate of potash, and counter-irritation to the throat. At 5 A.M., December 25th, the child, who had gone to sleep quietly, waked in a frightful paroxysm of dyspnoea, gasping, clutching at its throat, and with oppressed whispering voice. ILLUSTRATIVE CASES. 125 Emetics of alum were given, and produced free emesis, but without the rejection of any false membrane, nor was any yet visible in the fauces. The powders were continued. The dyspnoea persisted and grew steadily worse; the voice remained suppressed. Membranous exudation was noticed in the evening on the tonsils, and during the following night the obstruction to respiration became so intense that, after consul- tation with Dr. Meigs, tracheotomy was performed by Dr. H. Lennox Hodge. The trachea was opened just below the isthmus of the thyroid gland. No false mem- brane could be seen at the level of the opening, nor was any rejected. A few hours later it became necessary to remove the canula, cut an oval ]iiece from the trachea, and replace the tube, during which proceeding artificial respiration had to be maintained. The neck was surrounded by gauze. Nutritious enomata, with small doses of laudanum, were given every two or three hours. Cream and brandy were given by mouth, and the attempt was made to give quinia and iron, but the child abso- lutely refused to take it. The breathing became somewhat easier, but at 9 a.m., December UGih, it was 66, and the pulse 160. The internal tube was frequently removed and cleansed of very thick viscid mucus, which rapidly collected in it; and the other treatment was continued. In the afternoon it became evident that the internal tube was entirely too small, and it was therefore abandoned and the external one alone retained. Warm lime-water was now atomized down the tube every two hours, and on the first occasion of its use was followed by the rejection of a large piece of thick, dark-gray, glue-like false membrane. This was followed by marked relief to the dyspncea. The child was kept gently under the influence of opium ; and was nourished by enemata of beef tea. f Jj ; brandy, f5J ; tr. opii, gtt. iv, given every three hours; which were retained unless they provoked a fecal discharge, which happened two or three times. The urine was passed freely, and was not albuminous. The respirations were conducted solely through the tube and once during sleep fell as low as 32. Df^rcmher 27. — Still refused to eat, and the bowel also became somewhat irritable, so that several of the enemata were rejected. The respirations varied from 35 to 48; the pulse from 132 to 140. The treatment was continued; the atomization of lime-water through the tube being repeated every three hours. Towards the close of each interval the face became flushed, and the child grew restless, throwing the arms about excitedly, at times leaping up in bed, and turning round so as to lean forward on the pillows and bury his face in his hand, or else looking round with an apf)ealing expression. The atomization was always followed by cough, and the rejection of pieces of false membrane and thick puriform matter. Towards evening he began to swallow some food. Dtccmh^r 28. — The tissues of the nock had become so much infiltrated and swollen, that the canula was no longer long enough to reach from the cutaneous surface into the trachea; it wa.s in this way pushed forward till it obstructed the tracheal open- ing and caused great dysjinoca. It was consequently removed, and the child, though much exhausted, sank into a gentle refreshing sleep, with quiet regular breathing. The tube was not replaced, the breathing being readily performed through the wound. There was still marked indi?position to take food, and for a few times ho wa.s forced to swallow by holding his nose and pouring beef tea down his throat; this was not, however, continued, a.« the effort exhausted him very much, owing to his most violent resistance. The discharge from the trachea through the wound was quite fluid, purulent, and very fetid. A solution of carbolic acid, gtt. x, in Oss. of tepid water, was atomized through the wound ; and the atmosphorc of the room was kept impregnated by atomizing a stronger solution about the chamber. During the day be swallowed more fuodge, the trachea being ojiened just below the isthmus of the thyroid gland, and a small oval piece excised from iU walls. A good deal of venous haemorrhage occurred during the operation, but stopped immediately after the trachea was opened, and the lube adjusted. No ansesthetic was used, but the child made no resistance, and evidently was slightly benumbed from asphyxia. Soon after the operation the respirations grew more easy, a large piece of false membrane was thrown oflT through the opening, the flush disappeared from the face, and the features became composed and placid. Very soon after the op^-ralion the respirations fell to iJ8, and throughout the day remained easy and regular. The pulse fell to about 120. The child slept well, hut would eat but little, and still had enemata of beef tea, f^j, q. t. h., given it. The air of the room was kept pure, but warm and moist. The canula wan c(»vered with folds of gauze moistened with lime-water, and the wound was covered with a piece of greased linen, fo as to protect it from the canula. The inner tube wa? romoved every hour, cleaned, anointed with glycerin, and returned. Warm lime-water was atomized through the tube every three hours, and always produced strong cough- 128 PSEUDO-MEMBRANOUS LARYNGITIS. in<;, with the expectoration of thick purulent matter, and occasionally of flakes of tough white false membrane. All medication was suspended, save the ad- ministration of gtt. ij, or iij, of Tr. Opii Deodorata sufficiently often to keep the child gently under its influence. During the ensuing night the internal tube was removed, owing to the difficulty in expelling the thick viscid mucus. Saturday^ 16/A.-^The respirations were 24; pulse 116. During the day the child took more beef tea and wine and water, but still had nutritious enemata given. There was great thirst, and she still complained of pain in swallowing. There was no coryza, and very slight, if any, enlargement of the cervical lymphatics. Towards evening, breathing again grew obstructed, evidently from accumulation of mucus and pseudo-membrane below the end of the tube, which was consequently removed. Its removal was followed by the discharge of several large pieces of false membrane through the wound, the edges of which were well consolidated by lymph. The breathing quickly became noiseless, easy, and tranquil again. During the fol- lowing night the child enjoyed some refreshing sleep, and took more nourishment. The atomization of lime-water through the tracheal opening was repeated about every two hours, and with such great relief that she several times asked for it her- self by signs, as it each time provoked cough, and caused the expulsion of thick purulent matter, dried mucus, and shreds and flakes of false membrane. Urine was discharged freely, and contained no albumen. Sunday 11th. — In the morning she appeared quite comfortable. The voice was still whispering, but the cough seemed looser, and she expelled purulent matter more freely through the opening ; no false membrane was discharged. The thirst was still great, but the child took beef tea more freely. The bowels have for seve- ral days been opened two or three times daily. Kespirations 20-25; quite full, without recession of the base of the chest. Pulse 130-186, of rather better vol- ume. Hands fairly warm, though at times there was a little tendency to coolness. The wound was evidently contracting. Slight emphysema of the base of the neck, which caused complaints of pain about the neck and shoulders. At 4 P.M. it was observed that the breathing was again growing obstructed, and that there was recession of the base of the thorax during inspiration. Lime-water was freely atomized through the opening, but without causing any discharge of membrane. The difficulty of respiration increased until 5^ p.m., when suddenly symptoms of asphyxia appeared. Prolonged efibrts at artificial respiration were made, and life was thus maintained for a short time, but no essential relief was af- forded, and death soon followed, on the thirteenth day of the disease and fifty-eight hours after the operation. The chest was frequently ausculted throughout the course of the case. Before the operation it was impossible to isolate any respiratory murmur, owing to the loud, snoring, whistling, and cooing tracheal and bronchial rales. After the operation, and still more after the final removal of the canula, a faint respiratory murmur could be detected, mingled with the above rales. On the morning before death only was there an obscure flapping sound transmitted to the ear with the tracheal and bronchial rales, but even then it was indeterminate in character. During the efforts at artificial respiration, a long tubular false membrane was ejected. It had evidently been the immediate cause of death. Autopsy, twenty-four hours after death. Brain not examined. Thorax and Air-passages. — The wound in the neck looked well, without pseudo- membranous exudation. The larynx itself could not be examined. A long false membrane, extending from the tracheal opening down through the right bronchus to the third or fourth division, lay loose in the trachea, having been detached from the mucous membrane. In the bronchia it was still slightly attached, but sepa- rated readily on traction. It was firm, very tough, and white, and, in the upper part of the trachea, at least one line thick. Below the bifurcation it was tubular for the rest of its course ; and in its terminal portions grew softer and more yellow- ish. There was also, in the trachea, a large patch (1^ inches long by ^ inch wide) DISEASES OF THE LUNGS AND PLEURA. 120 of false membrane, of dull white color, and tightly adherent. Upon raising it, numerous little delicate fibrous prolongations were seen attaching it to the mucous membrane. Beneath this patch the mucous membrane was deeply reddened, dry, excoriated-looking, and slightly roughened by minute elevations. There was no enlargement of the mucous follicles. The vascularity of the mucous membrane di- minished in the lower part of the trachea, and was but slightly marked in the sec- ondary divisions of the bronchi. No ulceration was seen at any point. There was no pseudo-membrane in the left bronchus or an\' of its branches, and the mucous membrane here was less reddened than on the right side. In all probability the false membrane removed immediately after death had come from the left bronchus. The right lung was largely distended, the posterior border dark and congested, but the rest of the organ pale and emphysematous. The left lung was dark, purplish, non-crepitant, collapsed, and yielded on section an abundant flow of dark, airless, bloody serum. No pleurisy or pleural effusion. Heart. — The left ventricle was very firmly contracted and empty, and the tissue of its walls hard, tough, and florid red. The walls of the right ventricle were re- laxed, and the cavity filled with fluid dark blood, without any clots. No excess of pericardial efl'usion. The liver and kidnevs were gorsjed with dark blood. CHAPTER 11. DISEASES OF TPTE LUNGS AND PLEURA. GENERAL REMARKS. It would be difficult, perhaps, to overestimate the importance to the medical practitioner of a thorough kno^yledge of the different diseases of the lungs and pleura, as they occur in children. The diseases of the respi- ratory organs — and much the most frequent of them are pneumonia and bronchiti.s — cau.se, according to West, very nearly a third of all the deaths under five years of age in England; while not above one child in four dies under that age from diseases of the nervous system, and not above one in seven from those of the digestive system. In this country, it would seem, from the bills of mortality, that a larger proportion of children die of di.s- eases of the digestive than of the respiratory system. But, while this is true, there can be no doubt that the diseases of the latter system are de- serving of our utmpst attention, since not only are they of constant occur- rence and of fatal tendency, as idiopathic affections, but since, al>«o, they frequently appear as complications in the course of other di.seases, adding greatly thereby to their severity and danger. In measles, for instance, by far the most frequent cau.se of danger is the occurrence of some inflam- mation of the lungs or pleura. In .scarlatina and typhoid fever, bron- chitis and pneumonia are very common accidents, and recent researches have shown that in hooping-cough, and in all states of great debility and prostration, a certain change in the condition of the pulmonary tissue, to which the term collapse has been applied, is ver}* apt to occur. 9 130 CONGENITAL ATELECTASIS. The morbid condition of the lunj? last referred to, that of collapse, is one that has been well understood only within a few years past, and yet it is so important a one, in a practical point of view, as to excite a feeling of surprise that it had not been discovered before. AKTICLE I, ATELECTASIS PULMONUM, OR IMPERFECT EXPANSION OP THE LUNG. The title of atelectasis pulmonum, from areAvyi?, imperfect, and exTaaiq^ expansion, was first employed by Dr. Edward Jorg, to designate a con- dition of the lungs observed by him in new-born children, a condition in which larger or smaller portions of those organs had never been penetrated by air. The respiration of the infant had, in such cases, been only im- perfectly established at birth, and some parts of the pulmonary tissue had, consequently, never undergone expansion under the distending influence of the inspiratory act; these undilated parts continued in the foetal state. In addition to this congenital form of imperfect expansion of the lung- tissue, this condition is met with at all ages of life, though with especial frequency in young children, as the consequence of a collapse of portions of the once-expanded lung, or, in other words, of their return to the foetal or unexpanded state. To this latter form of imperfect expansion, the terms post-natal atelectasis, collapse, and foetal condition have been given. Before the discovery of its real nature was made, it had often been de- scribed also under the well-known names of carnification and lobular pneumonia. We shall designate it by the title of collapse or post-natal atelectasis, while under that of congenital atelectasis pulmonum, we shall describe the congenital variety of imperfect expansion. CONGENITAL ATELECTASIS. Anatomical Appearances. — In congenital atelectasis the parts of the lung most frequently affected are the posterior portion and lower edge of the inferior lobes, the middle lobe of the right lung, and the languette and lower edge of the upper lobes. In some instances that we have ex- amined, the greater part of the lower lobes of both lungs, while, in others, still larger portions of these organs have been found to present this con- dition. The imperfectly expanded portions of the lung are of a dark-red or purplish color, and are diminished in size, so as to be depressed below the level of the healthy parts. They are solid to the touch, and yet they have not lost their cohesive properties, as they are neither friable, easily torn, nor readily penetrable by the finger ; their cut surface is perfectly smooth ; they do not crepitate under the finger, and no air-bubbles are seen in the fluid squeezed out by pressure ; they sink when thrown into water. They, in fact, resemble exactly the foetal lung. The most con- CONGENITAL ATELECTASIS. 131 vincing proof of the real nature of this condition is obtained by the infla- tion of the lung. When this is done, the depressed, hard, and dark- colored portions — unless the subject from whom the specimen has been taken raay have lived long enough to have allowed the different tissues of the lung to become adherent — rise to their natural level, become elastic, soft, and crepitating, and change, under the influence of the enter- ing air, from a dark and livid tint, to the rosy or pink color of healthy pulmonary tissue. In recent cases, this inflation is performed with great ease and with perfect success; while in other instances, in which the child has lived for some weeks or months, the distension is either effected only by strong eftbrts, or in a very imperfect manner, or it may fail en- tirely, owing to some permanent change having taken place in the tissues of the unexpanded portions. In a case that occurred to ourselves, the subject of which died, at the age of fourteen months, of acute pleurisy of the right side, after having presented, at birth and throughout its short life, many of the symptoms of atelectasis, the inferior two-thirds of the lower lobe of the left lung exhibited in the greatest perfection all the atelectasial characteristics. The whole of the unexpanded part was dis- tended by means of inflation with a blowpipe, but only after repeated and powerful expiratory efl^orts ; and Dr. E. Wallace, who made the examin- ation, assured us that he was obliged to use a degree of force much greater than he ever employed to inflate healthy adult lung. In some cases, there are found small patches of vesicular emphysema associated with the areas of pulmonary collapse. If, in consequence of commencing post-mortem decomposition, there has been any development of gas in the tissue of the lungs, it is seen, by the aid of a lens, in the form of irregular air-bubbles scattered through the interstitial tissue, which are easily distinguished from the minute shining air-bubbles, crowded together in regular arrangement, which are seen in lungs which have been inflated. — Bouchut, Jour.f. KinderkraJikheiten, 1863, 3-4, p. 263. In most cases, the foramen ovale and the ductus arteriosus are found to be still open, or the latter has but partially closed. The causes of congenital atelectasis have not been satisfactorily ascer- tained. The conditions that are probably the most frequent causes are: original debility of the infant, from any cause that has interfered with its proper development in utero, as feeble health on the part of the mother during pregnancy, or multiple pregnancy; and accjuired debility, brought about by the fact of the infant's being exposed at birth to unfavorable hygienic influences, and particularly to those which interfere with the proper performance of the respiratory act, as cold, a vitiated and close atmosphere, and the use of too heavy or tight clothing. A very hurried and rapid labor ha.s been thought to cause, in some instances, this imper- fect expansion of the lung-substance. In a case that occurred to one of us (see Am. Jour, MM. *Sc., Jan. 1852, p. 83), the only explanation of the condition, which seemed at all plausible, was that the placenta had been separated from the uterus at too early a period of the labor, in consequence of the violent and rapid character of the latter, so that the child wan for a short time before birth cut off* entirely from it« connection with the 132 CONGENITAL ATELECTASIS. raother-^a time sufficient so to lower its vital forces as to bring on a con- dition resembling syncope, and to deprive it of the muscular strength necessary on entering the world, to produce a full expansion of the thoracic cavity, and so of course to effect a dilatation of all parts of the lungs. In addition to this, congenital collapse of the lungs may result from the air-passages of the child becoming obstructed with mucus or fluid in con- sequence of the umbilical cord being ruptured during labor, and an in- spiration thus becoming necessary, before the head is free from, the liquor amnii or the secretions of the mother's passages. Finally the want of ex- pansion has been in some cases found to be dependent on pressure upon the medulla oblongata, implicating the roots of the pneumogastric nerves, resulting from inflammatory exudation or from effusion of blood owing to injuries incurred during delivery. Symptoms. — The symptoms depending on congenital atelectasis vary a good deal in different cases. There are some, however, which exist in most instances. These are the following: the child comes into the world feeble and weak, and instead of crying vigorously and loudly the moment or very soon after it is born, it fails to cry at all, or the cry is low and weak, or it is whimpering or wailing ; the color, instead of being brick-red or dark-red, is pale and whitish, leaden, or livid ; the muscular movements, which, in healthy children, are strong and vigorous, are in these, languid and slow, or there are none or scarcely any, the limbs being relaxed and motionless. If the breathing is observed, it is found to be short, high, and imperfect, and it is evident that the thorax is but imperfectly dilated at each movement of respiration. When these symptoms exist in a very marked degree, the infant either dies soon in a state of asphyxia, or, the muscular force slowly increasing, the respiration gradually improves, and the child is, after a longer or shorter time, either out of danger, or it falls into the same state as that of one in whom the symptoms have been from the first less severe. Under the latter circumstances, the infant continues feeble and weak. It breathes shortly, rapidly, and imperfectly, but often without any appearance of effort. The cry is rare, and when heard, is low and feeble, or there is with each respiration a constant plaintive moan, which is very characteristic, and strongly expressive of exhaustion. The color continues pale and whitish, or it is bluish, and the temperature of the extremities is lower than natural. The child sleeps the greater part of the time, and is unable to nurse or nurses very feebly, but can swallow ■when fluid is poured into the mouth. In such cases as these, the infant does not necessarily die, but will often recover when properly treated. In favorable cases, the symptoms just enumerated may last from a few hours to a day or two, or even a few weeks, without much change ; then, under the influence of correct hygienic and medical treatment, they will often begin to improve. The color becomes less pale or less bluish ; the mus- cular movements are somewhat stronger; the child begins to cry, and in a louder tone ; the act of swallowing is easier and more perfect, or the infant is able to suck when applied to the breast, at first feebly and only for a moment, and then more strongly ; the respiration becomes slower. SYMPTOMS. 133 fuller, and more Datural, and gradually the dangerous symptoms disap- pear. lu unfavorable cases, on the contrary, the respiration fails to improve, but becomes more and more short, quick, and imperfect; the temperature of the body falls ; the color of the surface changes, becoming leaden, bluish, or even livid, the change showing itself first in the neighborhood of the mouth, and in the hands and feet, and extending gradually to the rest of the body; the difficulty in swallowing becomes greater, and very generally some spasmodic twitchings begin to show themselves about the muscles of the face. The respiration is very often attended with slight wheezing or rattling, and the convulsive movements returning frequently, and becoming more violent and more general, the child dies in convul- sions, or it sinks very slowly and gradually, without convulsions, as though in a state of syncope. According to Steffen (Klinik. d. Kinderkr., 1865, 1 Bd., p. 50), thrombosis of the cerebral sinuses has been found after death under such conditions. There is another symptom of imperfect expansion of the lungs in new- born and very young infants, which ought not to be passed unnoticed. It is one mentioned by Dr. George A. Rees, of London, in an essay on this subject (London, 1850), and is of much diagnostic value, although not a pathognomonic symptom of this condition as regarded by him. It is an altered movement of the ribs in respiration. During the inspiratory effort the ribs are seen to move inwards toward the mesial line of the trunk, in- stead of outwards as in ordinary respiration, thus diminishing instead of expanding the transverse diameter of the thorax. The explanation of the altered movement is as follows: when the diaphragm descends, the lung ought to expand in such a way as to fill up the increased space produced in the thoracic cavity by the descent of that great muscle. Instead of this being the case, however, the lung is collapsed and inexpansive, and can- not enlarge sufficiently to fill up the space alluded to, so that there would remain a vacuum in the chest were it not that the thoracic walls are driven inwards by the pressure of the atmosphere upon their outer sur- face. In a case that we saw ourselves in a child fourteen months old, who had presented symptoms of atelectasis from birth, and in whom we found after death very extensive collapse, this symptom was very marked. The base of the thorax was indented on both sides by a deep gutter or depres- sion, which remained depressed and unchanged during the ins{)iratory movements, or which, indeed, rather became more distinctly visible during those motions, .so that the chest presented the curious spectacle of dilata- tion or expansion in its upper parts, during inhalation, and of contraction or collapse at its ba.se. In regard to this interesting sign the reader is referred to our article on rickets, where is mentioned the explanation given of It bv Jcinur, In c«iorc taking up the regular consideration of p)st-natal collapse, aa it occurs at all agG<« of childhood, we wish to refer, for a moment, to that condition aj» it appears in the first few weeks of life, in infants who have exhibited no 134 ATELECTASIS PULMONUM. sign of it whatever, perhaps, at the moment of birth. We desire to do this now, because the symptoms to which it gives rise resemble much more those of congenital atelectasis, than those of collapse in children over a few months old. And let it be remarked that these symptoms are very differ- ent, and much more severe and threatening than those of collapse at later periods. They are in fact those of cyanosis, and, in some instances, are as strongly marked as those observed in the worst cases of that condition, caused by malformation of the heart or great vessels. The cyanosis and other symptoms of disordered circulation evidently depend on the obstacle offered by the collapsed and condensed portions of lung-tissue to the dis- charge of blood from the right side of the heart. Though this obstacle to the venous circulation is doubtless the chief cause of the symptoms in these cases, we cannot but think ourselves, that the great difference be- tween the symptoms of congenital atelectasis, as well as of post-natal ate- lectasis occurring in the first few weeks of life, and the collapse of later periods, must be explained in part, at least, by the fact that the foetal openings, the foramen ovale, and ductus arteriosus, and especially the former, are still patulous, or in such a condition that they may be re- opened under pressure, and so allow a portion of the contents of the overloaded and congested right side of the heart to pass into the left auri- cle, thence into the left ventricle and aorta, and so to the whole body. In this form of atelectasis, the child may have been born perfectly healthy, or only weaker than usual, or it may have had some difficulty in establishing the respiration, which, however, has afterwards been effected in the most complete manner. Some days, or even weeks after birth, from a cause disturbing the function of respiration, portions of the lung may collapse, and give rise to the different symptoms of that condition in the manner above described. The most important of these symptoms are difiiculty of breathing, consisting either in an increased or diminished rate of that function, diminution of the muscular power, cyanotic hue of the skin, and slight or severe spasmodic phenomena. In a case that occurred to one of ourselves (see Am. Journ. Med. Sc, loc. cit.), a child who had ex- hibited at birth, and for five days after, every appearance of fine health, was observed on the sixth day to cry rather violently in the morning. At one o'clock in the day he began to moan, and appeared distressed ; at two he ceased to moan, became bluish, and seemed to lose his breath. He was placed in a bath, in which the blueness passed off, but the breath- ing continued irregular and uneven. He soon became blue again, and breathed slowly and irregularly, but had no spasm. At about four o'clock another paroxysm occurred, in which the whole surface became first blu- ish, and then dark, while at the same time, the trunk and limbs became stiff and rigid under the influence of tonic muscular spasm, and the res- piration was slow and imperfect. After the attack had lasted for some moments, the blueness and spasmodic phenomena disappeared, but the child remained in a state of stupefaction. There were two slight parox- ysms of convulsive stiffening between this and evening, and later in the evening there was still some blueness, with irregular and short respiration. During the night the breathing was short and uneven, and attended with SYMPTOMS. 135 moaniug, but on the following day the symptoms had disappeared entirely, and there was no return. In another case the symptoms of collapse did not appear until the twenty-tifth day after birth. The infi\ut had been hearty and strong at birth, and had established its respiration fully and completely. Between the birth, however, and the time of the attack, circumstances connected with the lactation had caused the development of diarrhcra with thrush, which had debilitated the child a good deal. On the day of the attack, frequent sneezing, with stuffing of the head, and some cough, seenied to show the existence of catarrh, and on the same day, the child was unfor- tunately exposed, owing to the accidental opening of one of the gas- burners, to the inhalation of some gas. Late in the evening, a slight whistling or stridulous sound was heard in the breathing, the skin became suddenly a little bluish, and a slight convulsion followed. During the night there were frequent and strong convulsive seizures, always preceded and followed by deep blueness of the mouth, hands and feet, and it was noticed that the least disturbance, as lifting or nursing, or changing the position, always brought them on. The next morning the attacks con- tinued, but with diminished violence, under the effects of treatment, and they ceased after the middle of the day. The color of the skin had now changed ; it had become rosy red, instead of pale or blue, and the hands and feet, which had been cold, were now warm and natural. There was DO return after this. In a third case, a female infant, who had been perfectly well at birth and up to the moment of this attack, was put suddenly into a bath by the nurse on the eighth day, directly after its waking from sleep. The child, who was not thoroughly waked up, seemed greatly terrified, and began to scream most violently. Instead of removing the infant from the water, the nurse persisted in holding it immersed for some minutes, when it became deeply blue, and partially convulsed ; it frothed at the mouth and nose, seemed to be suffocating for breath, and appeared to be dying. These symptoms continued for three-quarters of an hour, when they gradually passed away, and it fell into a heavy sleep. When we saw the infant, soon after this, the only signs of disorder that remained, consisted of an unusual paleness, drowsiness, and an expression of feeble- Dess. Some three hours later, it waked, nursed, and from that time seemed quite well. In a fourth case, a child bom apparently well, with the exception of its having had a rather frequent respiration, and who nursed very well on the second and third day, was attacked on the fourth day with blue- ness, moaning, short and panting respiration, and then with slight con- vulsive symptoms. It was unable to nurse, and though kept perfectly Btill, and fed from time to time with small quantities uf milk and brandy, became gradually more dee|)ly blue, had paroxysms of very slow res- piration and circulation, with general convulsive seizures, and died at the end of twenty-four hours. The reader will alsf) find this form of cyanosis referred to in our article on that disease. 136 ATELECTASIS PULMONUM. Diagnosis. — There can be no difficulty in detecting the nature of the case when the imperfect expansion exists from birth, and when the physi- cian is present at that event. When, however, collapse of the lung-tissue continues after birth, and the physician is called upon to determine, at the age of some days, weeks, or even months, the cause of the feeble health and puny growth of the child, or to explain those sudden attacks of collapse in very young infants who had previously well established, to all appearances, the respiration, the diagnosis becomes more difficult. In the former class of cases, attention to the following points will usually, however, enable us to make a correct diagnosis. The previous history is particularly important, since, in all such cases, it will be found that the infant was either still-born and resuscitated with more or less difficulty, or that it was born weak and feeble, and that the respiration had not been established as thoroughly and completely as it ouglit to have been. Dr. Rees states that certainly half of the cases of this form, in his own practice, occurred in twins, and that they were all born in a more or less completely asphyxiated condition. The present symptoms are also very important. The feeble appearance of the child, and its puny growth, in connection with its past history, and the absence, as ascertained by careful examination of the case, of other morbid condi- tions to explain the general ill-health, ought to direct the attention of the physician to the true nature of the disease ; and if we add to these con- siderations the local thoracic symptoms, the short, rapid and imperfect breathing, with, perhaps, the altered movement of the ribs, the indentation instead of expansion during inspiration, mentioned above ; the absence of fever; and the existence of the physical signs of more or less extensive solidification of the pulmonary tissue, without those of pneumonia; there will seldom be any difficulty in forming a correct diagnosis. The cases described under the head of collapse in the early weeks of life may be readily understood from the simple fact that the symptoms can- not be satisfactorily explained by referring- them to any other condition than that of collapse of portions of the lung, with impeded and deranged circulation. Prognosis. — The condition of imperfect expansion of the lungs in a new-born child, does not necessarily cause it to die immediately or very soon after birth. The fate of the child will depend very much upon the cause of the atelectasis, upon its degree of innate strength and vigor, and upon the kind of hygienic conditions to which it may be consigned. When the child is well developed, and not enfeebled by any fault in the mother's health during the pregnancy, but merely by some momentary condition that has occurred during the labor, there is every reason to hope that proper hygienic and medical treatment may restore it to health. The danger is greatest in those who continue weak and feeble, in spite of the proper measures of care and treatment, for some days or weeks after birth. We have a record of ten examples of this condition in new-born children, in nine of which the symptoms persisted during a period varying between six hours and five days. Of these, seven lived, while three died in from twenty-one hours to three days. TREATMENT. 137 The prognosis of the second class of cases — those in which collapse oc- curs suddenly a few days or weeks after birth, and after the apparently complete establisliment of respiration — will vary, of coui*se, with the vio- lence of the symptoms. Of five cases of this kind that came under our observation, recovery took place in three in spite of the most dangerous and alarming symptoms, while in two death occurred in a period of about twenty-four hours. In cases where the collapse of the lungs has been extensive, and has in part persisted without proving fatal, serious organic changes in the heart have been found to follow, both by F. Weber and Steffen. The long-con- tinued obstruction to the pulmonary circulation prevents the closure of the ductus arteriosus, and subsequently causes hypertrophy with dilatation of the right side of the heart, a patulous state of the foramen ovale, and at last eccentric hypertrophy of the left auricle and ventricle. Undoubtedly, in most case;?, death occurs before these changes in the heart are induced, but it is important to be aware that imperfect expansion of the lungs may thus serve to develop serious cardiac disease of a form likely to be attended with cyanosis. When the imperfect expansion depends upon the presence of accumula- tions of mucus in the air-passages, well-directed efforts usually succeed in effecting the removal of the obstruction, and the establishment of free in- spiration. In those cases, finally, where there is pressure upon the pneumo- ga^tric nerves near their origin, a fatal result must always follow. Treatment. — The treatment of congenital atelectasis must be directed to the removal of its probable cause. If this is suspected to be obstruction of the air-passages by collections of mucus, the infant's mouth should be cleansed, and vomiting provoked by tickling the fauces. In addition to this, all the measures calculated to stimulate respiration should be employed. When the imperfect expansion appears to depend merely on the weak- ness of the infant, the treatment resolves itself almost entirely into the em- ployment of such means as tend to invigorate the general health of the child, and to promote the activity of the respiratory act. In a recent case, one dating from birth, in which the function has always been imperfect, and in which there are present great feebleness, drowsiness, and paleness or blueness, the room in which the infant is placed should be kept up to a temperature of 70^ or 75^, and the child should be abundantly covered with warm clothing. Perfect quiet, or at least very gentle motion, is very important, and when there is any disposition to deep blueness or to convul- sive movements, attention to this point is essential. It \s in such cases, and in those in which these symptoms come on a few days or weeks after birth, that the position recommended by the late Dr. C. D. Meigs, for the treatment of cyanosis neonatorum, wjis found by him so useful. This j)osi- tion is one upon the right side, with the head and shoulders raised at an angle of 45°. It is obtained by arranging pillows in such a way as to form a plane inclined at that angle. Up<^)n this the infant is placed, and orders are given that it is not to be moved at all, if possible, or only with the greatest care and gentleness, for twenty-four or forty-eight hours. There can be no doubt that this position and the attendant repose have, in many 138 ATELECTASIS PULMONUM. cases recorded by Dr. C. D. Meigs, and in several that we have seen our- selves, been of very great use in controlling the symptoms. Its good effects in cyanosis were supposed by him to depend on the fact that the septum auricularum becomes horizontal in this position of the body, so that the blood in the right auricle must rise against gravity, in order to pass through the foramen ovale, while, at the same time, the valve of that opening is disposed to fall down by its own weight, and close the foramen, and is, moreover, pressed downwards by any blood that may enter the left auricle from the pulmonary veins. This explanation will apply, of course, only to those cases of atelectasis accompanied by very extensive and deep blueness or purple color of the surface, in which we may suppose that so much of the pulmonary tissue is solidified, as to produce a degree of ob- struction to the passage of blood from the right side of the heart into the lungs, sufficient to overload the right ventricle and auricle, until the latter pours a portion of its contents into the left auricle, thus causing admixture of the two kinds of blood. In a large majority of the cases of atelectasis, however, this explanation of the benefit resulting from the treatment re- ferred to, cannot be received, as there is no reason to suppose that in them the slight cyanotic symptoms present indicate anything more than the ex- istence of a moderate degree of congestion of the right side of the heart, unattended by any escape of blood from the right into the left auricle. In such cases the position on the right side is useful, because it is the one most favorable to a full and easy performance of the respiratory and circulatory functions. It leaves the left side free and unembarrassed, so that the heart can act with the greatest possible freedom, while the partial elevation of the head and shoulders renders the movements of the chest more easy and complete than when the body is lying on a horizontal surface. The perfect quiescence which constitutes a part of the treatment is also very important, as in many recent and particularly in cyanotic cases, the symptoms are greatly aggravated, and convulsive attacks often brought on by moving the child, especially if this be done suddenly or rudely. Various means are also recommended for rousing the force of respira- tion, as by compelling the infant to cry, by frictions of the surface, by plunging the body alternately into warm and cool water, or by allowing a stream of cold water to fall on the nape of the neck with the view of ex- citing the respiratory nerve-centres. Attempts may also be made to produce full inflation by gentle mouth- to-mouth respiration. The other modes of attempting to accomplish this are either (as by compressing the thorax at regular intervals) of but little value, or (as in case of Hiiter's proposal to inflate the lungs after catheter- ization of the larynx) highly objectionable. Perhaps the most important point of all in the treatment of this affec- tion, especially when the symptoms tend to become persistent, is the mode of nutrition of the child. If possible, the infant should always have a good breast of milk, and if unable to suck, the milk ought to be drawn by means of a breast-pump, and given to the child in small quantities from a spoon. About two or three teaspooufuls may be given at first every half hour or hour, and the quantity gradually increased until the child gains strength COLLAPSE OF THE LUNG. 139 enough to be put to the breast. If breast-milk canuot be procured, cow'3 milk and water may be substituted, in the proportion of one part of the former to two or three of the latter. The only medicines to be given are, at first, while the child is still very young and weak, mild stimulants, of which the best, in our opinion, is fine old brandy. Of this about five drops may be given each time that the milk is taken ; or, we may make use of from three to five drop doses of the aromatic spirit of hartshorn, or of proper quantities of wine-whey. When the symptoms of congenital atelectasis tend to persist for several weeks or months, or when we first see the patient some time after birth, the chief points to be attended to in the treatment are, as before, the mode of nutrition, which ought to be by nursing and the use of gentle stimulants and tonics. Brandy, wine, or Huxham's tincture of bark, are the best stimulants ; whilst quinine, in the dose of a quarter or half a grain, three times a day ; extract of cinchona, in the dose of from one to three or four grains, three times a day ; or iron in the form of Quevenne's powder, or in that of the iodide, are the best tonics. Vogel (Dis. of Children^ Amer. ed., 1870, p. 55) speaks very highly of the advantage derived from the cautious application of electricity to the pectoral muscles. COLLAPSE OF THE LUNG, OR POST->'ATAL ATELECTASIS. General Remarks. — By collapse of the lung is meant the return of that organ to its fcetal or unexpanded state. It is in fact a condition of atelectasis or imperfect expansion of its vesicular structure. The terms collapse or post-natal atelectasis are employed to contradistinguish it from congenital atelectasis, the former being applied to imperfect expansion as it occurs in lung-tissue after previous expansion, and the latter, as stated in the preceding article, to the same condition as it exists in children who have never expanded certain portions of the pulmonary substance. The true nature of collapse of the lung was never understood, and its great practical importance never appreciated, until since the year 1844, when MM. Legendre and Bailly published, in the Archives Gauraks de 3ftd€cine, their researches on the subject. Since then various observers have repeated the investigations of those gentlemen, and thrown new light upon the matter. Among the most important of the later writers on this subject, we may mention Dr. Charles AVest of London, MM. Hardy and Behier of Paris, Dr. W. T. Gairdner of Edinburgh, and MM. Till lie t and Barthez, in the second edition of their work. This discovery in pathology was one of very great value, not morcly be- cau.se it renders our knowledge of the morbid conditions of the lungs more exact and philosophical than it ever was previously, but because it explains certain anatomical changes in the pulmonary structures, often before noticed and described, but never satisfactorily accounted for; and still more, because it points to methods of treatment much more rational and much more successful than those employeortions have been de- scribes! by the term lobular pneumonia. The peculiar or fundamental characters of collapsed pulmonary tissue 142 COLLAPSE OF THE LUNG. are the same in both varieties. We will mention them as succinctly as possible, and then compare them with those of pneumonia, for the reason that it is with the lesions of that disease that those of collapse have been so frequently confounded. Collapsed lung is generally of a dark violet color, but it may be much darker in tint, and even black, when it is much engorged with blood. Its consistence is always changed ; the condensation may amount merely to slight hardening, with a diminution of the crepitation, or it may be very dense with an entire absence of crepitation, in which case portions thrown into water sink rapidly. Though more or less hardened, the tissue still retains a certain degree of flaccidity and suppleness. When cut into, the surface is seen to be smooth and uniform, having somewhat the appear- ance of muscle, and presenting no granulations. Pressure or scraping causes the exudation of more or less semi-transparent bloody serosity. Close examination shows that the organic elements of the tissue, the ves- sels, bronchia, cellular tissue, etc., can still be distinctly traced. Lastly, inflation of the lung distends the condensed parts, and gives to them again, more or less completely, their natural physiological characters. MM. Rilliet and Barthez, in their second edition, treat, at considerable length, of congestion of the lung as a very constant accompaniment, and as a very important element in the state of collapse. They regard this congestion as being connected nearly always with bronchitic inflamma- tion, and as being not merely a passive state, but as exhibiting phenom- ena, in most instances, which prove it to be in some degree an active con- dition. They say (op. cit, t. i, p. 428) : " We readily acknowledge that a state of debility, prolonged dorsal decubitus, and the obstruction to the circulation thus occasioned, facilitate the production of this condition, and give to it the appearance of a simple passive congestion. But we believe that there exists, moreover (frequently, if not always), a really active and even inflammatory movement." They regard this opinion as proved chiefly by the fact that they have found the texture of the affected parts to be somewhat softened, as shown by the facility with which they are torn by the finger or by scraping with a scalpel ; by the swelled and turgid condition the tissues exhibit ; by the quantity of sanguineous or sero-sanguineous liquid which escapes on pressure ; and by the presence of a serous exudation around the pulmonary vesicles, while the interior of the vesicles appears to be healthy. The last-mentioned condition they found upon their own observation, and upon a microscopic examination made by M. Lebert. The color is different in the two alterations ; being, in collapse, purple or livid, and, in pneumonia, brownish-red or fallow-red. In pneumonia the pleura covering the hepatized portions is often covered with false membrane, showing thereby the inflammatory nature of the disease ; in collapse this is rarely the case, and only when there is some accidental concomitant pneumonia. The density of the lung in the two conditions is of a different kind : in pneumonia it is hard to the touch, and unyield- ing ; in collapse it always retains a certain degree of flaccidity and soft- ness, like that of muscular tissue. In pneumonia the diseased part is ANATOMICAL LESIONS. 143 turgid and swelled, so that it projects above the common level of the sur- rounding surface; in collapse, on the contrary, it is shrunken and de- pressed below the neighboring parts. lu pneumonia the ettect of the in- flammatory process on the tissues is very strongly marked, and produces changes in them very different from those occasioned by mere collapse. In the former disease the cohesive properties of the pulmonary structure are very much lessened, so that the inflamed parts are readily penetrated by the finger, and are easily torn ; in simple collapse, on the contrary, the diseased part is as firm and resisting, or even more so, than in health ; whilst in collapse occurring in bronchitis and attended with congestion, though the cohesion of the tissues is somewhat lessened, it is never nearly so much so as in pneumonia. In the true hepatization of pneumonia, a cut surface always presents a granular aspect, while in collapse, on the contrary, it is smooth and even. On scraping a cut surface it is found that, in the former alteration, a plastic, fibrinous matter, of a yellowish, orange, or gray color, comes off on the knife; while, in collapse, only some semi-transparent bloody serosity is scraped off. In the former, the anatomical arrangement of the lobules cannot be seen, as the inflamma- tion attacks iudiflerently the lobules themselves, the interlobular septa, and parts of neighboring lobules; but, in the latter, the alteration can always be seen to be more or less regularly confined to the lobules, the cellular interstices between the lobules remaining more or less apparent; so that in pneumonia the alteration is not bounded at all by the outlines of the lobules, while in collapse the alteration always affects, more or less, the lobular form. To conclude, the effects of inflation are altogether dif- ferent in the two conditions. M. Legendre (Recherches Anatom.-Pafh. et Clin, stir quelque.i Mai de V Enfance, p. 164) states that air can never be made to penetrate by inflation into a completely hepatized lung. Neither in hepatization of the lobar form, nor in true partial hepatization, has he ever been able, even with the utmost effort, to push air into the inflamed tissues. After repeated trials, the tissue remained compact and friable, and sank as rapidly as before when thrown into water. In the foetal state, on the contrary, the slightest effort sufl[iced to fill and distend the collapsed air-cells, and to give to the altered portion its natural appearance, except- ing that it became more red in consequence of the oxygenation of blood contained in the capillaries. Dr. Gairdner (Pathol. Anat. of Bronchitis, etc., Edinburgh, 1850, pp. 13, 14) remarks that, though this test " is very useful in demonstrating the nature of the lesion, in a favorable case, to one not familiar with its character, I do not believe it to be applicable to the determination of the presence or absence of pneumonia in those mixed cases in which alone there is any difficulty." He has observed, in fact, that partially pneumonic lung may be inflated when the affortion is rerent and combined, as it frequently is, with bronrhitic collapse, while in the latter lesion, in its purest forms, cr>mplete inflation is often very difficult or impossible after the collapsed state has been of .some duration. The part of the lung in which collapse is mcjst frequently met with de- pends somewhat on the form of the alteration. In the diffused vari»'ty, it may affect a more or less considerable portion of either or both lungs, 144 COLLAPSE OF THE LUNG. but is most commoD at their posterior part. The lobular variety is most common ou the anterior edges, but may, like the diffused, occur in any other part. As a general rule, the alteration is most frequent at the pe- riphery of the organ, where its edges are thin, as along the margins of the lobes, in the languette of the upper lobes, and at the bases of both lungs. The parts just named are those most distant from the primary air-passages ; they are those in which the inspired air would arrive last, and with the least force of impulsion. Causes. — It has been generally acknowledged that there are two prin- cipal causes by which to explain the production of collapse of the lung. These are the presence in the bronchia of some condition which acts as an impediment to the ready passage of the inspired air, and a want of power in the muscular apparatus by which the function of respiration is carried on. To these Dr. Gairdner adds another, — the inability to cough and expectorate, and thus remove the obstructing mucus ; but this is, in fact, included in the preceding. The most important of the above-mentioned causes is evidently the de- ficient respiratory power, since this is noticed and insisted upon by all ob- servers. It has been found, in fact, that collapse seldom occurs to any considerable extent except in children who are exhausted and debilitated. The debility may be congenital, it may be the result of wearing diseases, as diarrhoea, hooping-cough, measles, typhoid fever, etc., or it may depend on exposure to unwholesome and enfeebling hygienic conditions. It is easy to understand that a child who is either born weak and feeble, or who becomes so in after years from any of the causes just alluded to, must lose, ■with the general decay of the strength of the body, some portion of the muscular power by which alone a complete and efficient dilatation of the thoracic cavity can be accomplished, and that, when this is the case, the inspirations must be short and imperfect, and that portions of the lung most distant from the primary air-passages, not being reached by the in- spired air, will I'emain in an unexpanded or collapsed state. If we add to this state of feeble respiratory power, the presence of opposing secretions in the air-tubes, whether these be the consequence of bronchial inflamma- tion, as they are in the immense majority of cases, or, as Dr. Gairdner suggests they may sometimes be, the mere natural secretion of these tubes, accumulated for the want of power to throw them off, it becomes abun- dantly easy to comprehend the mode of production of collapse, in at least some of the examples. Whether a simple deficiency of inspiratory force alone, without obstruct- ing mucus in the bronchia, W'ill give rise to collapse, is a somewhat mooted point. Dr. West agrees with MM. Legendre and Bailly, in the opinion that it is often due to the inspiratory power having been inadequate to overcome that natural elasticity of the lung which opposes a full dilatation of the organ. Dr. Gairdner {loc. cit, p. 33) cannot "see reason to believe with Dr. West, that mere debility, apart from any obstruction in the tubes, is a sufficient cause for collapse in the child." He remarks, and with strong show of reason, that the very fact of the lesion being usually more or less lobular, or partial in its distribution, appears to indicate special circum- CAUSES. 145 stances of a local kiud, as having a marked influence on the production of this affection. What is of most consequence, however, to the working physician, as an important practical truth, is the fact stated by several observers, and adverted to by Dr. Gairduer himself, that in some cases no signs whatever of obstructive bronchitis or of bronchial accumulation can be discovered during life. Before leaving this point, we desire to call attention to the opinion of Hasse {Pathol. A)iat., Syd. Soc. ed., p. 253), that, though this partial introduction of air might be deemed at variance with the laws of respiration, inasmuch as the atmospheric pressure must necessarily distend the entire lung equally, not to the exclusion of a lobe, and still less to that of a lobule, the objection falls to the ground when it is considered that the o|>eration of these laws is the result of previous muscular action. He refers to the fact that in pleurisy one-half of the thorax, and in partial pleurisy certain portions of that cavity, do not share at all in the movements of the remainder. " "We need, therefore," he says, "be at no loss to understand how defective breathing may originate in a merely partial activity of the intercostal or other respiratory muscles." Dr. Gairdner, as already stated, considers as one of the causes of col- lapse, an inability to cough and expectorate, and thus to remove the ob- structing mucus. The views which he expresses on this point are very interesting, and also, we think, very important. He states that Laeunec supposed the expiratory force of respiration to be weaker than the inspi- ratory, while in fact the experiments of Hutchinson and Mendelsohn, to which he refers, prove that though ordinary inspiration is more of a mus- cular act than ordinary expiration, yet the residual effective force for over- coming adventitious obstruction is very considerably greater in expiration. " The forced or muscular expiratory act is, in fact, about one-third more powerful, as measured by its effect upon a pressure-gauge, than the extreme force of inspiration ; and it is this force which is thrown into action when obstruction in the tubes is to be overcome." In the act of coughing, the air in the vesicles is brought to bear upon the obstructing substance within the bronchia, at a maximum amount of outward pressure, and with the additional mechanical advantage of a sudden impulse, so that the practical efficiency of the expiration in forcing air through obstructions must be far greater than that of inspiration. It is clear, therefore, that if the secre- tions in the air-passages be so abundant or so viscid as to interfere materi- ally with the entrance and exit of air, they must necessarily occasion col- lapse, either partial or total, of the parts beyond them, since not only does the air enter with difficulty, but being expelled with greater force and in larger quantity than it can be drawn in, the amount remaining in the vesic- ular structure must gradually dirainij^h. This effect of obstruction will be still more remarkable when the muscular force of respiration is diminished by debility of the patient, for then the inability of the inspiratory act to replace the air driven out by expiration, will be yet more marked than when the muscular powers of the body retain their full force. There is still another mechanical condition which tends to produce col- lapse from obstruction, to which Dr. Gairdner refers. This condition is to 10 146 COLLAPSE OF THE LUNG. be found in the form of the bronchial tubes. These tubes are a series of gradually diminishing cylinders, and if a plug of any kind, but especially one closely adapted to the shape of the cylinders, and possessing consider- able tenacity, be lodged in any portion of such a cylinder, it will move with much more difficulty towards the smaller end, and in doing so will close up the tapering tube much more tightly against the passage of air, than when moved in the opposite direction into a wider space. From this arrangement of the parts, it will happen that at every expiration a portion of air will be expelled, which, in inspiration, is not restored, owing in part to the comparative weakness of the inspiratory force, and in part to the valvular action of the plug. "If cough supervene, the plug may be en- tirely dislodged from its position, or expectorated, the air, of course, re- turning freely into the obstructed part ; but if the expiratory force is only sufficient slightly to displace the plug, so as to allow of the outward pas- sage of air, the inspiration will again bring it back to its former position, and the repetition of this process must, after a time, end in pefect collapse of the portion of lung usually fed with air by the obstructed bronchus." We have been thus particular in our consideration of the causes of col- lapse, because we are convinced, from personal observation, that it is a subject of very great importance in practice. Many times, in the last few years, we have met with cases of bronchitis, either primary or secondary, in weak and debilitated children, in which the general and local symptoms have pointed clearly to the existence of collapse of the lung, and in which, moreover, the good effects of a sustaining and even stimulating treatment have shown the great utility of an acquaintance with the nature of this affection, and its proper remedies. Symptoms. — As collapse of the lung occurs almost always in connection with bronchitis, though sometimes, also, after, or concomitantly with pneu- monia, it is clear that the symptoms which reveal its existence must be mingled, in a greater or less degree, with those of the two diseases just named. It is true, nevertheless, that it sometimes occurs unassociated with more than very slight evidences of any other disease of the lung. Cases of the latter kind have been usually observed only in children dying in states of utter exhaustion, in whom the muscular power of respiration has been so greatly weakened, as to prevent a dilatation of the thoracic cavity sufficient to carry air into the deeper parts of the lung. In such instances, the symptoms of collapse do not show themselves until a very short time before death, and they consist in the sudden appearance of very rapid and oppressed breathing, with little or no cough, in more or less extensive dul- ness on percussion over different parts of the chest, but most frequently the inferior dorsal regions, and in feeble or suppressed respiratory murmur, or more frequently a distant and imperfect bronchial respiration. In some cases, however, in which there is very little bronchial complication, as shown by the rarity and small amount of the catarrhal rales, the symptoms of collapse continue with more or less irregularity, as to situation and ex- tent, for periods of several weeks, or even months. But here, also, as in the cases previously referred to, the general debility and low health of the child are strongly marked, and are, with slight variations persistent. * As ILLUSTRATIVE CASE. 147 an instance of this kind of collapse, we may cite the following case, which occurred in the practice of one of ourselves : A boy, between throe and four months old, who, at birth, and up to the time of this attack, had presented every appearance of strong and vigorous health, was seized, on the 3d of October, 1840, with symptoms of a somewhat irregular and anomalous character, but which we soon suspected te be the signs of an intermit- tent fever. "We were induced in part to make this diagnosis, from the fact of having attended the mother during her gestation of this child, in a severe attack of inter- mittent fever. At the beginning of the sickness, there was some little coryza, but no cough whatever. On the 3d of October, after the coryza had lasted for a few days, he became worse, and wc were sent for. During the six days following this, he had one or two attacks each day of coldness of the extremities, followed by vio- lent fever, and ending sometimes with perspiration. He was exceedingly fretful, screamed a great deal, was at times drowsj^ and dull, and vomited occasionally. The stools were regular and perfectly' natural. The breathing was rapid and short nearly all the time, but there was no cough whatever. On the seventh day, the respiration was 100 by the watch, and irregular. The child was pale, weak, drowsy, and entirely without cough. Percussion revealed nothing, and no. rales could be beard. On the eighth day, the breathing was 9G, and a slight, dry cough was heard two or three times. When roused up, the intelligence of the child seemed perfect. On the ninth day, the breathing was 63, and the pulse 120. There was rather more cough, though still very little, and there was a slight return of the coryza, of which there had been none for several days before. Neither auscultation nor percussion revealed any decided change in the lungs. On the eleventh day, the paroxysms of chilliness, followed by fever, were still noticeable, though there was no clearly marked perio<^city in the returns. When without fever the breath- ing was 54 ; during the fever it was 67. Auscultation revealed nothing decided. Percussion showed dulness beneath the right clavicle. By the seventeenth da}', the intermittent nature of the disorder was more decidedly marked, and under a few doses of quinine the symptoms had improved, so that the breathing fell to 30 during sleep. The cough was a little more frequent, though still very slight, and it was loose. The coryza, also, was more considerable, tlie nasal discharge being quite abundant. After this the case went on badly, owing, we think, in great measure, to the cir- cumstance of the quinine being abandoned in consequence of the opposition made by the parents to its administration, an opposition which we allowed to influence us more than was proper. During November and December, the child remained wpak, pale, languid, and with uncertain appetite, sometimes refusing the breast for a whole day at a time. The quinine was suspended at first on account of the great improvement which had taken place in the symptoms, and though resumed after- wards, was given in such small quantities, and for so short a time, for the reasons just mentioned, as to be of no service. In December the child was very ill. It looked badly, having a pale, waxy face, and a dull, languid expression, though without any want of intelligence ; it emaciated moderately, and had occasional vomiting; the stools were natural. At this time al.«o it took the mother'.s breast with some difficulty, and refused artificial food altogether. Occasionally during this month there was observed a slight blueno^s around the mouth, and also about the hands and feet. Late in the month it was attacked with thrush in a slight degree, which la.*ted several days. In the first week of January, finding that it was fast sinking from refusing the mother's breast and artificial food, a wetnursc was procured, and for a few da}* it seemed to improve a little, but this did not last. It grew weaker and thinner, the thrui»h returned, it had now a good deal of loose cough, the aMomen became somewhat contracted and f»'lt hard and doughy, and the breathing was very rapid, though not greatly oppressed. The child died 148 COLLAPSE OF THE LUNG. at last on the 26th of January, having, for ten days before that event, looked wretchedly languid and haggard, and having presented for three days before, slight diarrhoea, loose, frequent cough, entire loss of appetite, thrush, drowsiness, and, finally, coma. At the autopsy there were found some fibrinous exudation, and a few adhesions over the lower half of the left lung. The lower two-thirds of the left and the lower half of the right lung were dark-colored, more dense than usual, not friable, and exhibited no granulations on a cut surface. These portions were in fact col- lapsed. The upper lobes were spongy, crepitant, and healthy. Not a tubercle was found. The foramen ovale presented an oval-shaped opening, of the size of a goose-quill. The abdominal organs were healthy. When, as indeed most usually happens, collapse occurs in the course of bronchitis, it is associated of course with the symptoms of that disease. The bronchitic symptoms have lasted in their usual form for several days, having been marked by sonorous, sibilant, and subcrepitant rales, when suddenly, or in the space of a few hours, the breathing becomes much worse, the pulse rises in frequency but becomes small and feeble, and cer- tain changes take place in the physical signs which are very important. The subcrepitant rale continues to be heard, but it is associated now with prolonged expiration, and a little later with bronchial respiration, which, however, is of a different kind from the bronchial respiration of pneumo- nia, being distant and smothered, instead of near and metallic, as in that disease. The percussion becomes, at the same time, dull and obscure, but never, scarcely, to the same extent as in pneumonia. The general symp- toms are those of exhaustion, rather than of high reaction. The surface is pale or slightly bluish, the skin is either natural in temperature, slightly warmer than usual, or coolish, the strength is very much reduced, and the child appears more seriously ill, and particularly more oppressed than the amount of bronchitis present would seem to explain. As an example of collapse occurring in the course of bronchitis, we will give the following case : A girl between two and three months old, healthy when born and up to the time of this sickness, saving that she was rather paler and smaller than most robust in- fants, was seized with coryza and slight cough, and after a few days with the symp- toms of a mild bronchitis. For two daj's there was frequent cough, some little fever, quick but not oppressed breathing, occasional sibilant and mucous rale, per- fect ability to nurse, and very moderate restlessness or fretfulness. On the third day, without any apparent reason, the symptoms became suddenly very alarming. The breathing became extremely rapid and most violently oppressed, so that the movements of the chest at each respiration were heaving and laborious, the shoul- ders being lifted high at each respiration, the outer angles of the mouth drawn downwards, and the alse nasi widely dilated. There were at the same time abund- ant subcrepitant, intermingled with dry rales over the dorsum of the chest. There was marked constriction of the base of the chest with each inspiration. The cough was frequent and racking, and occurred in paroxysms. The child was still and quiet, pale, had a haggard and exhausted look, was unable to nurse at all, and its surface was cool and white, especially that of the extremities. These symptoms continued with very little modification for twenty-four hours, when, under the use of brandy administered every hour in milk drawn from the mother, of the spirit of Mindererus and paregoric, perfect quiet, and the assiduous employment of mild revellents, they began to moderate, and at the end of another twenty-four hours I DIAGNOSIS. 149 the constriction at the base of the thorax diirins: inspiration had disappeared, the breathing was easy and gentle, the extremities had become warm, the child nursed eagerly and abundantly, and, with the exception of a slight catarrh, which lasted a few days longer, it was well. Collapse depending on bronchitic iuflamraation, in debilitated children, may sometimes last a considerable length of time. In one case, indeed, that we saw a few years since, and of which an account was published (see Am. Journ. Med. Sci. for January, 1852, p. 98\ the symptoms, owing probably to the fact that the bronchitis causing the collapse was an ac- companiment of hooping-cough, continued with slight variations in degree for a period of about three months, after which the child entirely recov- ered. Diagnosis. — The diagnosis of collapse of the lung must always be more or less uncertain where it is of the lobular form, for the reason that the collapsed lobules being disseminated irregularly through the pulmonary tissue, afford no physical sign by which we can detect their condition. The presence of this form ought, however, to be suspected whenever, in a chronic disease, and especially m the course of a catarrhal attack occur- ring in a feeble and debilitated child, the breathing becomes excessively quick and labored, the skin pale and coolish, when the base of the thorax presents a depression instead of an expansion during inspiration, and, espe- cially, when these sN^mptoms occur without there being a sufficiently severe and extensive bronchitis to explain their existence. In cases of collapse affecting a considerable or the greater part of a lobe, the diagnosis, though still perhaps rather uncertain, is much more clear and positive than in the lobular form. In the latter form we are obliged to depend, indeed, almost exclusively upon the rational symptoms, the physical signs being either very slight or entirely null. In collapse of CDnsiderable portions of the lung-tissue, we have, on the contrary, some very useful physical signs. These are, the existence of dulness, greater or less, on percussion; feeble respiratory murmur; prolonged expiratory sound, and .sometimes bronchial respiration ; which, when they occur in connection with, and in the course of bronchitis, are usually quite suffi- cient to render the diagnosis easy. The only diseases with which collapse of the lung, presenting the physi- cal signs just mentioned, could be confounded, are pneumonia and pleurisy. From lx>th of these it is usually distinguishable by the absence in collapse, or the slight severity, of the reactional .symptoms, by the paleness or blue- nes and coolness of the surface, by the absence of acute pain, by the greater severity in collapse of the bronchitic symptoms, and by the fact that it rarely occurs except in enfeebled, broken-k blood in 16 of 39 primary, and in 2 of 7 complicated ca.'^es, and did not deplete at all in the 2 fatal ca«es. M. Barthez report* 212 ca,«ert, treated by the expectant nietho^l, with only 2 deaths, or le^s than one in a hundred ; and these caset*, too, in children between 2 and 15 years of age, in hospital practice. These last stati^ties are the most surprising we have seen. We have been unable to find the original memoir of M. I'ur- 182 PNEUMONIA. thez, but have seeu the report made to the Academy of Medicine, by M. Blache {Bulletin de VAcad. Imp. de Medecine, t. xxx, p. 21), on the me- moir, in which it is stated that " the author has taken care to eliminate the lobular or generalized pneumonias, the pseudo-lobar pneumonias, broncho-pneumonias, and catarrhal pneumonias ; he has also thrown aside the lobar congestions which occur in the course of low fevers, and the secondary lobar hepatizations ; that is to say, those which occur in the course of any well-determined disease, and particularly tuberculosis." We cannot help thinking that the elimination of so many forms of pneu- monia, must be a chief reason for the very great success of the plan of treatment used. This much, however, has been plainly established by the observations and experience of late years, that the old plan of bleeding, as a rule of absolute practice, merely because of the existence of pneumonia, and es- pecially the Sangrado system of bleeding, coup sur coup, was a gross mistake, and one which did great harm. But we do not think it has been proved that the restorative or expectant system, to the exclusion of blood- letting under any circumstances, is always and inevitably the right one. We have been led to think that bloodletting was not the only cause of the heavy mortality under the old systems of treatment, but that the use of such agents as antimony, ipecacuanha, and perhaps calomel, in large and frequently administered, and long-continued doses (and particularly the antimony) by their action upon the stomach, in destroying all power to take and digest food, and by the general prostration which their action (especially antimony) upon the nervous system occasioned, were answer- able for a large share of the fatal results of those days. We doubt, in fact, whether depletion, used in anything like moderation, is not safer for the patient than the continued use, for two or three days, of nauseants and depressants, more particularly of antimony. But of the action of anti- mony upon children, we shall speak more at length hereafter. Our own opinion,, after the enlarged experience of later years, is, that depletion should not be used save in exceptional cases. When the pneu- monia is pursuing a regular and safe course, it is best to trust to the sim- ple means to be spoken of hereafter — to follow a mild expectant method. Where the physician doubts as to its propriety, and especially when he is young and inexperienced, it is safest to abstain from it entirely, or to em- ploy it only in a very moderate degree. But there is a certain class of cases, in which we believe that local depletion, by cups and leeches, is not only allowable but most useful. When the subject is vigorous and strong, with a fine sanguification ; when the temperature is very high ; the pulse strong and full ; the muscular force good, and the side-pain and cough very severe, we think that the local abstraction of from two to four ounces of blood, at the age of three or four years, has great power to relieve all these symptoms. Again, when the dyspnoea is very great ; when the heart pulsates with great force, whilst the pulse is small and feeble, showing that the right heart is overloaded, and the arteries comparatively empty, in con- sequence of obstruction to the passage of blood through the lungs ; and when the child is tolerably vigorous, and not reduced by previous illness, TREATMENT — ANTIMONY. 183 a moderate venesection is often of more use, and of more efficacy in pal- liating these conditions, than any treatment we know of. The quantity to be taken should seldom be over four ounces, at the ages of from three years and upwards. We venture upon these statement,^ the more boldly when we tind such men as Chambers and Niemeyer, and even Bennett, giving the same advice. Dr. Bennett (loc. cif.) lays down amongst his axioms the following: ** Small bloodlettings, of from six to eiglit ounces, may be used in extreme cases, more especially in double pneumonia and broncho-pneumonia, as a palliative to relieve tension of the bloodvessels and congestion of the right heart and lungs." 'Siemeyer (Te.vt- Book of Pract. Med., Amer. ed., vol. i, p. 184) says, pithily: "Highly as I prize venesection, however, in certain emergencies which may arise in the dis- ease, I had rather that any one, dear to me, and sick of pneumonia, were in the hands of a homoeopath, than in the hands of a physician who thinks that he carries the issue of the malady upon the point of his lancet." He recommends venesection in three conditions: 1. When the pneumonia lias attacked a vigorous and hitherto healthy subject, is of recent occurrence, the temperature being higher than 105^ F., and the frequence of the pulse rating at more than 120 beats a minute. "Here danger threatens from the violence of the fever, and free venesection will reduce the temperature, and lessen the frequence of the pulse. In those who are already debilitated and ansemic, bleeding increases the danger of exhaustion. Should the fever be moderate, bloodletting is not indicated, even in healthy and vigorous individuals." 2. " When collateral a?dema, in the portions of the lung unaftlcted by pneumonia, is causing danger to life, the pressure of the blood is reduced by bleeding, and by prevention of further transudation of serum into the vesicles, insufficience of the lung, and carbonic acid poi- soning are averted. Whenever the great frequence of respiration, in the commencement of pneumonia, cannot be traced to fever, pain, and to the extent of the pneumonic process alone, as soon as a serous, foamy expectora- tion appears, together uith a respiration of forty or fifty breaths a minute, and when the rattle in the chest does not cease for awhile after the patient has coughed, we ought at once to practice a copious venesection, in order to reduce the mass of blood, and to moderate the collateral pressure. The third indication for bleeding arises upon the appearance of symptoms of pre.-sure uprjn the brain, not headache and delirium, but a state of stupor or transient paralysis." We have made this long quotation because the authority is so high, and because we have nowhere found such clear and conci.se statements upon this most important point of practice. Antimony. — In a former edition of this work it wa.s stated that tartar emetic, in the dose recommended by some of tlie highest authorities of the day, had been found by us a very dangerous drug. Time has but confirmed this opinion. At that time we were in the habit of administering it in doses of a forty-fifth or sixtieth of a grain every hour or two hours. This waa at a time when Rilliet and Barthez used it in doses of from two to four grains, dissolved in four ounces of water, in twenty-four hours, for very young children, and for those who were older six gniins in the ^ame space of time. They continued it for two, three, or four days, and advised its 184 PNEUMONIA. suspension should it give rise to excessive vomiting or severe diarrhoea. Dr. West at that time gave it in doses of one-eighth of a grain, at the age of two years, every ten minutes, until vomiting was produced ; to be con- tinued every hour or two afterwards for a period of twenty-four or thirty- six hours. Dr. West had reduced the doses, and the time of continuing it, one-half, between the time referred to and the date of his essay on pneu- monia, published in 1843. The doses used by us, as mentioned above, may seem to some who have not employed them ludicrously small, but we soon found that even they were quite frequently, in certain constitutions, more than could be given ■with safety. Antimony, even in those small quantities, sometimes caused a very peculiar general prostration. Perhaps without any vomiting what- ever, or with only a rare effort at that act, the patient would refuse all nourishment, become very pale and weak, grow limp and motionless, take on a haggard and pinched expression of face, pass into a state in which it would pay no attention to what was going on around, be very peevish and irritable when disturbed, get a very frequent and feeble pulse, and look to an experienced eye as though a very little deeper degree of such prostra- tion might end fatally. After seeing this condition a few times, and find- ing that the withdrawal of the drug and the use of small doses of brandy (ten to twenty drops in water or milk) every hour or two hours, was fol- lowed by rapid improvement, we learned the greatest caution in the use of the remedy. Of late years we never use tartar emetic at all, but give, not unfrequently, in strong and vigorous children, with high febrile heat and rapid circulation, small doses of the precipitated sulphuret of antimony, always watching its effects carefully, and withdrawing it at once should the above symptoms make their appearance. The formula found most useful and safest is the following : B;- — Antimon. Sulphurat., .... gr. j. Pulv. Doveri, . . . . . gr iij. Sacch. Alb , . . . . . . gr. xij. M. et div. in chart, no. xii. One to be given every two, three, or four hours. To infants under two years of age it is best to give no antimony at all. Mercury. — In former years, in obedience to the prevailing rules of the day, we gave calomel in very moderate quantities in some cases of pneu- monia. We never felt sure that it was of any special service, and of latter years do not give it except under some very clear indication. When, how- ever, especially in the early stage, there are signs of gastro-hepatic con- gestion, such as a flabby tongue with whitish fur, fulness of the hypochon- driac regions, anorexia and perhaps nausea, a few small doses of calomel, or of blue mass followed by a mild saline laxative will be followed by relief. Salines. — Citrate of potash, either in the form of the neutral mixture or dissolved simply in water with a little sugar, is one of the best febrifuges that can be used. In doses of two and a half grains to children over three or four years old, and half a grain to a grain for younger children and TREATMENT — IPECACUANHA — MURIATE OF AMMONIA. 185 infants, every two hours, it is an excellent remedy. It may bo given alone, or combined witli small doses of syrup of ipecacuanha and opium. Spirit of nitrous ether may be added when the urine is scanty, or when the ipe- cacuanha cannot be borne. The solution of acetate of ammonia, either alone or combined with the spirit of nitrous ether, is useful when the child is feeble, and when the stomach or bowels are irritable, in which case the citrate of potash some- times otiends the stomach and acts upon the bowels. The dose of this remedy may be from twenty or thirty drops to half a drachm or a drachm, accordintr to the age, in sweetened water, or some aromatic water, every two hours. Quinia is unquestionably a remedy of great value in both forms of the pneumonia of children. When given in full doses, it diminishes the intense febrile heat and the great rapidity of pulse ; and, at the same time, is be- lieved by many observers to possess a tendency to check the extension of the exudation process. It is usually perfectly well accepted by the stomach, and does not interfere with the power of taking food ; while, on the other hand, by its tonic influence it must be of service in sustaining the system until the necessary stages of this exhausting disease have been passed. Ipecacuanha is preferable to antimony in all conditions except those referred to above. In infants under two years of age, in children of highly nervous temperament, or of feeble and delicate constitutions, in most cases of the secondary form, and in all mild cases, it is much safer than the other drug. The most convenient preparation is the syrup, of which ten drops may be given every two hours at four yeai*s of age, five drops between one and three years, and from one to three drops to infants of two or three months. It is often useful to combine the spirit of nitrous ether with it, and, when the stomach is irritable, or the patient very restless and irritable, to add small doses of opium. When the patient is much oppressed by the presence of secretions in the bronchia, and not too much prostrated, an emetic is oft^n very useful. Ipecacuanha is the most suitable remedy for this purpose, a? it produces less exhaustion and depression than any other, except, perhaps, alum. Muriate of Ammonia has of late years been very largely employed in the acute pulmonary affections both of adults and children. It has seemed to us to possess the power of hastening the softening and resolution of the exudation, and when there is expectoration, of rendering it less viscous and freer. The best period for administering it is in the lobar form after the hepatization is clearly established and the attack has rear-hed it,s full development ; or, in the catarrhal form, after the acute symptoms have somewhat subsided. It may then be given, associated with the febrifuge employed, or else dissolved in a little syrup of Tolu or syrup of wild cherry bark and water. The proper dose is one grain for children under 2 years of age, and 2 to 3 for those between 2 and o years, given every <», o, or 4 hours, according to it« effect and the wav in which it is toUraf'-d by the Stomach. If the resolution of the exudation do^- not progress rapidly, and c-jk'- 186 PNEUMONIA. cially if symptoms of exhaustion make their appearance, the carbonate of ammonia may be substituted in about the same doses, for the muriate. Purgatives. — A ptirgative dose, with or without a previous small dose of a mercurial, is useful at the beginning of the attack, when the child is constipated, and when the abdomen is tumid and hard. A teaspoouful of castor oil, or two teaspoonfuls of simple syrup of rhubarb, will answer every purpose. After this period cathartics need be used only so as to keep the bowels moderately soluble. If they are moved spontaneously every two or three days, there is no occasion to give purgative doses. If they do not move, a simple enema, or the doses mentioned, will be sufficient. Violent or frequently repeated doses of purgatives are injurious, by ex- hausting the patient through the disturbance of the stomach which they occasion, or by setting up diarrhoea. External Applications. — MM. Rilliet and Barthez. were of opinion that neither blisters. Burgundy pitch, nor tartar-emetic plasters, exerted the least influence upon any one of the symptoms of pneumonia, but that, on the contrary, they increased the fever. Dr. West gave up the use of blis- ters entirely, in consequence of the irritation and fever they occasioned, and because of the disposition to sloughing which he observed to follow their use amongst the poor. At one time we thought we had observed great benefit from the use of a blister when other means had failed to pro- duce some moderation of the symptoms after four or five days. If they are used at all, it ought to be with great care, especially in very young or feeble children, whose nutrition is depraved. In children of less than two or three years old, a blister should never remain on the skin longer than two hours. As a general rule, the mother should be told positively to re- move it at the end of one hour and a half, even though the surface be still unchanged. A warm bread-and-milk poultice is then to be used as a dressing, and this rarely fails to cause vesication in a few hours. Employed in this way, we have had but once the misfortune to see a blistered surface slough, and this occurred in a child whose skin had been very much irri- tated by frictions with amber oil and ammonia. Since the spring of 1845, however, when we were led to make frequent use of mustard poultices and foot-baths in the treatment of the bronchitis and pneumonia of measles, we have rarely employed blisters, but have preferred the employment several times a day of the remedies just indi- cated. Two parts of Indian meal and one of mustard, for young children, and for those who are older equal parts of each, are to be mixed with warm water, and spread thickly like a poultice on a piece of flannel or rag five or six inches square. This is to be covered with fine muslin, linen, or gauze, and applied first over the back and then the front of the thorax. It may remain from fifteen to forty minutes, or until the child cries or complains, or until the skin is reddened. The mustard foot-baths may be employed at the same time with the poultices. These applications are useful when- ever the oppression is very great, and, when resorted to in the evening, they often allay irritability, and dispose the child to sleep. The number of applications to be made in a day must depend on the urgency of the II •I TREATMENT — TONICS AND STIMULANTS. 187 symptoms. We have employed them from ouce a day to every two or three hours. The use of hot linseed-meal poultices, so highly recommended by Dr. Chambers, of London, we have found apparently of much service. The poultices should be spread quite thick on a cloth or flannel as broad as the circumference of the thorax, and deep enough to cover the whole chest, from the collar bones to the hypochondria. The size of the poul- tice will be determined by the amount of lung-tissue, though we usually have them spread large enough to cover the whole affected side, even if but a portion of the lung be involved. They should be changed several times during the day, and care should be taken that a fresh hot poultice is ready for application before the one in place has been removed. In order to keep them in place, it is often necessary to have a tape stitched on in front, and a tape behind, which can be tied over the shoulder in the manner of a shoulder-strap. Tonics and silmiiltuiUs are to be resorted to in cases which manifest un- doubted signs of debility. When, therefore, the attack- occurs in a feeble child ; in secondary cases ; when the inflammation remains unresolved after the use of other remedies, and when extensive bronchial respiration persists, though the fever has moderated; or when, in any case, during the acute stage, the child falls into a typhoid state, as shown by pallor of the surface, frequent, uneven pulse, dry tongue, prostration of muscular power, and either incessant jactitation or the listless quiet of exhaustion ; attention must be paid to the state of the constitution even more than to the local disease. The vital forces must be sustained and strengthened in order to give time and power to carry on the operations necessary for the removal of the local obstruction. To effect this purpose, we must depend upon the use of food, alcoholic stimuli, and certain toni{^-J. The food most suitable for such a condition is milk, animal broths, soft-boiled eggs, and perhaps small quantities of raw or slightly cooked meats. The be^t stim- ulants are brandy, given either in the milk or in water, as the child will bfe-t take it, and wine and water, or wine-whey. The amount of brandy given may be stated as 3,4, or 5 teaspoonfuls in the course of 24 hours at 4 years of age. The best ionie to give in conjunction with the alcoholic stimulus is, as has already been stated, quinia, which should be adminis- tered in the quantity of from gr. iv to gr. \"j in 24 hours, given in divided doees. When the exhaustion is marked, especially when associated with great embarrassment of respiration and copious viscid secretion from the brrinchial tubes, we should recommend the use of the muriate or carbonate of ammonia, either of which may be given in mucilage, in doses of gr. ij to iij every 3 or 4 hours, at 4 or o years of age. Opium is constantly of great service in the treatment of pneumonia. It should always be used when the patient .suffers much, either from the side-pain or from cough, whether this be hara**sing and exhausting from its mere frecjuency and persistence, or from its effect in developing the stitch ; when there is painful jactitation, an unusual degree of distrcMs and malaise, or marked tendency to morbid vigilance. When the fever is very high, the pulse vibrating, the nerves on a rack, opium is of the greatest 188 * PNEUMONIA. advantage. The mere comfort it gives is a good warrant for its use, but it has long seemed to us to aid in shortening the duration and lessening the severity of the constitutional disturbance. The choice of the preparation, and the doses and times of administra- tion, must vary in different cases. When used early in the case, to act upon the circulation and allay general irritability, it is best to give it with the febrifuge every two or three hours. When used to control cough, it can be added to the sulphurated antimony in the form of Dover's powder, as already suggested, or to the syrup of ipecacuanha and spirit of nitrous ether, in a liquid form ; or when the cough is particularly troublesome at night, as often happens, it can be given with more advantage in a single dose, or two doses in the evening. The preparations we have found most useful are, laudanum, especially the tr. opii deodorata, paregoric, solution of morphia, or Dover's powder. Under six months of age, half a drop of laudanum, from five to ten drops of paregoric, or two or three drops of the solution of morphia, may be given, and repeated twice or three times in the twenty-four hours, according to the effects. From the age of six months to the end of the second year, these doses may be doubled. In the third and fourth years, two drops of laudanum, ten to twenty of pare- goric, five to ten of solution of morphia, may be used several times a day. Where the remedy is given every two or three hours, we have found one drop of laudanum quite enough at the ages last mentioned. When the dose is given only at night, from three to five drops of laudanum, ten to fifteen of solution of morphia, and thirty to fifty of paregoric are suffi- cient as a general rule. After the age of four and five years, the doses must be increased in proportion to the age. In very young children, the doses given at first should always be watched with a good deal of care, and never carried to such a quantity, or continued long enough, to in- duce constant and heavy drowsiness or stupor. In some instances of very nervous and hypersesthetic children, in whom there is determined, by the violence of the reaction, a degree of irritability of the nervous centres tending to the tetanic state, the doses must be much larger than those mentioned ; but here the physician should see the patient himself at least twice, and sometimes three times in the day, to watch and regulate by the dose the exact action of the drug. We have occasionally seen the cough most harassing and exhausting in its effect, occurring almost with every breath, and lasting for twelve and twenty-four hours. Under such circumstances, a mixture like the following has proved most beneficial in our hands : 1 R.— Tr. Opii Deodorat., gtt. xxxij. Vin. Antimon., . Ext. Valerian, Fl., Syrup, Simp., Aquae, . Dose, a teaspoonful every hou gtt. xxxij. f^iss. — M. or two hours, at the age of four years and up- wards, until the cough is controlled. Paregoric, in the proportion of two drachms to half an ounce, in place of the laudanum, sometimes proves more soothing and comforting. GENERAL MANAGEMENT. 189 General Management. — Since the reign of restorative nuMliciue has set in, the jj^eueral mauairement of the patient has reeeivod a di'iiree of at- tention which it had never attracted before. Under the expectant plan it constitutes, indeed, the chief portion of the treatment. The most impor- tant point;? to be attended to under this head are tlie diet, drinks, eK)thing, air, and state of repose. The patient ought not to be allowed to go entirely without food even in the early days of the disease, neither should there be any ettort made to stuff the child with large quantities of nourishment. The appetite is nearly always in great measure abolished, at first, and food is unwillingly taken except in very small quantities. A nursing child must not be al- lowed to nurse as heartily as usual. If it attempts to do so, it is probably from thirst and not from hunger. Water, therefore, should be offered to it from time to time, and the breast be allowed only every three or four hours for short periods. Weaned children should have only milk, always reduced by the addition of half or a third water, and pure water ought to be given frequently. The thii-^t in this disease is intense, and the phy- sician should himself see that the patient has water freely. We have seen the most violent and obstinate screaming, and painful restlessness, quieted at once by a copious draught of cold water. In children over two and three years of age, milk and water is still the best food ; but when this is refused, thin chicken or beef tea may be given in doses of a wineglass- ful or a gill every four hours. After three or four days have passed by, the administration of food is a very important part of the treatment. The child should now be induced, by persuasion and even gentle force, to take a little food at least three or four times in the twenty-four hours. As the severity of the symptoms subsides, the food ought to be increased in quantity. The clothing ought to be such as to keep the body comfortably warm. In winter, which is the season when the disease almost always occurs, thin and .soft flannels ought to be worn, and, when the child is very restless, either in the bed or on the lap, a sack made high in the neck, with the sleeves to the wrists, buttoning in front, and consisting of a soft and pli- able woollen stuff, ought to be put over the bed-dress. The room ought to be, if possible, a large one with a high ceiling, well ventilated, warmed by an open fire, and kept at a temperature of 65^ to 68^. If the child is very young and delicate, a temperature of 70° is not too high, if only the ventilation be good. The bed or crib is the proper place for a child with ])nmetime> epidemic amongst children as it is amongst adulte. It is important also to be aware that there is a strong tendency to attacks of bronchitis in rickety children. The only exciting causes whose effect* in the production of the disease seem clearly proved are sudden transitions from a warm into a cold at- mosphere, and sometimes the contrary change ; prolonged exposure to cold, particularly when combined with moi.sture; and the inspiration of irritat- ing gases. We believe ourselves, from what we have seen in this city during the last thirty years, that the most fruitful caiwe of bronchitis, and 192 BRONCHITIS. also of pneumonia, croup and angina in early life, is the style of dress almost universally used for young children. The dress is entirely insuffi- cient. It consists usually of a small flannel shirt, cut very low in the neck, scarcely covering the shoulders, and without sleeves ; of a flannel petti- coat, a muslin petticoat, and an outer dress made in nearly every case of cotton. The dress, like the flannel shirt, is cut low in the neck, is without sleeves, and fits very loosely about the chest, so that not only are the whole neck, the shoulders, and the arms exposed to the air, but in consequence of the looseness of the dress about the neck, it is fair to say that the upper half of the thorax is also without covering. In the infant, from birth to the age of six or eight months, the dress is made long, a wise provision so far as it goes, but from the time the skirts are shortened, up to the age of four or five years in boys, when happily the time for boys' clothes arrives, and throughout childhood in girls, the trunk of the body and the arms are dressed, or rather left undressed, as above described. But, not only are the neck, breast, and arms left bare, but in many children the greater part of the legs also is kept uncovered, or at least, short stockings, scarcely ris- ing above the ankles, and muslin or sometimes Canton flannel drawers, not reaching, or scarcely reaching to the knees, leave exposed to the air a large proportion of the cutaneous surface of the lower extremities. Now, in this dress, the child passes the day in a house, the sitting-rooms of which are heated usually to 68° or 70°, but in which the entries, and sometimes the parlors, are frequently at a temperature of 60°, 50°, or even lower, as we ourselves have tested with the thermometer. And not only are the entries and parlors, and indeed all the rooms, saving the one or two in constant use, frequently at the temperature just mentioned, but the air of the nursery itself is often allowed, through the negligence of the servants, and especially early in the morning, to fall to 60° or 58°, or possibly lower still. That the style of clothing is not correct, is proved by the simple facts that children who are dressed nearly the same in summer as in winter, suffer scarcely at all from colds in the summer season, when the thermom- eter seldom ranges below 76°, and is usually above that point ; and also by the fact that adults have been driven by long and almost forgotten experience, to wear clothing twice or three times as warm as that which they put upon their children. How constantly do we see the strong and fully-developed man comfortably enveloped in a warm, long-sleeved flannel shirt, woollen or thick cotton drawers, and cloth pantaloons, vest, and coat, in the same room and in the same temperature with the little — often puny, pale, and half-naked — child. But it is almost impossible to make people understand that children need as much clothing as themselves. They always insist upon it that, as the child passes the greater part of the day in the house, it cannot require as much clothing as the adult who is obliged to go out and face the weather ; forgetting, or refusing to see, that the former wears less than half, or probably not more than a fourth, as much covering as the latter, and that the adult, when in the house, and in the same rooms as the child, finds his one-half or three-fourths warmer clothing not at all superabundant or oppressive. 1 ANATOMICAL LESIONS. 193 We have repeatedly had patients to get well of chronic catarrhal and laryngeal coughs, and to cease to have, as before, frequent recurrences of these disorders, under the simple treatment of a long-sleeved and high- necked merino or Haunel shirt; long woollen stockings, and stout Canton flannel drawers coming down below the knees; and that, too, after the most patient and assiduous, and sometimes over assiduous trials of drugr, diet, and confinement to the house, had entirely failed of any permanent good efiects. The fact is, that though there are some few children who can bear the dress above-described without injury, there are a great many more who, while they wear it, either suffer all winter long from frequently repeated attacks of cold, in the shape of croup, chronic laryngeal irritation with cough, chronic pharyngitis, bronchitis, acute or chronic, or more rarely pneumonia ; or, if they escape these direct effects, resulting from the con- stant and rapid waste of their caloric, they are rendered more pale, thin, and delicate-looking than they would be v.ere their vital forces husbanded by warm clothing, instead of being wasted in the constant-struggle to keep up the Beat of the uncovered body at the natural point. AxATOMiCAL Lesions. — We shall describe, first, the lesions met with in cases in which the disease is confined to the larger bronchia, the in- flammation not extending into the capillary tubes ; and next, those ob- served in cases in which the disease has attacked the capillary bronchia. The former are those which constitute the form designated under the title of acute ordinary bronchitis of moderate severity, while the latter are those to which the term capillary has been applied. Patients seldom die of the first-named variety of the disease alone; but as it often occurs as an accidental complication, or a more or less essential part of difl^erent severe and frequently fatal diseases, the morbid alterations which characterize it have been very thoroughly studied and ascertained. The morbid alterations of acute ordinary bronchitis always exist in both lungs, and are confined to the larger bronchia, ceasing on a line with the -mailer tubes and the capillary divisions. The most constant alteration is redness of the bronchial mucous membrane, caused by injection of the Tiiinute vessels of that and the subjacent tissues, and varying in shade from a rosy to a bright-red or brownish tint. The mucous membrane is sometimes softened, a change which can be ascertained only in the largest tubes, and it sometimes presents a thickened, unequal, and rough a{)i)('ar- ance. Ulcerations are very rare. The inflamed bronchia contain a more or less abundant viscid, transparent, or opaque yellowish mucus. In cipiUnry bronchitiji the alterations of the mucous membrane of the capillary tui>es do not always reveal the existence of the disease. That membrane is sometimes pale in the minute ramifications, and exhibitn morbid changes only in tbo.se of medium size. The alterations of the membrane consist ib redness, which is made up either of a number of fine points, .seated in the membrane itself, or of arborizations seateh as the latter become more abundant. As the dry rales cease to be heard, they are replaced by mucous or subcrepitant rales, or by feeble- ness of the respiratory murmur. The sibilant nlle is often heard over the whole thorax, though it may be confined to the posterior portions. It is not restricted to cases of inflammation of the larger bronchia only, but is alsfj present in capillary bronchitis. Moi^t Rides. — Mucous and subcrepitant rales do not exist in all cases without exception, as they may be absent in such as are very mild. They may generally be heard over both sides behind, more rarely over the whole of the chest, and almost always both in inspiration and expiration. They are generally persistent, but are sometimes suspended for a moment and replared by sibilant rale or feeble respiratory sound. Ft»ble rejtpiratory murmur is sometimes observed. It is not permanent, occurs during the interruptions of the subcrepitant or sonorous rale, and does not occupy the whole extent of the thorax, but is limited ; it is inter- mittent, and is not accompanied by diminished resonance. When dilatation of the bronchia exist,s to a considerable extent it gives rise to bronchial or even cavernous re?*piration, and to bronchial resonance of the voice, cr)*, and cough. The bronchial respiration differs from that of pneumonia by iU tone, and by it* intermitting character. The percus- sion is generally sonorous. It ha.-* already been stated in the account of the symptoms that it hap- pens not infrequently in severe bronchitis, and also in mild bronchitis occurring in debilitated children, that the respiratory sound suddenly be- comes feeble, or even entirely 8upprei*sed, over parts of the lung, while in other instances a distant and im|)erfectly marked bronchial rcrjiiration 202 CHRONIC BRONCHITIS. takes the place of the natural vesicular murmur. These changes are heard either over small disseminated points of the lung, or over large sur- faces ; they are associated with more or less evident dulness on percussion, and what particularly characterizes them, they are very fugitive, being present at one examination, and absent perhaps at the next. The appear- ance of these changes in the phenomena afforded by auscultation depends on the occurrence of diffused or lobular collapse of the tissue of the lungs. The physical signs above described are not invariably present in bron- chitis. Cases do occur, though they are very rare, in which auscultation fails to reveal the characteristic signs of the disease. Rational Symptoms. — The rational symptoms are of the utmost im- portance in informing us of the degree of severity of the attack. Cough generally exists from the beginning, being in mild cases more or less frequent, and either dry or loose, while in severe cases it is frequent or very frequent, at first dry and then moist, and very rarely hoarse. In acute capillary bronchitis, the cough has a peculiar character. From the first day it occurs in short paroxysms, lasting from a quarter to half a minute. The paroxysms vary greatly in violence, occur at irregular in- tervals, and generally continue without interruption to the fatal termina- tion, though they are sometimes replaced by simple loose cough a few days before that event. The cough is rarely painful, so long as the in- flammation remains simple. Expectoration is never present in very young children. When it occurs in those over five years of age, it consists, in the mild form, of a sero-mucous or of a frothy and yellowish mucous liquid. In general bronchitis it is sero-mucous at first, becoming after a few days yellowish and more or less viscous ; it is sometimes nummular and sometimes amorphous. In the capillary form, as already mentioned, the sputa consist of mucus tinged with blood, or of pure blood even, and in some rare cases there are mixed with the mucus, shreds of false membrane, which may present the form of casts of the minute ramifications of the bronchial tubes. The respiration varies in its characters according to the extent and vio- lence of the disease. In mild cases, it is not much increased in frequency, being generally between 28 and 40 in the minute. In more violent cases, and particularly when the disease implicates the smaller bronchia, it be- comes very frequent. The acceleration is slight in the beginning, but increases regularly as the case progresses ; thus it may be 30 at first, and rise afterwards to 50, 60, 80, and even 90. When not very much quick- ened, it remains even and regular ; when more so, it becomes somewhat laborious, and the movements of the chest are full and ample ; in severe cases, attended with much dyspnoea, it is often irregular, or assumes the characters to which M. Bouchut has applied the term expiratory, that is, the order of the movements is inverted, each respiration beginning with the expiration, leaving a pause between the inspiration and expiration, in- stead of between the expiration and inspiration. In chronic bronchitis with copious purulent or pseudo-membranous expectoration, the dyspnoea is generally habitual. Fever. — The fever is slight in mild cases, the pulse rising very little DIAGNOSIS. 203 above its Datural standard. The heat is not great, and the febrile move- ment usually subsides before the termination of the disease. In the sinive or capillary form, on the contrary, the pulse is always frequent, and con- tinues to increase in rapidity as the disease advances. It varies between 104, 120, 160. and in very violent cases, rises as high as 200. Early in the attack, it is vibrating, rather full and regular, whilst in fatal cases, it always becomes small, irregular, trembling, and unequal. The skin is generally hot in proportion to the activity of the pulse, except towards the termination, when the extremities often become cool. The temperature does not rise so rapidly nor reach so high a point as in pneumonia. Thus Roger gives as the highest temperature observed by himself in bronchitis 102.2°; while the average in his cases of the acute febrile form was 100.9°. The skin is almost always dry. In very young children it is often pale and cold, and covered with perspiration from the beginning. The expression of the face is unchanged in mild cases, but when the dis- ease is violent and extensive, becomes deeply altered after a few days. The eyes are then surrounded by bluish rings, and the expression is uneasy, anxious, and sometimes, but less frequently, exhibits an appearance of pro- found exhaustion. The anxiety of the countenance increases with the op- pression ; the alae nasi are dilated, the nostrils dry or incrusted, and the lips and face, which are extremely pale or momentarily congested, assume a purple tint, particularly after the paroxysms of cough. The deciibitis is indifferent at first, but as the disease progresses, the child lies with its thorax more or less elevated, or is restless and constantly chang- ing its position. In dangerous cases there is great distress and restlessness after the first few days, or even from the beginning. In some instances the irritability and peevishness are excessive and uncontrollable, while in others there is heaviness and somnolence, especially towards the termination of fatal cases. Some of the disorders of the nervous system just mentioned are present in all the grave cases. Digestive Orgam. — There is moderate thirst and incomplete anorexia when the disease is mild, but, when severe, the thirst is generally acute, and the appetite entirely lost. The state of the bowels varies. The tongue and abdomen present no special characters in idiopathic cases. Urine. — The great majority of recorded obser\'ations of the condition of this excretion in bronchitis, relate to the disease as occurring in the adult. The followinir summary is taken from Parkes : the condition of the urine in bronchitis varies greatly with the grade of the disea.«se ; in the grave forms, it resembles that of pneumonia, the urea being increased, and the chloride of sodium at times entirely absent. The urine has also been quite frequently found to be temporarily albuminous in such cases. DiA<^;Nf»sis. — The mild form of bronchitis, in whioh the inflammation is confined to the larger bronchia, is not likely to be mi.stakcn for any- thing but the early stage of hooping-cough. The diagnosis can be made only by attention to the different characters of the cough, which i;* more spasmodic and paroxysmal io pertussis, by the absence of fever in that 204 BRONCHITIS. disease, and by the development of the peculiar symptoms of each, as the case progresses. The diagnosis between bronchitis and pneumonia is seldom difficult, ex- cept when the latter is grafted upon the former, or in cases of partial pneu- monia, attended with bronchitis. In well-marked cases of the two diseases, there can be no difficulty. The restriction of the physical signs to one side alone of the chest in pneumonia, the peculiar crepitus of that disease, or when this is not heard, the fineness of the subcrepitant rale, limitedto the upper or lower regions of one lung, the bronchial respiration and bron- chophony, the dulness on percussion over the seat of disease, the greater sharpness and severity and the different location of the pain, the more acute character of the febrile reaction, as marked by the pulse, skin, and thirst, the more abrupt and higher elevation of temperature, and the kind of expectoration, when there is any, will always enable us to dis- tinguish the two with almost absolute certainty. In cases, however, in which the two are combined, the diagnosis is not so easy, but even here the presence of dulness on percussion, and of crepitant or fine subcrepi- tant rale, or, when these are absent, of pure metallic bronchial respiration with bronchophony, over limited portions of the lung, will generally ren- der the matter clear. The sudden supervention of dulness on percussion over large portions of one of the lobes of a lung, or over disseminated patches, with feeble or absent respiratory sound, or with muffled and distant bronchial respiration, generally indicates the occurrence of collapse in the part of the lung over ■which these signs exist ; and when these symptoms show themselves without any increase in the severity of the febrile reaction, but rather with a diminu- tion, there is every reason to suppose that they depend, not upon inflam- matory condensation of the parenchyma of the lung, but upon simple col- lapse, from the presence of obstructive secretions in the bronchia. Dr. Gairdner {loc. cit., p. 6) has called attention to a difference in the character of the dyspnoea in the two diseases, which is, we think, of con- siderable importance, and which we have often remarked ourselves. In bronchitis, of any considerable severity, the respiration is always evidently labored ; it is performed only with the aid of all the accessory muscles of respiration, and in really severe cases it is extremely laborious, the inspira- tion being long-drawn, exhausting, and inadequate. The dyspnoea of pure pneumonia is, on the other hand, quite different. It is merely an " accelera- tion of the respiration, without any of the heaving or straining inspiration observed in bronchitis, or in cases where the two diseases are combined." Dr. Gairdner states that he has repeatedly seen patients affected with a great extent of pneumonia of both lungs, in whom the extreme lividity and rapid respiration, numbering fifty or sixty in the minute, showed infallibly the amount to which the function of the lung was interfered with, who, nevertheless, lay quietly in bed, breathing without any of the violent effort, or disposition to assume the erect posture, so constantly accompanying the more dangerous forms of bronchitis. In children these differences are even more marked than in adults. Chronic bronchitis may be mistaken for tuberculosis of the lungs or of PROGNOSIS — TREATMENT. 205 the bronchial glands. The distinction can be made only by careful study of the history of the case, and of the phenomena afforded by auscultation and percussion, which are detailed in our article on tuberculosis. It is also important that we should not overlook the evidences of rachitis, which, as before stated, very often exist in children who are predisposed to attacks of bronchitis. Prognosis. — Bronchitis is rarely a fatal disease, so long as it remains contined to the larger bronchia, constituting the acute simple form, of moderate severity. Capillary bronchitis is, on the contrary, a very dangerous affection at all times and at all ages. Even ordinary, simple bronchitis, however, may prove fatal in young infants, and in debilitated children of all ages, from the supervention of collapse of portions of the pulmonary tissue ; and it is necessary, therefore, that the prognosis given should always be guarded, when the disease occurs under either of these two conditions. The prognosis differs also in the primary and secondary forms of the disease, since, as might be expected, the danger is much greater in the latter than in the former variety. We have met with a large number of cases of bronchitis, out of which we have kept more or less copious notes of 123. Of these, 108 were mild, and 15 capillary. Of the 108 mild cases, 6d were primary, all of which recovered ; and 43 secondary, of which 2 died. Of the 15 capillary cases, 11 were primary, of which one died, and four secondary, of which 2 died. Of the whole number, 123 in all, 5 proved fatal. The danger from the disease depends very much also upon the hygienic conditions in which the patients are placed. In hospitals and amongst the poor it is much more dangerous than in private practice amongst the easy classes of society. This is shown by the fact that all the cases of the capillary form observed by MM. Rilliet and Barthez and Fauvel, in ho^pital practice, proved fatal, while of 15 cases seen by ourselves, in private practice, under the most favorable hygienic conditions, only 3 died. The symptoms indicating great danger are, increase of the dyspna\a; extreme anxiety, small and irregular pulse, coolness or coldness of the skin with clammy sweats, much jactitation, and delirium, drowsiness, or coma. With such symptoms the danger is greater and the fatal termina- tion more imminent in proportion as the child is younger, less robust, and its constitution exhausted by preceding or coincident disease. Tkkatmext. — The acute simple form of bronchitis is frecjuently so mild as to need no other treatment than careful attention to the hygienic condi- tion of the patient, and the administration of some simple febrifn^'o and expectorant. The child ought to be confined to one room, in a mild and uniform temperature, and should be kept quiet until the develo|)ment of the symptoms shows what is to be the type of the attack. The degree of repose of the body necessary will depend on the presence or ab?iencc of fever. We believe that the practice of keeping the body er- fectly well without bloodletting of any kind. We now believe that such practice is unnecessary in any of this class of cases. Attention to hygienic meas^ures is, however, even more important than in the milder cases. Con- finement to the bed ought to be a positive rule in such cases. If the bowels are not freely moved, a dose of castor oil, rhubarb, or magnesia should be given, and the patient then put upon the use of one of the febrifuge mix- tures recommended above. When the fever is very high, and the j)atient over a year old, antimonial wine may be substituted, with advantage, for the syrup of ipecacuanha. If, as the case progresses, the bronchial secretions become very abundant and the dyspnoea severe, the proper remedy is an emetic. This may be ipecacuanha, either in powder or syrup, or a teaspoonful of powdered alum, to be repeated if necessary, in ten or fifteen minutes. The latter substance is, as we have stated under the head of croup, a very certain, efficient, and safe emetic. Great benefit may be obtained in all forms of bronchitis, from the more or less frequent application of mustard poultices to the front or back of the thorax, and from mustard foot-baths. The mercurial preparations, so much recommended by many of the English and by some of our own writers, are, in our opinion, very seldom, if ever, necessary in this, or indeed, in any of the forms of bronchitis in children. It may be known that the occurrence of gastric du«turbanc© with coated tongue, anorexia, and a torpid state of the bowels, may, in some 208 BRONCHITIS. cases, call for the administration of a single dose of blue mass followed by a mild saline laxative. MM. Rilliet and Barthez recommend, when the cough and sibilant rale persist after the disappearance of the febrile symptoms, the use of small doses of the flowers of sulphur. We have ourselves known this remedy to prove of service in such cases. About four grains may be given every three hours to a child four years old. The treatment of the grave acute or capillary form of this disease brings up again the question of bloodletting. We, like all the rest of the world, have abandoned the practice as a rule, but we think that when, in a case of the kind now under consideration, the age being over two years, the oppression is very great, the right heart laboring, as shown by a congested surface and a throbbing cardiac impulse at the base and left edge of the sternum, and the strength not too much reduced, the abstraction of from two to four ounces of blood from the interscapular space by cups or leeches, would be a useful and legitimate practice. We venture to give this advice from our own past experience, and from the views taught quite lately as to the effect and value of depletion in relieving the overdistended right heart, produced by an obstacle to the pulmonic circulation. There is no occasion for repeating here what has been said, under the head of pneumonia, in regard to tartar emetic. But if the temperature be very high, and the pulse full and strong, we believe that the small doses of sulphurated antimony (gr. yL) we then recommended, in combination with Dover's powder, every two or three hours, are very useful in moder- ating the inflammatory symptoms. Should this be followed by nausea or vomiting with exhaustion, they must be suspended at once. The physi- cian, and especially the young and inexperienced one, ought to know that the susceptibility to the action of all antimonials is singularly different in different individuals. We have seen a hearty adult woman thrown into a most violent, and for a time alarming choleraic condition, by two doses of j^3^th of a grain of tartar emetic each. We saw once a fine hearty boy five years of age, vomit violently, grow pale, weak, and faint away, from two teaspoonfuls of the mel. scillse compositum, containing in the two doses, the fourth of a grain of tartar emetic. And even twelfths of a grain of the sulphurated antimony will sometimes cause a degree of nausea and prostration in young children which ought not to be kept up, though we never saw it occasion such effects as those just mentioned as following the use of tartar emetic. When, therefore, the sulphurated antimony acts with any undue violence, it ought to be stopped, and we should substitute the citrate of potash mixture proposed for the mild form of bronchitis. In connection with one of these internal remedies, counter-irritation to the surface of the chest will be found of very great service. Indeed, we doubt very much whether it is not the most important part of the treat- ment. It may be obtained by applications of dry cups to the back of the chest, or if this be inconvenient or objected to for any cause, by the use of mustard poultices. The poultice ought to be about the size of the hand, or one-half larger, and it should be made of one part mustard to two of Indian meal or flour. It is to be mixed with warm water, covered with I TREATMENT. 209 book muslin or cambric, and applied first to the dorsum of the chest ; after having reddened at that point, it should be shifted to the front of the ihorax. The time uecessjiry for each contact is usually from ten to fifteen or twenty minutes. These applications ought to be renewed once in four hours, when the symptoms are only severe, but when these are urgent, they should be made every two hours. We are in the habit of depending very much, also, on mustard foot-baths. When the oppression is severe, and especially when there is any coolness of the extremities, the use of a foot-bath simultaneously with the mustard poultice will often assist very much in relieving the breathing. In very young intants, antimony ought not to be employed, in our opinion, and in these, therefore, we need some other remedy. In them ipecacuanha is much safer than antimony, and it is quite active enough. The best preparation is the syrup, of which from three to five drops may be given every two hours to infant? six months old. In older children, also, in whom we have been obliged to suspend the antimony, and in those in whom its use has been contraindicated by delicacy of constitution or by feeble health, the ipecacuanha is preferable. The doses must vary with the age. At five years, about ten drops every two hours, in combination with the game quantity of spirit of nitrous ether, is a proper dose. When the child presents a pale surface and a languid expression, and particularly when the skin is very slightly warmer than usual, or coolish, the following pre- scription has proved a most useful one in our hands: E- — Liq- Ammon. Acetat., f^ss. Syrup. Ipecac, ....... f^j. Liq. Morph Sulphat., ^tt. xl. Syrup. Acacia?, ....... f^j. Aquae, f5J^;;.— M. Ft. mistura. The dose of this is a teaspoonful for a child two years old, to be repeated every two hours. Should there be any nausea present, the syrup of ipe- cacuanha ought to be reduced to half the quantity; and if there be any [drowsiness, the morphia must be left out. In very severe cases of the disease, in which the dyspnnea is excessive, the ipul.«e rapid and small, the skin cool and pale, the jactitation very great, Imnd when there is present extensive mucous and subcrepitant rale, the I treatment generally recommended is the frequent employment of emetics, I and the French authors usually prefer tartar emetic. For our own part, we would not venture to administer, under such circumstances, so power- ful a remedy, and especially .so potent a seflative, as antimony, one that we liave so often known to cau.«e alarming and dangerous prostration in rhii- dren laboring under much slighter disorders than suffocative bronchitis. If any emetic be given, it ought to be one of milder action and less |>er- turbing influence than tartar emetic, and we should choose, therefore, either ipecacuanha or alum. The plan of treatment we prefer, however, is to make assiduous u-^e of counter-irritants, and to give internally the spirit of Mindererus and a weak decoction of seneka ; or we may combine 14 210 BRONCHITIS. with the decoction of seneka, in a suitable form, small doses of the muriate or carbonate of ammonia. Depletion is, in these cases, entirely contrain- dicated ; we may, however, with advantage apply a few small dry cups to the dorsum of the chest in the interscapular space, or over the lower lobes of the lungs. In the bronchitis of children it often becomes proper and necessary to make use of stimulants. In the suffocative form, when the symptoms as- sume the character described in the last paragraph, small doses of brandy or wine-whey may be administered alternately with the spirit of Mindere- rus, with great advantage. In milder cases, also, when a sudden increase of the dyspnoea occurs, especially in feeble and debilitated subjects, and when we may suppose, from the character of the rational and physical signs, that collapse of portions of the lung has taken place, it is best to abandon for the time all nauseating remedies, and to make use simply of brandy in doses of from five to twenty drops every half hour or hour, or of wine-whey in dessert or tablespoonful doses, and of counter-irritants, with very light fluid nourishment. In cases where there is such marked debility, tonics are very useful, and good results may be obtained from the administration of quinia, which was strongly recommended a few years ago, in the form of capillary bronchitis occurring in tropical climates, by Dr. Cameron {London Lancet, November 9th, 1861). In cases of this kind, we have used with great advantage of late years small doses of quinia, prepared as follows : R. — Quinise Sulphat., gr. vj. Acid. Sulph. Dil., gtt. xij. Syrup. Simp., f.l^s. Aquae, f^ijss. — M. Give a teaspoonful every two hours, to children two or three years old. In older children the proportion of quinia to the dose ought to be doubled. If this should sicken, as it will sometimes do by the disgust its bitterness produces, and the consequent resistance to the doses, it is best to lay it aside after two or three trials, and to administer the quinia in the form of pow- der mixed with a little extract of liquorice and sugar, or to substitute the following : R.— Elix. Cinchon. Flav., f.^^ij. Cura^oa, fjij. Acid Sulph. Dil., f^^xij. Aquae, f^fij^s. — M. Dose, a teaspoonful every two hours. Here, as well as in other conditions calling for the use of quinia, but where it is difficult to administer it by the mouth, we may give it with good effect in the form of suppositories made with cocoa butter, as small as possible, and containing one or one and a half grains of quinia each. The child ought to be laid on an inclined plane of pillows, and, with the exception of turning it gently towards one side or the other, from time TREATMENT. 211 to time, it should be kept perfectly quiet. These directions are particu- larly importaut iu very youug children, as it is in them that debility and exhaustion of the muscular forces are apt to bring about the state of col- lapse just referred to. As an example of the kind of case in which stimulants arc useful, and to show also the dangerous effects which antimony sometimes produces, we will quote the following: A girl between seven and eight years old, was attacked while in good health with severe bronchitis. On the second day, when we were called, she was very much oppressed, the skin was hot and dry, the pulse rapid, and the surfiice pale. We ordered a cupping to the amount of four ounces, with some dry cups besides, over the back, and two drops of antimonial wine with ten drops of sweet spirit of nitre to be given every two hours. On the third day a blister was applied over the sternum. On the fourth day we found the child in the afternoon very pale, dozing or tossing about on the bed, and sometimes rising up on her hands and knees with a bewildered look ; she was inattentive, so that it was almost impossible to catch her eye ; the eyes were sunken, and the countenance was distressed and anxious; she moaned constantly and looked very ill ; the skin was still hot ; there was neither vomiting nor purging. The respiration was very much oppressed, and she coughed a good deal, though not so much as before. We suspended the antimony at once, and gave a teaspoonful of brandy in water, directing it to be re- peated in three-quarters of an hour; after the second dose a teaspoonful was to be given in a wineglassful of milk and water every two hours throughout the night. On the following morning, the child looked better; she was less pale, and the eyes were not so excavated. The breathing was better. She was still very drowsy, but often waked partially with scream- ing and affright, and when awake took very little notice. The milk and brandy were continued every two hours. On the afternoon of this day, all the unpleasant symptoms had disappeared ; there remained only those indicative of a slight bronchitis, and she was soon quite well. Now it seems to us exceedingly clear that, had the antimony been continued in this case, on account of the hot, dry skin, oppressed breathing, freipient cough, and from the absence of vomiting or purging, the child would have died. The most impf)rtant points in the treatment of rhrom'c cn.^ex, are to insist upon a rigorous and persevering regulation of the hygienic conditions of the patient, and to make use of tonic, balsamic, and expectorant remedies. The child should be carefully and warmly clothed, and, when at home, kept in dr\', well-ventilated, and, if possible, airy rooms, at a uniform tempera- ture. The living room of such a child ought to be heated in winter by a wood-stove, or open wowi-fire, if that is sufficient to keep up a proper tem- perature. In our cold winters we have found no plan so good as a well- managed wood-stove. Cfjal fires cannot be lowered or extinguished at night, as they ought to be, and often keep up. throiiLdi tin- (la\ . to., liij-h a temperature. They are unmanageable. These, indeed, constitute the truly important part ol th<- trfMiriK-nt, lor without them, there is but little chance that drugs of any or of all kinds, 212 BRONCHITIS. diet, or any other measures, will be of any real service. The dress and temperature ought to be the first things attended to, and after them, and as a secondary matter, certain medical substances will assist in removing the disease. The child ought to be taken as often as possible into the air in fine weather, and only in fine weather. The diet should be selected with a strict view to the improvement of the strength and vigor of the constitu- tion ; the food may consist, if the child be of proper age, of light meats, of potatoes and rice, as the only vegetables, and unless there is some contra- indicating circumstance, of a small quantity of wine with the midday meal. The best wine is port, of which one or two tablespoonfuls may be given in a considerable quantity of water. Tonics must be administered throughout the course of the disease, or until the appetite and strength shall have improved to such an extent as to make them no longer necessary. The best are quinine, in the dose of a grain morning and evening, to be continued for several weeks ; or, when the child is thin and anaemic, small doses of arsenic with iron, as recom- mended in the article on eczema, and cod-liver oil, in doses of half a tea- spoonful to a teaspoonful, three times a day after meals, either pure or in some carefully-made emulsion, will often greatly assist in curing these chronic forms of catarrh. In one case of chronic bronchitis, which came under our care, the patient recovered under careful regulation of the hygiene, and the use of a decoction of seneka, prepared by boiling a drachm, each, of seneka and liquorice-roots, in a pint of water, to half a pint. The decoction was strained, and a large teaspoonful given three times a day. The remedy was continued during a period of two months ; under its use the child grew fat and strong, and recovered entirely from the disease. Other remedies, proposed by different authors, are the various resinous preparations, the balsams of tolu and copaiba, benzoin, and the sulphur- ous mineral waters. In cases of long standing, where mucous rales per- sist throughout the lower part of the lungs, showing an abundant morbid secretion, tannic acid has been found, by several good authorities, of much service. While these means are employed, it is recommended, also, to make use of counter-irritants. If any are used, they ought to be such as will not produce too much inflammation of the skin ; as, for instance, weak Burgundy pitch plasters, daily frictions with hartshorn and sweet oil, a simple diachylon plaster, or very mild pustulation with croton oil, or a mixture of croton oil and iodine, such as the following : R.-Ol. Tiglii, f^j. Ether. Sulph., f^j. Tr. lodinii, Alcoholis, aa f^iij.— M. S. Locally. EMPHYSEMA. 213 ARTICLE IV. EMPHYSEMA. Emphysema of the lungs is of quite frequent occurrence in children. It is much more generally met with in an acute form, developed during the progress of some pulmonary disease, than in the chronic form which it so often assumes in the adult. It is probahle, however, that in many cases of asthma in childhood, there is an emphysematous condition of the lungs which has been gradually developed at an early period of infancy, in consequence of the respiratory embarrassment attending rachitic dis- ease of the thorax. There is probably in such children a congenital deli- cacy and weakness of the lung-tissue, and subsequently, if the constitution is re-established, and the deformity of the thorax removed, as it frequently will be, there may be a restoration, to some extent, of the elasticity of the pulmonary tissue, with a corresponding decrease in the evidences of emphy- sema. It is also highly probable, judging from the frequency with which, in fatal cases of acute pulmonary disease in young children, more or less marked lesions of emphysema of the lungs are found, that this condition is frequently developed to a certain degree in the course of such cases which recover, and that subsequently the lung-tissue regains its normal state. Anatomical Appearances. — The term emphysema of the lungs, is usually employed to include two conditions essentially dissimilar, and to only one of which it is in reality applicable. One of these is vesicular emphysema, which is dependent on dilatation or coalescence of the pul- monary air-cells, without any escape of air into the connective tissue of the lung, and which would, therefore, be more correctly called rarefaction of iunf/-tis.me. The use of the term vesicular emphysema is, however, so universal and long-establi.shed, that it does not seem desirable to discard it. The other variety is interlobular or true emphysema, in which the air escapes from some point into the connective tissue of the lung, and dis- sects its way between the lobules and under the pleura. In vesicular emphysema the portions of lung usually worst affected are the apex and the anterior border; it may, indeed, be limited to these parts, or may be present, in varying degrees of intensity, along the biise and even over the entire surface of the organ. Usually it is present in both lungs simultaneously, though often much more highly developed on one side than the other. The dilatation of the vesicles causes marked enlargement of the part affected, and when both lungs are K*riously involved, thoy jtroject for- wards, occupying the mediastinal space, with their ant^-rior borders ch>sely approaching each other. The emphysematous portions do not collapse when the thorax is of)ened ; they are pale, dry, and bloodless, and, when pressed with the finger, afford a .%oft, doughy feeling, with but an impt-rfect 214 EMPHYSEMA. sense of crepitatioD. On examining the surface carefully, the dilated vesi- cles are clearly visible, forming clear, usually round spaces as large as a pin's head or a millet-seed. The effect of this distension upon the sur- rounding viscera and upon the shape of the thorax are the same in kind, though not so great in degree, as are met with in the adult. The dis- tended anterior portion of the left lung covers more of the heart than normal, and tends to depress this organ downwards and to the right. In the same way when extensive emphysema of the right lung is present, the liver is usually depressed. If both lungs are affected with marked and diffuse emphysema, the thorax is considerably distended, the curve of the ribs is increased, while they are elevated so that their course becomes more horizontal, and the thorax becomes shorter, deeper in its antero-posterior diameter, and more rounded. The other variety of emphysema — really the only one which strictly merits the name in its usual intention — is the interlobular. Here the air makes its escape from a rupture of some air-vesicle or minute bronchiole into the connective tissue of the lung, and then readily makes its way along the bronchial tubes between the lobules so as to reach the surface of the lung. Here it presents itself in the form of minute bubbles of air, of rounded or elongated form, easily recognized by their paleness and trans- parency, usually arranged in irregular, curving and branching lines, and which can be proved to be in the interstices of the lobules by the fact that they can readily be pressed by the finger from one place to another, or forced to coalesce. When these little bubbles are thickly crowded together they produce an appearance well compared by Rokitansky to froth. Asso- ciated with them are often found larger bullae, where the air has separated the pleura from the surface of the lung; these form flattish, convex prom- inences above the surrounding surface, and are freely movable. It will be understood that in interlobular emphysema of the lungs, the size of the organ is comparatively little affected, and consequently that little or no influence is exerted by it upon adjacent viscera or upon the shape of the thorax. This condition is comparatively rare, and is not usually associated with marked vesicular emphysema; indeed, the anatomical relations of the two forms are not clearly understood. In cases where the pleura is stripped off from the lung over a considerable space, the membrane may be ruptured and air escape into the pleural cavity, constituting pneumo- thorax, examples of which accident will be found in our article on this latter affection. In other cases, the air makes its way along beneath the pleura to the root of the lung, or by penetrating into the substance of the organ, and following up the divisions of the bronchi, it reaches the same point. It may then pass into the mediastinal spaces, where the loose con- nective tissue becomes highly emphysematous, so as to present numerous large vesicles with delicate walls, altogether resembling the appearances seen in animals in the slaughter-house. From the mediastinum the air readily passes upwards into the connective tissue of the neck, where it may first produce a crepitant swelling in the suprasternal, supraclavicular, or inframaxillary regions ; and may even extend thence over the surface of the trunk and extremities so as to produce general emphysema. ANATOMICAL APPEARANCES. 215 In the following interesting ease, wliioh has already appeared in print,' the subcutaneous emphysema did not extend below the clavicle. The minute perforation on the anterior surface of the upper lobe. wi\s perhaj)s due to the inflation of the lungs at the time of the examination, or may have occurred just before death. It would certainly have led to pneumo- thorax, had it been earlier present : Case. — Acuie Miliary Tuhercxilosis : Cough and Dysjmaa : Cervical Emphysema — Interlobular Emphysema — Interlobular Emphysema with Perforation of the Pleura : Emphysema of Mrtliastinum and Neck. — John F. was born •f a stout, hearty ytuing woman, 17 years of age, who nursed him ; and he seemed to thrive until eii:jlit days before his death, which took place January 24tii, 1868, at the age of four months. The symptoms during his sickness were dyspnoea, occasional dry, hacking cough, and am>rexia. A few days before his death subcutaneous emphysema made its appearance over the lower part of the neck in front, spreading over both sides, and altering the entire contour of the neck, but not descending below the clavicles. The post-mortem examination was made fifteen hours after death. The head was not examined. The subcutaneous emphysema persisted as above described. On removing the sternum, the mediastinal spaces were found much distended with air, the meshes of the connective tissue in some spots forming vesicles more than one inch in diameter, and sugsresting forcibly the appearances often seen in animals in the slaughter-house. The emphysema extended up along the trachea and larynx, and to a considerable distance on either side of the neck. There was not a trace of decomposition of the tissues. The lungs collapsed but slightly ; the posterior portions were deeply congested, purplish, and almost non-crepitant, but expanded almost fully on inflation. There was neither pneumothorax nor pleuritic effu>ion or adhesions. The larynx, trachea, and lungs were removed, and inflated under water, when air was found to escape from the right lung in two places — on the anterior face of the upper lobe, and on the inner surface of the apex. On ex- amining the rupture of the anterior surface of the upper lobe, the opening was found to be very small, and to be seated in the midst of a spot where the pleura was separated from the lung so as to form a large vesicle. There were other smaller pearl-like vesicles studding the surface of the lung. The apex was the seat of numerous miliary tubercles, both in the substjince of the lung and immediately beneath the pleura. At one point on its inner aspect there was such a subpleural deposit, half an inch in diameter, which had undergone cheesy change, and in the centre of which there was an ulcerated opening in the pleura. The escape of air through this perforation was prevented by the close apposition of a tuberculous bronchial gland, about half an inch in diameter, which lay immediately on the right bronchus. The other bronchial glands, especially on the right side, were also tuberculous. The left lung presented no perforation of the pleura. At several points, especially along the anterior edge of the lung, there were large emphysema- tous bullae, one inch long by half an inch wide, and in the neighborhood were numerous smaller vesicles of the same nature. On incising the lung near these, small clusters of gray miliary tubercles were found. Miliary tubercles were also found on the peritoneal investment of the liver and spleen, and in the substance of these organs and of the mesenteric glands. There were small irregular ulcers in the lower part of the ileum, and numerous small yellowish submucous deposits in the cjecum. Causes. — Although the vesicular and interlobular forms of emphysema ' W. Pepper, On rome Ca»e8 of Emphysema of the Neck. Philada. Med. Timec, August 1, 1872. 216 EMPHYSEMA. are anatomically quite distinct, they may advantageously be considered in connection with each other as regards the mode of their development. Age. — Vesicular emphysema, though a frequent sequel of acute thoracic diseases in children, cannot be regarded as a disease of childhood in the same sense as the interlobular form. It is true that the delicacy of the walls of the air-vesicles during early life would seem to favor the occurrence of dilatation, but experience shows that it does not favor the development of emphysema nearly so strongly as does the gradual degeneration and weakening of the walls of the air-vesicles which comes on in advanced years. Interlobular emphysema, on the other hand, is much more frequent in children, and reaches degrees of severity which are scarcely found in later life. So, too, the occurrence of subcutaneous emphysema, in consequence of the rupture of some minute bronchiole or air-vesicle, with the produc- tion of subpleural and then mediastinal emphysema, is an accident almost limited to early childhood, since of the recorded cases (about 25) in which it has occurred, four-fifths (20) have been observed in young children. Of these 20 cases of " general emphysema in children," to employ Roger's term^ (of which 19 were collected by him, and 1 subsequently published by one of ourselves),^ 6 occurred under the age of 2 years, 10 between 2 and 4, and only 4 between 10 and 15 years of age. Previous Diseases. — In children, emphysema occurs as a sequel to some other disease, pulmonary or laryngeal. The affections which most strongly predispose to it are hooping-cough, the bronchitis of measles, simple bron- chitis, pneumonia, and pseudo-membranous croup. Of all these, hooping- cough is by far the most fruitful cause. It will be observed that the dis- eases named present the common symptom of severe cough, often attended with impediment to the escape of air, either from spasm of the air-passages, or accumulation of secretion in the bronchi, or mechanical obstruction of the larynx by false membrane. Mechanism or Mode of Production. — The way in which pulmonary em- physema is developed has been made the subject of frequent and conflict- ing speculation. Of the two chief theories which have been advanced in explanation, one (the inspiratory) regards the overdistension of the vesicles as the result of the excessive operation of the forces concerned in inspira- tion ; the other (the expiratory) explains it as caused by violent but im- peded expiratory efforts. The inspiratory theory is still upheld by some eminent writers, but clinical observation is leading to its abandonment. In its original form as advanced by Laennec, it was based upon the erro- neous notion that the forces of inspiration are greater than those of expi- ration, and that consequently emphysema might result from mere exces- sive inflation of the lungs. This has, however, been universally abandoned as of general application, since the discovery of the important fact that in forcible breathing the power of expiration is considerably (at least one- third) greater than that of inspiration ; though it is probable that in some 1 Henri Roger, Archives de Medecine, 5eme ed., tome xx, pp. 129, 288, 403. 2 W. Pepper [loc. ante cit.). MECHANISM OR MODE OF PRODUCTION. 217 morbid conditions of the pulmonary tissues, violent inspiration may of itself be capable of producing emphysematous distension of the air-vesicles. The form of the inspiratory theory, which is still retained by some authorities, is based upon modifications introduced by Dr. William Gaird- ner, and is an expansion of the idea that if certain portions of the lungs are, from collapse or other cause, incapable of expansion, the atmospheric pressure will determine excessive dilatation of the remaining portions, in order to prevent the occurrence of a vacuum as the thoracic walls expand. There are, however, such grave objections to this theory, which, it will be observed, rests upon the supposition that the expansion of the thorax and the amount of air inspired remain at the normal point, although portions of the lungs are collapsed or otherwise rendered unable to expand, that we are strongly inclined to regard the expiratory theory as the only one capa- ble of general clinical application. We owe to Sir William Jenner chiefly the satisfactory refutation of the principal argument which was formerly brought against this latter theory, that "the expiratory act is mechani- cally incapable of producing distension of the lung, or of any part of it. The act of expiration tends entirely towards emptying the air- vesicles by the uniform pres^sure of the external parietes of the thorax upon the whole pulmonary surface ; and even when the air-vesicles are maintained at their maximum or normal state of fulness by a closed glottis, any further dis- tension of them is as much out of the question as would be the further dis- tension of a bladder, blown up and tied at its neck, by hydrostatic or equalized pressure applied to its entire external surface" (Gairdner). A little consideration of the anatomical relations of the lungs to the thorax shows the falsity of this argument. The different portions of the lungs are in contact with surfaces and tissues of very different degrees of resisting power, and while the entire postero-lateral portions are supported by the unyielding ribs, the apices are covered only by soft tissues, and the ante- rior borders of the lungs are supported externally by the comparatively yielding costal cartilages, while centrally they are able to encroach con- siderably uix>n the tissuas of the mediastinal spaces. In ordinary free ex- piration the air is forced out of the lungs by a pressure so moderate and gradual that even the weakest parts of the thoracic walls are sufficiently firm to maintain it. But when the expiratory efforts become more violent, the air is pressed with great force from the central, basic, and lateral por- tions by the ascent of the diaphragm and the compression of the thorax, while the outward current from the apices and anterior margins is com- paratively feeble. If, therefore, from any cause the normal relation be- tween the volume of the expiratory current of air and the calibre of the large bronchi be di.sturbed, the portion of air which cannot escape will be driven violently into the apices and anterior margins, not only overcoming the outward current of air proceeding from those |>ortions of the lungs, but producing an excessive degree of distension of their air-cells. The strong- est possible confirmation of the truth of this view is to be found in the fact that emphysema, both of the vesicular and interlobular form, is found to be develoj)ed in the various parts of the lungs in precise correspondence with the degree in which they lack firm external supixjrt. 218 EMPHYSEMA. There are two ways in which a disturbauce of the above relations may- be effected : either by an obstruction in the air-passages, which prevents the free escape of the air, or by the expiratory act being so sudden and violent that the volume of air hurriedly forced from the air-vesicles is too great to pass freely through the primary bronchi. Instances of this latter condition are familiar to all in violent fits of coughing, during which, even when there is no obstruction in the air-passages, the degree of disten- sion of the apices may be appreciated by the bulging of the supraclavicu- lar tissues. The full pulmonary resonance, which is elicited by percussion of this bulging, proves conclusively that it is due to distension of the apex ; and it is therefore easily understood how the repeated operation of such a cause may gradually lead to the development of vesicular emphy- sema, or how in an abrupt, violent, and prolonged expiratory effort, at- tending a fit of coughing, there may be a rupture of some minute bron- chiole or air-vesicle, followed by interlobular emphysema. Undoubtedly, also, the mechanical effects of such overdistension will be greatly enhanced by morbid conditions of the lung-tissue which weaken its elasticity, such as are present in severe bronchitis, especially when associated with consti- tutional diseases. Far more frequently, too, there is associated some cause of partial obstruction to the escape of air, such as the spasmodic contrac- tion of the air-passages in hooping-cough, the presence of layers of false membrane in the larynx or trachea, or thickening of the bronchial mucous membrane with plugs of viscid tenacious mucus in the tubes. It is very possible, also, that in some cases interlobular emphysema may be caused by the implication of a minute bronchiole in the progress of the softening of some spot of diseased tissue, so that the air might find en- trance to the interstitial connective tissue without any mechanical cause of overdistension and rupture of air-vesicles. Thus in the case reported above (p. 214) there was certainly a very close connection between the position of the patches of tuberculous deposit and the bullae of subpleural emphysema, so much so that we cannot doubt that the escape of air was in some way favored by their presence. In another case also, where inter- lobular and subpleural emphysema, followed by pneumothorax, occurred, and which is reported at length in our article on this latter affection (p. 250), it seemed to us that probably the softening of superficial circum- scribed patches of pneumonia had opened into minute bronchioles, and thus allowed the escape of air. Symptoms. — We have already seen that in young children emphysema occurs usually in an acute form in connection with some acute disease of the lungs. Although, therefore, its presence may be suspected in such cases where violent paroxysms of cough have occurred, associated with prolonged, severe dyspnoea, there are scarcely any physical signs by which its existence can be determined. The percussion-resonance will continue clear, or even become somewhat exaggerated, and this fact of the absence of any dulness (due to pneumonia, collapse, or pleural effusion), in a case of hooping-cough or bronchitis, when severe cough has occurred with un- usually extreme dyspnoea, is of diagnostic value. The respiratory murmur undergoes no immediate change in its character, and it is not possible, SYMPTOMS. 219 owing to the violent and rapid respiratory efforts of the child, to detect any diminution in the force of the murmur. Expiration in such cases is, however, often already prolonged and laborious. The development of acute vesicular or interlobular emphysema, then, is suspected rather on account of the character of the disease from which the child is sutiering than from any distinct substantive symptoms; of these conditions. Exception is to be made, however, of the rare cases, in which suddenly, in the course of an acute pulmonary disease, a swelling is noticed at some part of the neck, or in the subclavicular space, which on palpa- tion is found to crepitate. This may be regarded as, in all probability, connected with extensive interlobular emphysema. The other chief cause of such subcutaneous emphysema is perforation of the larynx or trachea, and the previous symptoms will enable us to exclude this rare condition without difficulty. In other ci\ses, however, vesicular emphysema in children assumes the chronic form, more usually found in adults, and will then be attended with the well-known symptoms of this affection. At times, it occurs evi- dently as a sequel to some acute pulmonary disease, in the course of which it has been developed in the manner above described, and after the original lisease has passed away, it persists, either owing to original weakness of the lung-tissue, or to the extreme degree of the dilatation of the air-vesicles. At other times, it is met with as a purely chronic affection, which may begin in early childhood, and gradually increase until the disease is fully developed. In such patients there is probably some congenital weakness and tendency to degeneration of the pulmonary tissues. It is not unfre- quently found that there are also evidences of rachitic disease of the ribs in such caifes. Children with chronic emphysema present various degrees of habitual dyspncea, which is always readily increased by exertion. They are very -ubjeet to attacks of bronchitis, during which the breathing is much em- barrassed and wheezing, the chest is full of sonorous and sibilant rales, and the cough occurs in severe paroxysms without much exj^ectoration. During these attacks, not unfrequently the child suffers at night from vio- lent paroxysms of spasmodic asthma. Indeed, it may happen that attacks of asthma will be induced in emphysematous children by the most trifling cau.-es, such as changes of weather, indigestion, and the like. The attacks of bronchitis vary greatly in different cases in their relation to season and temperature ; in some they occur almost exclusively during the damp, cold weather of fall and winter, while in others they are most frecpient and -evere during summer and sjiring, and the child finds more relief during cold weather. The cough varic:^ much in its intensity and character. During the attacks of bronchitis it is usually very severe, occurring in long spells, at fir>t with a little mucous expectoration, and later, as the attack passes over, with more abundant muco-purulent sputa. In the intervals of the attacks it may continue as an occasional dry and rather wheezing cough, or it may be more troublesome on account of a certain degree of chronic bronchitis being always present, or finally it may altogether subside. After 220 EMPHYSEMA. the disease has lasted a considerable time, however, cough may become persistent, occurring most severely at certain periods of the day, and attended with a considerable quantity of muco-purulent expectoration. In such cases, when emphysema is conjoined w^th chronic bronchitis, the sus- picion is apt to arise that the child is suffering from phthisis, and the posi- tive determination of the diagnosis may indeed be attended with some difficulty. The reader is also referred to the remarks made in this con- nection on the subject of chronic bronchitis (see p. 200). In young children under the age of 5 or 6 years, emphysema rarely reaches so great a degree, or persists for so long a time as to induce marked changes in the shape of the thorax, or to seriously affect their nutrition. In children somewhat older, however, when the disease is more severe and chronic, it may be attended with most of the symptoms familiar in the adult. The appearance of such children is apt to be frail and delicate, their muscular system develops slowly, and they become so readily fatigued and out of breath that they avoid play or much exer- cise. The shape of the thorax becomes gradually altered ; the shoulders grow high and rounded, and the chest is prominent and distended in its upper part, while owing to imperfect expansion of the lower lobes, there may be perceptible retraction of the base of the thorax in front, or even a marked depression around the entire base of the chest. Of course, this is likely to occur to a more marked degree if the emphysema is associated with rickets. The physical signs vary greatly with the extent and degree of the em- physema. In cases where it is limited to small areas of the lungs, scarcely any physical sign can be detected ; but in partial and more severe forms, the following phenomena can be observed : The respiratory movements are restricted especially in the way of expansion ; and during inspiration the movement is chiefly one of elevation effected by overaction of the upper respiratory muscles, and attended with an evident deepening of the depression around the base of the chest. The percussion-resonance is very full and clear, or even tympanitic, though owing to the marked resonance normal in children, it is difficult to determine the degree of its exaggera- tion. There maybe associated some impairment of resonance over the retracted base of the thorax, and especially posteriorly, where there may be congestion of the lung with accumulation of secretion in the air-pas- sages, due to the coexisting bronchitis. The respiratory murmur is weak- ened, though rarely to the degree noticed in adults ; the expiratory mur- mur is decidedly prolonged and frequently wheezing. Both inspiration and expiration are apt to be accompanied with sonorous and sibilant rales. These, and especially the sonorous rales, are most markedly developed over the posterior parts of the lungs, near the larger bronchi. In some cases, moist rales may also be heard over the postero-inferior parts of both lungs, owing to the presence of an unusualfy large quantity of secretion in the smaller bronchial tubes. During one of the acute aggravations of the bronchitis, attended with nervous asthma, to which we have above al- luded as being so frequent in such patients, a dry sibilant rale, distributed SYMPTOMS. 221 over the entire thorax, is ofteu the only sound heard accompanying: the lahored respiration. In marked cases, there will also be impairment of the resonance and fremitus of the voice, couirh or cry. The apex-beat of the heart may be concealed by the distended king, and the area of cardiac dulness is dimin- ished. As before said, the alterations of the shape of the thorax and the marked physical signs now described are very rarely observed in children under the age of 5 or 6 years, and become more constant and more marked at later periods of childhood. Case. — A., aet. 8 years, came under observation in the fall of 1873. Tho flnnjrli- tor of healthy parent-s, she was nursed until the asreof 2 years. She suffered much from occasional diarrhoea for the first three years of life, but then improved in this respect. She cut her teeth without difficulty, and as rapidly as usual ; bejran to walk at usual age. Has always perspired profusely atniirht, especially about neck find head, and when an infant was very troublesome from constantly kickinjx off the bedclothes at nicjht. There was no muscular soreness. At the age of 4 years she had a severe attack of spasmodic croup, and since then has been subject to frequent attacks of bronchitis, often associated with asthma. At first, there were only a few attacks each year, but for the past year thoy have followed each other with scarcely any intermission. She always suffers more dur- inc summer than in winter, and has found relief on several occasions by spondinsj a fow weeks durint; the summer at the seashore. The attacks usually behysema is such as to threaten life, minute punctures may be made in the distended skin, and the escape of the air favored by gentle pressure with the hands towards the point of puncture. The most important field for medical treatment is, however, to be found in those cases where emphysema, whether acute or not in its incipicncy, has passed into a chronic or persistent form. The indications for treat- ment which here present themselves, are mainly to relieve the chronic bronchitis, which is almost invariably asw>ciated with emphysema, if it has not been its ehiefcau.se; to eradicate any rachitic tendency which often coexists and, .so far as possible, to counteract its result-; U) guard against and relieve the acute attacks of bronchitis often accompanied with 224 EMPHYSEMA. nervous asthma, from which such children suffer ; and finally to favor, so far as lies in our power, the restoration of the dilated lung-tissue to its normal condition. There are several considerations of a general character, which will be found to have an important bearing upon these requirements. Change of climate, when it can be judiciously made, is often attended with excellent results, particularly as regards the bronchitic irritation and the attacks of asthma. We have known children who suffered most se- verely from these conditions, which were aggravated by any trivial causes so long as they remained in their native place, but who on removal to other climates, received marked relief and gradually outgrew the disease. It is not at all necessary that this change should be to a distant spot ; often the most convenient, dry, elevated, inland locality will answer excellently. The clothing of such children should be carefully studied and regulated. Without being so heavy as to oppress, it must be at all times warm enough to thoroughly protect; and at the same time there should be a suit of flannel or silk (consisting of an undershirt with long sleeves, and long drawers coming down to the ankles), of varying thickness to suit the season, worn throughout the year, to protect the surface of the body from the chilling effects of sudden vicissitudes of temperature. As further means to secure activity of the circulation and function of the skin, the use of salt baths (of a temperature to suit the season), and followed by brisk rubbing with a coarse towel, are to be recommended. In no condition of the system is the use of gymnastic exercise more to be insisted upon. We should select those exercises with light dumb-bells or Indian clubs, which will tend to strengthen the muscles of respiration, expand the lower portions of the chest, which, as we have already pointed out, are apt to be retracted, with some incurvation of the ribs, from the co- existence of rickets at an earlier age. As children in whom emphysema assumes the chronic form are usually over the age of 6 or 7 years, such exercises can be readily carried out Very recently several forms of apparatus have been devised for enabling the respiration of air of different degrees of condensation or rarefaction to be employed with accuracy. The one which we have ourselves em- ployed is known as Waldenburg's apparatus, having been designed by this eminent physician, who also has been chiefly concerned in introduc- ing this new method of treatment. In the case of emphysema, the patient is caused to expire into a receiver containing rarefied air. It is evident that this will exert an increased suction power on the air in the lungs, and thus will favor the emptying of the air-vesicles and the contraction of the chest to its normal limits. Undoubtedly in children, this method, which we have used with good results in adults, should be employed with caution ; but it is especially in young persons, when the elasticity of the ribs and of the lung-tissue is greater, that the most positive effect may be hoped for in causing a restoration of the chest to its normal size. The selection of the diet should be made with care. It will often be found that all the symptoms are aggravated by any digestive disturb- ance, and we have seen, as is indeed frequently the case in emphysema of TREATMENT. 225 adults, violent paroxysms of nervous asthma induced by indigestion. As the digestion in such children is apt to be weak, this point requires the greater care. As regards medication, the most important remedies are such as will affect the constitution favorably. We should recommend the use of cod-liver oil in properly graduated doses, and, especially where there are evidences of rachitic disease, the compound syrup of the phosphate or the lacto-phosphate of lime may be advantageously associated in the form of emulsion. If iron is not thus administered in the form of the phosphate, the oil may be given alone, and iron should be taken separately in some other combination, as in the following: R. — Potassii Bromidi, ^\j. PotAssii lodidi i;r. xlviij. Syr. Ferri lodidi, f^ij Syr. Tolutani, f :5vj. Aquae, f^ij. Ft. sol. S. — A teaspoonful thrice daily in a little water. The dose here directed is for a child of about 8 years of age. "We have also found the prolonged use of arsenic for it5 constitutional effects of much value in some cases. Cough should be relieved, so far as possible, without the use of opiates and nauseating expectorants. Among the drugs which we have found most useful in controlling it, as well as in relieving the chronic bronciiitis upon which it usually depends, are the iodide of potassium, which may be advantageously combined with the potassium bromide, as in the above prescription, the bromide of ammonium, and the muriate of ammonia. If the cough be very troublesome, especially at night, tincture of hyos- cyamus and minute doses of morphia may be occasionally associated. It may, however, become necessary to substitute for these, or to combine with them, other alterative and stimulant expectorants, such as .seneka or copaiba. The useof quinia,and, at times, of strychnia with it, is indicated through- out a large part of the treatment for the u.seful influence of these drugs upon the digestion and general nutrition, and especially upon the tonicity of the muscular system. The acute attack.*? of nervous asthma which are apt to occur from time to time must be relieved at the moment by the prompt use of relaxing emetics, hot rau.'*tard- water foot-baths, the inhalation of ether or of the smoke of >tramoniura cigarettes. The frequency of the.*ecomes afterwards perceptible only in the interscapular space, or at the inferior angle of the scapula, while the respiration is feeble or absent over the lower portions of the lung. In acute cases the feeble respiration re- mains limited to the dorsal region, and disappears after a few days, — in from five to eight, according to our exiK-rience; while in chronic cases it extends over a larger surface, and cuntitiiic- for several weeks, or even months. /'. I yion. — This means of diagnosis is very important in all cases of ill. . ~ ;i-^ accompanied by effusion of liquid, unless the quantity be ex- ceeeing taken of gra,«p- ing the instrument so that not more than one inch shall be free, to avoid all possibility of wounding the lung. It is preferable, we think, if a simple trocar and canula be used, that a piece of narrow india-rubber tubing should be attached to the end of the canula, and that the trocar should be passed through from the outside of the tube close to the canula, so that after the puncture into the chest has been made, the trocar may be withdrawn, when the little hole in the elastic tube will close and prevent any entrance of air. The free end of the india- rubber tubing should be carriee furnished with a ring of caoutchouc, placed between the instrument and the skin, to prevent excoriation. After the pus has been withdrawn, the pleural cavity may be washed out thn>ugh the canula with tepid water, and then there may be injected about an ounce of a mixture of 1 part of tincture of iodine to from 4 to 7 parts of tepid water, eflfected by the aid of a little iodide of potassium. The canula should then be closed by a cork, and not disturbed for twenty-four hours, when the accumulated ])us should be witlulrawn, and a second injection practiced. In the first injections it is better probably to allow the iodine solution to run out again ; but after we have assured our- selves of its effect, it may be allowed to remain. Throughout the contin- uance of the treatment the pus should be allowed to escape at least once every day, though as the secretion diminishes the iodine injections may be practiced only at longer intervals, as once in two, three, or four days. The effects of these injections are usually very beneficial ; they correct the fetor of the discharge, diminish its amount, and never, so far as we are aware, are productive of pain or increased inflammation. In cases where they appear to have lost their good effects, other agents may be substituted, as weak solutions of carbolic acid, chlorinated soda, or aromatic wine. In cases which terminate favorably, the discharge diminishes gradually, though often very slowly, the chest contracts, and finally there is nothing left but a fistula, which for a short time discharges a few drops of serous pus before healing. As an example of the tolerance to this treatment shown even by young children, and of the good results finally obtained iu many desperate cases, we would refer the reader to the extraordinary case recorded at length in Trousseau's Clinique MCdicaie (t. i, pp. 650-.j2), where, in a boy of 6 years, the canula was allowed to remain for eleven months, during which time medicated injections were constantly emjiloyed. The amount of pus discharged in all is estimated by Trousseau as not less than 80 pounds, and yet perfect recovery finally ensued, and at the date of the report the child's health was excellent. Another method of operating in cases of empyema, which, following the example of Dr. H. Lenox Hodge of this city, we have performed with entire success, consi.st« in passing a large curved needle with a stout handle, armed with fine rubber drainage-tube, into the chest through the soft tis- sues io an intercostal space, and bringing it out through the next interspace above. The needle is then unthreaded and withdrawn ; the drainage- tube remains; the spf)t is covered with a fK)ultice or a wad of oakum ; dis- charge occurs freely through the tube ; and it is easy to conduct any subse- quent treatment, such as al>ove recommende<]. The following case is abstracted from the hospital record, as illustrating the excellent results of this mode of treatment : 246 PLEURISY. Empyema of right side of 8 months duration : paracentesis : introduction of a drairi- age-tube, followed by entire recovery. E. A., a healthy boy of 12 years of age, was attacked in February, 1875, with severe pleurisy on right side. The acute symptoms subsided in 7 weeks, but left him weak and short of breath. On admission to the Hospital of the University of Pennsyl- vania, the physical signs indicated an effusion on right side reaching up to clavicle, and it was evident from general symptoms that it was purulent in character. On October 13th, 1875, the day of admission, he was tapped by Dr. Pepper in the seventh interspace on line of anterior border of right axilla, and f^xxx pus were withdrawn. A considerable amount still remained, and on October 22d, the effusion having re- formed, a fine rubber drainage-tube was introduced around the seventh rib by means of a large curved needle. A wad of oakum was applied over this and secured in position by a bandage. The amount of discharge was at first very large, but steadily diminished. The chest contracted, the lung expanded partially, the heart returned to its normal position, and in February, 1876, he was discharged cured, the dis- charge having ceased and the opening closed after the withdrawal of the drainage- tube. The general treatment consisted of cod-liver oil, quinia, syrup of the iodide of iron, nutritious diet. In October, 1876, one year after this operation he was carefully examined. The chest was found to have returned to its healthy symmetrical state, and all traces of the previous disease had disappeared. During the course of such cases, every attention must be paid to sustain- ing the child's nutrition by abundant nourishing food, stimulus, if needful, bitter tonics, iron, and cod-liver oil. We subjoin the following case to illustrate thie remarks we have made upon the treatment of pleurisy, and to show the importance of faithfully employing suitable internal remedies before resorting to paracentesis, in. cases where the effusion is serous and not so excessive as to seriously em- barrass respiration. Case of chronic pleurisy of the. left side., beginning iinlh acute symptoms ; extensive effusion^ with displacement of the heart to the right of the sternum: recovery. — The subject of the case was a boy four years old, of delicate stature and appearance, but enjoying good health. We saw him first at 1 p.m on February 12th. He was per- fectly well the day previous, slept soundly during the night, and rose apparently in good health in the morning. He ate his usual breakfast but complained after- wards of feeling unwell. Soon after this he complained of headache, of soreness and weakness in the knees in going up stairs, and then of violent pain in the left side beneath the armpit. At the time of our visit, he was in bed, in the following condition : pulse 130, full and strong; skin warm and moist; headache ; sharp, severe pain at the prsecordia, extending backwards under the armpit, and aggravated by motion, crying, and by deep inspirations ; respiration quick and jerking. No cough at all ; absolutely none. Abdomen natural ; neither vomiting nor diarrhoea. Tongue slightly furred and moist. Action of heart violent ; impulse strong and felt over a large space ; sounds loud and strong ; to the left, and beneath the nipple, a soft murmur with the second sound. Percussion dull over a larger space than natural. Behind, percussion dull over whole of left side ; natural on right side. Kespira- tion natural on the right side ; feeble and indistinct, without bronchial sound, on the left. Ordered a teaspoonful, each, of extract of senna and syrup of rhubarb, to be given TREATMENT — PARACENTESIS. 247 immediately; to have a warm batli in the evenins:, and to tiike one of the following powders every two or three hours, beginning in the evening: R.— Pulv. Opii et Ipecac, gr. iij. Potass. Nitmt., gf- vj. M., et div. in chart, no. vi. February 13. Passed a restle^^ night. Better to-day. Pulse 130; softer; skin moist. Impulse of heart less violent. Pain not so severe. Respiration still quick, and when the child is excited or irritated, it becomes jerking, while at other times it is quiet. Physical signs as before, except that the murmur, with the second sound of the heart, is no longer heard. Ordered three ounces of blood to be drawn bjT leeches from the left side; powders to be continued so as to allay restlessness and pain. February 14. Has had a better night. Pulse less frequent. Respiration 30, and without jerking; no cough at all; makes no complaints of pain. The appetite is returning. February 15. Better in all respects; no fever nor pain; no cough. Physical signs a* before. The case went on until the 27lh of March, when we paid our last visit, making the whole duration of the case over six weeks. During the last two weeks of Feb- ruary, there were no acute symptoms. The fever had disappeared entirely. The r--i i'ltion c»»ntinued, however, from 28 to 30 during all that time. The effusion tKvuji.d n*»arly the whole of the left sid»^, which was manifestly larger than the right, and the intercostal spaces were protruded. Behind, there was total flatness on percu.«sion. from the spine of the scapula downwards, and in front from a short distance beneath the clavicle. The respiratory murmur was absent in the lower three fourths of the dorsal region, and feeble above. In front, respiration was heard only above and just beneath the clavicle. In the course of this period the heart was gradually forced over to the right side of the sternum, so that at lust its impulse was felt, not to the lefi, but to the right of that bone. The cardiac sounds were loudest and most distinct in the same rcijion. The displacement was so re- markable that the mother discovered it herself, as we had avoided telling ht^r to save her from anxiety. The new position of the heart did not seem to produce any inconvenience in addition to that occasioned by the pleuritic effusion. During the last two we«'ks of March the child was k^pt in bed ; his diet was milk and bread ; a large Burgundy pitch plaster was kept on the side, and he took internally, vine- gar of squill and tincture of digitalis. Finding th«t the effu.-ion remair.fKl stationary under this treatment, we prpscrihed a grain of iodide of potassium three times a day, in a tea.spoonful of conipound syrup of sarsnparilla. The diet was changed at the same time. He was allowed small quantities of meat every day, and was taken from bed and placed in a chair by the window. Under this treatment h*» gradually improved, so that by the 27lh of March, when we paid our last visit, the effusion had in great moa^ure «lisap- peared, and he was able to play atmut the room all day. The side was slightly contracted; the respiration was pure and vesicular, but rather more feeble than on the left side ; the h«>art bad returned to its natural position. We examined this child six years later, and found him to be in excellent health. Excepting a slight contraction of the left side, there was no perceptible difference between that side and the right. 248 PNEUMOTHORAX, AKTICLE VI. PNEUMOTHORAX. In this condition there is an accumulation of air in one or both pleural cavities. The source of this air is either from without, when there is an opening through the chest-wall ; or from the bronchial tubes, when there is perforation of the pulmonary pleura. There are a certain number of cases recorded, in which it is supposed by the authors that a secretion of gas has occurred from the pleural surface, or that it has been directly de- veloped from the decomposition of some inflammatory effusion in the pleu- ral cavity ; but the evidence upon which the possibility of such occurrences rests is insufficient, and for clinical purposes, at least, it may be assumed that where pneumothorax exists, there has invariably been some communi- cation established between the pleural cavity and the atmospheric air. It is, therefore, to be regarded not so much as a distinct disease, as a compli- cation of many other pathological conditions. There are peculiarities, both as to the cause and symptoms of this condition as it occurs in childhood, which render a separate account of it desirable. It is, however, certainly comparatively infrequent in children, owing in part to the rarity of the in- juries and wounds, which often cause traumatic pneumothorax in adults ; and in part to the fact that the diseases, especially empyema and tubercu- losis with the formation of vomicae, which are the most frequent causes of it in adults, are either less frequently attended with this complication in children, or are of comparatively rare occurrence. Anatomical Appearances. — Pneumothorax may be found to exist on both sides, but as a mere pathological condition which, of course, must have produced death immediately. It is nearly always limited to one pleural sac, and before the thorax is opened, the affected side is observed to be dis- tended, with prominent intercostal spaces. The percussion-phenomena, which will be hereafter described, persist, and it is sometimes possible by rapidly moving the body, while the ear is placed in contact with the chest, to develop a succussion-splash. If a small opening be made through an intercostal space, the compressed air will often be heard escaping with a hissing sound, and occasionally the current has so much force as to extin- guish a lighted candle held near the opening. The air which escapes is usually, but not always, of offensive odor, in consequence of being tainted by the decomposition of the pleuritic effusion which is apt to coexist. If the entrance of air has followed a penetrating wound of the chest, or a compound fracture of the ribs, the familiar appearance of these lesions will be found. More frequently it has depended upon perforation of the pulmonary pleura, in consequence of some morbid action, and we may then detect the spot of perforation, and study its characters, by filling the chest with water and blowing through a tube into the trachea, when a stream of air-bubbles will be seen to rise through the fluid from the point of aperture, ? I ANATOMICAL LESIONS. 249 unless this has been obstructed by hiyers of false membrane. The lung itself will be found more or less extensively collapsed, according to the nature of the lesion which has caused the perforation. It can rarely be inflated completely in consequence of the free escape of air through the pleural opening. The adjacent movable viscera are displaced by the pres- sure of the gaseous collection, even to a greater extent than in many cases of hydrothorax. The position of the perforation in the pleura varies, but is most frctjuently found at some part of the middle lobes, or the a'djacent parts of the upper and lower lobes. We have, however, found two points of rupture in one case, both seated near the apex. The opening itself is usually rounded, or occasionally lenticular; in size it varies from one to three lines in diameter. The edges of the pleura are thin, and often softened and discolored. There may be but a single point of perforation, or several may coexist, either grouped closely together over an abscess of considerable size, or scattered over the surfiice of the lung (as in the case on the following page\ each opening corresponding to a distinct abscess. The condition of the lung varies exceedingly, and, of course, presents the appearances proper to the lesion which has caused the pneumothorax. Thus there will be found in about the following order of frequency, the appearances, elsewhere described in their appropriate places, of tubercu- losis of the lungs (either in the form of softening subpleural miliary for- mations, or of small superficial vomica?) ; of small superficial abscesses resulting from lobular pneumonia ; of circumscribed apoplexy or gan- grene of the lung; or of vesicular and interlobular empliysema with subpleural bulhe. In most cases, there are evidences of pleurisy asso- ciated, and the pleural cavity contains a variable quantity of tluid, either turbid or bloody serum, or ichorous pus ; and, at the same time, the sur- faces of the pleura may present patches or organized layers of lymph. Of course, these appearances will be most marked in cases where the per- foration of the pleura has resulted in consequence of a previous empyema. In other cases, the fluids found in the pleural sac have in part escaped from the lung-tissue through the perforation, and are in part due to the pleuritic inflammation suj^rinduced. The irritation caused by the mere admission of air into a healthy pleural sac is not always suflicient to ex- cite inflammation, and thus in rare cases, where pneumothorax results from the rupture of an emphysematous bulla, the pleura may present no inflammatory exudation whatever. But in the great majority of cases, either from the fact that pleurisy coexists, or that there is an escape of pus from the lung at the time of perforation, the pleura presents the ap- pearances above described. It occassional ly happens that, owing to the previous existence of pleuritic adhesions over a part of the lung, the es- caping air is circumscribed, and produces only a local pneumothorax. In such cases, of course, all the alterations of the thorax, as well as the atten- dant physical signs, are limited to the seat of the gaseous collection, and may, indeed, be associated with the evidences of chronic pleurisy, with re- traction of the remaining parts of the chest. In still other cases, although the pleura has been perforated, the escape of air is entirely prevented by the existence of adhesions of the pleura over the point of rupture ; or, tm 250 PNEUMOTHORAX. in the interesting case reported on page 221, by the close apposition of en- larged bronchial glands. The following case, which, owing to the absence of any clinical history, possesses chiefly an anatomical interest, may be given, as showing the usual conditions of a pneumothorax dependent upon pneumonia : Case. — Partial Suppurative Pneumonia: Superficial Abscesses, with Suhpleural Emphy!?ema: Perforation of the Pleura: Pnewnothorax : Miliary Tuberculosis. — Mary McC, aged 13 months, died February 11th, 1868, after a short illness, dur- ing which the most marked symptoms were dyspnoea and cough, with occasional vomiting. At the autopsy, there were all the physical signs present of pneumo- thorax of the left side. The right lung was found congested and partially collapsed, but admitted of complete inflation. In the posterior part of the fissure between the upper and middle lobes, the upper lobe presented a separation of the pleura from the lung to the extent of half an inch in diameter. On the apposed portion of the lower lobe there was a similar large bulla. The lung-tissue immediately subjacent to these cavities was consolidated to a distance of an eighth of an inch. On cutting into the bullae, they were found to be distended with air and dark sa- nious pus, and their cavities presented minute trabeculae and septa, consisting of bronchioles and the remains of ruptured air-vesicles. There evidently was no gan- grene of the lung-tissue, so that it appeared that these lesions had resulted from a combination of patches of suppurative pneumonia of the superficial laj^er of the lung with suhpleural emphysema ; and it seemed reasonable to conclude from the unusual relations of the emphysematous bullae, that they were due to the process of softening, which had opened a connection between some of the terminal bronchioles and the suhpleural connective tissue. There were scattered miliary tubercles in the upper lobe. The left lung presented two similar but larger bullae (fully one inch in diameter), in exactly the corresponding position between the upper and lower lobes. There was a small perforation of the pleura in the one in the upper lobe. Two other similar but smaller cavities were found on the surface of the lower lobe, in each of which the separated pleura presented a perforation about one-sixth of an inch in diameter. There were traces of localized pleurisy in the neighborhood, but no ad- hesions ; and a considerable pneumothorax had resulted, causing collapse of at least one-half of the lung. The bronchial glands, spleen, and kidneys contained miliary tubercles. There was no decomposition of the tissues. Causes. — Although, as already stated, pneumothorax is a compara- tively rare disease in children, it will be found, when present, to occur most frequently in young children (under the age of 5 years), and espe- cially in those of feeble constitution. The causes which directly lead to its development vary greatly in their relative frequency, as compared with the causes of pneumothorax in the adult. Thus we find that the most fruitful cause of pneumothorax in children is unquestionably tuberculosis of the lungs. In adults this condition leads to perforation of the pleura usually only after the production of a vomica; but in children, excavation of the lung-tissue to any extent is rare in tuberculosis, and when it does occur is quite constantly associated with such close adhesions of the neighboring pleural surfaces, as would effec- tually prevent the escape of any air into the pleural cavity, even in event of a perforation of the walls of the cavity. It is found, therefore, that pneumothorax more frequently results from the softening of small SYMPTOMS. 251 superficial tubercles, which iuvolve the pleura and load to its softening and perforation. The next most fruitful cause of pneumothorax in children is probably pneumonia, when it passes on to the staire of suppuration with the forma- tion of a superficial abscess, which seems most likely to happen when the iufiammation occurs in a localized and circumscribed form. The three cases with which we have ourselves met were all due to this cause. It is probable that this unfortunate termination is much more frequent is sec- ondary pneumonias (especially those following such diseases as measles, or, as in one of our cases, severe remittent fever), and, in a number of the eases, miliary tubercles have been found associated, as in the instance quoted above by us. In such cases the plastic exudation formed on the pleural surface is often too small to prevent the escape of air after the perforation has occurred. Gangrene of the lung and the softening of superficial patches of pul- monary apoplexy, are mentioned by several authors, particularly by Ril- liet and Barthez, as following next in order of frequency. But, according to our own observation, empyema, with consequent ulceration of the pleura and communication witli the bronchi, although not so frequent a cause of pneumothorax in children as in adults, yet furnishes more cases than either of the former rare conditions. Occasionally, also, when the purulent fluid in empyema has discharged itself externally by an ulcerated opening in an intercostal space, air has found entrance to the pleural cavity, and pro- duced a pyopneumothorax. Finally, pneumothorax has been known to follow the rupture of a sub- pleural bulla in cases of interlobular emphysema. It is especially in such cases that the collection of air may be found without any coexisting liquid efl^ision. It is probable, however, that were life to be prolonged after such an occurrence, some pleural inflammation would be established, and lead to serous efl^usion. In most cases the actual perforation of the pleura is the result of the progress of the pulmonary disease which has ultimately involved the serous membrane in its course ; but it is probable that the rupture may be at times precipitated by any violent eflfort, particularly by a fit of cough- ing or severe vomiting. Symptoms. — In some cases where the antecedent disease is a very grave one, and the strength of the child is greatly reduced, the supervention of pneumothorax is with difficulty detected, and death occurs from the sud- den increa.se of obstruction to the respiration before an opportunity is aflforded for careful examination. The occurrence of the perforation is often marked by an abrupt and decided increase of the dyspncea which has already existed in consccjucnce of the preceding disea,se. It will, however, be readily understood that this increase in oppression is not of such constant occurrence in children as in adults, owing to the fact than in the former all acute disetistis of the chest are apt to be attended with an extreme degree of dyspntca. So, too, the sharp lancinating pain iwually complained of by adults at the time of the development of pneumothorax may be latent, or only revealed by 252 PNEUMOTHORAX. increased agitation, and more hurried, shallow breathing. In some of their cases, Rilliet and Barthez observed a cough which they considered peculiar, and described as "short, frequent, jerking, painful or convulsive, and sharp or piercing;" and a similar cough has been noticed by other observers. In cases where death does not occur very quickly, and where a careful examination of the chest can be secured, the physical signs of pneumo- thorax are much more characteristic than the general symptoms. The affected side is distended, and its intercostal spaces bulge slightly. The respiratory movements are overactive on the opposite side to atone for the marked impairment of motion of the affected one. Percussion over the seat of the pneumothorax gives either merely exaggerated resonance, or a tympanitic or amphoric sound. Frequently this morbid resonance will be found associated with dulness upon percussion in some parts of the thorax, owing to the coexistence of consolidation of the lung or of pleuritic effu- sion. It may also happen that if the distension of the affected side be extreme, the tympanitic resonance will grow more or less flat, owing to the overtension of the thoracic walls. According to the condition of the lung and the character of the opening in the pleura, the respiratory murmur may be absent, or be present as metallic bronchial breathing, or more frequently as pure amphoric breathing. The vocal fremitus has generally been found decidedly diminished. Metallic tinkling has been detected in several instances; it was observed by Barrier to be most distinct during the effort at coughing. We are not aware that a splashing sound, such as can so frequently be developed in cases of pneumothorax in the adult, by succussion, has yet been observed in children. The adjacent movable viscera are found to be displaced by the pressure of the gaseous accumulation, especially in left-sided pneumothorax, where the dislocation of the heart to the right is very marked. Of course, if the pneumothorax be circumscribed, the above physical signs will be limited to the same spot. It will thus be seen that the symptoms of this condition in children closely resemble those which it presents in the adult ; but that in many cases it is impossible, owing to the great agitation of the child, to fully demonstrate their existence. Course; Prognosis. — The course of pneumothorax in children is usually a rapid one. Occurring, as it does, as a complication of some serious pre-existing disease of the lung, it so increases the respiratory em- barrassment as to generally induce death in from a few hours to a few days. In rare instances only is life prolonged for a few weeks. The prognosis, although regarded by Rilliet and Barthez as, on the whole, less unfavor- able than in the same condition in adults, is still exceedingly grave, both from the serious character of the condition itself, and from the grave nature of the diseases (tuberculosis, secondary pneumonia, gangrene of the lung, interlobular emphysema) in whose course it occurs as a compli- cation. Rilliet and Barthez observed one case where recovery ensued after the positive signs of pneumothorax had persisted for twenty days in COURSE — PROGNOSIS. 253 a boy 3 years of age. They regarded the case as origiually one of pneu- monia. We have also observed a case, in a boy 11 yeai-s old, during an attack of secondary pneumonia, complicating a severe bilious remittent fever, where complete recovery ensued, though after a most violent illness; and it would indeed seem that, with the exception of the comparatively rare traumatic cases, the prognosis of pneumothorax in children is most fa- vorable when it occui-s in this connection. SteHen {Kiinik d. Kindei'krankheiten, bd. i, p. 137, et al.) expresses this opinion also, and places as the next most favorable variety that which is associated with empyema. Although it might be expected that pneu- mothorax resulting from the rupture of emphysematous buUiv would be of favorable prognosis, on account of the trifling amount of pleural in- flaniFuation which often attends that lesion, the fact is that this condition of the lungs themselves is so serious that a fatal result has followed in all cases so far recorded. In regard to the diagnosis, it is quite true that the occurrence of pneu- mothorax in the course of one of the thoracic diseases which we have seen it may complicate is apt to be overlooked, either owing to the want of symptoms definite enough to arouse suspicion of the development of some new lesion, or to the difficulty of securing a careful physical examination of the chest. When, however, this physical exploration is made with the frequency and care which are demanded in every case of acute thoracic disease, especially when threatening symptoms exist, the characteristic physical signs will be determined, and can scarcely be attributed to any other than the true cause. Treatment. — The management of pneumothorax must be considered always with reference to the primary disease which it complicates, and its occurrence must not be allowed to interfere with the prosecution of the treatment necessary for this. As it is evident, however, that this addi- tional le.*ion will still further tax the vital powers, and as the only chance of recovery lies in maintaining life till the cause, if curable, is removed and the air absorbed, we would advise that all remedies capable of re- ducing the strength or disturbing nutrition should be discarded, and that by every means the system should be sustained. In addition, we >hould recommend the moderate use of sedatives — either in the form of the prep- arations of opium or hyoscyamus, associated with bromide of ammonium if the cough be very severe and paroxysmal, to quiet agitation and ex- cessive dyspncea, and to relieve the cough. Great relief will also be ob- tained by .strapping the afliected side with strips of adhesive pla.ster, overlapping each other, and reaching from the spine to the stenuim, so as to restrict the mobility of that side to a great extent, and also to exert a considerable pressure up*^)n it. If the distension of the affected side and the pressure on the surround- ing organs be great, and the evidences of im|>eded circulation and oxida- tion of the blomi are threatening, recourse may be had to puncture thrriugh an intercostal space with a very fine trf>car. Although the results of thi« operation must be regarded as palliative rather than curative in moet 254 HOOPING-COUGH. cases, yet as the paracentesis itself is attended with no danger, its perform- ance is to be recommended whenever the signs of pressure from the accu- mulation of air in the pleural sac become alarming. It is especially in cases where there is a liquid effusion associated with the gas (constituting a hydro- or pyopneumothorax) that paracentesis will afford most relief. In one case of this kind, Hennig performed paracentesis, evacuating a large amount of purulent liquid and gas, with very great relief to the symptoms of oppression. The child, a boy of 4 years of age, lived four weeks after the operation, and then sank from exhaustion. ARTICLE VII. HOOPING-COUGH, OR PERTUSSIS. Definition; Synonyms; Frequency. — Hooping-cough is character- ized by a hard, convulsive cough, occurring during expiration, and accompanied by long, shrill, and laborious inspirations, which are called hoops. The cough occurs in paroxysms, which are terminated by the expectoration of tough phlegm, and often by vomiting. The disease is known by various other names, of which the most com- mon are tussis ferina, chincough, and kincough. The frequency of the disease is exceedingly variable, as it occurs both in the sporadic form and as a widely-prevailing epidemic. Some idea of its frequency may be gained from the facts that, during the five years from 1844 to 1848 inclu- sive, there were 390 deaths from it in Philadelphia, under 15 years of age, out of a total mortality of 31,162. During the five years from 1864 to 1868 inclusive, there were, out of a total mortality of 76,354, 543 deaths from hooping-cough ; a proportion considerable smaller than that during the first period of five years above mentioned. The irregularity is even more strikingly seen by comparing single years with each other: thus, while in 1867, there were but 65 deaths from this cause, there were no less than 208 in 1862. Causes ; Age. — It occurs generally in children, and may be met with in the first weeks of life; indeed, Watson in his lectures, mentions a case where the mother, during the last week of her pregnancy, lived in a house where the disease was prevalent, and her infant hooped the very day it was born. Of 208 cases in children, in our own private practice, 26 occurred in the first year of life, 147 between the ages of 1 and 7 years, and 35 between 7 and 12 years. To be more explicit, we will state that of 188 cases in which the age was accurately noted, 11 occurred in the first six months of life ; 9 between 6 and 12 months ; 30 in the second year; 17 in the third, 32 in the fourth, 17 in the fifth, 30 in the sixth, 16 in the seventh, 13 in the eighth, 8 in the ninth, 3 in the tenth, and 1 in the eleventh and twelfth years of life each. Of 130 cases in children, col- SYMPTOMS. 2o5 lected by M. Blache, 106 occurred between 1 and 7 years of ago, and only 24 between 8 and 14. Of 29 cases observed by MM. Killiot and Bartliez, there were 26 between 1 and 7 years, and 3 between 8 and 12. It is stated by MM. Blache, Rilliet and Barthez, and Valleix, to be most com- mon in girls. Of 208 cases observed by oui-selves, 10(> occurred in boys, aud 102 in girls. Some writers have asserted that certain co)i.'osed to it. The fact of its being propagated by direct contaffion is proved beyond doubt by numerous observations. We have rarely known CDC child in a family to be attacked without its extending to all the othera Dot protected by having had the disease previously. That it often appears also in the form of an epidemic, is established by the testimony of many writers, so that at present no doubt is entertained upon this point. Symi*toms. — It is customary to describe three stages of hooping-cough. The first is called the stage of invasion, or the catarrhal stage ; the second the stage of increase, or the spasmodic stage; and the third the stage of decline, which is characterized by an amendment of all the symptoms. Fir.*t Stage. — The great majority of the cases begin with the ordinary symptoms of simple catarrh. These are coryza, sneezing, slight injection of the conjunctivie, and dry cough. The cough rarely has any peculiarity in the beginning which will enable us to distinguish it from that of an ordinary cold, though some persons have asserted that they could recog- nize it. We have often listened with great care to the sound of coughs which parents supposed might be hooping-cough, but were always obliged to confess our inability to determine, until time gave them more decided characters. In addition to the symptoms enumerated, there is generally more languor, lassitude, drowsiness, and irritability, than are commonly present in simple catarrh. In a small proportion of cases the first stage is wanting, and the disease assumes its peculiar features from the first. The duration of this stage is very uncertain, and is ascertained with difhculty. Our own experience would fix it at about two weeks as the average, though it may last undoubtedly a much shorter or longer period. The earliest period at which we have known the distinctive hoop of the disease to be heard was in three days. In another ca.^ it was five days. We have also known it to appear at a later period than usual. In a good many instances it has l)een as late as three weeks, but very rarely later. Second Stage. — At the beginning of this stage the disease has a.s8umed its f)€culiar convulsive and paroxysnuil character. It consists of violent fits or paroxysms, or as they are often called, kinks of cough, recurring after longer or shorter intervals. Just before the paroxysm the child seems restless, anxious, and irritable, or else keeps perfectly quiet and evidently tries to retard its approach. When it begins, the child, if lying down, rises up suddenlv, or if playing about runs to take hold of some fixed object, by which to .support itself during the accession. The cough is dry, spasnunlic, and sonorous, and occurs in a succession of short, rapid expirati(»nM, by which the thorax seems to be emptieertussi3 appear to have been made. Gibb and Johnson, however, state that they have found sugar in variable quantities in almost every case. This question 'appears well worthy of full investigation, since, if this statement is confirmed, it would link itfelf in the most interesting manner with the other evidences in this disease of irritation of the pneumogastric nerves, which are at least some- what concerned in the glycogenic function of the liver. The total duration of the disease, in simple cases, may be set down at from 17 258 HOOPING-COUGH. one to three mouths. We have never known a case to last so short a time as a mouth, and have rarely found the whole duration much within three months. Complications. — Though it has happened to us, on several occasions, to meet with children who have been very ill from the violence of the disease under consideration in its uncomplicated condition, we have never knowu a case to prove fatal except in consequence of some kind of complication. It is exceedingly important, therefore, that the various accidents apt to occur in the course of the disease should be carefully considered. Convulsions. — This complication is not a rare one, since it occurred in 5 of 29 cases observed by MM. Rilliet and Barthez, and in 12 of 208 ob- served by ourselves. It is one of the most dangerous accidents liable to occur in the course of the disease. Of the 7 cases reported by the authors quoted (5 of their own, and 2 belonging to M. Papavoine), 6 died. Of our 12 cases, 5 died. In all that we have seen, the convulsions were gene- ral, extremely violent, and accompanied by insensibility in the fatal cases to the last, and in the favorable ones, during from a few minutes to half an hour. In two of the fatal cases the pertussis had lasted nearly two months, and was accompanied by extensive bronchitis. The fatal event took place within twenty-four hours from the supervention of the spasms. The subjects were eight and nine months of age respectively. In the third case, the convulsions came on in the seventh week of the disease, in a child who had been laboring for a number of days under bronchitis. They ended fatally in seven hours. In the fourth they occurred in a child in the second year of its age, at the end of about four weeks, proved fatal in two days, and were caused by bronchitis and collapse of the lung-tissue. In the fifth case they occurred likewise in a child in the second year of life, were attended with violent laryngismus and contraction, and proved fatal in the third week of the disease. One of the favorable cases occurred in a child five months old, who had been attacked with bronchitis three days before the occurrence of the convulsions, which came on during the height of a severe paroxysm of coughing. The convulsive movements were general, and continued for about half an hour, after which the child was drowsy or irritable for some hours longer. The hooping-cough continued to be severe for two weeks after this, as many as 42, 46, and 48 paroxysms occurring every day. At last, however, perfect recovery took place. The second favorable case was that of a girl between two and three years old, in whom a convulsion oc- curred in the third week of the disease, before the paroxysms had become violent, and evidently in consequence of an attack of fever dependent upon dentition. The seizure lasted only a few minutes, was followed by drowsiness for a few hours, but on the following day all the unpleasant symptoms ha!i disappeared. In a third case, in a boy between two and three years old, a violent convulsion occurred at the end of the second week, at the beginning of an attack of pneumonia. The child remained very ill, and nine days afterwards had another convulsion, which was much slighter than the first. After this he gradually recovered. In a fourth case, in a girl between two and three years old, a slight but well- COLLAPSE OF THE LUNG -TISSUE. 250 marked convulsion occurred at the onset of an attack of bronchitis, wliich took place at the beginning of the third week of the hooping-cough. The bronchitis proved to be very severe, but there was no return of the spasm, and the child recovered. In a titth case, in a boy nine months old, a severe fit occurred in the sixth week, just at^er the child had been brought home from an expetlition to procure his daguerreotype. It lasted fifteen minute^:, and was attended with total insensibility, and pur()le discolor- ation of the face, but in half an hour after, the patient was nursing well, and was entirely conscious. There was no return of the convulsions, though the disease was very severe after this attack. In the sixth case, also in a boy nine months old, a slight convulsion occurred during one of the parox>*sms in the fifth week, but was not followed by any bad con- sequences. Amongst the complications ought to be ranked, we think, though this has not generally been done by writers, an excessive degree of the laryn- gismus which constitutes one of the natural and essential features of the disease. In some children, in fact, and especially in those of a nervous ten t. and in the anemical and debilitated, and, likewise, in cer- taii i<' types of the disease, this laryngismus assumes a degree of severity which is not only distressing but positively dangerous. In one case that occurred to ourselves, in a child who had suffered many months before from laryngismus and contracture, the occurrence of hooping-cough re; lie lar}*ngismus, and after a few weeks caused death almost in-- >ly, at the beginning of a paroxysm, as the child was sitting upon the floor, where it had been placed only a few moments before to play, it having presented before this no very threatening symptoms. In another case, in which we could detect no other complication, the spasm of the glottis was so very violent, that after a few days the spells were attended with convulsions, and very soon ended fatally. In a third, this symptom was so violent that in many of the spells the child ceased for the time to breathe, seemed to faint, became entirely unconscious, and had to be fanned and carried to an open window to be revived ; this pa- tient ultimately recovered. In a great many cases, this symptom, without <'{]:■ r tmplicatioD, has been most distressing, and has required particular *: ut. ' ;/j«rially the bronchitis of [)er- tu»*i^, Would be very apt to become associated with collapse. Late re- searches accordingly show that of all the lesions met with in hor)ping- cough this is much the most frequent and important. Dr. Ciraily Hewitt, of I»ndon, in a lecture on the pathology of hooping-cough, read before the Ha-' ■::: ^ i- TV of I>mdon, in 1855, shows "that the catarrhal inflam- niari ji ^r tn- t.ronchial tubes, which occasions h, attended almost univen»ally with collapse of the lungs." He states that his observations were made upon nineteen subjects, whose age varied from four yean to one month, the average being eighteen months. " In 260 ^^^^TWraWWuGH. ^^^^^^^H all, the state of the lungs was carefully noted. The chief lesion found after death was collapse of the lung-substance. The following is a state- ment of the degree to which this pathological condition manifested itself in the difterent lobes of the two lungs. " In the right lung, portions of the upper lobe were found collapsed in six cases, and in four more to a less degree. The middle lobe was col- lapsed, wholly or in part, in sixteen cases. The lower lobe w^as more or less affected with collapse, in eighteen cases. In the left lung, the upper lobe presented the same lesion in fifteen cases, the whole of the anterior tongue-like prolongation being in most of the cases affected. The lower lobe was collapsed more or less in eighteen cases. In seven of the cases, the portions collapsed were also congested, in some to a high degree. " The test of MM. Bailly and Legendre, viz., the inflatability of the por- tions of the lung thus affected, was used in almost all the cases ; and on that and other grounds, it was determined, that the particular part of the lung in question was collapsed and not hepatized. " It will be at once perceived, that the occurrence of collapse was almost universal ; all the cases, with the exception of one, in which there was ex- tensive tuberculization of the lungs, presenting a greater or less amount of lung-substance affected in this manner." We have had but few opportunities of testing this matter for ourselves by post-mortem examinations ; but in one case to which we were called in consultation, that of a boy not quite a year old, this lesion was shown, by autopsy, to be present to a great extent. The child had had the disease during three months with considerable severity. He was thought to be doing well, until he was taken one day a long drive into the country. After the ride he seemed very much fatigued, and that night was seized with very great dyspnoea, increased violence of the coughing spells, and after a short time with general convulsions. We saw him on the follow- ing day. He was breathing very rapidly and with much effort, there was a good deal of subcrepitant rale through the chest, the skin was cool, and about the mouth had a cyanotic tint, and he was unconscious. The same symptoms persisted through the day with occasional convulsive seizures, and on the following day he died. At the autopsy, there was found very extensive collapse of both lungs, as proved both by the anatomical ap- pearances, and by inflation. There was no pneumonia, and very moderate bronchitis. Bronchitis has always been supposed to be the most frequent complica- tion of hooping-cough, and there can be no doubt that it is one of the most important. The recent discoveries of the existence and nature of collapse have shown, however, that many of the fatal cases, hitherto ascribed to bronchitis, or to bronchitis and pneumonia combined, must have been cases of collapse, so that large allowances must be made for all statistics collected before the discovery of the true nature of the last-named lesion. There is, as has already been stated, a certain amount of pulmonary catarrh in every case of hooping-cough. This is a normal element of the disease. To constitute a complication there must be a true bronchitis, an inflammation of the bronchial mucous membrane, sufficient to produce the COMPLICATIONS. 261 orHinarv symptoms of that disease. This exists in a great many cases; M>[. Killiot and Barthez found it to exist either alone or combined with pneumonia in half of the fatal cases. Of the 208 cases observed by our- selves, it existed to a greater or less extent in 42. In 28 of these it was mild or onlv motierately severe, and of these all but one recovered. In 14 it was severe and very extensive, or else capillary, and of these 6 died. Of the fiital cases, it was in several no doubt attended with collapse of the lung- tissue. In fatal cases, it has often been found accompanied by continuous dilatation of the smaller bronchia. Pneumonia, according to the authors above quoted, is about as frequent as bronchitis. When, however, the ftital termination took place soon after the beginning of the disease (18th, 26th, or 27th days) it was not generally present. After these periods, on the contrary, it was almost always ob- served. As these authors, however, include under the title of lobular pneumonia, many cases of bronchitis with collapse, it is clear that a large number of their cases of supposed pneumonia ought to have been ranged under the head of bronchitis. For our own part, we have met with only five well-marked cases of pneumonia. Two of these occurred in girls of seven and nine years old respectively, one in a girl between one and two years of age, a fourth in a boy between two and three years old, and a fifth in a bov in his ninth year. Thev all recovered. The des^ree of dan^rer from this complication is in proportion to the earliness of the age at which the disease occur?, and to the extent of the inflammation. Emphysema undoubtedly follows or accompanies hooping-cough in some cases. In a considerable proportion of fatal cases the lesions of vesicular, and, less frequently, of interlobular emphysema are discovered. These will be found described in full in our article upon the latter affeetion, where we have also alluded to the rare occurrence of emphysema of the subcutaneous tissue of the neck, and even of the entire body, as a conse- quence of the free escape of air into the connective tissue of the lung, and th • the meflia.«»tinal spaces. It is therefore probable that, in cases 01 , ^ which end favorably, but in which the paroxysms of cough have been severe, a less degree of emphysema occurs, which in most in- stances speedily passes away after the disappearance of the primary affec- tion. Indeed, as nearly all the children whom we have attended with hooping-cough, continue under our charge, and as only in a very few cases do any symptoms of emphy.«ema persi.st, we must conclude either that it less frequently attends pertussis than would naturally be supposed, or else that the lung-tissue soon regains its elasticity, and the overdistension of the air-vesicles disap[)ears. In some instances, and especially in those where chronic bronchitis follows the attack of hooping-cough, all the symp- toms of emphysema may gradually develop themsplvas. Vomiting is a verj' frequent incident in pertussis, but ought not to be re- garded as a complication, unless df|x*ndent on some disease of the digestive organ.?, or symptomatic of cerebral disease. Where it occurs in simple cases, or in those complicated with bronchitis or pneumonia, it has always seemed to us to he advantageous. Tuberculoeis and scrojula are not infrequently found to follow hooping- 262 HOOPING-COUGH. cough, in cases where a marked predisposition to these conditions exists. The tuberculous affection is most apt to take the form of pulmonary or bronchial phthisis. These sequelae are frequently observed in hospitals, and among the ill-fed and feeble children of the poor, but are comparatively rare among the better classes of society. Diagnosis. — The diagnosis of pertussis is difficult only during the first stage of the complaint. It is impossible, indeed, to distinguish, during that stage, between it and simple mild laryngitis, or the mild catarrhal attacks which are so common in our climate. After it has once fairly en- tered upon the second stage, it is scarcely possible to confound it with any other malady. MM. Rilliet and Barthez state, however, that acute bron- chitis with paroxysmal cough is not unfrequently mistaken for pertussis, and we recollect perfectly having made this mistake ourselves, in a little girl, five years of age. The cough assumed so exactly the features of per- tussis, that after waiting a few days we announced, authoritatively, the presence of pertussis. Only three or four days after this we were forced to take it all back, for the whole thing had disappeared, bronchitis, per- tussis, and all. The patient was entirely well. But the mistake need sel- dom be made, if it be recollected that in acute bronchitis with paroxysmal cough, the invasion is sudden ; that there is violent fever, great dyspnoea, and the physical signs of bronchitis ; that the hoop is generally wanting, or feebly marked, and that the disease is violent and rapid in its course ; all of which circumstances are widely different from what occurs in per- tussis. The same authors assert that tuberculosis of the bronchial glands gives rise to a cough which may be mistaken for pertussis. The following table extracted from their work will show the differences between the two dis- orders : PERTUSSIS. TUBERCULOSIS OF THE BRONCHIAL GLANDS, Often epidemic, attacking several chil- Always sporadic; non-contagious, dren at once; transmissible by cmtagion. Three distinct stages, of which only the No distinct stages, second is accompanied by kinks. Kinks attended with hooping, ropy ex- Kinks generally very short, without pectoration, and vomiting. hooping, ropy expectoration, or vomit- ing- Pure respiration in the intervals between Physical signs of tuberculosis of the the kinks. ganglions; but, in certain cases, absence of these signs. In the intervals between the kinks, res- Accessions of asthma in some cases, piration and pulse natural, so long as the with the kinks; continuous febrile disease is simple. movement, with evening exacerbations, sweats, progressive emaciation, etc. Voice natural. Voice sometimes hoarse. Course generally acute. Chronic course. We would add that we have known the paroxysmal cough attendant upon the development of miliary tubercles in the lungs to simulate hoop- ing-cough so closely as to render it very difficult to distinguish them. In PROGNOSIS. 268 one case where this resemblance was very great, the circumstances rendered the diagnosis additionally ditticult. The patient, the eldest of three chil- dren, had a perfectly well-marked attack of hooping-cough in his fourth year. Two years later, his little brother and sister contracted the disease in a marked form. Nearly at the same time, the eldest boy, then about six vears of age, was attacked with severe paroxysmal cough, recurring in kinks, often inducing vomiting, and occasionally terminating with a sort of hoop. Physical exploration of the chest yielded only negative results. Still our suspicions were aroused by the facts that a previous attack had occurred, that the hoop did not become so perfectly developed as in true hooping-cough, and that there were progressive emaciation and weakness to an unusual degree. In the second month of the cough, the symptoms of tubercular meningitis appeared, death ensued, and, at the autopsy, in addition to tuberculosis of the membranes of the brain, the lungs and spleen were studded throughout with numerous miliary granulations. In the meantime, the two younger children passed successfully through the stages of hooping-cough and entirely recovered. Proc;nosis. — Pertussis is rarely a dangerous or fiital disease so long as it remains simple. Of the 208 cases observed by ourselves, 143 were simple, all of which recovered. Nevertheless even the simple disease does some- times terminate fatally, from the excessive violence of the paroxysms of couirhing. The danger in ho4iping-cough, which is considerable, depends, therefore, almost entirely on the complications which are so apt to occur, for which rea^D the physician should watch with the closest attention, in order to prevent their occurrence, and that he may recognize and treat them in their earliest stages. The most dangerous complication is convulsions, and after that bronchitis and pneumonia. So long as the child seems well and lively, and without fever or dyspnoea, in the intervals between the fits, there is nothing to be feared. But if, on the contrary, it becomes languid and irritable, with indisposition to take food, feverishness, and some in- crease of the rate of respiration, the practitioner should be upon his guard. A very early age and natural delicacy of constitution, are unfavorable cir- cum.«tances in the disease. Some form of complication occurred in 65 of the 2<>8 ca^e^ observe*! by ourselves. Of the Go, 12 died. Five of the 12 fatal ca.«e8 ended with convulsions. Of these 5 cases, the convulsions were caused by bronchitis and collapse of the lung in 4, the fatal result being the consequence, in fact, of the lung complication. One of the cases wa.s independent, apparently, of disease of the lung (though, as no post-mortem examination was made, this cannot be asserted posi- tively), but seemed to be the result of the violent laryngismus, with con- tracture and general convulsions, such as will be described in the article on laryngismus stridulus. Two of the cases occurred in children of eight and nine months old, respectively, and proved fatal in twenty-four hours after the setting in of the convulsion.s. Two others occurred in children in their second year, and the fifth occurred in a boy between three and four yean old, and caused, death in seven hours. Of the remaining seven fatal cases, one was the result of collapse of 264 HOOPING-COUGH. the luDgs, supervening suddenly upon a mild bronchitis, in a twin child between two and three mouths old. The second was caused by tubercular disease of the lungs, in a child between three and four years old, and the remaining five by bronchitis, associated, to a greater or less extent, in all probability, with collapse of the lung. Of the last-mentioned five cases, one occurred in a child between five and six months old, and was rapid in its course ; two occurred in children between one and two years old, one being rapid and the other lingering in its course; one occurred in the third year of life, and was attended with severe diarrhoea from teething, as well as with bronchitis and collapse ; and the fifth occurred in a child in its fourth year, and was slow and gradual in its course. To sum up, it may be stated that of the 12 fatal cases, 10 were the result of bronchitis and collapse, 1 of tuberculosis of the lungs, and 1 of laryngismus stridulus. Nature of the Disease. — There is no essential anatomical lesion in pertussis, except, perhaps, slight inflammation of the bronchial mucous membrane. In most of the cases, the membrane lining the larger and smaller air-tubes, and very rarely that of the trachea, is reddened and per- ceptibly thicker than natural, and the tubes contain a considerable quantity of frothy mucus, or a thick, viscid, and tenacious phlegm. As to the nature of the disease, it seems to us very clear that it ought to be regarded as comprising two elements of morbid action, one of which consists in slight inflammation of the respiratory mucous membrane, and the other of disordered action of the respiratory system of excito- motor nerves. It is neither a pure neurosis nor a pure inflammation, but par- takes of the characters of both, and much more of the former than of the latter. The authors of the Compendium de Medecine Pratique (t. ii, p. 526) regard it as a neurosis, on the following grounds : " 1. In the greater number of cases the respiratory apparatus presents no kind of alteration, or else the lesions are so multiplied or variable, that they are surely not the real origin of the disease. 2. The clearly remittent course of the symptoms, and the total absence of fever, unless some complication is present, are not observed in ordinary or even specific inflammations. 3. The cessation or sudden return of the paroxysms, under the influence of moral emotions or change of place, belong to a disorder of innervation, and not to inflammation, which commonly passes through certain stages before it is resolved. 4. The complete return to health, the integrity of all the functions in slight cases, the resistance which it opposes to treatment, the uselessness of antiphlogistics, and the success obtained from narcotics and antispasmodics, are all so many circumstances peculiar to hooping- cough and to many of the neuroses." It has, however, so many points of resemblance to the various constitu- tional diseases, as its undoubtedly contagious nature, the facts that it runs a definite course, and that one attack protects the system against a second, that it also probably depends upon a morbid state of the blood, due to the introduction of some specific poison which possesses the peculiar power of irritating the pneumogastric nerves. Treatment of Simple Pertussis. — Hooping-cough, like all other dis- eases, varies greatly in its degree of severity. It is sometimes an afl^air of TREATMENT — BLOODLETTING. 265 DO consequence scarcely, the patient passinjx through its stages without suffering, and without any injurious consequences whatever to the general health. We have known a large family of children to pass through the disease without other treatment than attention to a prudent hygiene, and with no other medicine than a few doses of a mild cathartic, given to re- lieve some uncomfortable gastric symptoms. We have known one child in a family where jhe disease was prevailing at the time, to have the cough for only five weeks, and to hoop only on two or three occasions, and to lose neither appetite nor spirits for a moment. Such cases evidently need no interference, and a wise physician will, in such, order no drugs. His business will be simply to direct that the child be guarded against cold and against imprudences in diet. In other instances the disease assumes, from a very early period, or sometimes not until later, a character of a very different kind. AVithout any complication whatever, the natural symptoms of the disease develop in great intensity. The spells of coughing are very frequent, very violent, and very long-continued. Instead of some twenty spells or less in twenty- four hours, as is the rule in mild and moderate cases, the patient will aver- age two or more every hour, having fifty or sixty spells in the day. The Iar}'ngismus, instead of being slight, will be violent and distressing, so that in lieu of three, four, or five hoops in a paroxysm, there may be four- teen or fifteen, and these so shrill, acute, and prolonged, as greatly to exhau.«t the poor little patient. Or the laryngismus may be so intense as to cloee for a few seconds the glottis, and arrest entirely the respiration, giving rise to the most painful attacks of struggling and suffocation pos- sible to behold. Or the vomiting may be so frequent as seriously to inter- fere with the nutrition of the child, and thus cause threatening and even dangerous debility. In certain families, and in certain epidemic types of the disease, it assumes these severe features, and such cases must take the same rank in this disease that grave cases of scarlet fever, measles, or variola, take in those affections. Cases of this latter kind imperatively demand treatment, and they are, we are happy to state, susceptible very generally of great and striking alleviation, by the use of proper means, — means, too, which in themselves are ver}* safe. At one time we were very much disposed, we confess, to avoid all inter- ference so long as we saw no complication in the case, under the suf)po- sition that the disease in its simple form wan always safe, and might be tnisterl to the efforts of nature. More enlarged experience has taught us, hf»wever, that tlie verj' violence of the disease, even in its simple form, was a source of danger; and that, moreover, such severe cases were much more liable than milder ones to complications, while a proper treatment, in-'tituted so soon an the disease began to show thcs(? severe characters, has almo<*t always, after a few days' perseverance, brought about and main- tained a most evident amelioration of the symptoms, thus keeping within due bounds a development which might otherwise have gone on to a dis- T!-' iiiatiftn. J, ,,y, — Depletion is very rarely necessary in simple pertussis. 266 HOOPING-COUGH. The only cases in which it can be called for are those occurricg in SBrnguine children, where the laryngismus is so extreme and the paroxysms so vio- lent as to lead to great engorgement of the right side of the heart, and even to endanger the brain by overdistension of the veins. Under these circumstances, we might resort to venesection merely for the mechanical relief afforded, as recommended under similar conditions in pneumonia. In such cases only then, a small bleeding, or the application of a few leeches to the temples or behind the ears, may be proper ; but even these may generally be safely treated by reduced diet and by a few doses of saline cathartics, without a resort to the more powerful and more perma- nently exhausting means of depletion. As for the treatment of simple pertussis by repeated venesections, in the hope of curtailing its duration, or under the idea of their being rendered necessary by the violence of the malady, it seems to us forbidden by the present state of medical knowl- edge, which informs us that the greater number of the cases do not en- danger life so long as they remain simple, however violent they appear to be. Of the 143 simple cases treated by ourselves, depletion was not used in any, and all recovered. Narcotics and Antispasmodics. — Of the various remedies of this class which have been more or less extensively employed, the most important are belladonna, opium, and hydrocyanic acid. Assafoetida and, of recent years, several of the bromide salts have also been much used with apparent success. Belladonna is highly recommended by several German authors, by MM. Rilliet and Barthez, who state that it is beyond contradiction the one most deserving of confidence, by Trousseau and Pidoux, and by numerous Eng- lish and American writers. MM. Trousseau and Pidoux employ the fol- lowing formula : R. — Pulv, Belladonnse, . ' gr. iv. Extract. Opii Aquos., gr. iv. Extract. Valerianae, ^ss. M. et div. in pil no. xvi. S. One to four in the course of the day. If the child dislike the pilular form, they give it in syrup, according to the following formula : R.— Extract. Belladonnse, gr. iv. Syrup. Opii, ] Syrup. Flor. Aurantii, aa f^j. — M. Of this, from one to eight teaspoonfuls are to be given in twenty-four hours. We have ourselves used belladonna in a very large number of cases of hooping-cough, and with such unquestionable benefit, that we regard it as one of the most valuable remedies for this disease in our possession. We have certainly never seen it cut short the course of the disease as it has been asserted to do, but we have almost invariably found it to mode- rate the laryngismus, shorten the paroxysms and diminish their number TREATMENT — ANTISPASMODICS — EMETICS. 267 and probably also shorteu the duration of the attack. We have not, how- ever, been in the habit of prescribing such large doses of bcUadiuma as those quoted above (gr. i) ; but have usually given it in combination with alum or with bromide of ammonium, in the dose of Tr^th of a grain of the extract, every four hours, to a child of one year old. The formula which we employ will be found in our remarks upon the use of alum, BeUadonna has also been largely used, especially by Dr. Fuller, in com- bination with sulphate of zinc, and with excellent results. This latter author states that he has observed a remarkable tolerance of belladonna in children, so that, be^rinning with quite large doses, the amount may be rapidly, though ciirefully, increased until the quantity taken exceeds out of all proportion the correspondingdoses which will be tolerated by adults. Even when given, however, in the comparatively small doses of rr'^th or f'jth of a grain, it is necessary to watch for any symptoms of the toxic action of the drug, so that its administration may be suspended or ihe amount diminished. Opium is confessedly a very valuable remedy in the disease, not as a curative, but as a sedative and palliative. When the cough is freijuent and fatiguing, especially if the patient have an irritable and nervous cou- stitutioD, some opiate preparation is of the utmost service in moderating the frequency and violence of the paroxysms, and in allaying irritability and restlessness. It is best given in the evening, and in combination with ipecacuanha. Hifdrocyanic acid has been employed by various observers, and is highly spoken of by some. Iti* poisonous properties, however, have deterred many, and amongst them ourselves, from resorting to it. Inasmuch as there are other and safer means for conducting the disease to a favorable termination, it seems to us useless to venture upon so potent a preparation as this. Since the discovery of the powerful antispasmodic properties of the va- rious bromiiUs, they have been much used in the treatment of this disease. The bromidr of ammonium has been recommended, especially by Clibb and G. Harley, a^ a pharyngeal and laryngeal anaesthetic, to diminish the spasm of these part*, while, at the same time, the alkali acts by rendering the secretion from the bronchial mucous membrane more free and readily expectorated. The bromide of potassfinm acts in the same way, and is pro- ductive, probably, of equally good results. We have used both of these M»its frequently, especially in combination with l)elladonna, and have ob- -- "' ' I marked reduction in the severity and number of the paroxvsms "I ' ^'ii in many of the cases. We have, also, used assafcctida in a num- ber of instances with decided benefit, both in relieving the general restless- ness and in moderating the number and severity of the paroxvsms. The d<^«'' in which we have given it are either two or three grains in pill, or a tea.-'pnfuI of the mistura a-ssafcetidic, three or four times a day to a child of four years old. Emrticjt and Xauseants are amongst the most important remedies in the tr;:: nt of hooping-cough, sincc they exert a powerful influence upon t;i' '. -itse, and unless carried to excess, are not in themselves likclv to be 268 HOOPING-COUGH. injurious. Some authors recommend the administration of an emetic every day or every other day, while others give them according to the ne- cessity of the case. Believing that frequently repeated emetic doses are un- necessarily severe, and productive of too much fatigue and exhaustion, we have preferred in the simple disease to give- only small doses of ipecacu- anha from time to time, so as to moderate the violence of the cough. Tar- tar emetic is never necessary, and ought to be avoided, on account of its disposition to irritate and inflame the gastro-intestinal mucous membrane, and because of its exhausting effects on the general economy. The syrup of ipecacuanha is the preparation we have almost always used. From ten to twenty drops, given three times a day to a child three years old, will very generally moderate the severity of the paroxysms. Purgatives are necessary in the simple disease only when constipation is present. The mildest ought to be preferred, in order to avoid irritation and exhaustion. Castor oil, magnesia, or syrup of rhubarb are the best. Particular Remedies. — Of the different specific remedies that have been employed, none have attained and maintained so high a reputation in this city as the carbonate of potassa, which, in the form of the cochineal mixture, is constantly used both by physicians and as a domestic remedy. The beneficial effects of this drug are equally recognized abroad, as may be judged from the language of Niemeyer, who, when speaking of its use in hooping-cough {op. cit., vol. i, p. 101), says, " Its effect in shortening the fits of coughing is often surprising." The following formula is the one generally administered : R. — Potass. Carbonat., 9J- Coccii, . . . . . . . . . ^ss. Sacch. Alb., 3J. Aquse Fontis, f,5iv. — M. Give a dessertspoonful three times a day to a child a year old. Believing the carbonate of potash to be the active agent in the mixture, we have generally left out the cochineal and used the potash alone, dissolving it in equal parts of syrup of gum and water. We have frequently employed this remedy, and believe that it, with alum and belladonna, are the most useful agents we have to keep down the violence of the disease. We have given it in the dose of a grain three or four times in the twenty-four hours, to children one and two years old, for several weeks at a time, without wit- nessing any injurious effects from it. Alum was first highly recommended as a remedy in pertussis by Dr. Golding Bird (Guy's Hospital Reports, April, 1845). He states that in the second or nervous period of the disease, when "all inflammatory symptoms have subsided, and when, with a cool skin and clean tongue, the little patient is harassed by a copious secretion from the bronchi, the attempt to get rid of which produces the exhausting and characteristic cough, alum will be found to be of much value." He adds, that he " has not yet met with any other remedy which has acted so satisfactorily, or af- forded such marked and rapid relief." From reading Dr. Bird's remarks on alum, and prompted by our knowledge of its admirable qualities in the TREATMENT — ALUM. 269 treatment of croup, we were formerly led to make trial of it in the disease under consideration, and we believe we may say that it has exerted a more decideti iutlueuce in moderating the violence of the disorder, than any that we have ever made use of We have administered it in 139 cases, begin- uing in the course of the second stage. In nearly all it was beneficial, and in some the effects were strikingly useful, the improvement being more rapid than we had ever seen to result from other remedies, or to occur when the disease has been allowed to pursue its natural course. In a boy, between five and six years of age, who had been coughing violently for two weeks, the jiaroxysms diminished so much in intensity and frequency, after he had taken the remedy two days, that he was not once disturbed at night (though before he had always been waked several times), and the spells which occurred during the day were much less severe. After con- tinuing the remedy for ten days, the disease had subsided so much that its employment was suspended. Soon after, however, the paroxysms again became severe and troublesome. The alum was resumed, and with the same results as at firet. In another family in which there were three children all of whom had been taking syrup of ipecacuanha and carbon- ate of potash for some days, without any good effects, the alum was given and acted as in the case first referred to. The nights were comparatively quiet, and the spells occurring through the day very much moderated. We may repeat that, so far as our experience in the above 139 cases goes, the eff»*cts of alum have been more decided and satisfactory than those of any other remedy. We have never known it to produce ill-consequences, either at the time of its administration or subsequently, though we have given it to children from two months to seven years of age, and have con- tiDue the most proper in any individual case. Of late years we have usually given the alum and belladonna together, and have been much pleased with the results. If administered in large doses, alum produces vomiting. It does not constipate, but on the contrary, is apt to induce diarrhua, when continued for some time. Dr. Bird gives from two to six grains every four hours. Ili.- formula is us fullows: B.— Aluminis, . . . gr. xxv. Ext. Conii, gr. xij. S^Tup. Kboeadoi, f ^ij. Aqu« Anethi, f5iij.— M. Give a medium -si zed spoonful every three hours. To children under one year, we give from half a grain to a gmiii, three or four times a day ; and to those over that age, two grains every four or six hours. The formula we have employed is the following: B.— Aluminia, B'j'"'- Syrup. Zingib., Syrup. Acaci«, Aqu« Fontis, aa, . f5J.— M. 270 HOOPING-COUGH. When this is prepared with good syrups, it tastes very much like lemon- ade, and is not at all unpleasant, so that children take it without diffi- culty. The dose is a teaspoonful three times a day, or every four or six hours. As above said, however, we now generally employ a combination of alum and belladonna, and have obtained better results from it than from any single remedy we have ever used. For a child one year old we use the following formula : R. — Ext. Belladonnse, gr. j. Aluminis, ^ss. Syr. Zingib., Syr. Acacise, Aqute, aa . . . • f^j- M. et ft. sol. Dose, a teaspoonful four times in the twenty-four hours : in the morning, at noon, bedtime, and once in the night, if the cough be troublesome. Among other remedies which have been highly recommended, but which we have never found it necessary to resort to, may be mentioned the fol- lowing : Sulphur is much used by some German authorities, who greatly commend its effects both at the beginning and throughout the course of the disease. It may be given in powder diffused in milk or syrup, or in emulsion, in doses of three grains, two or three times a day, to children from two to four years of age. Subcarbonate of Iron has been successfully employed by Dr. Steyman and by Lombard, of Geneva. Dilute Nitric Acid, first recommended by Arnoldi, of Montreal, has been highly praised, especially by Gibb. Conium has also been frequently used, both alone and as an ingredient in formulse containing some of the other remedies here mentioned, and appears to alleviate the violence of the paroxysms, though to a less marked degree, we believe, than belladonna. Inhalations. — In was noticed in France, some years ago, that children suffering with hooping-cough, who lived in the neighborhood of gas-works, were rapidly cured ; and the plan has been recently tried with success, of sending patients with this disease to inhale the fumes arising during the purification of gas, which contain ammonia, vapor of tar, and several volatile oils. Dr. Bertolles {British Med. Jour., Nov. 5, 1864) states that "the register of the gas-works -at Ternes, shows that during the previous six months, 901 patients have been subjected to the vapor treatment, of whom 219 were cured and 122 relieved." M. Commerege (id. loc.) has also rei^orted the effects observed in 142 children who were brought under the action of the gases in the gas-works at St. Maude ; and believes that the treatment produces excellent results at all stages of the disorder. In general, twelve seances, each of which should be of two hours' duration, are required for the cure. We have ourselves known of quite a number of instances among the children of the poorer classes in this city, where patients, suffering with hooping-cough, have been allowed to inhale the fumes from the gas-works, and have experienced positive benefit. TONICS — TOPICAL APPLICATIONS. 271 Tonics. — In a uumber of cases that have come imder our notice, the patieut has grown pale and weak in the course of the disease, and this without any local complication, but from the disturbance of the digestive system that ot\en exists to a greater or less extent, from the great frequency of the vomiting, which prevents them from taking a sufficient amount of nutriment, and from the exhausting etiect of the violent muscular exertion undergone during the paroxysms. In such instances, when there has been no fever, or merely a little evening febricula, we have employed tonics with much advantage, and never to the injury of the patieut. We have genenillv made use of Huxham's tincture of bark, either alone, in doses of from ten to twenty drops three times a day, or in connection with the gyrup of the iodide of iron, or half a grain of the metallic iron (Pulv. Ferri). When the appetite has been very feeble, we have found that quinine, in the dose of a grain three or four times a day, at the age of three or four years, has restored it more rapidly than any other remedy we have used. Local Applications. — Beimlsives. — The milder revulsives are useful in certain complications of pertussis, and as palliatives. To make them the chief basis of the treatment, however, which has been done by some, is a mistake. In order to produce a decided impression upon the disease, it would be necessary' to resort to the more powerful remedies of this class., wich as moxas, issues, tartar emetic ointment, blisters, etc., the use of which is not warranted by the nature of the disorder. When the laryngismus has been severe, we have known the use of a belladonna plaster, 2 by 3 inches, applied over the larynx and worn for several days, to afford relief. Tnj,lfiil applications to the interior of the larynx of solutions of nitrate of silver have been used by several practitioners, as by Gibb and Eben Watson, and apparently with much benefit. The strength of the solution should vary according to the stage of the disease, being much reduced during the early acute period. In case* occurring in older children, where the spasmodic irritability of the larynx is extreme, we may employ with advantage the inhalation, by mean.< of the atomizer, of the vapor of water, or of weak alkaline solu- tions, to which minute quantities of morphia may be added. Before concluding our remarks upon the treatment of simple hooping- cough, we wish to state that cases of the disease occur not unfrequently of .-'• mild a form, as to need al)solutely no treatment other than the proper df ;rrf»- of attention to hygiene ; and that others again, more numerous than tho-. ju.-*t mentioned, will be met with, in which the only treatment neces- sary is the u.«*e, for a few days or weeks, of some mild expectorant and opiate at night to lessen the severity of the paroxysms, or of moderate do-*-^ of alum, belladonna, or carbonate of potash. In infants particularly it is proper to give as little medicine as possible, allowing the disease to go on without interference so long as it progresses safely. In a good many mild cases, small doses of paregoric and syrup of ipecacuanha, constitute the only remedies we have found necessary in the cases of infants. When, however, the j>aroxysms become numerous and 272 HOOPING-COUGH. violent, exhausting the strength of the child and distressing its nervous system, we must make use of some remedy to allay the severity of the attacks. We have found the alum and belladonna formula recommended above safe and effectual. At the age of two and three months, we have usually given from half a grain to a grain of the former, combined with oVth grain of extract of belladonna, three times a day, taking care to sus- pend it for a day or two if it caused troublesome vomiting or purging, and then resuming it in diminished dose. Or we have made use of a quarter or half a grain of carbonate of potash, also combined with the twenty- fourth part of a grain of the extract of belladonna, three or four times a day. Treatment of the Complications. — If any of the diseases which have been mentioned as apt to occur during the course of pertussis should arise, the treatment which is proper for them in their idiopathic form must be adopted without regard to the hooping-cough, with the following reser- vation : that care must be taken not to use means of too powerful and exhausting a nature, or such as have a tendency to irritate the organ with which they come in contact. For, it must be recollected, that after the complication is cured, the patient has still the original disease to go through with, and therefore requires all his strength ; and moreover, the various organs of the body are predisposed, by the very fact of the existence of the original malady, to assume diseased action, should any irritation in the shape of a violent remedy be applied to them. The cases of bronchitis which came under our observation were treated in the simplest manner. The children were put to bed, the diet carefully regulated, the bowels gently opened with castor oil or syrup of rhubarb, and small doses of syrup of ipecacuanha or antimonial wine, with sweet spirit of nitre, were administered every two hours. Mustard poultices were applied once or twice a day to the interscapular space, and mustard foot-baths used every night, or more frequently, if the dyspnoea were con- siderable. If the bronchial secretions were very profuse, and the cough troublesome, the decoction or syrup of seneka was given in connection with occasional doses of laudanum or paregoric. The treatment of collapse of the lung should be that which is recom- mended in the article on that subject, modified, of course, as may be ren- dered necessary, by the existence of the hooping-cough. A mild emetic, if the patient seem strong enough to bear one; counter-irritants, and espe- cially sinapisms or mustard poultices applied to the chest, nutritious food, and mild stimulants, as brandy, wine-whey, tincture of bark, quinine, or aromatic spirit of ammonia, must form the principal means of treatment. The complication of pneumonia should be treated somewhat differently. At the present time we should advise the use either of the combination of sulphurated antimony and Dover's powder, or of one of the alkaline mixtures, recommended in the article on pneumonia, in conjunction with external applications and the use of the foot-bath ; and should not resort to bleeding, whether local or general, unless the indications, elsewhere laid down as calling for depletion in pneumonia, should be present in a marked degree. Indeed, in such cases, the early use of moderate stimulation and 1 TREATMENT OF THE COMPLICATIONS. 273 of full tonic doses of quiuia is apt to be indicated on account of the te*n- dencv to depression. When couviiisions occur they must be treated according to the cause which produces them, and the consititution and present state of the child. If the patient be strong and sanguine, and not exhausted by previous sickness, the treatment should consist of depletion by leeches to the tem- ples, or behind the eai*s ; of cold applications to the head; the warm bath; large doses of bromide of potassium by the mouth or by enema; cathartics or purgative enemata; and revulsives in the form of sinapisms, or of a small blister to the nucha. If, on the contrary, the ]^atient is of delicate constitution, or exhausted by long illness, and especially when the convulsions are the result of extensive collapse of the lungs, occurring spontaneously or supervening upon bronchitis, we must be content to resort to warm baths, revulsives, antispasmodics, and anodynes, stimuli, and stimulating enemata. Of the 12 cases of convulsions that came under our notice, 5 proved fatal. Two of the fatal cases occurred in children who had long been laboring under bronchitis, probably associated with collapse', that had baf- fled all treatment. Death took place within twenty-four hours from the appearance of the convulsions, which were in fact the result of the diseased condition of the lungs. No treatment further than the warm bath and sinapisms, was resorted to. In the third case, the convulsions came on in the seventh week of the disease, in a child who had been laboring for a number of days under severe bronchitis; they ended fatally in seven hours. The treatment employed at the beginning of the fit was a w^arm bath, an enema, and mustard plasters. After a few hours, solution of morphia with fluid extract of valerian were given by enema, cold was applied to the luvid, and a blister to the nucha. In the f(mrth case, which occurred in a child in the .second year of its life, they were caused by bronchitis and collapse, and proved fatal in two days. The treatment consisted in the use of warm baths, counter-irritant*, alum, and small doses of brandy. The fifth case likewise occurred in thesecond year. This was one in which all the symp- toms of laryngismus stridulus — prolonged laryngismus, contracture, and general convulsions — were added to those of the primary disease. It was treated with belladonna, opium, assafnetida, and warm baths, but all to no eff*ect. Of the favorable cases, one occurred in a boy five months of age, on the third day of a severe attack of bronchitis. The child was immediately placed in a warm bath, and large sinapisms applied over the front of the chest and upon the extremities, when the convulsions ceased. After tliis he wa.« treated with half-grain doses of alum, repeated every three or four hours, mustard foot-baths, and poultices, and small doses of wine of opium. On the sixth day of the attack, the third after the convulsive seizure, there having been no return of the ronvulsions, tin; bronchitis sub-id**! with copious sweats and cold hands and feet, for which small quaMtities of brandy and water and wine-whey were used. The recovery was perfect. A second case occurred in a hearty boy nine months old, and sei^mcd to depend on congestion of the brain, brought on by a severe fit of coughing. 18 274 HOOPING-COUGH. lu this iustance a venesection to a small amount was performed, the child was placed in a warm bath, and cold applied to the head. No return of the spasms took place, and the child recovered without difficulty. In another case the convulsion was caused by an attack of fever depending on dentition, and was treated by lancing the gums, by a warm foot-bath, and by the administration of a grain of calomel in a teaspoouful of castor oil. In the fourth case the convulsions were caused by pneumonia, and were managed by treating the pneumonia, except that at the moment of the attack a warm bath and a stimulating enema were made use of. In a fifth the convulsion, which was a short one, occurred at the onset of an attack of bronchitis. No particular treatment beyond what was necessary for that disease was required. In a sixth, in a boy nine months old, the convulsion occurred suddenly, was violent, and lasted fifteen minutes. The cause could not be ascertained. The only treatment used for the con- vulsion was a warm bath. There was no return. In a seventh case, in a boy nine months old, a slight convulsion occurred during one of the par- oxysms in the fifth week. No treatment was necessary, as the attack was very short, and there was no recurrence of the symptoms. Hygienic Treatment. — This part of the management of the disease is of the highest importance, for it is by careful attention to its details that the complications which constitute the chief danger of the malady are to be prevented. In a considerable number of cases of pertussis, nothing more need be done than to insist upon strict attention to hygienic rules. The chief indications are, to preserve the child from taking cold, and to prevent indiscretions in diet. The clothing ought to be warm, and during the autumn, winter, and spring, flannel should always be placed next to the* skin. The child ought to be kept in the house during damp weather at all seasons, and whenever, during the winter season, it is intensely cold. The diet should be nutritious, but of easy digestion. All heavy, rich food ought to be absolutely forbidden during the continuance of the malady. Treatment of the Paroxysm. — It often happens that the paroxysms are so violent that the child seems to be in imminent danger of suflTocation or of convulsions. This is especially true of infants. In six cases that we have seen, in infants under six months old, the kinks lasted so long, and the spasm of the larynx was so unyielding, that the children struggled as though laboring under tetanus; the countenance was disturbed and anx- ious ; the face and hands, at first flushed, became purple from deep con- gestion ; and on some occasions the breathing was suspended for several seconds, so that life seemed for the time in the greatest danger. The diffi- culty in these cases depends on the spasmodic closure of the glottis, which is sometimes, no doubt, completely shut. We have never known these alarming symptoms of asphyxia to occur when the hoop has been clear and distinct, for when that is present, the larynx cannot be very tightly closed. When the symptoms above described occur in a child several years of age, the patient should be raised and supported in the sitting posture ; when in an infant, the child ought to be held lightly in the arms, so that it may take any position which instinct prompts it to. At the same time, TREATMENT OF THE PAROXYSM. 275 cold water ought to be spriukled from the fiugers upon the face, the child shouUl be gently fimned, or, if the weather be warm, taken to the open window ; and if there be time, it is well to put the feet into mustard-water. It has been recommended on such occasions to apply compresses dipped into cold water to the sternum. We would propose the trial of a moans which the late Dr. C. D. Meigs found very successful in arresting tonic spasm of the respiratory muscles, in a case of laryngismus stridulus. This is the sudden application of a piece of ice wrapped in linen to the epigas- trium. When the laryngeal spasm is very intense and obstinate, a bella- donna plaster, as before recommended, or a small blister to the front of the neck, may be useful in controlling it. M. Bell speaks very highly of the results obtained by sprinkling a little ether on the clothes of the patient at the onset of the paroxysm ; and Dr. Churchill ( Di>ieaj*es of Childhood, p. 223), who has tried ether in 12 or 14 cases, and chloroform in 6, regards it as a valuable addition to our reme- dies. He directs that about half a drachm of sulphuric ether should be spilled on the nurse's hand and held before the child's nose and mouth at the commencement of a tit of coughing. In only one or two cases no bene- fit accrued, while in others great mitigation of the spasm, and in three or four almost complete relief followed when the ether was thus applied. We should certainly recommend a trial of this procedure, making use, how- ever, from preference, exclusively of the sulphuric ether. CLASS IL DISEASES OF THE CIRCULATORY ORGANS. ARTICLE I. CYANOSIS. Synonyms; Definition. — This peculiar condition, known under the various names of Morbus Coeruleus, or the blue disease, and Cyanosis, may- be defined as a permanent state of lividity or blueness of the skin, depend- ing upon numerous malformations or derangements of the heart and great vessels. In a comparatively slight degree, this condition attends many of the chronic organic diseases of the circulatory organs ; and is also transiently present in the course of some acute diseases ; but under neither of these circumstances does the lividity merit consideration as a separate affection, being merely due to the imperfect oxygenation of the blood. There is, however, one form of cyanosis which we have occasionally met with that merits a special reference. In these cases, the blueness of sur- face has appeared from three or four days to as many weeks after birth, has been intense in its degree, and associated with marked disturbance of respiration, and yet, under proper treatment, the infants have usually re- covered. AVe believe that the cause of such cyanosis is to be found in atelectasis of the lungs, which acts partly by causing general venous con- gestion, and partly perhaps by obstructing the flow of blood through the pulmonary artery, so that the right cavities of the heart become over- distended, and there results an admixture of venous and arterial blood through the still unclosed foramen ovale. Before attempting to explain the peculiar blue color in cases of true cyanosis, it will be convenient to allude to the various lesions which have been found present in such cases. Morbid Anatomy. — The blood in cyanosis is dark, and contains an excess of carbonic acid ; it has also lost, to a great extent, its coagulability. The only organs beside those of circulation which present lesions, with any constancy, are the lungs. Dr. J. Lewis Smith (Dis. of Infancy and Childhood, 1869, pp. 578-599), who has studied this disease with great care, and collected all the cases of it upon record, finds the condition of the lungs recorded with more or less minuteness in 110 out of 191 cases. In 26 cases there was tuberculosis, either confined to the lungs, or chiefly exhibited in these organs ; in 35 CYANOSIS — MORBID ANATOMY. 277 cases the lungs were of small size, either from compression by effusion in the pleural sacs or pericardium, or sometimes, apparently, from the per- sistence of the fa?tal state over a greater or less portion of the organ. lu 35 cases the lungs presented a dark color, owing either to atelectasis or to engorgement and congestion. In 9 there was emphysema in a part of the lungs; in 2, pneumonia; in 2, the color was pale; in 1, a bright crimson; in 1, the lungs were larger than natural ; in 1, the right lung was absent; and in 17, these organs were recorded as healthy. There is also found, in a large proportion of cases, venous congestion of the brain, liver, or kidneys. By far the most marked and important lesions, however, are those of the heart and great vessels, which are, ex- cepting in extremely rare instances, the essential seat of the disease. The number of these lesions already recorded is considerable, as will be seen from the subjoined table, borrowed from Smith, which shows their char- acter and relative frequency. 1. Pulmonary artery absent, rudimentary, impervious, or par- tially obstructed, 97 2. Rii^bt auriculo-ventricular orifice impervious or contracted, 5 3. Orifice of the pulmonary artery and the right auriculo-ven- tricular aperture impervious or contracted, ... 6 4. Right ventricle divided into two cavities by a supernumerary septum, 11 5. One auricle and one ventricle, ...... 12 6. Two auricles and one ventricle, ...... 4 7. A single auriculo-ventricular opening; interauricular and interventricular septa incomplete, ..... 1 8. Mitral orifice closed or contracted, ..... 3 9. Aorta absent, rudimentary, impervious, or partially ob- structed, .......... 3 10. Aortic and the left auriculo-ventricular orifices impervious or contracted, ......... 1 11. Aorta and pulmonary artery transposed, . . . .14 12. The cavae entering the left auricle, 1 13. Pulmonary veins opening into the right auricle, or into the cavae or azygos v^ins, ....... 2 14. Aorta impervious or contracted above its point of union with the ductus arteriosus; pulmonary artery wholly or in part supplying blood to the descending aorta through the ductus arteriosus, 2 162 It is evident from a glance at this table, that the vast majority of the above lesions must occur before the full development of the heart is attained ; and that consequently, in nearly every instance, cyanosiH is a congenital affection. But further than this it will be obnervcd, that in the first four groups in {Smith's table, or in 119 out of 102 rascn, the lesions affect the right side of the heart, and are precisely of the kind that we know are caused by inflammation of the endocardium. Bearing in mind then the well-a.«certained law, that cndrK-arditis occurring during fa-tal life, almost exclusively attacks the right hide of the heart, we can readily un- 278 CYANOSIS. derstand how such lesions could be produced by au attack of iuflamma- tion affecting either the valves of the pulmonary artery, or the tricuspid valves, or some part of the lining membrane of the right ventricle. Should such an attack of endocarditis occur after the development of the cavities and septa of the heart, and the closure of the foramen ovale and ductus arteriosus, and lead to occlusion of the orifice of the pulmonary artery, it would of course be impossible for life to be sustained. But w^here such a lesion is produced while the interauricular and interventricular septa are still imperfect, and the ductus arteriosus patulous, so much compensation may be effected that life can often be prolonged for many years. Thus, it is evident, that the first effect of the closure of the orifice of the pulmonary artery, at such an early period, will be to cause a large portion of the blood from the right ventricle to pass directly through the opening re- maining in the interventricular septum into the left ventricle. Usually this opening is not free enough to relieve the right ventricle entirely, and there is consequently pressure exerted backwards on the blood entering from the right auricle, which forces' part of it through the foramen ovale into the left auricle, and thus still further relieves the fulness of the right cavities. As there is no outward current through the pulmonary artery, owing to the occlusion of its orifice, blood flows back into this vessel from the aorta through the patulous ductus arteriosus, and thus supplies the lungs. At the same time the bronchial arteries become much en- larged, and, in some rare cases, blood has been able to reach the lungs through abnormal branches from the internal mammary or intercostal arteries. In cases of cyanosis which prove fatal very soon after birth, the most diverse and inexplicable lesions, as before enumerated, may be found ; but in those instances where life is prolonged, the heart is usually found to present the associated lesions above described : contraction or occlusion of the orifice of the pulmonary artery, imperfect interventricular septum, and patulous foramen ovale and ductus arteriousus. In such cases, when the compensatory communications between the right and left side of the circulation are free, life may be prolonged for many years. This was very nearly the condition found in the following case,^ the opportunity of examining and describing which we owe to the courtesy of Dr. C. H. Thomas. " The patient was a young man, set. 22 years, who had been markedly cj^anotic from infancy, and was poorly developed. He was unable to maintain a proper temperature. He suffered constantly from slight dyspnoea, with occasional exacer- bations. At the autopsy there was marked congestion of the abdominal viscera, and the gall-bladder was packed with gallstones. Both lungs contained numerous yellow miliary tubercles. " The heart was rounded. The cavities of the ventricles were not much en- larged, nor was there any hypertrophy of the walls of the left ventricle. The walls of the right ventricle were, however, decidedly thickened, though not equalling those of the left. The septum ventriculorum was disproportionately thick, and terminated about one-third of an inch below the level of the origin of the aorta 1 See Descriptive Catalogue of Path. Museum of Penna. Hosp., 'No. 1501, p. 84, by William Pepper, M.D. 18t59. MORBID ANATOMY — ILLUSTRATIVE CASES. 279 in a smooth, rounded edge, over which the endocardium was thickened. The septum also seemed inside of its normal position, so as almost to bisect the aortic orifice. The aorta, which was slightly dilated but quite healthy, thus communi- cated freely with both ventricles. The origin of the pulmonary artery was very much obstructed, owing to coalescence and contraction of its valves The ductus arteriosus was, unfortunately, not preserved, but, owing to the largp size of the pulmonary artery beyond the seat of obstruction, it had in all probability remained patulous. The foramen ovale was closed." In this instance, the orifice of the pulmonary artery not being entirely closed, the opening in the interventricular septum had been large enough to allow the right ventricle to relieve itself in that way, and consetjueutly the foramen ovale had closed. When writing of atelectasis pulmouum (p. 137) we called attention to the fact that in some cases, where the state of imperfect expansion per- sistetl, the continued obstruction to the pulmonary circulation was followed by the same train of lesions, viz., patulous ductus arteriosus and foramen ovale, and dilated hypertrophy of the right side of the heart, as are con- sequent upon obstruction of the orifice of the pulmonary artery, and which, as in the latter case, might be attended with cyanosis. The mere |>ersistence of the foramen ovale can scarcely be regarded as a cause of |>ermanent cyanosis. It is quite possible that during the early days of extra-uterine life, a certain amount of cyanosis might exist owing to the admixture of venous and arterial blood allowed by this opening, but after the forces of the circulation become equalized, it is quite certain that the valve of the foramen may remain unattached, or may even be some- what insufiicient to close the opening, and yet no cyanosis be present. As an illustrative ca.se of one of the rarer forms of cyanosis, and one which bears in the most interesting manner upon the theory of its produc- tion, we abstract the following from a more full account published in the Proceedings of tJie Pathological Society of Philadelphia? The child was a well-developed male, born at full term. No discoloration was noticed at birth, but on the twelfth day, as the grandmother was preparing to wash it, it bad a convulsion, and from that time presented coldness of the extremities, gradually increasing lividity, feeble and rapid pul.-e, and moaning and sighing respiration. During inspiration, the sternum and upper parts of the chest were elevated, but the lateral regions remained unexpanded, and there was marked recession of the base of the thorax. The percussion-resonance was diminished on both sides, but esp<-cially on the right. The ve.-icular murmur was puerile, except over the right side, whore it was feeble. The cardiac sounds were decidedly louder at the right scapula than over the left. The cardiac impulse at the left nipple was very indis- tinct, and the sounds there feeble but natural. On pressing two fingers lightly to the left of the ensiform cartilage, close to the costal cartilages, a very di-tinrt and quite vigorous impulse could be felt, one much more di^tinct than at the nipple. At this point, a distinct blowing sound attended the systole of the heart. The diag- nosis made at the time wa« : atelectjisis of both lungs, of the right greater than of » Transposition of the Arteries. Dr. J. F. Meigs Proc. of Path. Soc., vol. ii p. 37; and Am. Jour, of Med. Science*, vol. xi, 1800, p. 416. 280 CYANOSIS. the left ; dilatation with hypertrophy of the right ventricle ; obstruction of the pulmonary artery, and open foramen ovale. Death occurred on the forty-fourth day after birth. At the autopsy, the body was very small and thin. The thorax was flattened laterally, and contracted at the base. There was marked collapse of the lower lobes of both lungs, and especially of the right. The heart was one-half too large, and full, rounded, and distended with soft black clots. The walls of the right ventricle were very thick, and its cavity quite small ; it presented the ap- pearance we usually associate with the left ventricle. The walls of the left ventri- cle were thinner than those of the right; and its cavity was much more capacious than that of the right. The right auricle was dilated and considerably larger than the left. The foramen ovale presented an opening at its lower aspect of about 2 or 3 lines in diameter. The orifices of the venae cavse appeared smaller than usual. The aorta and pulmonary artery were transposed. The aorta arose from the right ventricle in the usual position of the pulmonarj^ artery; the pulmonary artery arose from the left ventricle, and passing under the arch of the aorta, gave to the latter, just beyond the left subclavian, the ductus arteriosus, which was quite pervious and of considerable size. The valves of the heart were healthy and not transposed. The pulmonary artery was of the natural size, and presented no obstruction at its point of origin. After giving oflf to the aorta the ductus ar- teriosus, it divided as usual into two pulmonary branches, which soon subdivided into others. The aorta was of full size and presented nothing unusual. It gave off at its arch the innominate artery, and then the left primitive carotid and the left sub- clavian. Just beyond the latter it received, from the pulmonary artery, the ductus arteriosus. The pericardium was normal in all respects. Theories as to the Production of Cyanosis. — -In the vast majority of cases the malformation which causes cyanosis is of such a character as to allow admixture of the venous and arterial blood, and, at the same time, to interfere more or less with the circulation of this mixed fluid. Ever since the time of Morgagni, authors upon this subject have been divided in opinion as to whether the coloration of the skin were due exclusively to one or the other of these causes : obstruction to the cardiac circulation and consequent venous congestion, or intermingling of the venous and arte- rial blood. In regard to the first of these causes, although it has numbered among its advocates Morgagni, Louis, and Stills, it cannot be considered com- petent to fully explain all the cases and peculiarities of cyanosis, al- though such central obstruction will unquestionably aid in its production. Nor can the second theory be held exclusively sufficient, since not only- are there cases met with where cyanosis is present and yet no admixture of venous and arterial blood is possible, but also, on the other hand, where a considerable degree of admixture exists without the production of cyanosis. It seems necessary, therefore, as Smith has clearly pointed out, that any theory which pretends to embrace all the elements of this complex condi- tion, should embody a reference to the fact that the essential defect in cyanosis is a want of arterialization of the blood. Symptoms. — Even in cases where cyanosis is due to congenital organic SYMPTOMS. 281 lesioDS, the peculiar symptoms are not always present until some time after birth. Thus, in 138 of the eases of cyanosis collected by Smith, the time at which lividity was first noticed is stated as follows : In 97 it was within the first week, and often within i\ few hours after birth. In 3 at 2 weeks. In 6 from 2 to 5 years. *' 2 " 1 month. " 6 " 10" 20 " " 7 from 1 to 2 months. " 1 " 20 " 40 " " 5 " 2 '• t) •' " 1 over 40 years. " 5 " 6 '* 12 " — «' 3 «' 1 " 2 years. 41 Dr. Smith adds, " that in these 41 cases, in which blueness did not occur till after the age of one week, if the patient were less than two years old when it commenced, there was frequently no obvious exciting cause; but above this age, with three exceptions, such a cause is known to have been present. It is interesting to observe how trivial the exciting cause fre- quently is " (an acute attack of sickness, an attack of convulsions, difficult parturition, a fall, or even a severe blow), " and equally interesting to note how long patients have enjoyed good health, not having the least lividity, although the anatomical vice, to which the final development of cyanosis was due, had existed from birth." The most characteristic symptom of cyanosis is the lividity of the sur- face, which varies in different cases from mere duskiness to a deep purplish tint. This color also varies in degree in different parts of the body, being most marked in the distant and especially the dependent portions, upon the mucous membranes, and wherever the capillary vessels are abundant, as on the face. Its degree varies, finally, in the same case with the condition of the circulation. In slight cases, when the patient is quiet and the circu- lation tranquil, the discoloration of the surface may be imperceptible, but upon any exertion, and especially in the more severe cases, the lividity becomes much intensified. In some instances, such as that narrated by us below, there may be actual ecchymoses of the surface, as in purpura. The .state of the general nutrition is much impaired, and the subjects of this di.*ea.se are usually stunted and illy developed. In many instances the generative system appears even more imperfectly developed than the rest of the economy. The temperature of the body is always reduced, and exposure to cold is ver}' poorly borne. In a good many cases the thorax presents the deformity .«o often found in a.«.soriation with rickets, known as the " pigeon-brea.st." It usually hap- pens, also, that the ends of the fingers and toes become bulbous. Distur- bances of the circulation and respiration are of frequent occurrence. Thus there is oflen .«ome abnormal bruit heard in the cardiac region, duo to the abnormal condition of tlie heart. The pulse may be regular and of fair volume, but more frequently is small, irregular, or intermittent, and palpi- tation is \ery readily induced by exertion. The disturbance of respira- 282 CYANOSIS. tion usually corresponds in degree with the embarrassment of the circula- tion. While the patient remains quiet his breathing may be easy and regular, but usually any sudden movement or exertion or emotion is sufficient to induce a paroxysm of dyspnoea, during which the lividity of surface be- comes much deeper. In infants these paroxysms not rarely terminate in convulsions. Headache is frequently complained of, and is very apt to be caused by whatever disorders the circulation. During the paroxysms of palpitation, pain is often complained of in the region of the heart, but is rarely persistent. Owing to the extreme venous stasis frequently present, there is a tendency to passive haemorrhages in cyanosis, which expresses itself by bleeding from the nose, mouth, stomach, or rectum, or under the skin. (Edema of the lower extremities is often met with as a temporary condition after long standing on the feet ; it is also apt to appear and to invade the rest of the body towards the close of the case, when the circulation becomes more en- feebled. Modes of Death. — Many cyanotic patients die from the effect of some intercurrent acute disease, as hooping-cough or one of the exanthemata, all of which are very badly borne in this condition. The theory that venous congestion is opposed to the development of tuberculosis, was applied by Rokitansky to this affection ; but without any sufficient ground, since, as we have seen already, tuberculosis was found as the cause of death in no less than 26 of the cases collected by Dr. Smith. In other cases death occurs suddenly, either daring an attack of convul- sions or a paroxysm of dyspnoea. In severe cases of cyanosis life is rarely prolonged more than a few years ; but in less marked cases the patients may even attain middle age. In 186 cases collected by Dr. Smith, the age at death was as follows : In 17 under age of 1 week. In 21 from 5 years to 10 years. " 10 from 1 week to 1 month. " 41 " 10 " " 20 " " 12 " 1 month to 3 months. '' 20 " 20 " " 40 '* «' 11 " 3 months to 6 " " 4 over 40 years. u 17 u 6 u u 12 " " 12 " 1 year to 2 years. 186 " 21 " 2 years to 5 " So that in 67, or more than one-third, death occurred before the close of the first year; in 121, or more than three-fifths, before the age of 10 years ; only 24 survived the age of 20 years, and 4 the age of 40 years. We subjoin the history of a case of cyanosis which we had under obser- vation for several years, in which the symptoms of this peculiar condition were extremely well marked. J. W., set. 16 years and 7 months, has been cyanotic since infancy, but for the past few years, at least, has enjoyed fair health. At present there is marked lividity of the lips and of the nose, especially at the extremity, which seems somewhat in- creased in size. His hands habitually appear as though stained with solution of carmine, the skin being uniformly livid over the whole hands, but becoming lighter colored on the forearms. Pressure partly removes the lividity, which returns TREATMENT. 283 slowly after the withdrawal of the pressure. At times there have been little ecchy- nioses of the surface, followed by the etJusion of serum under the epidermis, and the formation of superficial excoriations, which have left small cicatrices. Only a few of these have appear«Mi on the hands. Those vascular disturbances are. even more marked in the lower extremities. The feet are continually deeply livid; and over their surface and the ankles, very numerous ecclu-motic spots have appeared, which underwent the same changes as those en the hands, and have left shining cicatricial spots, of a deep blarkish-red color from the deposit of pigment, and surrounded b\' a dark brownish stain. There has also been a good deal of oedema of the feet lately. All of these condi- tions have been improved by the use of tight-laced stockings. The skin of both the hands and feet is rather soft and moist. The last phalanges, both of the fingers and toes, are markedly clavate and hypertrophied. Firm pressure upon them re- duces their size; but, upon withdrawal of the pressure, the blood slowly returns, and they regain their former size. The temperature of the body is always low, and he suffers extremely from exposure to cold. He suflers somewhat from dyspnoea, even upon slight exertion, but less so than formerly. He is also troubled with cough during the winter months. There is marked deformity of the thorax, the first and second pieces of the sternum uniting at an obtuse angle, and the cartilages of the third, fourth, fifth, and sixth ribs, forming a marked prominence on either side of the sternum ; the ensiform cartilage is considerably depressed. The apex-beat of the heart is in the fifth costal interspace, and just inside of the vertical line of the nipple. The heart's action is regular, and at present there is no abnormal cardiac murmur, though two years ago there was a distinct soft systolic bruit. The pulse in the standing posture is 114, in the sitting, 108. He has occa- sional attacks of epistaxis, and sufi'ers quite frequently from attacks of gastric dis- turbance attended with severe headache. The above note was taken in December, 1869. Since our last edition, this case has terminated fatally, and a post-mortem examination proved the existence of marked congenital malformation of the heart, of the char- acter already fully described, originating evidently in obstruction of the pulmonar)^ orifice. Treatment. — In the form of cyanosis which we have described as de- pending on collapse of the lungs, the child should be placed in the position below recommended as rendering the heart's action most free; the temper- ature of the body should be carefully maintained, and a few doses of brandy in water or breast-milk should be given at intervals. There is evidently but little good that can be done by mere medication in cyanosis depending on malformations of the heart. When the heart's action is feeble and irregular, digitalis, iron, and quinia, may be administered. During the paroxysms of palpitation and dysj)n(ea, the best remedies are diffusible stimulants, such as Hoffman's anodyne, spirit of chloroform, ammonia, and brandy; and derivatives, such as sinapisms to the chest or hot mustard foot-baths. In ca.ses where the digestion is markedly feeble, the use of vegetable tonics is indicated. By far the most importiint part of the treatment, however, is a strict attention to the hygienic conditions of the patient. He should, so far as may be practicable, avoid all excitement and active exertion ; his diet should be digestible and nutritious, his clothing should be warm, and, in addition, be should carefully avoid all exposure to severe cold. 284 DISEASES OF THE HEART. In cases where the venous congestion of the legs is marked and attended with oedema or with enlargement of the veins, laced stockings should be worn. It occasionally happens that cyanotic patients find that certain positions afford them peculiar ease and comfort. Believing that in cases where the lividity appeared soon after birth (cyanosis neonatorum), it was due to a patulous condition of the foramen ovale, the late Dr. Charles D. Meigs was led to recommend (Diseases of Children, 1850, p. 92), that such chil- dren should be placed upon a pillow, on the right side, the head and trunk being inclined upwards about 30° or 45°. The object of this position was "to bring the septum of the auricles into a horizontal position, so that the blood in the left auricle might press the valve of Botalli down upon the foramen ovale." In a certain number of cases the adoption of this recommendation has undoubtedly seemed to relieve the lividity, so that it is perhaps desirable that all cyanotic infants should be placed in this position ; though from a glance at the anomalies in the formation of the heart which frequently attend cyanosis, it is evident that in most cases it could furnish no material relief. We are ourselves inclined to attribute the relief afforded by this position, not to any influence upon the foramen ovale, but to the fact that the heart's action is far most free and unincumbered when the child is placed upon the right side, with the trunk somewhat elevated. ARTICLE II. DISEASES OF THE HEART. As we are prevented, by the limits of this work, from giving any detailed account of many of the affections which merely occur in childhood in com- mon with adult life, we propose in this article to offer only a few practical remarks upon the differences presented by diseases of the heart occurring at these two periods of life. Apart from those congenital malformations of the heart, already dis- cussed in the preceding article, the diseases of this organ most frequently met with in childhood, are pericarditis, and acute and chronic endocarditis, with valvular disease. The most frequent causes of these affections are rheumatism, the peculiar alterations of the blood present in scarlatina, rubeola, and diphtheria, and extension of inflammation from the adjacent tissues, in cases of pleurisy or pneumonia. Of these well-recognized causes, rheumatism is by far the most frequent ; for, although young children are comparatively rarely the subjects of this disease, it is followed by some cardiac complication in a larger proportion of cases in childhood than in after years. This fact will be more fully referred to in our remarks upon rheumatism, where we dwell ACUTE PERICARDITIS. 285 upon the importance of recognizing this marked tendency, and of watching most critically for the appearance of any symptom indicating that the heart has become involved. This extreme watchfulness is the more neces- sary, because it frequently happens in young children, that for several days before the development of any local articular trouble, there may exist marked rheumatic fever, with serious inflammation of the membranes of the heart. In a few instances an acute cardiac aftectiou cannot be traced to any of the causes above-mentioned, but appears to occur idiopathically, without exposure to any recognizable exciting cause. So, too, in some cases of chronic valvular disease, and especially, it has seemed to us, of contraction and thickening of the mitral valve, the lesion cannot even be traced to any acute attack of endocarditis, but seems more akin to a fibroid degeneration, whose cause and early symptoms have been obscure and entirely overlooked. Possibly, in some of these interesting cases, the real starting-point of the disease may have been an attack of endocarditis in foetal life, which par- tially spoiled the valve, and set on foot degenerative changes, which slowly increased until they produced fatal symptoms. Acute Pericarditis may occur at any period after birth. In very young infants it has been observed in conjunction with peritonitis, and was apparently due to erysipelas; while in other cases no cause could be asisigned for its occurrence. The symptoms are, however, so vague and difficult to appreciate at this tender age, that the lesion is rarely recognized until after death. The infant is evidently in pain ; the features are pinched and shrunken, the skin hot at first, and the pulse and respiration greatly accelerated. The physical signs can, however, rarely be satisfactorily de- termined, partly because death usually occurs before the lesions reach any considerable degree of development. In older children the physical signs are often obscured by the coex- istence of some inflammatory condition of the lungs or pleura, and the existence of pericarditis can only be surmised by the presence of a degree of disturbance of the circulation and respiration out of all proportion to the amount of lung trouble. When, however, pericarditis occurs without any such complication, it may be often recognized by the seat of pain ; the existence of great dysp- noea, amounting at times to orthopna»a; the great frequency of the pulse, which is often small, and even irregular; the disturbance of circulation, as shown by lividity of the lips and face; and, finally, by auscultation and percussion, which reveal at first merely a friction-sound, and later, when eflTusion has occurred, distant and feeble heart-sounds, with an in- creased area of cardiac dulness. When severe, pericarditis in children usually proves fatal. After death the same anatomical lesions are found as after pericarditis in adult life. The membrane is, in the first stage, reddened, injected, dr}'ish, and slightly roughened ; while later it is still injected and even ecchymowd, thirkened, softened, and covered with patches or uniform layers of whitish or yellow- ish-white lymph, the surfaces of which are usually flocculeut or irregularly 286 DISEASES OF THE HEART. roughened. The pericardial sac contains a variable quantity of turbid, or, at times, bloody serum ; or, in secondary cases, a sero-purulent fluid. In cases where recovery takes place, the results of the previous inflam- mation are found, after death has occurred from some other cause, in the form of more or less extensive adhesion of the two layers of the pericar- dium, or merely of thickening and opacity of that membrane. Treatment. — In idiopathic cases, if the disease be recognized in the early stage, we should advise local depletion over the prsecordia by three or four leeches or cut-cups in a child of Ave years of age, followed by the application of warm mush-poultices, the depletion being repeated if indi- cated ; the internal use of large doses of acetate of potash and iodide of potassium, associated with doses of veratrum viride of appropriate strength, to quiet the excessive vascular excitement ; and the careful administration of nutritious diet and small amounts of stimulus, if the powers of the cir- culation seem likely to yield to the influence of the disease. In the very rare instances where the disease becomes chronic, and the effusion remains unabsorbed, the treatment should consist in the repeated application of small blisters over the prsecordia, and the internal use of iodide of potassium, iodide of iron, with tonics and nutritious diet. In still more rare cases, the effect of chronic pericarditis is to induce ex- tremely thick layers of lymph enveloping the heart. In one instance which we lately saw in consultation with Dr. C. H. Thomas^ where pericar- ditis of several years' duration existed, the sac was obliterated by a layer of succulent almost gelatinous lymph fully one-half inch in thickness. In such a case, it is difficult to distinguish the lesion from hypertrophy of the heart. It might be done, however, by the absence of valvular mur- mur, and the feebleness of the apex-beat and of the heart-sounds. If, moreover, we have observed or can get an accurate account of the original attack, its character and the future course of the case would be of great value. Endocarditis. — In many cases, acute endocarditis in children occurs in conjunction with pericarditis, although it also occurs frequently as an independent aflfection. It is due to the same series of causes, also, as have been already enumerated when speaking of this latter disease ; of these undoubtedly rheumatism is far the most frequent. And as it is of far more frequent occurrence than pericarditis, and productive of even more serious results, it is necessary that we should, if possible, be more upon the alert to detect the very earliest symptoms of its presence. Since recent obser- vation has established the occurrence of acute afl^ections of the heart in the course of some other specific diseases, as stated in our remarks on peri- carditis, it is an important rule to use the same care in repeatedly examin- ing the heart in these cases also. In severe cases, whether occurring idiopathically, or as a complication or sequel of some other disease, there is violent disturbance of the circula- tion, with great dyspnoea, and short, dry cough, without any of the physi- ^ See report in Transactions of Philadelphia Pathological Society, vol. vi, 1876-77. ENDOCARDITIS. 287 cal signs of pulmonary disea:?e. The child is extremely restless, and, upon ausoultation, an abnormal bruit is heard attending the heart's action. The valvular murmur, it must be remembered, is not harsh and strong as in some cases of chronic valvular disease, but may be so gentle and soft as to be heard with difficulty. In most eases, the mitral valve is chiefly atiected in acute endocarditis, and the murmur detected on auscultation is heard over the body of the heart and to the let\ of this organ, and often has its seat of greatest inten- sity near the apex. We have most frequently observed the murmur to be syst'^lic in time, attending and more or less obscuring the fii*st sound of the heart, in such acute cases. Of course, this indicates the existence of some imperfection in the closure of the mitral valves, allowing more or less regurgitation of blood into the auricle with each contraction of the ventricle. Occasionally a double murmur, attending both the systole and diastole, and indicating roughness as well as insufficiency of the mitral valve is heard. In more rare instances, we have found the aortic valves to be the seat of acute endocarditis, as shown by the presence of a single or double bhiwing murmur over the base of the heart, and transmitted most strongly upwards over the upper part of the sternum to the second right costal cartilage. But more frequently the acute symptoms are not so marked or charac- teristic as this, and, when ensuing, for instance, in the course of acute rheu- matism, may consist merely in a little increase of the heat of the skin, frequency of the pulse and restlessness, with or without vague complaints of pain about the praecordia. Absolutely the only way of recognizing such cases is by auscultation, and consequently we would urge the immense importance of carefully aus- culting the heart daily, not only in every case of acute rheumatism in a child, but also in every case where anomalous febrile symptoms, with ac- celeration of pulse, are present, and particularly if there be general sore- ness, or even resistance to motion. In very severe attacks of acute endocarditis, death may occur early ; but more commonly the disease is less severe, and the urgent symptoms subside, leaving, however, in but too many cases, organic valvular disease. When death occurs during the acute stage, the endocardium is i\m\u\ injected, reddened, softened, and readily detached from the muscular wall. The lesions are most marked on the left side of the heart, and esi)ecially on the endocardium covering the mitral valve, where, in addition to the above-mentioned appearance", there are usually patches or rows of minute granular vegetations, which form a fine beaded line along the free border of the valves; or, in other cases, delicate fringe-like processes which hang from the leaflets. We have alluded at some length in our article on chorea, to the theor}- which has been framed to explain the fre(|Uont oc- currence of this latter di.«ease in connection with rheumatism, by the sepa- ration of minute fragment** of such vegetations, and their impaction in some of the vessels of the brain. The treatment of acute endocarditis should be the same as that recom- mended for acute pericarditis. 288 DISEASES OF THE HEART. CHRONIC VALVULAR DISEASES. There are certain general remarks which we desire to make in connec- tion with these affections, which are applicable to them, without reference to the particular valve diseased : in addition to which, we will call atten- tion to the diagnostic signs and special features of the diseases of each set of valves. Causes; Frequency. — In very many cases, heart disease in young children is recognized for the first time when such marked lesions exist as to convince us that the disease has already been of some considerable duration. Undoubtedly this is partly because the acute symptoms of the early stage have been entirely overlooked. This is particularly the case when the disease is rheumatic in its origin. We are convinced that acute rheumatism is often overlooked in young children, and also that endocar- ditis occurring in the course of such attacks not rarely escapes detection. It is, therefore, very difficult to say in what proportion of cases in young children, valvular diseases have been of acute origin. In our own experi- ence they have, with the exception of contraction of the mitral valve, almost universally followed an attack of endocarditis. In the case of mi- tral contraction, however, it is quite often impossible to trace the disease to any acute attack. It would appear, therefore, either that, contrary to the usual rule in early life, this lesion is often the result of a slow degene- rative, fibroid change, or else that, in some cases, it may arise in foetal life. This latter view does not seem at all impossible when we remember how slow is the development of this lesion, and for how long a time it may remain latent. As to the relative frequency with which the diflferent sets of valves are aflfected, lesions of the mitral valve undoubtedly preponderate largely. We have, it is true, met with extreme aortic disease in quite young chil- dren, marked by all the physical signs that are familiar as occurring in the adult ; but such cases have been rare compared to those in which the mitral valve was the seat of the disease. Anatomical Appearances. — The lesions which are found in chronic valvular diseases do not differ from those which are found in the adult, nor are they materially dependent upon the mode of their origin. It is, however, probably true that in those cases which have followed acute en- docarditis, it is more usual to find numerous and large vegetations upon the valves, than where the lesion has been chronic and of gradual devel- opment from the start. The lesions which are found usually, are vegeta- tions or calcareous incrustations on the valves, or there may be thickening, contraction, and coalescence of the valves and their chordae tendinese, either of which conditions may be attended with contraction of the orifices of the heart, and obstruction to the passage of blood. On the other hand, the contraction of the valves may be in such a direction as to render them insufficient to close the orifice, and thus allow regurgitation. The effect of these lesions upon the walls and cavities of the heart will vary with their degree and suddenness of development. Usually they are followed by dilatation of the cavities involved, and by thickening or hypertrophy of f DISEASES OF THE AORTIC VALVES. 289 their walls, which has usually seemed to us more constant and to boar a larger proportion to the dilatation than in adults. Symttoms. — The general symptoms during the early stages of chronic valvular disease, are often extremely slight, consisting merely of some interference with the general development of the body ; a little palpita- tion of the heart, and dyspno?a on exertion ; occasional precordial distress, and j>erhaps slight prominence of the cardiac region. The vague character of these symptoms accounts for the fi\ct that, after the subsidence of the acute symptoms of endocarditis, when the disease has begun in that way, such cases are very often neglected, and receive no proi>er care until the occurrence of dyspnoea, cough, and dropsy, gives warning only in time to recognize the approach of the fatal termination. We make these remarks especially to call attention to the insidious mode of approach of many case^ of chronic valvular disease of the heart in children ; and to impress upon our readers the important practical rule that, whenever, in the investigation of a child suffering with obscure ill health, we learn of the previous occurrence of acute rheumatism, or find mentioned among the symptoms any irregularities of the circulation or action of the heart, careful physical exploration of the heart should im- mediately be practiced. The special symptoms which attend the diseases of the different valves, may be briefly described as follows : DUeases of the Aortic Valves. — These affections are, as already said, comparatively rare in children. The blowing murmur which attends them is usually strong and distinct. If the lesion causes obstruction of the aortic orifice, the murmur will attend the first sound ; if there be re- gurgitation through the valve, it will attend or take the place of the second sound. In many cases the lesion causes both obstruction and in- sufficiency, and there is therefore a double murmur. In either case the murmur will be heard extending from the base of the heart upward and across the sternum to the second right costal cartilage, as well as down- ward along that bone to the xiphoid cartilage. It is also transmitted into the arteries. The murmur is often so loud that, especially in cases of re- gurgitation, it may be heard down over the body of the heart to the apex ; and also to a varying distance on either side of the sternum over the upper part of the chest. Occasionally also a thrill may be felt over the upper piece of the .sternum, in the second intercostiil space at either the right or left edge of the sternum, or at the supra-sternal notch. The action of the heart is regular, and may not be accelerated, though exertion readily excites palpitation. The apex-beat is quick and strong, and is found after a time below and to the left of ita normal |K)sition. The area of cardiac percussion-dulne»s also becomes mohy of the walls of the left ventricle. The pulse is small, quick, and in ca»e» of regurgitation, jerking and un- gustained, or receding. Id severe cases, there are marked evidences of interference with the ar- terial circulation. The surface i.<< pale, and shows the insufficient amount of blood which passes through the arterial capillaries. 19 290 DISEASES OF THE HEART. The respiration is usually but little disturbed, excepting in consequence of unusual exertion, so long as the lesion is limited to the aortic valve, and the walls of the left ventricle undergo sufficient compensatory hypertrophy to overcome the obstruction to the circulation. The prognosis in aortic disease of moderate severity has not seemed to us unfavorable so far as regards prolongation of life. Thus, for example, we treated a girl of 9J years, who had a violent attack of acute articular rheumatism with endocarditis. This was followed by a double aortic mur- mur, which persists to the present time, although she has grown up, mar- ried, and has one child. Her health is delicate, and she has very moderate dyspnoea on exertion. We have frequently observed this same tolerance of serious aortic lesions for a number of years. We have never met with a case in which sudden death occurred in the course of aortic regurgita- tion, as so frequently happens in adults. Mitral Obstruction. — This interesting form of cardiac lesion would merit a more full description here than any other valvular disease, because its symptoms are somewhat peculiar, and more especially because it is of such comparative frequency in childhood. Its origin, as we have already remarked, is usually insidious, and it is frequently impossible to gain any history of acute disease in cases where marked mitral obstruction is detected. The general symptoms which first attract attention to the heart are rarely noticed before the age of 7 or 10 years ; and we may then learn that during previous years the child has seemed as active and playful as usual, or that he has always shown an indisposition to active play or ex- ertion, and has become tired readily. Attention is attracted to the heart by the increased tendency to dyspnoea and palpitation on exertion, and by the readiness with which cough of a bronchial character is contracted on very slight exposure. Occasionally during these attacks of bronchitis with pulmonary congestion, haemoptysis may have occurred. Examina- tion may now show the existence of prominence of the prsecordia ; and the area of cardiac dulness is usually increased, though not to a marked extent. Frequently a thrill can be felt over the prsecordia, and careful examination will show it to occur just before the apex-beat. We have known this thrill to begin distinctly about the base of the heart, and to extend quickly down towards the apex, terminating as the apex-beat was noticed. On auscultation, a murmur, usually of a low, hoarse, or churn- ing character, is heard, which presents these additional peculiarities : it is generally distinctly presystolic or auriculo-systolic in time, occurring, that is. in the long period of silence preceding the first sound ; its relation to the phenomena of the cardiac action can usually be determined without difficulty by observing that it follows the second sound, and that it stops just before, or else runs into, the time of the first sound and the pulse of the carotid artery. This murmur, also, although usually quite strong, is, as a rule, remarkably localized in comparison to other valvular murmurs : its seat of greatest intensity is at or near the apex, and it loses force rap- idly on leaving this point in any direction. Attention to the peculiar MITRAL REGURGITATION. 291 physical signs above given, as well as to the general symptoms, will gener- ally render the diagnosis clear. The prognosis, as regards prolongation of lite and maintenance of com- fort, is comparatively favorable ; as regards improvement in the organic condition of the heart, it is of conrse entirely the reverse. AVe have nnder our care at })resent a lad of 16 years of age who presents the typical symp- toms of mitral obstruction, but who, by care in his manner of living, enjoys entire comfort. Usually, however, the frequent recurrence of pulmonary congestion injures more and more seriously the equilibrium of the heart's circulation and the efficiency of the right ventricle, and eventually grave symptoms of failure of cardiac power, with general venous stasis, appear, and increase until a fatal result occurs. Mitral Beffiirffitntiou. — This, which is the most frequent form of cardiac disease in young children, depends upon inflammatory alterations in the mitral valve, which render it insufficient to close that orifice during the systole of the left ventricle. In most cases it arises from an acute endo- carditis, chiefly of rheumatic nature. In this condition, as in the last, the pulmonary circulation is apt to be disturbed from time to time, and there- fore the early general symptoms which attract attention to the thoracic organs are usually shortness of breath on exertion, liability to cough, and palpitation of the heart. Of course, where we are in attendance upon the case of rheumatism when the acute cardiac inflammation occurs, the fact will be recognized by the symptoms detailed under the head of acute en- docarditis. But unfortunately it often happens that this acute stage is quite overlooked, and we would therefore again urge the importance of a careful physical examination of the heart in every case where a child is brought to us complaining of vague symptoms of embarrassed breathing, though no suspicion has ever been raised of the existence of heart disease. Sometimes, indeed, much more marked general symptoms will have ap- peared, as, for example, severe dyspnoea on exertion, pulmonary congestion with cough and moist or dry rales over the posterior parts of the lungs, palpitation of the heart, lividity of the lips and fingers, and even oedema of the feet. On physical exploration we often find prominence of the pnecordia, with signs of more considerable hyi^ertrophy and dilatation than in cases of mitral obstruction. The impulse is extended and too forcible, or may even be heaving; it is rarely attended with any thrill. On auscultation a blow- ing murmur, which varies very greatly in different cases in its force and character, will be heard accompanying or replacing the first sound of the heart. This murmur is heard at the base, and is transmitted most strongly towards the apex, where it often has its point of greatest intensity. It is also strongly transmitted to the left of the apex, being well heard in the infra-axillary space on the level of the a|K^x-beat, and fre(juently, also, on the dorsum of the left chest, at the angle of the scapula. The only other form of valvular disease with which it is possible to confound this is mitral obstruction ; but attention to the evident points of difference noted above will render the diagnosis easy in most cases. The prognosis varies extremely in different cases, def>endiug upon the 292 DISEASES OF THE HEART. extent and rapidity of development of the lesion ; the completeness with which the disturbance of the circulation is compensated by the hypertrophy and increased power of the walls of the left ventricle ; and the vigor of the system and the preservation of the tone and nutrition of the muscular fibre of the heart. This form of heart disease illustrates more clearly than any other the more favorable prognosis which may be made in many cases of organic valvular disease in children, as compared with the same condition in adults. This depends partly upon the fact that when the lesion is not extensive, and when the patient is placed under favorable circumstances, the heart accommodates itself in its growth to the defective state of the valves, and overcomes the impendiment to the circulation by acquiring in- creased propulsive force. Not only, however, are the valvular lesions in childhood thus partly compensated by hypertrophy of the walls of the heart, but there is also an undoubted tendency, in some favorable cases, for the valvular lesions, both mitral and aortic, themselves to diminish. Thus among the following cases, which we have selected from a large number of records collected in our practice, there will be found several where positive abnormal bruits, due to organic valvular disease, have gradually disappeared in the course of years. Acute articular rheumatism ; endocarditis ; recovery ; murmur persistent hut di- viinishing. — H. S., a boy, set. 12 years, had a severe attack of acute articular rheu- matism in April, 1869, with swelling, redness, and pain of joints ; a systolic murmur appeared at the apex without any pericarditis. He recovered, under the use of alkalies and opium. In November, 1869, seven months after the attack, he seemed perfectly well; had no dyspnoea except on violent exertion. The murmur at the apex is still audible, but less marked than three months ago, when he was last examined. Acute endocarditis (rhewnatic?) ; fnarked imp7^ovement in general symptoms, but persiste7U mia^tnur — B. H., a girl, at age of 4 years suffered from an ordinary ca- tarrh, when we detected a loud, high-pitched murmur at the apex, and, on inquiry, learned that, when 2^ years old, she had a violent inflammation of the chest, sup- posed to be catarrhal fever. At present, at the age of 12 years, she is in excellent health, without any of the rational signs of cardiac trouble, but she still has a well-mai'ked, rather prolonged, high-pitched, systolic murmur at the apex. Repeated attacks of rheumatism with severe mitral disease; improvement in general symptoms and force of the m,urmur. — L. S., a girl, was subject to attacks of rheuma- tism from very early age, and has presented symptoms of cardiac disease from in- fancy. At age of 13, there was a strong systolic murmur heard over base and toward apex. She suffered much from violent palpitation, pain in prspcorditi, head- ache, and habitual dyspnoea, much increased on exertion. At age of 18, there is still a systolic mitral murmur, but of much less intensity than formerly. Her gen- eral health is excellent, and she has but little dyspnoea or palpitation at any time. The heart's action is still readily excited; the impulse strong, but without thrill; there is marked increase in the area of cardiac dulness, but no positive prominence of the praecordia. Acute rheumatic endocarditis, chr(mic mitral disease / recovery in five years. — F. R., a girl, at the ago of 6 years, was attacked with slight rheumatic fever, without any articular symptoms. In a few days, a distinct but not loud, rather low-pitched systolic murmur was heard at the apex. The treatment consisted of rest in bed, quinia, and Dover's powders. After ten days, all the acute symptoms disappeared, but the murmur continued. She regained her health, but for two years the mur- CASE. 293 mur could be detected, but then ajradually diminished ; and now, five yenrs after first attack, no murmur can be detected, the first sound at the apex beinsj: merely a little prolonged. Her general health is excellent. Acute t'hrtimafie endocarditis ; valrnlar diicnse, (jradualb/ rccovcrin(^ in coio'se of two years. — M. B., a girl, at the age of 7 years had fever of a type that made us suspect pneumonia or pleurisy, but without cough, pain in the chest, or any of the physical signs of pulmonary disease. On the third day, there was coniplaint t)f pain in one groin, but with no other articular symptoms; rheumatism being sus- pected, a careful examination detected a roughish systolic murmur at the apex. She was leeched at the prax'ordia, confined strictly to bod, and had Dover's powders given her. The fever subsided, but the murmur continued for two years, gradu- ally growing faint, and finally disappeared. It is, however, only when the general nutrition of the patient is good, so that the tonicity of the heart's tissue is preserved ; and when all ex- pn to hygiene and medical treatment we are able to preserve the tone and nutrition of its muscular tissue. CLASS III. DISEASES OF THE DIGESTIVE OKGANS. CHAPTEE I. DISEASES OF THE MOUTH AND THROAT. "We have adhered to the arrangement of this subject adopted in our last edition, and shall consider the diseases of the mouth in the following order : 1. Simple or erythematous stomatitis. 2. Follicular stomatitis, or aphthae. 3. Ulcerative, or ulcero-membranous stomatitis. 4. Gangrene of the mouth. 5. Thrush, or stomatitis with curd-like exudation. 6. Affections of the tonsils. 7. Simple, or erythematous pharyngitis. 8. Retropharyngeal abscess. In the early editions of this work, we described pseudo-membranous pharyngitis in this place, but further observation and research have clearly established the fact that this is but the local manifestation of a constitu- tional affection, diphtheria ; and we have accordingly given a full account of the whole subject, under this latter name, in the section on constitutional diseases. ARTICLE I. SIMPLE OR ERYTHEMATOUS STOMATITIS. Definition ; Frequency. — This form of stomatitis consists of simple diffuse inflammation of the mucous membrane of the mouth, unattended by vesicular or pustular productions, by ulcerations, or by membranous exudation. It is a disease of infrequent occurrence, except in the forming stage of other kinds of stomatitis, and of little importance, seldom requir- ing the attention of the physician. The causes of the disease are the introduction of irritating substances, APHTHA. 297 such as hot drinks, and acrid or caustic preparations, into the mouth ; diffi- cult dentition ; and probahly sympathy with disordered states of the stom- ach. It occurs not uufrequently as a secondary aHection, particularly in the course of measles, scarlet fever, and small-pox. The ^yviptoim of erythematous stomatitis are more or less vivid redness of the mucous membrane, sometimes diflused, and at others punctated or disposed in patches; slight swelling of the same tissue; heat; and tender- ness to the touch, and also in the act of sucking or eating. The child is generally fi-etful and restless, and either loses its appetite, or refuses to nurse or take food freely, on account of the tenderness of the mouth. There are seldom any general symptoms except in secondary cases, in which they are those of the primary affection. The treatment is very simple. It consists in the use of some demulcent wash, as gum water, sassafras-pith mucilage, a little honey put on the tongue occasionally, and if the intiamiuation be at all considerable, in the appli- cation of some astringent preparation. This may consist of honey and borax, two or three parts of the former to one of the latter, or of the fol- lowing wash, recommended by M. Bouchut : R.— Mel. Rosa-, f5J. Aluminis, ^ss. Aqu» destillat., ^oss. — M. The application of any of the washes recommended is best made by means of a thick and soft camel's-hair pencil ; or it may be done with a soft rag, which should be dipped in the wash, and then conveyed into the mouth on the point of the finger. The remedy ought to be used several times a day. If signs of gastric or intestinal disorder are present, they should be attended to. ARTICLE II. APHTHiE. DEFixmoN; Syxoxyms; Frequency; Forms. — The term aphtha^ ought to be restricted to the vesicular and ulcerous form of disease of the buccal mucous membrane, in which that tissue is covered with an eruption of vesicles which break, and are followed by small rounded ulcerations. Under thi.s title writers formerly confounded the affection we are now con- .«idering with ulcerative stomatitis and thrush. It has been called by Billard follicular stomatitif?, and by several other writers vesicular stoma- titis. The freqtieney of the disease is very considerable. We shall describe two/omi>r, the discrete and confluent. Cal«i><. — The only causes which seem to have been ascertained with 298 APHTHJ3. any degree of certainty, are early age and the process of dentition : the contact of irritating substances, particularly stimulating and acrid articles of food, with the raucous raembrane of the mouth ; and the existence of some morbid irritation of the digestive tube, especially of the stomach. The confluent form is often connected with severe general disease of the constitution. Symptoms ; Duration. — Aphthae begin in the form of small red eleva- tions, having little white points upon their centres, which consist of the epithelium of the mucous membrane raised into vesicles. The vesicles are small in size, oval or roundish in shape, and of a white or pearl color. They soon break and allow the fluid which they contained to escape, after which there remains a little rounded ulcer, with excavated and more or less thickened edges, and surrounded almost always by a red circle of in- flammation. The bottom of the ulcers is usually of a grayish color,^ There is seldom any diffuse inflammation of the mucous membrane in this dis- ease. The number of aphthse varies in the two forms. In the discrete variety there are but few, whilst in the confluent form they are, of course, much more numerous. They generally appear first on the internal sur- faces of the lips and gums, and then on the inside of the cheeks, edges of the tongue, and soft palate. The discrete form is generally accompanied by symptoms of slight dis- order of the digestive organs, consisting of thirst, acid eructations or vomit- ing, imperfect digestion, and a little constipation or diarrhoea. The con- fluent form, which is much more rare, especially in very young infants, usually coincides, as has already been stated, with severe general or local disease. The duration of aphthae is different in the two varieties of the affection. The discrete form generally pursues a rapid course, lasting from the begin- ning to the time of cicatrization, between four and seven days. Some- times, however, when the vesicles are formed successively, one after the other, the disease lasts much longer. The confluent variety pursues a much slower course, and is much more difficult of cure. Diagnosis and Prognosis. — The diagnosis of discrete aphthae is not at all difficult, in consequence of their being isolated and succeeded by small and limited ulcerations. The confluent form, on the contrary, may be confounded with ulcerative or ulcero-membranous stomatitis, and with thrush. From the first-mentioned disease it may be distinguished, however, by attention to the circumstances that that affection begins by small white patches, and not by vesicles, as do aphthae ; that the ulcerations which fol- low the patches are covered with true pseudo-membrane; and that the white patches just spoken of appear first upon the gums, whilst aphthae generally begin upon the posterior surface of the inferior lip, and upon the ^ The grayish or yellowish-gray secretion, on the base of the aphthous ulcers, has lately been closely studied by Dr. J. Worms (Glasgow Med. Jour., July, 1864), who states that both microscopical examination and chemical tests invariably show its sebaceous nature. It is his opinion, therefore, that aphthae are the acne of the mucous membranes; in support of which, it will be remembered, that they are found most frequently where the muciparous glands are most abundant. GENERAL TREATMENT. 299 tongue. From thrush it is to be distinguished by the facts that that dis- ease commences by white points, which are not vesicuhir, and which, run- ning together, form a creamy exudation ; by the absence or very small number of ulcerations; and by the presence of the peculiar fungus of thrush. Discrete aphtha^ constitute a very mild disorder. They always recover without much ditticulty. The confluent disease is more serious, because its progress is much slower, its cure more difficult, and because it is often conn^ctatches, which approach each other, unite, and form bands of pseudo-meml)rane, somewhat uneven upon the surface, and adhering with considerable force to the tissue beneath. When the exudation is detached, the mucous membrane is found to be of a red or purple color, bleeding, and excoriated or ulcerated. The ulcerations which exist under the false membrane are of various depths, of a grayish, livid, or blackish color, with sA^elled, softened, and livid red, or bleeding edges. Those which are formed upon the inside of the lips are rounded in shape, whilst those seated in the angle between the lips and gums, are usually elongated. In mild cases of this affection, the local symptoms, though perfectly characteristic, are less severe than those just now described. The ulcerations are often few in number, amounting to four, five, or six upon the tongue, to a few scattered over the inner surfaces of the lips, and to some upon the gums, and esi>ecially about the necks of the teeth. The other symptoms are the same as those above mentioned, with the exception that they are milder in degree. When the disease is mild, and when it is properly treated, the false mem- branes become detached, leaving the mucous tissue merely excoriated, in which case it soon regains its natural condition ; or else the ulcers which exist beneath rapidly become healthy and cicatrize. In violent cases and in those badly treated, the infiammatiou, on the contrary, persists ; the pseudo-membranes increase in thickness, or if detached, are formed anew ; the ulcerations become deeper ; the disease extends ; and the case lasts an indefinite period of time. Other symptoms, besides those we have mentioned, characterize the dis- ease. The breath is always more or less fetid, and in bad cases, almost gan- grenous. The miliary and submaxillary glands are generally more or less swelled, hard, and painful, and according to some autiiors, the surrounding cellular tissue is in the same condition, though this is denied by others. The movements of the lower jaw are stiff and painful in severe cases. Def/lutition is not affected unless the disease extends to the pharynx. In violent ca.ses there is usually a copious diKchargfi of fetid, watery saliva, or of bloody serum, which flows from the mouth during sleep. When the ul- cerations are deep and large, the tissues beneath are more or less swelled ; the swelling, however, rarely assumes the hard, resisting, circumscribed characters, with the tense, smooth, hot, and shining appearance of the skin, which exists in true gangrene of the mouth. In most of the cases there is a moderate but decided febrile reaction, especially at the invasion. This 802 ULCERATIVE STOMATITIS. usually subsides or disappears after two or three days, though it sometimes increases if the disease becomes extensive. The disease begins, as already stated, on the gums, and unless limited to these parts, as sometimes happens, extends to the lips and cheeks. In many of the cases it attacks only one side of the mouth, and this is more frequently the left than the right. The course of the disease is usually rapid in epidemic cases, and in those which are properly treated. Where badly treated, on the contrary, it may last from one to several months, or terminate in gangrene of the mouth. Diagnosis ; Prognosis. — The diagnosis is, as a general rule, very easy, if proper attention be paid to the characteristic features of the disease. It has, as already stated, been very often confounded with gangrene of the mouth. The method of distinguishing between the two will be given in full in the article on that disease. From thrush it is to be distinguished in the manner which will be pointed out when that disease comes under consideration. T\\Q prognosis is favorable in the great majority of the cases. Sporadic cases probably always terminate favorably. The epidemic disease, though rarely fatal, sometimes proves so from its extension to the pharynx and larynx, or from its termination in gangrene of the mouth. We have seen a large number of cases in private practice, and have never as yet known one to become gangrenous or to prove fatal. Of upw^ards of 120 cases of this kind, observed by Dr. Coates at the Philadelphia Children's Asy- lum, in a period of three months, all but one recovered {loc. ciL, p. 21). The cases which occur in the course of other diseases are not dangerous in themselves, but are so as being the sign of a great severity of the pri- mary affection. Treatment. — The treatment may be divided into general, and local or topical. The general treatment should consist in most of the cases in at- tention to the diet, which ought, in healthy and vigorous children, to be simple and unirritating, and in those who are weak and debilitated, nutri- tious and digestible. If the bowels are costive, or the child feverish and uncomfortable, a laxative dose may be given with advantage ; or some simple diaphoretic, as nitre and water, or the neutral mixture, may be used through the day, and a warm foot-bath or an immersion-bath given in the evening. When the constitution is feeble, and the child Aveak or ansemic, tonic remedies are indicated. The best is probably quinine, or one of the ferruginous preparations; or the compound infusion of gentian, with addition of Huxham's tincture of bark, may be resorted to. The best internal remedy, however, and indeed the only one of any kind that is necessary in most cases, is the chlorate of potash, which possesses a stimulant and alterative action upon the mucous membranes. This is spoken of in the highest terms by Dr. West, of London, who regards it almost as a specific. We have used it now for many years past in a very large number of cases, and have seldom found it necessary to employ any other means, excepting some mild cathartic dose where the bowels have been constipated, and a wash of borax or alum in honey of roses, or borax TREATMENT. 303 in simple honey. The symptoms have begun to amend in every case in from three to four or five days, and recovery has taken place in about a week or a little more. The dose is from two to three grains every four hours for a child three years of age, and four and five grains for one of nine or ten years. Mr. Hutchinson {Med. Times and Gaz., 1856), who be- lieves also that this salt is almost a specific in this affection, recommends it in larger doses than the above, giving as much as five grains, thrice daily, to an infant of one year old. We have usually prescribed it in the dose of two grains four times a day, in a mixture of syrup of ginger and water, for children three or four years old. Prior to the discovery of the efficacy of the chlorate of potash in the afiection, the local treatment constituted the only effectual and reliable means of removing it, and the most violent and painful applications were thought necessary and were made use of. Strong solutions of nitrate of silver, and pure or diluted muriatic acid, were frequently employed in severe cases. Now, however, these caustic substances may probably be entirely dispensed with, except in cases that show a tendency to assume the form of gangrene of the mouth. In ordinary cases the only local ap- plications that need be used, and these are not essential when the child resists very much, are demulcent washes to keep the mouth clean, to be employed in the manner recommended in the article on aphtha?, and some mild astringent wash. This may consist of borax and honey, or borax and sugar, in the proportion of two or three parts of the former to one of the latter, or, what is in our opinion preferable to either of these, of a drachm of borax rubbed up with an ounce of honey of roses. Should the disease resist the treatment by the chlorate of potash and the simple washes just now recommended, we may employ the following combination, proposed by Dr. Dewees, and of which he says that it " has so far never failed us." R. — Sulph. Cupri, ...... gr. x. Pulv. Cinch. Opt., ..... ^ij. Pulv. G. Arab., 3J. Mel. Commun., i^]}. Aquae Font., f.^'O- — M. etftsol. The ulcerations to be touched with the mixture twice a day, with the point of a camel's-hair pencil. Or, we may resort to the following one rec- ommended by Dr. Coates (loc. ci7.), and of which he says, that he "settled down, after various trials, in the employment of the following: B.— Sulph. Cupn, 3ij. Pulv. Cinchona", ....... ^^^s. Aquse, ^.5'^. — M. To be applied twice a day, very carefully, to the full extent of the ulcera- tions and excoriations." MM. Killiet and Barthez recommended ver>' highly the plan pur^urd by M. Boneau at the Children's Hospital. This is to cleanse the mouth first, 30: GANGRENE OF THE MOUTH. and then to apply dry chloride of lime (calx chlorinata of the Pharma- copceia) to the diseased surfaces. The application is made by means of a piece of rolled paper, or a stiff pencil, which is to be moistened and then dipped into the powder so that some may adhere, or with the finger. The surfaces are to be gently rubbed with the powder, and after a few moments' contact, w^ashed clean with pure water. This is to be done twice a day, until the ulcerations assume a clean, healthy appearance, after which the following mouth-wash is to be employed : R.— Mucil. Gr. Acac, Syrup. Cort. Aurant., . Calc. Chlorinat., . f^ss. The chief danger from the disease depends on the circumstance that it sometimes terminates in gangrene of the mouth, to be presently described. Any disposition to such a termination should be carefully watched, and the proper preventive means, consisting of local stimulating or caustic applica- tions, with the internal use of stimulants and tonics, be at once resorted to. AKTICLE IV. GANGRENE OP THE MOUTH. Definition ; Synonyms ; Frequency. — Gangrene of the mouth is an affection which occurs chiefly in children of debilitated constitution, and especially as a sequel of some of the eruptive fevers. It begins generally by ulceration of the mucous membrane of the cheek, which after a longer or shorter time, runs into gangrene, and extends rapidly to the gums ; after a few days, if the disease be not arrested, the central tissues of the cheek become thickened and indurated, an eschar forms upon the integu- ment, and spreads in depth and width, until at last the cheek may be per- forated, the whole side of the face and jaws destroyed, the teeth loosened, and the maxillary bones exposed and necrosed. It is known by a great variety of names: gangrsenopsis, cancrum oris, gangrsena oris, canker of the mouth, gangrenous erosix)n of the cheeks of Underwood ; necrosis infantilis, gangrenous stomatitis, etc. It is a frequent disease in the hospitals for children in Europe, and a not uncommon one in institutions of the same kind in this country. It sometimes prevails endemically in hospitals. It is a rare disease in private practice, and we have as yet met with but few cases, excepting in public institutions. Predisposing Causes. — The disease is nearly, but not exclusively con- fined to the period of childhood. It is most common between the ages of three and six years ; is very rare, but does sometimes occur in infants ; and is of nearly equal frequency, probably, in the two sexes. Unfavorable hygienic conditions constitute a strong predisposing cause. Children living ANATOMICAL LESIONS. 305 in hospitals or any crowded institution ; those whose parents are poor or in want, and whose constitutions have been greatly deteriomted by long ill- ness, by the tubercular diathesis, or by acute disciises, are particularly apt to be attacked. It almost always follows upon some previous acute or chronic disease, particularly measles, or some other acute exunthem ; pneu- monia ; entero-colitis : hooping-cough ; long-continued malarious fevers, etc. MM. Guersant and Blache say {Diet, de Med., t. 28, p. OOn, "The exist- ence of some anterior disease is a necessary condition of gangrene of the mouth ; we have never known it, nor has M. Baron, to occur as an idiopathic affection.'' It has been affirmed by some persons to be confarjious, but this is exceedingly doubtful. The fact of its occurring sometimes in an endemic form has already been referred to. It has been known also to prevail as an epidemic. The ejcciting causes can rarely be ascertained with any certainty. The only one which seems to have been proved to exist in some instances is the exhibition of large doses of the mercurial preparations, and even this is questioned by some very good authorities. Anatomical Lesions. — Upon examination after death, it is found that the integinnent surrounding the mortified spot soon runs into putreftietion. The lip or cheek in which the disease is seated is swelled, hardened, tense, and shining, of a purple or greenish color, and presents a deep, circum- scribed engorgement. On the most prominent part of the swelling there often exists a rounded or oval, and distinctly limited eschar, of variable size, from a third of an inch to an inch, or even more, in diameter. In some instances the cutaneous slough is much larger, and extends irregularly to different parts of the face, to the chin, neck, eyelids, and even to the neighborhood of the ear, so as to occupy the whole of one side. Under these circumstances the tumefaction is neither so considerable, nor so regular, as when the slough is smaller. The eschar is always black, and generally dry and parchment-like, and extends a third or two-thirds of a line in depth, or quite through the integument. The tissues beneath the skin are not generally implicated, though in some cases the eschar is de- tached and there is a perforation of the cheek through which may be seen the alveolar processes. The mucous membratie of the mouth is always affected with mortification. The disease may be limited, so as to exist in the form of an elongated ul- ceration, of a dark grayish color, situated in the fold where the mucous membrane is reflected from the cheek to the lower jaw ; or, in a larger proportion of cases, it is seated on the internal surface of the cheek, oppo- site the inter\'al between the alveolar processes. Sometimes the disease is much more extensive, and occupies all or a part of the internal surface of the cheek. In such instances the whole thickness of the mucous tissue is destroyed, and it presents upon its surface a blackish or brownish pulta- ceous slough, almost liquid in consistence, which may be scraped off with a scalpel, leaving beneath hxifrc shred.-* of mucous membrane, without any trace of organization. The gums frequently participate in the di.sease, and are converted into shreds, or completely destroyed. The maxillary bones are sometimes, in severe cases, when the disease has 20 806 GANGRENE OF THE MOUTH. extended to the gums, exposed, blackened, and even necrosed. The teeth are very often uncovered and loosened, and not unfrequently some are lost. The tissues between the skin and mucous membrane are found either hard- ened and infiltrated, or sphacelated to a greater or less extent. In the least severe cases, the fatty cellular tissue, and the muscular structure of the cheek are infiltrated jwith serum, but preserve their organization. When the disease is more aggravated, the gangrene extends to these tissues also, and always to those adjoining the mucous membrane first; so that the cellular structure beneath that membrane, and then the muscles, are infiltrated with a sanious fluid, and either in a state of sphacelus or tending thereto, whilst some of the adipose tissue beneath the skin is §till merely infiltrated. In yet worse cases^ the sloughs formed on the two surfaces of the cheek come into contact, and if their separation from the sound parts has taken place, a perforation is the consequence. The condition of the bloodvessels in the midst of the diseased parts has been carefully examined by MM. Rilliet and Barthez. These authors state that when the tissues of the cheek are merely infiltrated, the vessels remain healthy, permeable, and their parietes are scarcely or very slightly thickened. AVhen the vessels run along the edge of the slough, they are still permeable, but their walls are thickened, and begin to assume the appearances of the mortified tissues. Lastly, when they traverse the' cen- tre of the eschar, they can still be traced out, but their canals are found obliterated by coagula, in the whole extent of the mortified parts ; or else the coagula occupy the vessels at their points of entrance into and exit from the slough, while between these points their walls are thickened, tend to assume the color and softness of the putrefied tissues, and their canals are filled with pultaceous gangrenous matter. The writers quoted do not suppose that the obliteration of the vessels is the cause of the sphacelus, since that change occurs only after the death of the surrounding tissues has already taken place. The disease very rarely occurs on both sides of the mouth at once, though this does occasionally happen. The submaxillary glands are nearly always in their natural condition, but in rare instances are softened and engorged. Gangrene of the mouth never, or very rarely, indeed, exists without lesions of other organs. Of these the most frequent are acute pulmonary affections, and after them, acute or chronic diseases of the gastro-intestinal tube, and then malarious fevers, pleurisy, pneumothorax, peritonitis, and nephritis. Symptoms ; Course ; Duration. — The following account of the symp- toms of the disease is taken chiefly from the work of MM. Rilliet and Barthez. Gangrene of the mouth generally begins during the course or convalescence of some acute or chronic disease, by ulceration, aphthae, or phlyctense of the mucous membrane, and, in rare instances, by oedema of the substance of the cheek. At the same time the face is pale, and usually continues so throughout the disease ; the nostrils and eyelids are often in- crusted, and the latter infiltrated or sunken, and surrounded by bluish circles; the lips are swelled and covered with scabs, or dry. The breath SYMPTOMS. 307 of the child is fetid from the begiuuing, and, as the disease progresses, be- comes gangrenous. There is but little fever at first, unless the case be accompanied by some acute disease ; the pulse is commonly frequent and small in the beginning, rising gradually from 80 or 90 to 100 or 120, and becoming insensible towards the end. In cases occurring in the course of other diseases, the pulse rises sometimes to 120 or 140, and is larger and fuller. The child is generally languid and quiet at first, or more rarely cross and peevish. The strength may be either lost entirely, merely di- minished, or the patient may retain a sufficient amount of force to sit up and observe what is going on around, and even to leave the bed the day before death. Half the children observed by MM. Rilliet and Barthez, in whom this symptom was noted, sat up in bed until within a few days of the fatal termination. In most cases but little complaint is made of pain in the mouth, though in some it is said to be severe. The ulceration already spoken of as forming the first symptom of the disease is generally of a grayish color, and resembles very closely that which exists in the ulcero-membranous form of stomatitis. It may be seated either on the gums, in the fold formed by the junction of the cheek or lip with the gum, or on the inside of the cheek, opposite the space be- tween the alveolar processes. It may present a gangrenous appearance from the first day, or not until after two or three days ; or lastly, it may pass through the stages characteristic of ulcerative stomatitis, and termi- nate in the afiection under consideration. Dr. B. H. Coates {loc. cit.) de- scribes, under the title of gangrenous sore mouth of children, the ulcero- membranous form of stomatitis, and a few cases of gangrene, and states that three or four children out of 120 affected with ulcerated gums "suf- fered small spots of mortification, and one by the delay arising from the tardy report of a nurse, suffered necrosis in a portion of an alveolus." The ulcerations just described assume the following appearances as the gangrenous nature of the malady develops itself They become grayish, and then dark in color, bleed easily when touched, and are covered with pultaceous sloughs, exhaling a characteristic fetid odor. The gangrene extends to the neighboring parts, from the gum to the cheek, or from the cheek to the gum, and implicates at last the whole side of the mouth, or of the lower lip. At the same time the affected cheek or lip undergoes a circumscribed infiltration, which is at first rather soft, but becomes after- wards firmer, and forms at last a hard and rounded knot or tumor in the centre of the cheek, which is now tense, shining as though smeared witli oil, and pale, or marbled with purple spots, while the slough on the inside is of a brownish color, more extended in size, and sometimes surrounded by a dark ring. The hard tumor of the cheek just described usually aj)pear8 between the first and third days after the sphacelation of the mucous mem- brane, though in some instances not until a later period. It is formed, as stated in the account of the anatomical lesions, by engorgement of the cellular and adipose tissues. The child, at this stage, is still aljle to sit up in bed and take notice, or shows evident signs of weakness and depression ; the face is swelled and destitute of expression on the affected side ; a bloody or dark-colored saliva runs from the mouth, which is partially 308 GANGRENE OP THE MOUTH. open; the appetite is not entirely lost in all cases, the patient still de- manding and taking food ; vomiting is rare, but diarrhoea is almost always present; the thirst is generally intense ; the skin is warm and feverish, natural, or too cool, and almost always dry, the differences depending probably more upon the concomitant disease than upon the mouth affec- tion. The respiration is natural or altered according to the nature of the primary disease, ^vhich is, as already stated, in a large proportion of the cases, a pulmonary affection. The intelligence is generally undisturbed, though in some rare cases there is insomnia, delirium, or piercing cries. If the disease continues to progress, as it almost always does when it has reached the stage we are describing, there appears in many, but not all the cases (8 of the 21 observed by MM. Killiet and Barthez), a slough or eschar upon the most prominent and discolored part of the swelling of the integument of the cheek or lower lip. This generally makes its ap- pearance between the third and sixth days of the disease, but in other cases, as early as the second, or not before the twelfth, or even later. The skin, at the point where the eschar is about to form, becomes purple, and then black ; sometimes a phlyctena makes its appearance, which is very soon converted into a small, dry, black slough. This, if not limited by a process of separation from the living tissues, becomes larger and larger by the extension of the sphacelation, until it may, as already stated, embrace the whole side of the face. In grave and fatal cases, the gangrene some- times extends to all the tissues of the cheek, and meeting at last, the dis- ease which had commenced on the inside of the mouth, occasions a per- foration, through which may be seen the teeth, alveolar processes, and the whole interior of the buccal cavity. In such instances as these, several of w^hich w^e have seen in the Pennsylvania and Philadelphia Hospitals, the appearance presented by the child is, as may well be imagined, of the most pitiable kind. Even under these circumstances, however, with the cheek perforated, the edges of the opening irregular and covered with shreds of dead tissue, the gums destroyed, the teeth loosened, and the maxillary bones exposed, blackened, and perhaps necrosed, with a dark and fetid sanies flowing from the mouth or perforation, and a putrefactive smell infecting the air around, the child may retain, in some instances, its strength, so as to sit up in bed, ask for food, and drink with avidity. In other cases, on the contrary, the patient, at this stage, is exhausted to the last degree, and refuses both food and drink. During the closing stage of the disease there is generally profuse diarrhoea, rapid emaciation, dry skin, small, rapid pulse, and at last death in a state of utter prostration. In favorable cases the recovery may take place in the early stage, before the integument becomes involved, and while the gangrene is limited to the mucous membrane, or at a later period, after the slough has separated. In the first instance the child generally recovers without deformity, though we saw one case in which necrosis of about an inch of the front of the in- ferior maxilla took place, without any loss of the soft parts. When the child recovers after the formation of the cutaneous slough, a very rare event, the gangrene ceases to extend, the eschar separates and is cast off, the edges of the opening assume the appearances of a healthy ulcer, and DIAGNOSIS. 309 after a length of time approach each other ami cicatriz^e, leaving generally a large, uneven, discolored scar, like that of a burn, which remains through life a horrid deformity. The duration of the disease varies according to its termination. When this is unfavorable, which happens in much the larger proportion of cases, death usually occurs about the end of the first, or in the course of the second week, though it has been known to occur at a later period. In favorable cases the duration is commonly longer, particularly if a cutane- ous eschar has been produced, as the separation of the slough and cicatri- zation of the ulcer which remains require a tedious and slow process on the part of nature. Complications are very apt to arise in the course of the disease. The most frequent is pneumonia. MM. Guei*sant and Blache state that it exists in nine-tenths of the cases; MM. Rilliet and Barthez found it in 19 out of 21 ; of the 19, it began in 8 during the progress of the gangrene, and apparently under the influence of the latter, whilst in the remaining cases it existed before, and acted perhaps as a predisposing cause to the afl^ection of the mouth. Another and more dangerous complication is the occurrence of gangrene in other parts of the body, particularly the soft palate, pharynx, oesophagus, anus, and more frequently the vulva and lungs. Diagnosis. — Some authors have described as identical affections, under the title of gangrenous stomatitis, the disease under consideration and the one already treated of as ulcero-membranous stomatitis. This has been done particularly by M. Taupin, who is followed in his description by M. Valleix (Guide du Med. Prat, t. iv). It seems clear to us, moreover, that Dr. B. H. Coates, in his very valuable paper on the "gangrenous sore mouth of children " (loc. cit.), mingles in his description the two diseases referred to. It seems clear, however, that the diflTerences between them as to frequency, symptoms, course, amenability to treatment, and termina- tion, which are fully pointed out in the diagnostic table below, fully war- rant us in regarding them as different and distinct diseases. The diagno.sis of gangrene of the mouth is, in most cases, very easy. The ulceration of the raucous membrane, followed by gangrene ; the deep- seated induration of the cheek, at first pale on the outside, then dark -col- ored, and terminating after a time in a characteristic slough ; the course of the malady, and the nature of the general symptoms, will generally prevent any difficulty in the recognition of the disease. From stomatitis it may be distinguished by attention to the points laid down in the following table taken from M^T. Killiet and Barthez : STOMATITIS. OANORENE. B^-uins by ulceration or by pseudo- Begins by iilceration, which is some- membranous plastic deposit. times grangrcnons from the first, or by oeti'-ma of the cheek. Odor very fetid and sometimes gangre- Odor always gangrenous. nous. But little extension of the local lesion, Considerable and rapid fxtonsion ; the which always retains the same apfKjar- tissues assume a peculiar dark grayish ances. tint. 310 GANGRENE OF THE MOUTH. STOMATITIS. GANGREJfE. But little swollin^of the cheek or lips, Extensive swelling and oedema of the or simiil}' oedema of those parts, without cheek, with deepseated induration, ten- deepseated induration, tension, or unctu- sion, unctuous appearance, purple spots, ous appearance. Salivation rarely so considerable as to Salivation abundant; constant escape flow from the mouth ; when present some- of fluid, at first sanguinolent, afterwards times sanguinolent; never mixed with putrefactive. shreds of gangrenous tissue. Never an eschar on the exterior. Often an eschar upon the cheek or lips. Never complete perforation of the soft Perforation of the soft parts frequent; parts; denudution of the bones never oc- denudation of the bones constant; curs ; loss of the teeth very rare. loosening of the teeth constant, ^nd their loss frequent. Course of the disease slow when left to Course rapid, and termination fatal, itself; recovery rapid under the influence as a rule, when the disease is left to of treatment. itself, and in spite of all treatment. Gangrene of the mouth may be confounded with malignant pustule. The method of diagnosis has been drawn by M. Baron in the following words : " Malignant pustule always begins on the exterior ; affects the epi- dermis first, and extends successively to the corpus mucosum, chorion, and subjacent parts ; whilst on the contrary, the gangrene under consideration attacks the mucous membrane first, then the muscles, and lastly the skin." Prognosis. — The prognosis of true gangrene of the mouth is exceedingly unfavorable. The great majority of the subjects die in spite of all that can be done. Dr. Coates {loc. eit, p. 14) says that a black spot on the outer surface of the swelling " has always been in my own experience the immediate harbinger of death. It is proper to state, however, that I have heard it said that cases had recovered in this city, in which the gangrene had produced a hole through the cheek." MM. Rilliet and Barthez state that "death is the ordinary termination of gangrene of the mouth ; though there are instances of recovery on record." Of 29 cases analyzed by them, only 3 recovered. MM. Guersant and Blache (^loc. cit, p. 596) state that unless arrested in the formative stage, it ends fatally almost constantly in from five to ten days, and frequently before perforation has taken place. Of 36 cases observed by M. Taupin in the Children's Hospital at Paris, not one escaped (Guersant and Blache, loc. cit, p. 597). The authors of the Compendium de Medecine Pratique say of this disease (t. i, p. 632), " Death is the almost inevitable termination." Dr. Marshall Hall {Edin. Med. and Surg. Journ., xiv, p. 547) reports six cases of the disease, two of which followed measles, one repeated attacks of pneumonia, one fever (type not mentioned), one worm fever, and one typhus fever. All but one, the case occurring in the course of typhus fever, in a girl, twelve years old, died. This girl recovered, with, however, falling in of the right cheek, "a frightful chasm" on the left side of the mouth, and caries of a portion of the alveolar process, palate bone, and second molar tooth. Recoveries sometimes occur, however, as in the case mentioned by Dr. Hall, after perforation, but nearly always with terrible deformities, with adhesions of the walls of the mouth to the jaws, with incurable fistulse, etc. I TREATMENT — LOCAL APPLICATIONS. 811 The prognosis is more favorable iu private practice tbau in hospitals. The tavorable circumstances iu any case are: good hygienic conditions ; vigorous constitution of the child ; the absence of dangerous concomitant disease ; the continuance of appetite and strength ; and a disposition to limitiition and separation of the slough. Unfavorable symptoms are weak and debilitated constitution of the patient ; severe coexistent disease ; pros- tration of the strength ; and extension of the sloughing process. Death may also occur from hemorrhage in consequence of the separation of the sloflgh, as iu a case quoted from Hueter by Bouchut. Tkeatmext. — The reader need but refer to the remarks on prognosis to be assured that no treatment as yet discovered promises much success. We would call attention also to the following statement, — that the remarks about to be made apply only to true gangrene of the mouth, and not to all the cases described by some writers under the title of gangrenous sore mouth or even that of gangrene of the mouth, since, as already stated, they confound together true gangrene and ulcero-membranous stomatitis. The treatment is divided into local and generaL The local treatment recommended by the French writers., consists in cauterization of the slough- ing parts with one of the mineral acids, with nitrate of silver, or with the actual cautery. This is the plan proposed by MM. Billard, Baron, Guer- sant and Blache, Barrier, Rilliet and Barthez, Bouchut, and Valleix. The authors of the BihUoth>qu€ d-e Mcdecin Praticien remark, however, that nearly all the patients subjected to cauterization die, and that of the small number saved, there are as many who had not been subjected to that treatment, as there are of those to whom it had been fully applied. They wonder, therefore, that recent authors continue to repose the same confidence in it, as did their predecessors. " For us," they say, " we are of opinion that cauterization exerts but slight influence, if it have any at all, and it is greatly to be desired that the zeal of practitioners might discover some more efficacious remedy" (loc. ct't., t. v, p. 551). It is very important to make use of the caustic application as early after the beginning of the sphacelus as possible, for if it be allowed to spread to any considerable depth or extent, there is scarcely a hope of arresting it by any means. MM. Guersant and Blache recommend pure nitric, sul- phuric, or muriatic acid ; MM. Rilliet and Barthez propose the acid nitrate of mercury, or muriatic, sulphuric, or acetic acid ; M. Valleix proposes the treatment employed by M. Taupin, which is to remove the pseudo-mem- brane and a part or the whole of the gangrenous eschar with scissors, to make some scarifications upon the healthy part", to apfily pure muriatic acid, and after the fall of the slough, to make use of dry chloride of lime (calx chlorinata). The acid most generally employed is the muriatic. The local treatment proposed by MM. Rilliet and Barthez is the follow- ing: As sf>on as the ulcerations assume a gangrenous appearance, to touch them with a brush or sponge dipped into acid nitrate of mercury, or pure muriatic acid, the brush to remain in contact with the sloughs for a few instants, and then to be applied rapidly around and on the parts beyond them. After this cauterization, an application is to be made of dry chloride of lime (in the manner recommended in the article on ulcere- 312 ^^T^NQRENE OF THE membranous stomatitis), which is to be left in contact with the sloughs for a few minutes, when the mouth must be thoroughly washed with a strong jet of water from a syringe. The cauterization and use of the chloride of lime are to be resorted to twice a day, and the mouth washed three or four times in the interval with large injections of simple water, barley-water mixed with honey of roses, or better still, with a strong decoction of cinchona. If the case goes on favorably, and the sloughs separate, the cauterizations are to be suspended, and the chloride of lime alone em- ployed. If, on the contrary, a slough forms on the outside of the cheek, a crucial incision must be made into it, and a brush charged with the same caustics introduced between the cuts; powdered cinchona is then placed in the openings, and retained there by a piece of diachylon plaster or by pledgets of charpie, dipped in a solution of soda. This treatment is to be continued until the slough separates, when the edges of the wound, and all the diseased parts that can be reached, are to be cauterized. In applying escharotics to the mouth, certain general precautions are required, of which it is necessary to give some account. When th6y are used upon the inside of the cheek, a spoon must be introduced into the mouth, with the concavity directed towards the alveolar processes, in order to preserve the teeth and tongue from being touched. When the application is made upon the gums, the cheek should be drawn to one side by an assistant, and the tongue pushed out of the way with the finger, or a spoon. If the acid happen to touch the teeth or tongue, it must be instantly washed off. The mouth ought always to be thoroughly cleansed with water immediately after the cauterization, to remove any super- abundance of acid. The kind of brush most suitable for the application of the mineral acids is one made of charpie, strongly tied to a solid handle. The sponge-mop, which is sometimes used, is made by fastening a small piece of fine sponge to the end of a stick. MM. Guersant and Blache recommend that the acid be applied to the slough every hour, until the sphacelus ceases to extend. They state that this plan is sometimes advantageous when the gangrene is confined to the gums only, but that it is generally powerless when the disease has ex- tended to the cheek, or has implicated the deepseated tissues. Under the latter circumstances, and when the inefficacy of caustics has been shown by trial, they propose the use of the actual cautery, as recommended by M. Baron, and other distinguished practitioners, and which, they add, has afforded them some brilliant results in very bad cases. M. Barrier advises that we should accurately expose the diseased parts by crucial incisions, and apply the escharotic to all the parts forming the limits of the gangrene, in such a way that the tissues already disposed to slough shall be thoroughly cauterized, while those a little beyond are so in a less degree. In applying these powerful caustics, several authorities recommend the administration of an anaesthetic. The English writers, and those of our own country, seem rather less dis- posed than the French to make use of powerful escharotics, and lay more TREATMENT — LOCAL APPLICATIONS. 813 stress upon the general treatment. Underwood, following Dease, of Dublin, advises that "the parts should be washed and likewise injected with muri- atic acid, in chamomile or sage tea, and afterwards dressed with tlie acid, mixed with the honey of roses, and over all a carrot poultice." Dr. Symonds (Lib. of Pract. }fed., vol. iii, p. 23) directs the cheek to be fre- quently rubbed with a stimulating embrocation of camphorated oil and ammonia, on the first appearance of the swelling, and in the intervals to be kept moist with a tepid lotion containing muriate of ammonia and alcohol. On the slightest appearance of an eschar upon the interior of the mouth, it is to be touched with solid nitrate of silver, or strong muriatic acid. If slougliing have already commenced, the nitrate of silver lotion is said to be the best application. The mouth is to be frequently washed or syringed with a solution of chloride of soda, and when mortification has taken place, we are to endeavor to prevent it from spreading, by carrot or fermenting poultices. Maunsel and Evanson say that the early application of muriatic acid, undiluted, or mixed with one or two parts of honey, is the only efficient application in these forms of gangrene. Dr. Fleming (Dublin Hosj^. Gaz., May 1st, 18G5) recommends the application of a concentrated solution of nitrate of copper, to the sloughing surfaces, and also paints the circumference of the disease and the surrounding cheek with collodion, which, he believes, acts favorably upon the capillary circulation of the part. Dr. Gerhard (Lib. of Pract. Med., vol. iii, Am. ed., p. 24) says, "The best local applications are the nitrate of silver, if the slough be small in extent; if much larger, the best escharotic is the muriated tinc- ture of iron, applied in the undiluted state : after the progress of the dis- ease is arrested, the ulcer will improve rapidly under an astringent stimu- lant, such as the tincture of myrrh, or the aromatic wine of the French Pharmacopreia." Dr. Dungli.son (Prac. of Med., vol. i, p. 36) recommends the application with a brush, of a mixture of equal parts of creasote and alcohol, after incisions have been made through the gangrenous parts. Dr. Condie (op. cit., 6th ed., p. 174) states that he has found a strong so- lution of sulphate of copper (thirty grains to the ounce of water), applied very carefully twice a day, to the full extent of the gangrenous ulceration, by far the mo.st successful lotion. We have, ourselves, lately employed carbolic acid in two severe cases. The pure acid was carefully applied to the sloughing ulcer on the inside of the cheek, and subsequently a solution of one part of the acid in fifty of water, was frequently employed to wash out the mouth. The application of the undiluted acid seemed to have a beneficial effect, by checking the progress of the sloughing, and completely destroying the putridity of the dead ti.ssue which had not as yet separated. One of the cases recovered quickly, without perforation of the cheek ; but in the other death occurred, with .symptoms of profound adynamia, though there was little, if any, ex- tension of the gangrene. It seems to us very clear, after the study of the treatment recommended by the different writers quoted above, that the moat important part of the local management of the di.sease is the early application of some escharotic substance to the ulcerations, or to the mortifying parts ; the best is probably 314 GANGRENE OF THE MOUTH. pure muriatic acid. This should be made use of twice or three times a day, observing the precaution to wash the mouth with water, immediately after- w^ards, by means of a syringe. Later in the disease, when it has extended to the skin, the use of escharotics, or of the actual cautery, is still recom- mended by many writers, but opposed by others. We confess we should be inclined to prefer, at this stage, the use of muriated tincture of iron, as recommended by Dr. Gerhard, of carbolic acid as used by ourselves, of strong lotions of sulphate of copper, of solutions of nitrate of silver of moderate strength, or of the dressings of muriatic acid and honey of roses, as proposed by Underwood, in connection with carrot and fermenting poul- tices, as recommended by Underwood and Symonds. Throughout the course of the disease the mouth ought to be frequently cleansed by wash- ing or injecting with solution of chlorinated soda, mixed with eight parts of water, or with a dilute solution of carbolic acid, which corrects at the same time the terrible fetor of the disease. The importance of these measures can scarcely be overestimated, since the presejice of gangrenous tissue about the oral cavity must lead to the introduction of the poisonous results of putrefaction into the system, both by the fetid discharges which partly flow down the oesophagus, and still more by the contamination of the inspired air. Indeed, it seems quite pos- sible, as urged by Dr. Keiller (Edin. Med. Jour., April, 1862), that in cases of unchecked gangrene of the mouth, death occurs in a great measure, from secondary blood-poisoning, resulting from the continued and unavoid- able inhalation of air poisoned by emanations from the gangrenous sloughs. It is evident, therefore, that local applications, both of caustics and anti- septic lotions, must be of great service, by arresting the sloughing and cor- recting or checking the foul discharges. General Treatment. — All writers recommend the use of tonics, stimu- lants, and nutritious diet, unless the presence of high fever, or the state of the digestive organs, seems to contraindicate their employment. From our own personal experience in the treatment of this affection ; from a consid- eration of what we have seen most successful in other forms of gangrene, as that following accidents and surgical operations in deteriorated consti- tutions ; from what proved effectual in a case of idiopathic gangrene of the vulva, in a child ten years of age, which came under our charge ; and from what is necessary in that analogous condition of the constitution which accompanies typhoid and cachectic diseases, we are induced to be- lieve that the general treatment must be of at least as great importance as the local, and that the steady and persevering use of tonics, stimulants, and of the most strengthening diet, should always be insisted on from the earliest period, whether fever be present or not. The quantity of stimu- lants, and the amount of food, ought, it seems to us, to be measured only by the capacity of the digestive organs to receive and assimilate them. Of the tonics, the best are quinine and muriated tincture of iron, which may be given in syrup, in doses of a grain of the former with from three to five drops of the latter, four or five times a day, to a child three or four years old. The most suitable stimulants are very fine old brandy, Madeira wine given in considerable quantities, and, if the stomach is sure THRUSH. 315 • to receive it well, carbonate of aniinouia, or better still, the aromatic spirit of hartshorn. The diet must consist of milk made into punch with brandy, wine-whey, the yelk of eggs beaten up with wine, strong soups and beef tea, animal jellies, and, if the child wish it, tender meat finely minced. The room in which the child is placed ought to be large, if possible, and at all events thoroughly ventilated. ARTICLE V THRUSH. Definition ; Synonyms ; Frequency' ; Forms. — Thrush is associated with the growth of a peculiar fungus, the oidium albicans (Robin), and appears as a deposit upon the raucous membrane of the mouth, of a whitish or grayish-yellow exudation, of a soft cheesy consistence, at first adherent, and afterwards spontaneously detached, and generally unaccompanied by ulceration of the tissue beneath. This constitutes the whole disease in some cases, no other lesion being discoverable ; whilst in other instances, and probably in a large majority, it is connected with some more or less serious general or local disorder. It is the disease described under the title of aphtha? or thrush, by Underwood and Eberle ; of aphth?e, by Dewees ; of er}'thematic stomatitis, with curdlike exudation, by Dr. Condie ; and of aphtha lactantium, aphtha lactamen, and aphtha infantilis, by the older writers. It is the muguet of the French. The freqmnaj of the disease is very great in hospitals for children. It is common also amongst the children of the poor, and comparatively rare in the middle and upper classes of society. It occurs under two forms, the idiopathic or primary, and injmptomatic or secondary. By the first is meant the form in which the affection of the mouth is the only perceptible lesion ; by the second, that in which disease of other organs or of the constitution generally, precedes the buccal exudation. Causes. — Pkedisposixo Causes. — The disease occurs at all a^ex, but is by far most common during the first two months of life. Altered health from any cause, deficient ventilation, and ivant of cleanliness, strongly pre- di.«pose to the production of thrush. Miich diflTerence of opinion exists as to the nature of the connection between enf^riti^ and thrush, especially since the publication of the researches of M. Valleix, who thinks that the latter disease is almost always the consequence of the former, and who doubts the existence of purely local cases of thrush. MM. Trousseau and Del[>ech, on the contrary (Joum. de Med. de MM. Beau ei TroxiMean, Jan- uar}', Februar}', April, May, 1845 \ report 14 cases out of 58, in which there was neither gastric nor intestinal coniplication, and others in which enteritis did not occur except as a conserpience of thrush. They state, however, that though enteritis does not exist in all ra-ps, and is a simple 316 THRUSH. complication in others, it is sometimes the true cause, the sole origin of the disease. Again Dr. Berg, in a very accurate and careful history of the disease (Brit and For. Med. Rev., October, 1847, p. 429) in which he de- monstrates its cvyptogamic nature, states " that both the local and general symptoms which accompany thrush in the child are, in most cases, imme- diate or secondary consequences of the presence of the parasite, and not to be regarded as the causes of that fungoid vegetation." It is believed by many observers to be contagious. This opinion is rendered doubtful, however, by the assertion of MM. Baron, Billard, Guersant, and Valleix {loc. cit., t. iv, p. 63), that they have known children in health to be fed with the same spoon which has been used for others affected with the dis- ease, without their contracting it. M. Bouchut on the contrary, and Dr. Berg (loc. cit.), both of whom believe in the cryptogamic nature of thrush, assert it to be contagious. Dr. Berg is of opinion that it is " conveyed from one patient to another by sporules or fragments of sporules, in the dried state, floating in the atmosphere, but that still more frequently it is propagated by the bottles from which children with thrush have been fed, or by the nipple, especially where, as in many hospitals, two children are suckled by one nurse." This gentleman made many experiments in order to decide this question, all of which proved favorable to the idea of con- tagion. Of various predisposing causes which have been cited as productive of the disease, the ones most generally admitted are the use of artificial diet, particularly one consisting of farinaceous substances, and, in children who are suckled, an unhealthy state of the nurse's milk. To show the truth of these assertions, we make the following quotations. Underwood says : " A principal remote cause of this disease seems to be indigestion, whether pro- duced by bad milk, or other unwholesome food, or by the weakness of the stomach." Dewees remarks that " children fed much upon farinaceous substances are especially exposed to the attacks of this disease, particularly when their food is sweetened with brown sugar or molasses." Dr. Eberle says: "Unwholesome and indigestible nourishment, and overdistension of the stomach, during the early stages of infancy, almost inevitably lead to the occurrence of aphthae (thrush). Bad and old milk, and thick farina- ceous preparations sweetened with brown sugar or molasses, are especially apt to give rise to the disease." • Much influence is ascribed by Dr. Berg to the operation of artificial food in favoring the growth of thrush. M. Valleix {loc. cit, p. 60), who has studied the subject with the greatest care and attention, says that amongst the hygienic conditions which may act as predisposing causes " one alone has seemed to me to exert a positive influ- ence, and this is improper alimentation." He adds, that since the publica- tion of his Clinique, he has several times met with cases of thrush, " and I have always found that the children had been put upon feculent diet. On the other hand, I have never known a child to have the disease, who had been suckled exclusively during the early months of life." MM. Trousseau and Delpech, in the very valuable paper on muguet (thrush), already quoted, say: "We would be justified, therefore, in asserting, that we have never known an infant to die of thrush, who had been suckled at ANATOMICAL LESIONS. 317 a healthv breast, or whose health had uot been dangerously compromised by other causes.'' To show iu another mode the influence of this cause, we will state that of 29 cases of the disease observed by these gentlemen in children who were suckled, only 7, or one-fourth, died ; whilst of 22 in those who were not suckled, 17, or more than three-fourths, died. Our own experience is precisely that of ^IM. Valleix, Trousseau, and Delf>ech. Season exerts a considerable influence upon the production of thrush, as M. Valleix found that more than half the cases occurred during the three warmejit months of the year. Excitiufj Oiiists. — The deprivation of the breast, and a consequent resort to artificial diet, particularly one consisting of farinaceous substances, is probably much the most frequent exciting cause of thrush. An unhealthy state of the milk of the nurse will also act as an exciting cause. We have met with two cases of the disease, one of them fatal, which appeared to depend uix)n the latter circumstance. Dr. Berg believes that prolonged sleep from any cause disposes to the disease, by favoring the growth of the parasite, or by so changing the secretions of the mucous membrane of the mouth, as to render them important agents in augmenting the disorder. An acid state of the buccal secretion is cited as a cause by many authors, and is clearly proved to exist in a great many instances. Anatomical Lesions. — The characteristic deposit is found upon the mucous membrane of the mouth, pharynx, cesophagus, and in rare cases, of the stomach and intestines. The question of the possibility of the ex- tension of thrush to the gastric mucous membrane has been much dis- cussed, and the highest authorities have been almost equally divided upon it. This disagreement has arisen solely from the want of microscopical examination, which enables the observer to distinguish readily between true thrush and other appearances of the gastric mucous membrane which closely resemble it. The most conclusive demonstration of its occurrence upon the mucous membrane of the stomach has been recently furnished in a valuable article on this subject, by M. J. Parrot (Arch, de P/njsiologie Norm, et Path., Nos. 4 and 5, 1869) ; and in a still more recent article (id. op., vol. iii, 1870, p. 621), he has also determined the possibility of its de- velopment in the large intestine. It is a curious fact, and a very impor- tant one, insisted upon by MM. Trousseau and Delpech, and other ob- servers, that the false membrane never extends to the nasal or air-passages ; and they call attention to the singular diflerence in this respect between the aflTection under consideration and diphtheritic inflammation, which at- tacks almost exclusively the nostrils, pharynx, larynx, and bronchia. It ap|)ears, however, from recent observation, that the peculiar growth of thrush has been found upon both the epiglottis and the inferior vocal cords; and Parrot (loc. cit.) gives the details of a ca.se in which the fungus was found in the air-vesicles of one lung. Lesions of the digestive mucous membrane are met with iu nearly all the cases. M. Valleix states that softening of the gastric mucous mem- brane is almost constant, and that it is often accompanied by redness and thickening. The authors cited above are of opinion that the gastric 318 THRUSH. lesions have been greatly exaggerated, and assert them to be much the same as exist in other diseases foreign to the digestive apparatus. Various morbid alterations of the mucous membrane of -the intestines exists in nearly all fatal cases. This fact is acknowledged as well by MM. Trous- seau and Delpech, who deny the invariable connection of these alterations with thrush, as by M. Valleix, who asserts the connection almost without reserve. In nearly all cases the mucous membrane of the large intestine presents some of the following lesions, which are mentioned in the order of their frequency : thickening, injection, softening, or ulceration. In the ileum are found, in a great many cases, injection, softening, or thickening of the mucous membrane, unusual development of the mucous follicles, and tumefaction and ulceration of the glands of Peyer. In severe symptomatic cases a certain amount of erythematous inflam- mation is commonly found upon the skin of the buttocks and thighs, and ulcerations sometimes exist upon the inner ankles. Traces of inflamma- tion sometimes, but very rarely, exist in the membranes of the brain, and the lungs not unfrequently present the lesions of secondary pneumonia. Before leaving this part of the subject, we may remark that in the few cases we have met with in private practice, no ulcerations occurred upon the malleoli, and the erythema was observed only in the neighborhood of the anus. Dr. Dewees describes the autopsy of a child who died about the end of the first month of life, of what he designates as aphthae. The lesions coin- cide so closely with those which are characteristic of thrush, that we will quote the description, in order that the two may be compared together by the reader. " We found the whole tract of the oesophagus literally blocked up with an aphthous incrustation, to the cardia, and there it suddenly stopped. The inner coat of the stomach bore some marks of inflammation, as did several portions of the intestines; but not a trace of aphthae could be discovered below the place just mentioned." In the previous description of the case, he says that coat after coat of aphthae were thrown off, and each new crop appeared to be more abundant, and less amenable to reme- dies. {Dewees on Children, pp. 304-305.) Dr. Eberle says : " I have myself had an opportunity of examining the body of an infant, that had died of this disease (aphthae or thrush). In this case the aphthae were very distinct, throughout the whole course of the oesophagus. The stomach and bowels presented nothing that bore any re- semblance to this eruption ; but there were decided marks of inflammation in the mucous membrane of the small intestines, with a vast number of minute superficial ulcerations, and larger patches of softening of this tissue, throughout the colon and lower part of the rectum." {Diseases of Chil- dren, pp. 172-173.) Symptoms. — We shall first describe the characters of the exudation, and then proceed to the consideration of certain general and local phenomena which exist to a greater or less extent in both forms of the disease. The mucous membrane of the mouth is often somewhat red, dry, and tender for a longer or a shorter time (generally from one to three days), before the appearance of the exudation, and at the same time the papillae SYMPTOMS. 319 of the tongue swell and become protuberant. Next the exudation shows itself in the form of small, whitish point;?, sometimes on the tongue fii-st, and in other cases on the inside of the lips, whence it extends to the cheeks in idiopathic mild cases, and to the roof of the mouth, soft palate, pharynx, and tvsophagus, in the grave symptomatic form. The points of false membrane tirst deposited rapidly increase in size and thickness, so that in from one to three or four days, they assume the form of large patches, or a continuous membrane, which covers the whole or a consider- able portion of the cavity of the mouth. When the exudation is recent, it is thin, and its surface smooth; when, on the contrary, it has been longer deposited, it becomes thicker, and its surface is rough. It is at first of a milk-white or pearly hue, but when undisturbed assumes a gray- ish or yellowish color. It is soft in consistence, breaking down under the finger like cheese, and presenting no traces of organization to the naked eye. It adheres to the mucous membrane with considerable tenacity at first, but becomes looser after awhile, and is detached spontaneously at last without any lesion of the tissue beneath. The foregoing description applies to the exudation as it appears to the unassisted eye. We pass next to give an account of the characters it pre- sents, when subjected to microscopical examination, and in so doing shall quote the language of Berg, who first discovered that thrush essentially depended upon the presence of a peculiar parasitic fungus, to which Robin has given the name of oidium albicans. Dr. Berg {loc. cit.) states, that the white coating of the exudation consists of epithelium, thickened by the swelling of its constituent cells ; from the epithelium there springs a parasitic fungus in greater or less quantity, so that the chief portion of a patch of aphtha* (thrush) is composed either of epithelium or else of the parasitic growth. Under a magnifying power of from 200 to 300 diam- eters, an aphthous crust is seen to consist of epithelial cells, with a more or less interwoven coat of fibres, and a variable number of spherical or oval cells, without any sign of exudation-corpuscles, but only a small quantity of molecular albuminous deposit. "We can often trace the suc- cessive development of these cells from a spherical one of the smallest size, to an oval cell, and thence to a filament; and we have no doubt our- selves that the smaller cells are sporules, out of whose development the larger oval cells are formed, and finally, the filaments in the same manner a.s has been observed in other fungoid growths of this nature." Numer- ous projecting fibrils are observed in the circumference of an aphthous cru.st when submitted to the microscope ; but these are rendered infinitely more clear by a weak solution of potash, which di.ssolves the albumen, and renders the cells of the epithelium transparent, while, at the same time, it diminishes their intimate cohesion, and the network of vegetable fibres is more plainly seen. "These fibres are cylindrical, with sharply defined dark enally, and know exactly where he comes from, and what manner of man he may be. An honest farmer or dairyman who pastures and feed:* his own cows rm a h(falthy farm is the man to be employed to furni-h milk to the poor little baby who has to seek another 326 THRUSH. dairy than his own mother's. If the character of the milkman is not a sufficient guarantee, or if, from any accident, the milk has to be changed, or if any doubt arises as to its quality, there are some simple methods of judging which can be made use of by any person of ordinary intelligence, and which will reveal any gross deception on the part of the milk vender. A good specimen of cow's milk ought to be slightly acid or neutral ; it should contain a certain average proportion of cream, and it should have a certain average density. These points may be ascertained with sufficient accuracy to guide us in our choice or refusal of any sample of milk, in the following mode : Litmus- paper turns red when touched by any acid ; a very weak acid will do this. If a good specimen of litmus-paper (which can be procured of the apothe- cary) turns faintly red when dipped into milk, the milk is properly acid ; if turned bright red, the milk is too acid. When no change is produced on the litmus-paper, the milk is either neutral (which is sometimes the case with healthy milk), or it is alkaline. To determine whether it be neutral, turmeric-paper, which is turned brown by alkaline solutions, must be used. If the specimen is found to be alkaline in a marked degree, either the cow is diseased in all probability, or some alkali has been added to the milk. It is a curious fact that Dr. Parkes {Manual of Practical Hygiene, 2d ed., London, 1866) is almost alone in asserting that healthy cow's milk is either faintly acid or neutral. Most authorities assert that it is alkaline. In order to determine this matter for ourselves, we tested the milk of thirty-one fine cows, fed on the finest pasturage in the neighborhood of this city. This was done by taking the milk, just as it was drawn from each animal, separately iii the milking-house, and testing at once with the best litmus-paper. In all the paper was turned red more or less distinctly. Dr. John Ashhurst, of this city, tested for us, with both litmus- and turmeric-paper, the milk of nine fine Durham and of four Alderney cows, belonging to his father, all on the finest pasturage. He says that in one Durham and in one Alderney the milk appears to have been almost neutral, and in all the rest more or less acid. In testing the milk of another Durham, litmus-paper was reddened, whilst the turmeric was also slightly changed, but he supposed the latter change to be due to a greasy condition of the milk, owing to the fact that the cow was in the latter period of a long lactation. To determine the proportion of cream, we may make use of a glass ves- sel, made of a section of a cylinder, tall, and not too wide, and graduated to inches, with the upper inch divided into hundredths, or a French glass divided into centimetres, such as may be found in the shops for the sale of chemical apparatus. This is to be filled to the upper mark with milk, and put aside for twenty -four hours ; at the end of that time the cream will have separated and risen to the top, and its proportion can be read off* on the graduated scale. According to Dr. Parkes, the cream should be from 4 to 6 per cent. In the milk of Alderney cows, it will reach 30 to 40 per cent. This seems to us too large a proportion for the use of children. MODE OF TESTING MILK. 327 We think, however, that the average of cream given by Dr. Parkes is prohahlv rather too low. The Mai^on Biistiquc, a French work of very high authority on agriculture, states (tome iii, p. GD that the milk of cows, of good race, well kept, furnishes 15 per cent, of cream. The milk sup- plied by the milkman employed by one of us gave 14 per cent, of cream on one occa^^ion, and 10 at another. The specific gravity of the former specimen was found to be 1029. Of three other si>ecimeus bought at hazanl, of ditierent dealers, the proportion of cream was 7 per cent., 6 per cent., and 14 per cent., respectively. We are disposed to think, therefore, that families ought to endeavor to procure milk containing at least 10 per cent, of cream. We next have to ascertain the density, in order to determine the pro- portion of water. The most common adulteration of milk is, of course, with water, to increase its quantity, and so augment the profits of the salesman. The density or specific gravity, let it be remembered, is no safe guide as to the projwrtion of cream. That must be settled in the mode just described. But the density gives the proportion of water. The spe- cific gravity of good, pure milk is given by Dr. Parkes at 1030.5, or 1026, at a tem|>erature of 60° Fahr. We found it in an excellent specimen to be 1029. Dr. Parkes found that when, in milk of the specific gravity above mentioned, one part of water was added to nine of milk, the specific gravity fell to 1027 or 10i^3; when three parts of water were added to seven of milk, it fell to 1021 or 1017.5; and when five parts of water to five of milk, it fell to 1015. These were the proportions obtained by sev- eral experiments. We found that the specific gravity of a specimen of excellent milk, as ascertained by a hydrometer, was 1028. When to this milk was added one-fourth part of water, the specific gravity fell to 1024, and when a half had been added it fell to 1020. In another specimen, the specific gravity, obtained in the same way, was 1030 at a temperature of 64° Fahr. When to this specimen one-half water was added, the specific gravity fell to 1020. By these three simple methods of examination, the acidity or alkalinity of the milk, the proportion of cream, and the proportion of water, can be determined. If the milk is either strongly acid or alkaline, it is not to be trusted. If it be strongly acid, it has undergone the acid fermentation, and is not fit for use. If it be strongly alkaline, it has either been adulte- rated by the addition of an alkali, probably, according to Dr. Parkes, car- bonate of soda, to prevent or arrest the lactic acid fermentation, or it may have been taken from a diseased cow. Dr. Parkes suggests the latter probability in a doubtful way. Dr. J. F. Simon, of Berlin (Animal C/tem- iMrfj with Rpfereivre to the Physiology and Patholoyy of 3/a;i, vol. ii, p. 67), states, that he analysed milk drawn from the teat of a cow having vaccinia, and found it strongly alkaline, and showing with the microscope mucus- and pus-corpuscles, while that drawn from a healthy teat had a mild acid reaction, and contained no pus- or mucus-corpuscles. He also states (^page 68), that Herberger has analyzed the milk of cows suflfering from the grease, and found it to contain an increased quantity of the alkaline salts. 328 THRUSH. in the first stage ; in the second stage it was thick and viscid, and had, be- sides, an unpleasant and putrid taste and smell. In both stages, the pres- ence of carbonate of ammonia (an ingredient never before observed in the milk) was detected. The most common adulteration of milk is with water. The mode of de- tecting this, by ascertaining the specific gravity, has already been given. Starch is sometimes used to thicken a thin milk. The microscope will de- tect this by showing the presence of the starch-granules. The mother will often wish to preserve milk, especially in our hot sum- mer weather, or for a few days, when on a journey. The best preservative in hot weather, for the day, is of course a good ice-chest. Dr. Parkes says that when boiled, " the bottle quite filled, and at once corked up and well sealed, the milk lessens in bulk, and a vacuum is formed above. It will keep thus for some time. A little sugar aids the preservation. If the heat is carried in a close vessel to 250° Fahr., the milk is preserved for a very long time, even for years ; the butter may separate, but this is of no con- sequence ;" or, if a little carbonate of soda and sugar is added, without boiling, he says it will keep for ten days or a fortnight. Cooley, in his Cyclopcedia of Practical Receipts, states, that the addition of ten to twelve grains of carbonate, or bicarbonate of soda, to each pint of milk, will pre- serve it for eight or ten days in temperate weather, and adds that this addition is harmless, and, indeed, is advantageous to dyspeptic patients. The method of boiling, proposed by Dr. Parkes, is the one now so much used for preserving fruits fresh. Having determined upon the use of cow's milk, we have next to con- sider its mode of preparation. It should never be given pure to young infants, at least such is our clear conviction. We still believe that the old rule, of two parts of water to one of milk, is the proper one during the first month. We know that some of the more recent writers, and not a few of the physicians of this city, now order half w^ater and half milk, and some children do well on that proportion ; but we still believe that when the milk is of full average richness (containing ten or fifteen per cent, of cream, and having a spe- cific gravity of 1028 to 1030), the old rule of two-thirds water is safest. And this is certainly true of all sickly children within the month. It is easy to increase the proportion afterwards, if the child does not develop as it ought ; but the stomach once seriously deranged and overloaded by too rich a food, a severe and even a lingering illness may be the penalty the child will have to suflfer. When the child comes to be one or two months of age, the proportion may be increased to one-half, with care ; always, however, returning to the first rule, should the child exhibit signs of gastric disturbance, or should the stools contain many whitish lumps, consisting of undigested casein. At the age of five or six months the proportion may be made two-thirds milk, and thus, gradually, the milk may be given pure, though we have seen many children who, even at a year of age, did better with a moderate dilution than with the pure fluid. QUANTITY OF FOOD TO BE TAKEN. 329 The qiiunfity of food to be given each day is a very important con>;ider- ation. and one about which less is usually said than the matter deserves. In the first edition of this work, published in 1848, it was stated that, from various inquiries and observations, we were led to believe that a healthy infjint of two or three weeks old, would receive, from a good nurse, and digest well, about a pint of food in twenty-four hours, and that by the end of the fii*st, and in the second month, the quantity taken by the child increased to a pint and a half or a quart. Some of the data upon which these assertions were based were the following : A wonian, attended in her confinement by one of us, had a jiint of milk drawn, by the nurse, daily from the breasts, in addition to what the child took. On asking the nurse how much she supposed the child — a vigorous, hearty boy — took at the same time, her reply was that, judging from the frequency and vigor with which he nursed, she supposed he took as much as was drawn from the breasts. Another patient lost her child at birth, and desiring to go out as a wet-nurse, kept up the flow of her milk by using a pnppy. Six weeks after her confinement, a good breast-pump was given her, and she was de- sired to keep all the milk she could obtain in twenty-four hours. The quantity measured exactly a quart. It was also stated, in that edition, that careful inquiries were made, in regard to this matter, of one of the most experienced and intelligent monthly nurses wc ever knew. She was desired to answer accurately the two following questions: 1. How much milk do you think a healthy mother gives to her child daily, after the flow is fairly established? 2. What quantity of nourishment do you give in twenty-four hours, to infants you are compelled to feed exclusively? The reply to the first question was that she had often drawn more than a pint from the breasts in the twenty-four hours, in addition to what a healthy child took, and that she had frequently taken as much as three pint.s from women who had lost their children. She supposed, therefore, that a hearty child would take, during the first two weeks, at least a pint, and much more afterwards. To the second question she replied, that she usually gave to hearty chil- dren of one, two, and three weeks old, a pint of food in twenty-four hours. It was stated in the first edition of this work, that, judging from the above data, a young infant ought to take at least a pint of nourishment in the twenty-four hours. Our experience, since that time, has convinced us that, if anything, this estimate is rather too low than too high. Now we should say that, in the first ten days after birth, a pint or a little over is about the right quantity. After that period a pint and a half to a quart is probably the profK*r amount up to the second month. In the second and third months many children require a full quart, and some thn^e pints ; though, after all, we must be ruled very much by the instinctive wants of the individual child. When fed at regular intervals, upon food of the proper strength, we do not think children often take more than they need. In the first month the child ought to be fed every two hours, if it takes 330 THRUSH. the food well. After the first month, once in three hours, is usually the best rule. Feeding the child once in three hours, between six in the morn- ing and six in the evening, and twice in the night, would give six meals in the twenty-four hours.. If six ounces (a gill and a half) be given each time, the child would get thirty-six ounces, which is a little over a quart. As the age increases, eight ounces may be given every four hours, which would make a quart and a half; and we have met with very few children who exceed this, particularly as by this time the food consists of two-thirds or three-fourths milk, or even pure milk. It may seem needless to add that, unless the child is taking decidedly less than the average stated above, it ought not to be in any degree forced or enticed to swallow more than it takes willingly. The moment it has had enough, the nurse ought to cease to offer any more. As this matter of the quantity of artificial food necessary for the devel- opment of the child is a very important one, and as it is a point which has not been very clearly defined by most writers, we have thought it well to lay before our readers the following calculation of what infants may need, from the estiniate made by Dr. Parkes as to the amount of food necessary for adults. According to that author, an adult of average size and activity will, under conditions of moderate exertion, take in twenty-four hours from TT^gth to 2"V^^^ ^^ ^^® 0^^ weight in solid and liquid food. The relative proportion of the so-called solid and liquid food varies greatly, but is usually about 40 oz. avoirdupois of the former, and 60 oz. of water. As, however, all the so-called solid food — bread, meat, etc. — contains a certain amount of water, the actual average amount of water-free food taken by an adult, weighing 150 lbs., is 23 oz., or jl-^ih. of the weight of the body ; and the amount of water about 75 oz. Or, in other words, every pound weight of the body receives about 0.15 oz. of water-free food and 0.5 oz. of water in twenty-four hours. This water-free food is composed as follows, according to Moleschott : oz. avoirdupois = 437.5 gr. Albuminous substances, . . . 4.587 Fatty " 2 964 Carbohydrates, 14.257 Salts (of all kinds), . . . .10.58 22.866 On the basis of these calculations, an infant at birth, the average weight being 7 lbs., would require 1.05 oz. of water-free food ; and a child weigh- ing 20 lbs., which is probably the average weight of healthy children of five to six months old, would require 3 oz. Assuming the total solid of cow's milk to be 10 per cent., which is rather less than the average as given by Becquerel and Kodier (see composition of healthy milk), it would require to yield an ounce of water-free food rather more than 10 ounces of milk. Thus on this supposition (r. e., that the total solids of cow's milk of sp. QUANTITY OF FOOD NEEDED BY CHILDREN. 831 gr. 1026, equal 10 per ceut.) one piut imperial (20 oz.) \\\\\ coutain iu round numbers, Cju Lectures on the Morals of Trade, by R. Heber Newton, New York, 1876, Appendix A\ where it is stated that " the condensed milk is found, with few exceptions, to be made of skimmed milk entirely or in part. It is thus robbed of its cream, and is therefore deficient in fat (butter). This really renders it unfit for the nourishment of children aiid tlie fraud is more objectionable than that of diluting the whole with water." The re- port adds : " It is a notorious fact that most of the condensed milk com- panies regularly send cream to the New York market." We have al- ready said that Dr. Edward Smith asserts that " whilst in natural cow's railk the proportion of nitrogen (flesh-forming) to carbon (fat-forming) is 1 to 12, in the preserved milk it is not much more than one half or about 1 in 20." We suppose that Dr. Smith here refers to the condensed milk of the English factories. Dr. Thomas King Chambers (Diet in Health and Disease, Philadelphia, 1875, p, Qo), says of condensed or Swiss milk that *'it certainly is digestible, as is shown by the fact of infants brought up by hand upon it growing fat and apparently strong, a fact of which most of us have ocular proof. Great care should be taken that only the softest water is used for its solu- tion, and precautions taken against its adulteration. As it is a recent in- veDtion it is pure enough at present, but extensive use will probably teach ingenious methods of sophistication." Dr. F. W. Pavy {Treatise on Food and Dietetics, Philadelphia, 1874, p. 194), gives no personal opinion as to its value, but cites, in a foot-note, Dr. Daly's opinion (already quoted) of it. The causes which compel us to resort to artificial food for young chil- dren, are, of course, very numerous. Thus, it may be impossible, after the death of the mother, to secure a reliable wet-nurse; or the mother's supply of milk may be manifestly insufficient ; or again, although the quantity is abundant, the milk either disagrees with the child, and causes vomiting and diarrhcea, or does not nourish, it properly. In every case, therefore, where we have reason to sus[>ect that the mother's milk is of improper quality, we should subject it to a careful examination ; and, it is needless to add, that whenever a wet-nurse is chosen, a similar examina- tion of her milk should invariably be made. According to Vernois and Becquerel, who examined the milk of eighty- one nursing women, the composition of a healthy woman's milk is as follows : 1000 part** of milk contain — Water, f<^0 09 Sugar, 43 04 Ca^^ein, 3r».24 Buttf-r 20.00 SalU, 1.38 For practical purpose^, however, it is quite sufficient for the physician 22 338 THRUSH. to determine the specific gravity, the reaction, the amount of cream, and the microscopic appearances of the milk. The first three of these points are to be ascertained in the way already directed in the examination of cow's milk. The density of the milk should be about 1030 to 1032. The amount of cream, as tested by the graduated galactometer, should be at least three per cent. In regard to the reaction, our own observations are not in accordance with the statements of the majority of authors. Thus, according to Vogel (pp. eit., p. 32J, "fresh woman's milk is bluish- white or pure white, has a feebly sweetish taste, and alkaline reaction^ In order to determine this point, the following observations were made on forty- three women in the Philadelphia Hospital : The subjects chosen were all in good health, and varied in age from nineteen to forty-one years. They were all suckling their own children, who were from nine weeks to eighteen months old, and, in three-fourths of the instances, in good health and well grown. In a good many cases the children had suffered more or less severely from diarrhoea during their teething. The mode of testing was as follows: A few drachms of milk were first expressed from the nipple and rejected ; a couple of drachms more were then expressed into a spoon, and tested with litmus- and turmeric-papers. In no instance was there the slightest alkaline reaction with the turmeric. In one instance only was there an acid reaction, and that a very faint one ; while in forty-two of the forty-three cases, in nineteen of which the milk was tested twice, on successive days, the reaction was neutral. It is necessary, in thus testing the milk, to express it into a spoon, since litmus-paper is reddened when applied to the moist nipple. It would appear, then, from these observations, that woman's milk can, at least, not be regarded as unhealthy on account of having a neutral reaction. The microscopic examination should determine the quantity and size of the fat-globules, and the presence or absence of colostrum-corpuscles. The fat-globules, also called milk- globules, which are observed in healthy woman's milk, should not be very numerous, and should not vary in size more than from the 0.0012 to 0.0020 of an inch in diameter. The fat- globules, as present in milk, are invested with a delicate albuminous en- velope. If the milk be allowed to stand, and the upper stratum of cream which forms be examined, along with the ordinary fat-globules, there will be numerous others of much larger size. In addition to these fat-globules, there are also found in the milk during the first two or three weeks after confinement, a number of granule-cells, the so-called " cofosfrw7i-corpuscles." These bodies, which present the ordi- nary appearances of granule-cells wherever found, consist of an aggrega- tion of minute oil-globules in an albuminous basis ; they vary from 0.003 to 0.006 of an inch in diameter ; and when examined by transmitted light, appear opaque and dark-colored. After the period above mentioned (end of the second week), they should diminish rapidly in number, and only reappear in case the nursing woman is attacked with any acute febrile af- fection. If, therefore, they are found to persist long after the time men- TREATMENT OF THE GRAVE FORM. 339 tioned, or if, having almost disappeared, they return in numbers, the milk must be regarded as unhealthy. After these general remarks on the diet for hand-fed children, which we hoi>e will not be thought too tedious, having regard to the great im- portance of this subject, not only in thrush, but in all the diseases of child- hood, we return to the treatment of the special disease under consideration, thrush. Few children, with thrush, unless the case be a very mild one, will take the full allowance of milk and water we have assumed to be necessary in the first weeks after birth. It is clear, however, that if the patient be taking only half a pint or a gill a day, it cannot live long on so much less than the natural quantity. It ought to take, under these circumstances, about two or three tablespoon fuls of food every two or three hours, be- tween morning and evening, and once or twice in the night, which would amount to from eight to ten ounces in the day ; and this quantity ought to be given if the child can be induced, without forcing, to take so much. If the usual proportion of two parts water to one of milk, or if the arrow- root and gelatin preparation above recommended, should be rejected in hard curds, or if masses of undigested curd be found in the stools, it is best, for a few days, to dilute Avith three or even four parts of the arrow- root solution, or to try for a short time, merely cream and water, one part of the former to three, four, or five, of the latter, returning to the mixture of cream, milk, and water, as soon as possible. In mild cases of the disease, which have been caused by some tempo- rarily unhealthy state of the nurse's milk, or, as we have seen it, from the occasional use of artificial food to eke out a diminished supply on the part of the nurse, after regulating the diet as directed, the use of the following mixture, which we have employed for many years past, will often prove very successful and tranquillizing : R. — Soda? Bicarb., ^ss. Tr, Opii Camph., gtt. xl. Tr. Khei, gtt. Ixxx. Syrup. Simp., f^ij. Aq. Menth., f5xiv.— M. A teaspoon ful three times a day. This dose, continued for several days, or even weeks, will, unless the cause continue in force, relieve the pain ami wakefulness, lessen the diar- rhoea, and greatly promote the comfort of the child. In connection with this, the mouth should be touched, once or twice a day, with a solution of nitrate of silver, of one grain to the ounce. In the grave form of the disea.se it is necessary, after regulating the diet, to employ remedies for the disonlered condition of the alimentary canal. These should consist principally of alkalies, astringents, opiates, occa.sionally a dose of some laxative substance, nitrate of silver, and the external employment of baths, warm cataplasms to the abdomen, and sometimes of revulsives. The filhiUes usually employed are soda, lime-water, magnesia, chalk, and prepared crab's-eyes. Of these we prefer, in most cases, the soda, lime- 340 THRUSH. water, chalk, or crab's-eyes, to be given in the manner which will be rec- ommended in the article on entero-colitis. Dewees recommends very highly the following formula : R. — Magnes. Alb. Ust., gr, xij. Tinct. Thebaic, gtt. iij. Sacch. Alb., q. s. AquEe Font., f^j._M. A teaspoonful to be given every two hours nntil the bowels are tranquil. He says of it that he has '^long adopted it with entire success." In con- junction with the internal use of alkalies and astringents, we would rec- ommend the practice pursued by M. Valleix of employing opiate enemata and warm poultices containing laudanum, applied upon the abdomen. The enemata should consist of one drop of laudanum in a tablespoonful of starch-water for young infants, to be used morning and evening. The poultices maybe made of Indian. or flaxseed meal, placed between two pieces of soft gauze flannel, to be secured around the body by a band, and renewed from time to time. Purgative remedies are much used in this country in all cases of intes- tinal disorder. We believe them to be unnecessary^ and generally inju- rious, in thrush, except at the onset, and occasionally through the course of the disease, when we may suppose the bowels to contain accumula- tions of partially digested aliment, or highly irritating secretions. Under these circumstances, and only then, from half a teaspoonful to a teaspoon- ful of castor oil, or a teaspoonful of spiced syrup of rhubarb containing half a drop of laudanum, may be prescribed, and repeated in case the same condition of things should recur. When once the diarrhoea with green watery stools is established, we believe all cathartics to be, as a rule, injurious. Opiates, in moderate quantities, given in combination with alkalies or astringents, or used by injection or externally, are of the greatest service at all stages of the grave form of the disease. When the diarrhoea is severe and obstinate, and particularly when the stools contain mucus or blood, or are attended with tenesmic straining, nitrate of silver given internally, or used by injection, may be resorted to with very probable benefit. The doses and modes of administration will be described under the heads of entero-colitis and dysentery. Some authors recommend the application of one or two leeches to the margin of the anus, or over the left iliac fossa. We think they can rarely be proper, and if so, only in vigorous, hearty children, and in cases present- ing strongly marked inflammatory symptoms. When the symptoms indi- cate great exhaustion, or tend towards a state of collapse, resort must be had to stimulants, of which the best are weak brandy and water, or a mix- ture of equal parts of wine-whey and arrowroot water. Local Treatment. — The local treatment is important in all cases, but is of much less consequence than the general treatment, and particularly attention to the diet and other hygienic conditions of the patient. Topi- cal remedies undoubtedly have the effect, however, in some instances, of LOCAL TREATMENT. 341 arresting the progress of the exudation, and liastening the resolution of the disease of the mouth ; but we have uniformly found, in grave eases, that no remedies applied to the mouth had any decided influence upon the abdominal disease, which is, after all, the cause of the fatal termination in the vast majority of cases. Tiie local treatment ought, therefore, to be regardeil as adjuvant only to the general management of the disorder. In mild cases the most suitable local treatment, the one recommended by Underwood, Dewees, Eberle, and MM. Trousseau and Delpech, and that which we have generally employed, is the occasional application to the mouth of borax. It may be used mixed with an equal quantity of honey, and applied by means of a rag or pencil ; or with an equal quantity or two parts of finely powdered white sugar, of which a pinch is to be put upon the tongue every two or three hours ; or in solution, in the proportion of a dmchm to two ounces of water. The best mode probably is to mix it with honey. If this application fail to arrest the deposit of the exudation, we may resort to alum in powder or solution, or, better still, to solutions of nitrate of silver, or to careful cauterization with the solid nitrate. The alum may be used in the same manner as borax, or according to the fol- lowed formula, recommended by M. Valleix: R. — Aluminis, ....... jrr. xv. Mel. Ro>a:», ....... ^ijss. Decoct. Hordei, f5iijss. — M. In the use of the nitrate of silver, we should resort to a solution of five grains to the ounce of water. MM. Trousseau and Delpech, however, rec- oramend one of thirty grains to the half ounce, or more frequently cauter- ize lightly the whole mucous surface with the solid caustic. Solutions of salicylic acid, 10 or 15 grains to the ounce, effected by means of glycerin, or solutions of carbolic acid, have also been used by us with good results. Between the applications of any of the above-mentioned remedies, the mouth of the infant ought to be occasionally moistened and cleansed with some of the mucilaginous solutions, as gum-water, flax.seed tea, or that made from .cassafra,s pith, slippery elm bark, or marsh-mallow root. Strict and careful attention must be constantly paid to the state of the skin around the anus, and upon the thighs and buttocks. These parts ought to be well cleansed, after each evacuation of urine or stool, by gentle pressure, and not by rubbing, with a fine sponge dipped into tepid milk and water, then drie^I with a .'•oft napkin in the .same manner, and well anointed with simple cerate, or, what we find better than anything else, Goulard's cerate. These precautions ought to be still more carefully observed if erythema has already made its appearance. 342 AFFECTIONS OF THE TONSILS. ARTICLE VI. AFFECTIONS OF THE TONSILS. 1. Acute Inflammation of the Tonsils. — Tonsillitis. — This pain- ful affection (known also as angina or cynanclie tonsillaris), occurs in child- hood less frequently, but with the same symptoms as after the age of pu- berty. We have occasionally met with severe cases of it in children under the age of 5 years. Symptoms. — When the attack is sudden, there are marked fever, rest- lessness or heaviness, and complaints of severe pain on deglutition. If the child be old enough to answer questions, the pain will be found to radiate from the fauces towards the ear, and to be increased by opening the mouth. Painful enlargement of one or both tonsil glands will be found by pressing the finger below the angle of the lower jaw. On ex- amining the fauces, there is marked redness of the half arches and poste- rior border of the soft palate : the affected tonsil projects from its bed as a rounded, deep-red body, which may extend even beyond the median line ; and if, as less frequently happens, both tonsils are severely inflamed at the same time, they may even meet and entirely occlude the isthmus of the fauces. The surface of the gland often presents small yellowish points which closely resemble patches of false membrane, although careful in- spection will show that they are beneath the mucous membrane, and are really only the distended follicles of the gland. Deglutition is so painful, especially for liquids such as milk or water, that the little patients will at times utterly refuse to swallow. Course and Duration. — The disease lasts from 3 to 7 days, and ter- minates in different ways. It very rarely proves fatal, and only does so by obstructing breathing, and at the same time so seriously interfering with nutrition that the child^s strength fails. In most cases the result is favor- able, and the termination is either by suppuration or gradual resolution of the enlarged gland. When suppuration occurs, the symptoms have gone on becoming more and more aggravated until they reach their height, and the case seems attended with great danger, when suddenly, after an effort at vomiting, or spontaneously, the tonsillar abscess bursts, a gush of pus occurs from the mouth, and prompt relief is afforded. Occasionally the occurrence of suppuration is marked by a chill, or some decided change in the febrile movement. More frequently in children, however, the tonsil does not suppurate but gradually becomes smaller ; the redness subsides, and the distended folli- cles disappear. There is a strong tendency, especially after this latter mode of termination, for the tonsil to pass into a state of moderate chronic en- largement. Diagnosis. — The conditions with which acute tonsillitis in children is most apt to be confounded, are diphtheria and scarlatinous angina. From diphtheria it may be told by the more acute and sthenic character of the symptoms ; by the absence of enlargement of any but the tonsil TREATMENT — ANATOMICAL APPEARANCES. 343 glands, and by the local appearances, particularly the absence of pseudo- membranous exudation. From the angina of scarlatina it may be distinguished by the less fre- quent pulse and lower temperature, but chiefly by the absence of eruption, so that in some cases the diagnosis cannot be positively determined until the time at which the eruption of scarlatina makes its appearance has passed. Treatment. — So long as the child is able to swallow, quinia may be given in full doses, to diminish the fever, and perhaps diminish the liability to suppuration. It may be given combined as follows : K- — Quinise Sulph., gr. xviij. Tr. Ferri Chloridi, .... gtt. xlviij. PoUs^je Chlorjilis, . . . • gr. x.\x. Syr. Zingibtris, f^j. Aquj^, f5ij. Dose: Ft. s<>l. 2 teft5poonfuls 4 times a day, for a child 5 to 7 years old. If, however, the inflammation be very acute, suppuration will occur in all probability, despite our eflbrts. It is almost impossible to make any applications to the throat. That which is most readily eflTected, and affords as much relief as any other, is the inhalation of steam or vaporized warm lime-water. Warm, slightly sedative embrocations may also be applied to the neck. It is doubtful whether poultices, or any such applications, hasten suppuration sufiiciently to make up for the annoyance they cause the child. Even if the occur- rence of suppuration be suspected, it is usually impossible to obtain so full a view of the parts as to enable an incision to be made to evacuate the pus. As, however, the abscess will discharge spontaneously in nearly all cases, it is only when the symptoms of obstruction of the throat are very urgent, that it is desirable to in.sist upon such an examination. The treatment for the chronic enlargement which sometimes remains after an acute tonsillitis, will be considered in the next section. 2. Chronic Enlargement (Hypertrophy) of the Tonsils — Causes. — Tiie tonsils are in young children much more subject to this aff^M ti«»n than to acute inflammation. The enlargement may begin during the fir.-t year of life, but usually does not become sufficient to attract atten- tion until the second or third year. Most frequently it has no connection whatever with previous acute inflammation of the part, but is chronic and indolent from the l>eginning. It is often observed that several children of the same family will .suffer from this condition, and it is in fact associated in many cases with rickets or with scrofula. We have, however, observed marked and enduring enlargement in children of apparently sound con- stitution. According to West, the irritation of the latter period of first dentition may be the exciting cau.«e in .«»ome of these ca.ses. We have already alluded to the fact that occasionally, especially in some- what older children, it h&a been an acute attack of ton.«filliti.s — either sim- ple or diphtheritic — which has inducer] the state of chronic enlargement. Anatomical Appearances. — Both toufrils usually .«hare in the enlarge- ment, though not always to an equal degree. They project into the liauces 344 AFFECTIONS OF THE TONSILS. from either side, forming pale red tumors of rounded form, with a surface that may either be smooth and glistening, or rough and irregular from the rupture of numerous distended follicles. They impart a sense of elastic firmness to the finger when pressed. The exact anatomical condition is in part an enlargement of the follicles of the gland, associated with thicken- ing of the fibro-cellular stroma. The term hypertrophy, commonly ap- plied to this condition, must therefore be regarded as indicating merely the increase in size of the gland. Symptoms. — There can be no doubt but that many symptoms have been attributed to the influence of enlarged tonsils which are in reality depen- dent upon entirely difi"erent causes. The results which are constantly observed are loud snoring during sleep, and suufiling, thick voice. There is also often a tendency to acute catar- rhal attacks, during which the enlargement of the tonsils increases, and the interference with the breathing and voice is much increased. Indeed, in some unusually severe cases the respiration is constantly labored, and the child is annoyed by a frequent dry hacking cough. The pressure of the enlarged glands upon the mouths of the Eustachian tubes may produce tinnitus and hardness of hearing. The most serious results which are, by many authors, attributed to enlargement of the tonsils are alterations in the nose and upper jaw, and the production of the chicken-breast defor- mity of the thorax. In consequence of the obstruction of the nasal pas- sages caused by the upward pressure of the soft palate, the form of the anterior nares may be somewhat altered and contracted, but we are rather inclined to refer the small size of the features and the ill-developed upper jaw to the rickety cachexia which is so frequent a cause of enlargement of the tonsils. So, too, the narrowing of the isthmus of the fauces must tend to make inspiration difficult, and thus to prevent full expansion of the chest, but we can hardly imagine that such obstruction could produce marked chicken-breasted deformity of the thorax, if it were not for the fact that in such patients there is usually a high degree of rickets coex- isting. It must be borne in mind that precisely this deformity of the tho- rax is frequently met with in cases of rickets where there is no enlarge- ment of the tonsils. The condition of these glands and the changes in the jaws and chest-walls must then, we think, be regarded as results of a com- mon cause. So, too, it is probable that the sudden suffocative attacks which have been described as occasionally attending chronic enlargement of the tonsils have been spells of laryngismus stridulus, dependent upon rachitic disease of the bones of the skull. Prognosis. — It will be readily seen, therefore, that although this condi- tion of the tonsils is obstinate, and yields slowly, if at all, to treatment, it is rarely of itself followed by any serious consequences. In very many cases it gradually subsides after the patient reaches puberty, while in others treatment is successful in reducing the enlargement. We have, however, known it to persist most obstinately for many years, even after partial abla- tion and prolonged treatment. Treatment. — The frequent association of enlargement of the tonsils with a rachitic or strumous diathesis must be borne in mind, and if there TREATMENT. 3-45 is any evideuce of the existence of such a constitutional taint, tlie ap- propriate treatment must be adopted. Even where no decided evidence can be found, it seems desirable to administer such alterative tonics as the i«xlide of iron, or the compound syrup of the phosphates of iron and alka- lies. The prolonged use of cod-liver oil, with iron and arsenic, has also proved of service. Counter-irritation by the daily application of dilute tincture of iodine, or compound iodine ointment, behind and below the angle of the jaw, may be used, and sometimes appears to favor the reduction of the swelling. Local applications to the enlarged glands are of much service in some ca.-es, but to do good must be steadily persisted in, in conjunction with pi-oper internal remedies. Those which have on the whole appeared most useful to us have been Lugol's solution of iodine diluted with two to four parts of water, and nitrate of silver in the form of rather strong solution, as gr. X to the tiuidounce. We have also found it of material service in hastening the reduction of the enlargement to whiten the surface of the tonsils once in three or four days by a light application of solid lunar caustic. Recently, the use of injections of ergot and iodine as a means of causing the resolution of enlarged glands has been frequently recommended. We had found positive benefit from their employment in cases where the children were old enough to permit this little operation to be performed without too much alarm. The injections should be made into the substance of the bypertrophied tonsil, by means of an ordinary hypodermic syringe ; and may be repeated about once a week, or according to the effect produced. The amount injected should not exceed a few drops, 3 to 5, and should be in- troduced very gently, so as to avoid pain as far as possible. The fluid used may be either single solution of iodine diluted with water, or a dilute solu- tion of ergotin, 48 to 96 grains to the ounce. Careful attention to diet, and particularly to the proper and sufficient clothing of the child must be insisted on, so as to avoid, as far as possible, the repeated acute attacks of slight tonsillitis which are apt to occur. Under the persistent employment of the general and local means above recommended, we have usually found that the hypertrophy of the tonsils has diminished towards the age of puberty. In some instances, however, we must confess that all forms of treatment, general as well as local, have proved unavailing. We must then resort to excision of the enlarged glands, if the .«ymptonis caused by their presence are sufficiently urgent to render it advisable. The excision of the tonsil (or rather of the prominent portion of it, for the entire gland rarely needs removal; is an operation attended, in skilful hands, with little difficulty and no danger. It may be readily performed with a Fahnestock's or Physick's tonsillotome, or, as many operators i)rc- fer, by raising the gland from its bed with a special kind of forceps, and then slicing it off with a bistoury. The symptoms which would lead us to advise the early removal of the tonsils are frequent irritative cough, much interference with hearing or with the tones of the voice, or coexisting rachitic deformity of the chest. 3^6 iIMPLE PHARYNGITIS. ARTICLE VII. SIMPLE OR ERYTHEMATOUS PHARYNGITIS. Definition ; Frequency. — Simple pharyngitis consists of an erythem- atous inflammation of the pharynx, tonsils, and soft palate, unaccompanied by ulceration, deposit of false membrane, or gangrene. It is very frequent both as an idiopathic and secondary disease. We constantly meet with it in children of all ages during the cool months of the year. Causes. — It may occur at all ages, and is equally common in the two sexes. It is more frequently a secondary than an idiopathic affection. The diseases in the course of which it is most apt to occur are scarlet fever and measles, and next, pneumonia and bronchitis. It is often an accom- paniment of simple laryngitis. The idiopathic form is most common in this city in the late winter and early spring mouths. It is said to prevail sometimes in an epidemic form. The exciting causes of the disease are not always easily detected. • In most instances, however, we believe that exposure to cold is the cause of the attack. Anatomical Lesions. — In mild cases the alterations of texture ob ■ served during life, and in a few instances after death, the patient having died of some other disease, consist of greater or less redness, swelling, soft- ening, and a rough or granular and sometimes oedematous condition of the mucous membrane covering the soft palate, tonsils, and pharynx. The uvula and tonsils are generally tumefied, and the crypts of the latter filled with mucous or purulent fluid of a yellowish color. In one very severe case which proved fatal, MM. Rilliet and Barthez found the ton- sils very red, soft, only slightly swelled, and infiltrated with pus; the pharynx was covered with a thick layer of bloody mucus ; the mucous membrane of the throat was of a dark red color, thickened, and granular, but not softened. The submaxillary glands were of a grayish color, en- larged and soft. Symptoms. — Simple pharyngitis of moderate severity begins with rest- lessness, irritability, fever, slight cough, and in some instances, pain in the throat, which is complained of by older children, and betrayed in those who are very young by the refusal to nurse or take food, because of the difficulty of swallowing. The face is generally flushed, sometimes very deeply so. Young children are often drowsy, but from irritability and fever refuse to sleep except on the lap. The fever is marked by accelera- tion of the pulse, which rises to 100, 110, or more in children over five years of age, and to 120, 130, or 140 in those under that age, and by un- usual warmth or even heat of the skin. At the same time the respiration is generally more frequent than natural, but almost always regular ; in cases attended with high fever, we have counted the breathing at 42 and 50. Auscultation reveals pure vesicular murmur or slight sibilant rhon- chus. The voice is clear, or, in rather severer cases, obscured and nasal, and in some instances, speaking is painful and difficult. Cough is a fre- SYMPTOMS. 347 quent symptom. It has beeu present iu a great majority of the cases ob- served by ourselves. Iu some of these it was harsh aud croupal, so that the childreu seemed threateued with croup. The croupal souud seldom laj?ted over oue night, after which the cough was merely hoarse, aud grad- ually became loose towards the termination of the attack. In the remain- ing cases it was rare and dry iu the beginning, and more frequent and looser as the disease progressed. Pain is a frequent, but far from constant symptom at the outlet of the disease. It generally exists during degluti- tion. When present it is shown in infants, as stated, by their refusing the breast, or nursing only at long intervals, and with difficulty ; while in older childreu it is complained of. It is not, however, a constant symp- tom, as we have often seen children of one, two, and three yeai*s old, with severe angina productive of violent fever, who swallowed fluids and soft solids without a sign of pain. Throughout the acute period of the dis- ease there is generally considerable thirst; the appetite is diminished or entirely suppressed ; the stools are usually natural, or there is slight con- stipation. The throat should always be examined when there is the least reason to suspect that an attack of sickness depends upon inflammation of that part, and whenever a child has been seized suddenly with fever, particularly in cold weather, and there is nothing more evident by which to explain the illness. To examine this part well, the tongue must be strongly depressed with the handle of a .«poon, which should be carried back to the base of the tongue. This may be done in the youngest infant. The appenranees presented by the throat areas follows: The soft palate, uvula, tonsils, and generally the pharynx also, are more or less reddened and swelled, and the mucous membrane commonly looks rough and gran- ular. The fauces are often filled with frothy mucus, and in severe cases coated all over with mucous or purulent secretions, which sometimes line the inflamed surfaces in such a way as to resemble false membranes. They are to be distinguished only by careful examination, and by remov- ing a small portion on a pencil or sponge-mop, in order to ascertain their real nature. We have seen the mild form of inflammation in a child ten days old, in one eight weeks, another three months, and a fourth nine months old. Dr. Wertheiraer {Jour, fur Kinderkrankheiten, Band xxxii) calls atten- tion to a variety of angina, which he calls a'dematous, and which is spe- cially characterized by serous infiltration of the submucous tissue of the pharynx, the mucous membrane itself being pale and smooth, and soft and .nicky to the touch. The submaxillary (/lands and neighboring cellular tissue are sometimes swollen, in conse^juence of the extension of the inflammation to them. This is often evident to the eye, but it is more correctly judged of by the touch. At the same time the glands are usually somewhat painful to the touch. The* amount of swelling is slight in very mild cases, or there may be none at all. In severer cases it is much more considerable. The breath is said to be often fetid. We have not met with this char- a.rtcT in the simple disease. Expectoration is rarely present. We have SIMPLE PHARYNGITIS. never noticed it under six years of age. Slight nervous symptoms occur in nearly all the cases, consisting, as already stated, of restlessness and irritability in mild attacks, and of insomnia or drowsiness, with starting and twitching, in those which are more severe. The fever generally occurs at first only in the after-part of the day and during the night, often becoming intense at that time, with restlessness and starting, and subsiding or disappearing entirely towards morning, to recur again the next afternoon or evening. Children not unfrequently play about all the early part of the day, and are attacked with the symptoms just mentioned as night comes on. The disease generally pursues this course for three or four days, and then passes away entirely or, if it lasts beyond that time, the fever becomes continued, and the attack runs on for seven, eight, or ten days. In grave cases of simple angina, the disease begins with vomiting, fever, and severe nervous symptoms, in the shape of excessive restlessness, or som- nolence, and occasionally convulsions. The fever is violent, the pulse being very frequent and full, and the skin hot and flushed. The intense heat and flushing of the skin, which in sanguine children sometimes affects the greater part of the surface of the body, together with the activity of the circulation, not unfrequently make the onset of the disease resemble very closely that of scarlet fever. Four cases of this kind that have come under our notice presented severe nervous symptoms at the invasion. In a girl between two and three years old, they consisted of wildness and ecstatic expression of the face, and trembling uncertain movements of the limbs, which would probably have terminated in convulsions, but for the timely interposition of a warm bath. In the three others, general convulsions occurred. Two of the subjects in which convulsions took place were be- tween five and six years old, and one betweep three and four. In two the convulsions occurred at the onset, and in a third on the second day. The convulsive movements lasted from ten to twenty minutes, and were fol- lowed by somnolence for a few hours in two, and by stupor for a day in the third. It should be stated, however, that two of these subjects were predisposed by constitution and temperament to spasmodic attacks, as one had had a fit previously from a similar cause, and the other two from diffi- cult dentition. The third had never suffered from any symptoms of the kind, and did not appear predisposed to them. The tongue is generally dry and coated with a thick whitish fur in grave cases ; the respiration is quick, loud, and nasal ; and the voice gut- tural or nasal, and difficult. There is usually extreme thirst, and not unfre- quently delirium. The throat is commonly violently inflamed, of a deep- red color, and coated over with mucous or purulent secretions. The sub- maxillary regions are often swelled, and the deglutition sometimes, though not always, difficult. When the disease proves fatal, the different symptoms soon reach their height, and death may occur in two or three days. We have never, however, known simple pharyngitis to terminate fatally. The duration of the grave cases is variable. In the four that we have noted, it was between three and eight days. ,Secondary pharyngitis, which, as has been stated, is a very frequent DIAGNOSIS — PROGNOSIS — TREATMENT. 349 disease, will be treated of iu the articles on the various diseases in the course of which it occurs. Diagnosis. — The diagnosis of simple pharyngitis is not always without difficulty, a^ there are no local symptoms in two-thirds of the cases at the invasion, nor in some instances at any period of the attack. The physi- cian and attendants, therefore, are often deceived as to the real cause of the violent fever which has so suddenly made its appearance, and are dis- posed to refer it to any but the true one. It has happened to us several times in cases of children attacked with simple angina, to suspect pneumonia from the sudden occurrence of fever, rapid respiration, slight, dry cough, and the absence of pain iu the throat, difficulty of deglutition, or other symptoms, to call our attention to the real seat of disease. The diagnosis is to be corrected only bj^ the absence of the physical signs of pneumonia, and the consequent necessity of find- ing some other cause of the sickness. Angina may be mistaken also for indigestion, which is one of the most frequent causes of sudden fever in childhood, and is accompanied, like severe angina, by vomiting. The dis- tinction between the two is to be made by careful inquiry as to the history of the attack, by examination of the matters ejected from the stomach, and by inspection of the throat. Severe cases, particularly when ushered in by convulsions, may be mistaken for disorder of the nervous system dependent upon dentition. The only method of ascertaining the truth is again the inspection of the throat. Cases of this kind might also be mis- taken for the beginning of scarlet fever. Time only, and the development or absence of the symptoms peculiar to the latter disease, could enable us to determine the diagnosis. The diagnosis between simple and pseudo-membranous pharyngitis will be given under the head of dij)htheria. Prognosis. — Simple pharj'ngitis of moderate severity is very rarely, if ever, a fatal disease. Severe or grave erythematous pharyngitis, on the contrary, is often a dangerous malady. The four cases that have come under our care, however, all recovered. The unfavorable symptoms in such cases are : very violent fever, greatly altered physiognomy, difficult respiration, choked and guttural voice, excessive jactitation, delirium, con- vulsions, and coma. Tr.EATMENT. — Mild cases of simple angina need but little treatment. The child ought to l)e confined to a warm room in all cases, and kept in bed, or on the lap, if it have fever. The diet must be restricted to milk preparations and bread, so long as the fever continues. The therapeutical part of the treatment may consist in the use of some mild cvacuaiit, as one or two teaspcKjnfuls of castor oil, half a teaspoonful or a teaspoonful of magnesia, a small quantity of syrup of rhubarb, or what is all-sufficient iu many cases, a simple enema. At the same time we may give, if the frequency of pulse, heat of skin, and restk^^sness be considerable, a few doees of spirit of nitrous ether, or spiritus Mindereri, alone, or cond)ined with from one to four drops of antimonial wine, according to the age. A warm bath, if the child is not afraid of it, is an admirable remedy when there is much excitement of the circulation ; or a ft-bath, containing 350 SIMPLE PHARYNGITIS. salt or mustard, may be used. Frictions over the throat and neck are often very advantageous ; they may be made with hartshorn and sweet oil, 'with or without the addition of laudanum, or a small quantity of spirit of turpentine may be applied upon the skin, so as to produce slight counter- irritation. When there is much pain and difficulty of deglutition, the case is best treated by the use of nitrate of silver in solution (5 or 10 grains to the ounce), or of powdered alum, applied by means of a large throat- brush. In the severe form of the disease the treatment must be much more active than in mild cases. When the fever is very high, and threatening nervous symptoms are present, the most speedy means of controlling them is a warm bath, continued for fifteen or twenty minutes. If the effects of this should be slight or transitory, one or two leeches may be applied behind the angles of the jaw, unless the fright and consequent resistance on the part of the child are so great as to render their application objectionable. Some evacuant dose should be given early in the attack ; it may consist of castor oil, magnesia, epsom salts dissolved in lemonade, fluid extract of senna, or infusion of senna and manna. The quantity must be sufficient to produce several copious stools, and should it fail to operate in three or four hours, and the fever continue, it is always well to assist it by means of a purgative enema. Two hours after the exhibition of the cathartic, it will be proper to resort to small doses of sulphuret of antimony with Dover's powder, repeated every hour and a half or two hours, in the man- ner recommended in the article on pneumonia. If the secretions into the fauces be very abundant and tenacious, so as to impede respiration, the best means of getting rid of them is by an emetic of ipecacuanha or alum. If they collect again, the throat ought to be cleansed from time to time with a small sponge-mop. The inflamed surfaces should be touched two or three times a day with a solution of nitrate of silver (from five to ten grains to the ounce). The late Dr. C. D. Meigs was in the habit of employing with much benefit, in the severe angina of children, whether idiopathic or secondary, a wash made according to the following formula : R. — Cupri Sulphat., Quinise Sulphat., aa, gv. vj. Aquge Destillatse, ....... f^j. — M. This is applied in the same way as the lunar caustic solution, and we have frequently seen it produce most excellent effects. The four grave cases observed by ourselves recovered under very simple treatment. This consisted in the use of the warm bath, of doses of castor oil to move the bowels freely on the first day, and of syrup of rhubarb or enemata afterwards to keep them soluble ; of doses of antimonial wine and nitre every two hours in such quantity as to avoid sickness ; of mustard foot-baths ; stimulating frictions to the outside of the throat ; applications of lunar caustic solution to the throat internally, three or four times a day; and of rigid diet. In one case the warm bath was used three times in a single day, because of the extreme restlessness and heat of the skin, and was productive each time of much benefit. I RETROPHARYNGEAL ABSCESS. 351 ARTICLE VIII. RETROPHARYNGEAL ABSCESS. This name is applied to collections of pus formed in the cellular tissue between the posterior wall of the pharynx and the vertebral column. More frequently the abscess is seated quite high up on the level of the glottis, though cases are recorded where it occupied a lower position be- hind the oesophagus. Causes. — Retropharyngeal abscess occurs idiopathically, or as a sequel to some of the specific fevers, or, more frequently, in connection with caries of the cervical vertebrie. In one of our own cases, it followed directly upon a long sleigh-ride, and was due evidently to the severe chilling of the body. Although it cannot be regarded as a disease peculiar to child- hood, it is far more frequent in the first ten years of life than during any subsequent decade. Symptoms. — The early symptoms are irregular and not characteristic. In cases where the abscess is connected with caries of the cervical vertebra?, the symptoms of this latter condition have preceded. In all cases, how- ever, the fii-st indications which lead to a suspicion of the existence of a post-pharyngeal abscess are gradually increasing difficulty of swallowing and of respiration, which is attended with a loud, stertorous sound, unlike the stridulous breathing of croup. There is also marked stiflTness of the neck, and the head is rigidly retracted. Any effort to bend the head for- ward is followed by urgent increase of the dyspncea, and the same result ha.-^ been noticed to follow when the recumbent position was assumed. There is an appearance of fulness on one or both sides of the neck behind the angle of the lower jaw. Of course the child presents a high degree of restlessness and distress, which increases until the interference with breathing and swallowing may prove fatal from combined exhaustion and asphyxia. In the presence of such symptoms as the above, a careful ex- amination of the pharj'nx, both by direct inspection, if possible, and by the finger, should immediately be made. The mouth is usually filled with mucus, but the swelling of the pcjsterior wall of the pharynx may frequently be seen projecting forward so as to constrict the pharyngeal space, and obstruct more or less the opening of the glottis. The finger, if carried back over the root of the tongue, comes in contact with a rounded swelling, which is in the early stages firm and somewhat elastic, and later becomes fluctuating. When the abscess is fully formed, the most prom- inent point may appear yellowish. Occasionally, in the course of caries of the cervical vertebne, perforation of the posterior wall of the |)harynx occur* without being precedofl by any such wvere symptoms as have just been described as due to post-pharyngeal abscess. We have thus known the expectoration of purulent matter with small fragments of carious bone, to occur in such cases without any previous symptoms of marked obstruc- tion in swallowing or breathing. 352 ABSCESS. Diagnosis. — The recognition of this affection is often difficult, and it is only by bearing in mind the possibility of its occurrence, and making care- ful examination with the finger, that we can avoid overlooking its existence, in cases where the symptoms are not clearly pronounced. In all cases, therefore, where difficulty in swallowing is superadded to dyspnoea, such an examination should be made. The affection with which it is most likely to be confounded is membranous croup, but the absence of the peculiar croupy cough and stridulous breathing, and the existence of dysphagia, retraction of the head, with immobility of the neck, fulness at the angle of the lower jaw, and, finally, the detection of the swelling at the back part of the throat, will render the diagnosis easy. Prognosis. — The termination is always doubtful. When, however, the existence of the abscess is early recognized, and it is promptly evacuated so soon as fully formed, recovery frequently ensues. Even when connected with caries of the vertebrae, the prognosis, although of course unfavorable from the nature of the primary disease, is not necessarily fatal. In the case already referred to as having followed directly upon long exposure to severe cold, the child was very ill, with all the characteristic symptoms of this affection, for a week, after which the abscess burst spontaneously, and the child recovered. Treatment. — The approach of a post-pharyngeal abscess can rarely be detected so early as to enable any preventive treatment to be adopted with success. Indeed, but little could be expected from the use of mild counter- irritants, or absorbent applications to the throat. In older children, if rec- ognized before suppuration has occurred, some benefit might be derived from the use of one or two leeches to the angles of the jaw, or of a blister to the back of the neck. The use of small pieces of ice held in the mouth will also be found to afford relief. The main indication, however, is to watch for the occurrence of suppuration, and then to make as early an in- cision as possible. When the seat of the abscess is high up this may be done by an ordinary sharp-pointed bistoury, whose blade is guarded up to near the point by being wrapped with sticking-plaster. When the abscess is lower down it can sometimes be more safely reached and evacuated by a trocar and canula. As the opening should be small, there is danger of its closing with a reaccumulation of pus ; and it is therefore advisable, as recommended by West, to press with the finger upon the sac of the abscess occasionally for a day or two. In cases dependent upon caries of the vertebrse, it is better to postpone opening the abscess until urgent symp- toms are produced by it. Here also it is necessary to employ the other means of treatment suitable for that condition, and especially the use of some mechanical contrivance by which the weight of the head can be supported, and thus relief be afforded to the cervical spine. During the course of the disease every effort must be made to sustain the strength of the patient. If the interference with swallowing be extreme, nutritious enemata may be used until the abscess can be evacuated. In addition, we must use opiates in sufficient amount to quiet the excessive pain and restlessness. INDIGESTION. 353 CHAPTER 11. DISEASES OF THE STOMACH AND INTESTINES. GENERAL REMARKS, In our division of these diseases, we shall treat first of Indigestion, using this term to signify morbid conditions of the digestive function, which we suppose to be the result of functional disorder, or of mild, acute or chronic catarrh of the stomach. Under the title of Gastritis we shall describe the much more rare and dangerous form of disease, in which there is acute in- flammation of one or more of the coats of the stomach, and which is sel- dom met with except as the consequence of the application of some direct irritant to the organ. We shall then describe Simple Diarrhoea, in which we suppose the in- testinal disorder to be either merely functional, or one of slight catarrhal inflammation of the mucous membrane. Next, under the title of Entero- colitis or Inflammatory Diarrhwa, we shall treat of that form of diar- rhoea which is now by many writers styled acute or chronic catarrh of the intestinal mucous membrane, and the chronic forms of which we be- lieve to be of the same nature as the disease designated by most of the observers whose experience was gathered in the vast field of the late war, chronic diarrhoea. We shall pass on then to Cholera Infantum, limiting this term to cases in which the disease is of a true choleraic type ; and, lastly, we shall consider Dysentery. We have also added separate arti- cles on the diseases of the Caicum and Appendix Vermiformis, and upon Intussusception. SECTION I. FUNCTIONAL DIf«EA8E8 OR MILD CATARRH OF THE STOMACH AND INTESTINES. ARTICLE L INDIGESTION. Definition ; Frequency ; Forms.— By the term indigestion, wc mean that condition of the stomach in which ita function of digestion is dis- turbed or suspendwl, independent of inflammation or other disease of the organ, appreciable by our senses; or in which there has been found after 28 354 , INDIGESTION. death, in the few opportunities that have been met with to make such an investigation, the lesions which are now usually designated as mild gas- tric catarrh. The only anatomical alterations found in such cases, are reddening of the mucous membrane in spots by a fine injection, relaxation of its tissue, and the presence of a layer of tough mucus. It is a very fre- quent affection during the whole period of childhood, and is one of great importance on this account, and from the fact of its laying the constitution open, by the debility and cachexia which it produces, to various secondary affections. In our description of the disease, we shall distinguish between the forms which occur during infancy, and after the completion of the first dentition. Causes. — The principal causes of indigestion in infants are an un- healthy state of the milk of the nurse^ the use of artificial diet, and lastly, an impaired condition of the digestive function, which disables the stomach from digesting even the most healthful aliment. The milk of the nurse may be too old for the child, for it has been found that a breast several months old, sometimes, though not always, disagrees with a young infant, in consequence, no doubt, of the milk being thicker and richer at that time than immediately after parturition. The breast- glands may continue to secrete colostrum for weeks or even months after parturition, and when this is the case the child is almost sure to suffer from indigestion and diarrhoea. The milk may be unwholesome because the nurse is in bad health, or because her diet is not properly regulated. That the diet of the nurse affects her milk, we have no doubt, though it has been denied by some persons. We have known several children to suffer from indigestion, attended with vomiting, acid secretions, colic, and diarrhoea, in consequence of the nurse having indulged in a very rich diet, and particularly in vegetables and fruits. We do not mean to assert that all nursing-women should abstain from fruits, or even live on a very simple diet, for we have known some who could make use of the richest food, and eat abundantly of all kinds of vegetables and fruits, without the least injury to the child. But there are others who cannot do so without occasioning indigestion in their infants, because, probably, their children are unusually susceptible to the action of the materials absorbed from that kind of food. Again, it is clearly proved by recorded cases and by the opinions of various authorities, that the milk of the nurse i& affected by her moral condition. Children have been known to suffer greatly, and even to die, from taking the milk of a nurse who had just before undergone a fit of violent anger. The depressing moral emotions, as anxiety, grief, fear, and despair, are well known to affect the milk secretion in such a way as sometimes to occasion indigestion. The use of artificial diet for young infants, or as the expression is, " bringing up on hand or the bottle," is, we believe, by far the most fre- quent cause of indigestion during infancy. Very many children with whom this is attempted, die of indigestions, chronic diarrhoea, gastritis, entero-colitis, cholera infantum, and thrush. Very few escape frequent attacks of one or other of the diseases just named. Much depends, no doubt, on the selection and preparation of the food. It may be stated as 1 SYMPTOMS. 355 a well-established fiict, that a diet consisting wholly or in a groat part of farinaceous substances, very rarely fiiils to disagree with the child, and to produce indigestion and other disorders of the digestive system, which often prove fatal ; while one in which cow's or goat's milk enters as the principal ingredient, though inferior to the natural aliment, and often pro- ductive of indigestion, is tar less injurious than the one before spoken of. A third cause of indigestion was stated to be the absence or loss of the digestive power of the stomach, independent of the nature of the food. This is a condition similar to the dyspepsia of the adult. It may be con- genital or may result from causes brought into action after birth. It often remains as a consequence of previous indigestions from improper or exces- sive feeding. It exists during the invasion, course, and convalescence of various diseases. Dentition frequently diminishes or impairs the tone of the digestive function, so that the child is often unable, during that pro- cess, to digest aliment which had agreed with it perfectly well at other times. The causes of indigestion after the completion of the first dentition are congenital feebleness of the digestive function ; a certain want of power of that function, which remains often for years in children reared upon arti- ficial diet, and in those who have been debilitated by frequent attacks of disease of any kind ; the habitual use of improper diet ; the eating of crude, indigestible food ; the process of the second dentition ; the want of due exercise in the open air; residence in large cities; and undue exercise of the mental faculties in the conduct of the education of the child. Symptoms. — We shall describe first the symptoms of indigestion as it occurs during infancy, and secondly as it occurs during childhood, or after the completion of the first dentition. Indigestion during infancy may be advantageously considered under two heads: as occasional or accidental, and as habitual. By the former we mean that which occui-s in a healthy infant from a transient cause, such as repletion or a momentarily unhealthy state of the nurse's milk from some imprudence on her part as to diet, from some moral cause, or from sickness; and that which depends upon the passing influence of dentition. By habitual indigestion, we mean the form of the affection which is long continued in consequence of a persistence of the cause. The symptoms of occasional or accidental indigestion in infants are : paleness and contraction of the face; restlessness and peevishness; moan- ing and cr\'ing, or in some ca.ses, screaming; nausea, shown by excessive paleness, often by very great languor, and by occasional retching, which may either subside without vomiting, or as more fre(iuently happens, ter- minate in that act; flatulent distension and hardness of the abdomen, especially in the epigastric region, often accompanied with eructations; and in many of the cases simple diarrhoea. These symptoms usually com^ on soon after nursing freely, or after a very hearty meal of artificial food, in a child previously in good health. The attack seldom lasts more than a few hours or one or two days. The vomiting which almo-^t always takes place, and which relieves the stomach from the offending cause, very often accomplishes the cure. 356 INDIGESTION. Habitual indigestion in infants causes a train of symptoms which are different from and much more severe than those just described. Of these the most important are : frequent attacks of nausea and vomiting, and of simple diarrhoea repeated for days, weeks, or months in succession ; pale- ness, or some other unhealthy tint of the cutaneous surface ; continual restlessness and discomfort, with fretting or crying, particularly in the after part of the day and during the evening and night, in place of the natural ease and quiet of a healthy infant; constant fits of the most violent scream- ing from colic, sometimes lasting for hours ; dull and languid expression of the countenance, or else an uneasy, contracted look, like that produced by continued suffering; more or less emaciation ; failure of the natural growth in stature and size, so that the child is small and puny for its age ; want of calorific power, causing the child to suffer unusually from cold, as shown by frequent coolness of the hands and feet ; irregular appetite, which makes it necessary to tempt by frequent changes of the food, or more or less com- plete anorexia; and lastly, the various symptoms that indicate an impover- ished state of the blood and bad nutrition. In some cases there are added to the above symptoms, or there follow as a consequence of the indigestion, those of gastritis or entero-colitis, to be hereafter described. Indigestion probably seldom proves fatal in infants, except from the occurrence of some inflammatory complication, as for in- stance, one of the diseases just named, or acute disease of some other prin- cipal organ. Indigestion in children who have completed the first dentition may, as in the case of infants, be occasional or habitual. Occasional indigestion occurs in strong and vigorous, as well as in more delicate subjects. The attack generally begins, within a few hours or a day after the child has eaten some indigestible substance, with languor and chilliness in older children, and with languor and peevishness in those who are younger; after which there is headache, pain in the stomach in most of the cases, and very often a disposition to somnolence. If the child is attacked with vomiting soon after the appearance of these symptoms, and ejects the of- fending material, it will often seem perfectly well from that time. If, how- ever, this does not take place, fever, sometimes of a violent character, is almost certain to make its appearance. The pulse becomes very frequent, rising to 120, 130, 160 or over, and being full and resisting; the skin be- comes flushed, dry and very hot ; the appearance of the tongue is not gen- erally changed early in the attack; there is considerable thirst; the child is restless and uneasy, tossing from side to side, or it lies in an uneasy sleep, attended with frequent starting and jerking of the limbs or crying out; the abdomen is i^atural, or hard and distended over the epigastric region. When the symptoms just described make their appearance sud- denly, by which we mean in the course of a few hours, in a child two, three, four or five years old, after it has eaten some indigestible substance, there is reason to fear an attack of convulsions. The probability of the occurrence of this accident is great in proportion to the earliuess of the child's age, and the impressibility of its nervous system. The attack is particularly to be apprehended, and should be carefully guarded against, DIAGNOSIS. c57 whenever the fever is violent, especially if the pulse runs very high, when there are urgent complaints of headache, when the restlessness and agita- tion are very great, or when there is somnolence, with frequent startings or twitchings of the muscles. Convulsions sometimes occur without any pre- vious warning, or after such slight signs of disorder as would fail to pro- duce uneasiness in the parents or attendants. The symptoms produced by occasional indigestion generally continue until nature relieves the stomach by vomiting or diarrhcea, or until the remedies pro|3er in the case, the most important of which are evacuants, have been administered. It happens not unfrequently, that symptoms of gastric or intestinal disorder remain for some days after the violence of the attack has subsided, and in some instances the disturbance is so great as to occasion gjistritis, entero-colitis, or dysentery. Habitual ind'njedlon in children who have completed the first dentition, is not at all an uncommon affection. It is a condition analogous to, if not identical with, the dyspepsia of the adult. The symptoms of this form are the following. The general appearance of the child is delicate, as shown by a pallid or sallow tint of the skin, instead of the ruddy complexion of health, by thinness and want of proper development of the limbs and trunk, and by softness and flaccidity of the muscular tissues. There is an habitual air of languor and listlessness, with absence of the usual gayety and disposition to play natural to the age, and the child often complains of being tired. The appetite is feeble or uncertain, being sometimes absent, and at other times too great; or it is peculiar, there being a willingness to eat of dainties, but a refusal of food of a simple character. The tongue presents nothing }>eculiar. It is, however, more frequently somewhat furred than clean and natural. The temper is usually irritable and un- certain. The child rarely sleeps well ; on the contrary, the nights are restless and much disturbed, the sleep being broken and interrupted by turning and rolling, by moaning or crying out, and by grinding of the teeth. These latter symptoms, together with picking at the nose, which is a frequent accompaniment, are almost always referred by the parents and nurses to worms, and it is often impossible to convince them to the contrary, even though frequent and violent doses of vermifuges have failed to show the existence of entozoa. The state of the bowels is uncertain. In gome instances they are very much constipated, requiring frequent doses of laxatives, or careful regulation of the diet, to keep them soluble; in others they are inclined to be loose, and when this happens, the stools are often lienteric. In others, again, constipati(jn and diarrhea alternate. The alxlomen is usually natural, or somewhat enlarged from flatulent dis- tension ; complaints of pain are not uncommon. This form of indigestion, like dyspepsia in the adult, is generally a very chronic affection, seldom la-ting less than several weeks or months, and sometimes persisting for years. DiAGNOSLS. — The occasional indigestion of infants is not likely to be mistaken for any other complaint. The suddenness of the attack, the character and quantity of the matters ejected from the stomach, the ab- sence of symptoms indicating the invasion of any other disorder, the short 358 INDIGESTION. duration of the symptoms, and the rapid recovery, all render the true nature of the case very clear. That which occurs in older children, on the contrary, is not so easy of diagnosis. In many cases the invasion is not unlike that of scarlet fever. The vomiting, the rapidity of the pulse, the great heat of the skin, and in some cases a certain suffusion of the in- tegument dependent on the activity of the circulation, all render the case doubtful for some hours, or for a day, after which time the difficulty ceases, from the development of the symptoms peculiar to the disorder. We believe that not a few cases of simple angina are mistaken for indiges- tion, owing to the absence of complaints of sore throat, and the neglect of the physician to examine that part. In such cases the vomiting and sud- den attack of fever are ascribed, for the want of another mode of explain- ing them, to gastric derangement. The diagnosis can be made only by examination of the fauces. The diagnosis of indigestion accompanied by convulsions, will be considered in the article on the latter affection. The habitual indigestion of infants is not likely to be confounded with any other disease. The absence of fever, of tenderness of the abdomen on pressure, or other acute symptoms, all indicate the dependence of the dis-' order on functional distress of the stomach. The same remarks apply to this form of the disease occurring in older children. Nevertheless, the practitioner should never neglect to make a careful examination, both of the physical and rational signs, of all the important organs of the body, as it sometimes happens that latent disease of some one of them is the cause of the gastric difficulty. Prognosis. — The prognosis of occasional indigestion is nearly always favorable. It is rarely a dangerous disorder, unless accompanied by con- vulsions, or some other sign of violent disturbance of the nervous system. Under the latter circumstances, the prognosis should be very cautious, as the termination is not unfrequently fatal in consequence of injury done to the nervous centres. . It should be recollected also that this form of indi- gestion sometimes becomes the exciting cause of inflammation of the stomach or intestines, in which event the prognosis will be that of those diseases. Habitual indigestion in infants is a serious complaint, and ought always to awaken the solicitude both of the physician and parents ; for though a simple functional disease of the stomach is probably not often fatal, it is exceedingly apt to prove so by the introduction of gastritis, chronic enteritis, entero-colitis, or thrush, or by its laying the system open to other diseases, and rendering it less able to withstand them should they happen to occur. In older children it is not, according to our experience, so dangerous a malady. We have never, as yet, seen it terminate fatally. Treatment. — The treatment of occasiojial indigestion in infants ought to be very simple. The child has generally relieved itself by vomiting before the physician is called. If, however, it continues pale and languid, with vomiting or retching, after the stomach seems to have been emptied, the proper plan is to make use of remedies to calm the irritability of that organ. This can almost always be accomplished by giving a teaspoonful every ten or fifteen minutes of a mixture of lime-water and milk, consisting of one-third milk to two-thirds lime-water, or of equal proportions of each, TREATMENT. 359 or the saaie doses of a mixture cousisting of equal parts of lime-water and ciuuamou-water. At the same time a small mustard plaster, weakened with wheat flour, or flannels wrung out of hot brandy and water, may be applied to the epigastrium, or a warm Indian mush poultice, in a flannel bag, laid over the whole abdomen. Should these means fail to relieve the sickness, from half a drop to a drop of laudanum, or ten drops of paregoric, may be administered, and repeated, if necessary, in two houi-s. The child generally recovers its usual health after the sickness has entirely ceased. If, however, it remain fretful and uneasy, if it cry much as though in pain, it is probable that a jwrtion of aliment has passed, in a partially or wholly undigested state, into the intestine. The suspicion will be confirmed if the abdcvmen is found, upon palpation and percussion, to be swelled, hard, and resonant from flatulent collections in the bowels. Under these cir- cumstances, a laxative ought to be given. The best dose is half a tea- spoonful or a teaspoonful of castor oil, a teaspoonful of simple or spiced syrup of rhubarb, or, if there have been evidences of an acid state of the stomach, about a quarter of a teaspoonful of the best magnesia. The occasional indigestioii of older children demands a different and more energetic treatment. After ascertaining that the child has eaten something indigestible, we should inquire whether there has been vom- iting. If there has been none, or if only slight, it will be proper to give an emetic immediately. The best one under the circumstances is ipecac- uanha. This rarely fails to produce a full efl^ect, and does not perturbate the system, or irritate the stomach, like tartar emetic. It may be given either in powder or syrup. The dose is familiar to every one. If the ipecacuanha be not at hand, we may use hive syrup, which is kept in al- most every house, or a teaspoonful of powdered alum in honey or molasses, t« be repeated, if necessary, in fifteen minutes. Alum is less apt to fail than either ipecacuanha or hive syrup. If the child continue unwell after the operation of the emetic, which is often the case, and particularly if the fever be considerable, a purgative should be given as soon as the stomach will bear it. The best dose is castor oil, which is the most speedy and least irritating. It may be given in orange-juice, which forms an excellent vehicle, or, if the child is old enough, in the froth of beer or porter. A dessertspoonful is generally enough. If the oil cannot be taken, we may give infusion of senna and manna, the fluid extract of senna mixed with spiced syrup of rhubarb, syrup of rhubarb alone, magnesia, to be followed by lemonade, salts and magnesia, or the former alone, or, lastly, a seidlitz powder. If the fever continue, and the cathartic fail to operate in four or six hours, a purgative enema ought to be given to hasten its eflfoct. A hath at about 96' or 97° will almost always be found useful in these cases. The child should be kept in the bath from eight to twelve or fifteen minutes. The only circumstances which form an objection to this remedy are the facts of the patient being so irritable, or so fearful of the water, as to make it necessary to contend with him in order to succeed in using it. When this is the case, it had better not be employed, and spong- ing with tepid water and spirit should l>e substituted. If the child com- 360 INDIGESTION. plains of pain io the stomach, the application of a warm mush poultice over the epigastrium or whole abdomen will be found of much service. When in this form of indigestion the febrile reaction is violent, as it often is, and particularly when there are signs of great disturbance of the nervous system, consisting of excessive agitation, complaints of severe headache, drowsiness, moaning or crying out in the sleep, or twitching and jerking of the muscles, the ph5'sician should beware of a convulsive attack. In such cases as these, the patient ought to take a purgative dose of calomel (from two to three grains), or a dessert-spoonful of castor oil, have a warm bath at once, and soon after an injection. The remedies ought to be prompt and energetic, for the case is pressing. A convulsion is always a dangerous event in childhood, and should be prevented if pos- sible. If calomel has been given, a cathartic dose ought to be adminis- tered about two hours afterwards, in order to insure an action upon the bowels, and to carry the calomel out of the system. After the adminis- tration of an evacuant, a full dose of bromide of potassium (ten to fifteen grains) should be given, and as this remedy has the very great advantage of not arresting the action of the medicines previously administered, it may be repeated as frequently as indicated by the nervous symptoms. These means rarely fail to afford relief in a few hours. The diet should be absolute during the violent stages of the attack, and the usual diet is to be resumed only by degrees. The drinks may be plain water or gum- water, taken cold. It not unfrequently happens that occasional indigestion is followed by gastritis or enteritis, or by habitual indigestion lasting for weeks or even mouths. These different sequelae must be treated according to the plan proper for each. The habitual indigestion of both infants and older children, requires a very different treatment from the occasional or accidental form. In both the indications are nearly the same. The most important are very careful regulation of the diet in all its details, the use of tonics and stimulants to restore tone and vigor to the digestive function, the employment of reme- dies to correct the state of the bowels, whether they be relaxed or consti- pated, and attention to securing the child proper exercise, exposure to the air, and suitable clothing. If the symptoms of the disorder occur in a child at the breast, the milk of the nurse should be carefully examined, in order to ascertain whether it be good. If found to possess any unhealthy qualities, the nurse ought to be changed at once. Attention to this point alone will almost certainly cure the child. It needs no other remedy. If the patient is fed wholly or in part, it is essential to regulate the diet to suit the state of the digestive function. Milk ought in all cases to form the basis of the food, unless it has been found by patient trial to be abso- lutely repugnant to the stomach. We have often found that infants who had been thought quite incapable of digesting cow's milk, could do so very readily when it was very much weakened with water. The usual proportions for an infant of a few months old, are half and half, or two parts milk for one of water. When these are found to disagree, it is well TREATMENT. 361 to try three, or even four or five parts of water to one of milk, and if the stomach digest this, as it often will, the proportion of milk may be slowly and cautiously increased to the usual standard. If we conclude that milk cannot be digested by the child, it is best to try cream. Of this, one part to three or four of water may be given. When neither of these can be taken, some of the farinaceous substances may be tried ; arrowroot, sago, barley, tiipioca, oatmeal, or rice. We are clearly of opinion, however, that these articles prepared with water alone, never agree with children when they are continued for any considerable length of time. Some in- fants? of six or eight months old, it may be remarked, who cannot digest more than very small quantities of milk, will take and digest well, very delicate broths made of chicken or mutton, or small quantities of the lightest meats, as mutton, chicken, or very tender beef, minced up ex- tremely fine, and given by teaspoonfuls. In cases of this kind we have found a diet consisting of gelatin, milk, cream, and arrowroot, prepared in the manner directed in the article on thrush, to suit better than anything else. We have met with a number of children, whom it was necessary to feed to the amount of a pint or a pint and a half a day, in addition to their being nursed occa- sionally, who could take neither milk and water, cream and water, milk and arrowroot, oatmeal gruel, rice gruel, nor indeed anything that was tried, without vomiting, colic, and severe diarrhoea, who digested perfectly well and throve admirably upon the preparation alluded to. We have now used it during many years, and have recommended it for a great many children, and do not h*esitate to say that it agrees with a larger number than any diet we have employed or seen employed. The diet of older children laboring under chronic weakness of the di- gestive function is as important as that of infants. Two chief ends should always be borne in mind in selecting it, digestibility and nutritiousness. The former is all-important, for without it, the stomach, constantly irri- taleil by impro|)er food, has no chance of regaining its tone, while the latter is neces-sary in order to sustain the strength of the child, and allow it to carry on it« growth. We have generally found it most prudent, and often really necessary, to si)ecifS' as to the substances to be given at each meal. The morning and evening meal ought to consist of bread and milk, mush and milk, or of milk, warm water and sugar (called in this country children's or cambric tea), and bread and butter, and nothing else in most of the cases. It is sometimes proper to allow a soft-boiled egermitted a choice amidst such profusion, pale, thin, delicate, exposed to frequent indigestions, attacks of diarrhoea and entero-colitis, to gastric fevers, and the host of minor ills attendant upon feeble digestive powers. We are acquainted with some families in this city, the children of which, from the ^ge of two years, are allowed habitually to breakfast upon hot rolls and butter, hot buckwheat cakes, hot Indian cakes, rice cakes, sausages, salt fish, ham, or dried beef, and coffee or tea : and to dine U|X)n a choice of various meats and a great variety of vegetables, which latter they often prefer to the exclusion of meat, and then to make a rich dessert of pies, puddings, preserves, or fruits ; and lastly to make an even- ing meal of tea and bread and butter, almost always relished, as the term is, with preserves, stewed fruit-«, hot cakes of some kind, or with radishes, cucumbers, or some similar dish. Add to such meals as the above, the eating between whiles of all kinds of candies and comfits, which many children here regularly expect in larger or smaller quantity, cakes both rich and plain, fruits to excess and at all hours, from soon after breakfast to just before going to bed, raisins and almonds, and nuts of various kinds, and the wonder is, not that we are a pale, thin, dyspeptic, and anxious- looking race of people, compared with Europeans, but that we have any health at all, when our children are allowed to make use of the indiscrimi- nate and unwholesome diet just described. Such a system undoubtedly occasions frequent attacks of the disease under consideration, and unless the diet be cbaoged early in the attack, it is very apt to become chronic. It has been stated that simple diarrhrea sometimes followed as a ronse- quence of indigestion. We have known such a result to occur in children previously in fine health, and to continue for several weeks or months. In these instances, the disr>rder ap[>ears to depend in good measure on the loss of the digestive power of the stomach. This seems proved by the great influence which the character of the ffx)d has upon the malady, whirh is always aggravated by the use of any articles except those universally ac- 366 SIMPLE DIARRHCEA. knowledged to be the most digestible, and also by the frequent coexistence of lientery when the food is not of the lightest kind. We have several times met with cases which we could ascribe to no other cause than debility and want of power of the digestive organs, de- pendent upon too rapid growth. That sudden and rapid growth may pro- duce feeble digestion, or, in other words, a dyspeptic state, is, in our opinion, proved by the following consideration. It is attended with loss of appetite, emaciation, paleness, languor, and weakness, and frequent attacks of diarrhoea, or a chronic form of that disorder ; all of which symptoms are greatly influenced by the regimen of the child, and are most readily removed by attention to that point, and by the use of tonics and stimulants. The other causes enumerated need but little comment. We will merely remark that we have several times observed a predisposition to weakness of the digestive organs, transmitted apparently from parent to child. As to the influence of the second dentition, we have no doubt that it is a frequent cause of the complaint, and we believe that it is too little attended to by practitioners. Anatomical Appearances. — It has already been stated that w^e look upon this disorder as one of purely functional disturbance in many in- stances. We are led to take this view by the fact that it is so often unat- tended by any of the ordinary signs of inflammatory action, and because some very competent observers aflfirm that they hav^ failed to find in a certain proportion of cases of fatal diarrhoea, any lesions appreciable to tlie senses. Thus, M. Billard says {Mai. des Enfants, p. 392) : " Many children at the breast have diarrhoea without enteritis ; they lose color, become etiolated, fall into a state of marasmus, and yet at the autopsy not a trace of inflammation of the intestines is found." M. Bertin {Mai. des Enfants, 2eme ed., p. 574) states that of 57 cases of gastro-intestinal dis- ease observed by himself, there were four in which not a trace of inflam- mation, or any other appreciable lesion of the digestive tube, could be found. MM. Rilliet and Barthez, in their first edition (t. i, p. 491) assert that in about every twelve children affected with more or less abundant diarrhoea, and in whom we might expect to find colitis, there will be one in whom the gastro-intestinal tube will be found in a state of perfect in- tegrity. They add that this conclusion is deduced from a comparison of nearly three hundred autopsies. We do not find this statement given in their second edition, but we do find there (t. i, p. 693) the following para- graph : "Quite frequently, especially in early infancy, in cases in which the symptoms have pointed to some disease of the gastro-intestinal tube, an autopsy reveals no lesion of the solids, or only changes of minimum im- portance. The secretions alone are vitiated." One must suppose, there- fore, that the class of cases which we describe as simple diarrhoea, are some- times quite independent of any anatomical changes in the tissues, recog- nizable by our ordinary methods of examination, or that those changes are so slight and so evanescent as to disappear after death ; or that they are those only of the mildest forms of catarrhal inflammation. It is not un- likely, it seems to us, that further and more minute investigation, especially ANATOMICAL APPEARANCES — SYMPTOMS. 367 with the microscope, will reveal tissue-changes which are not discoverable by the uuassisted senses. When the anatomical changes, constituting the catarrhal state, are found in children who presented during life the symptoms of simple diarrha^a, they will be such as are described by Niemeyer in the following passage : "Catarrh rarely atlects the entire intestinal canal. It is most frequent in the large intestine, less so in the ileum, and rarest in the jejunum and duo- denum. The anatomical changes left in the cadaver by acute catarrh, are sometimes pale, at others dark redness, swelling, relaxation, and friability of the mucous membrane, which is sometimes diffuse, at others limited to the vicinity of the solitary glands and of Peyer's patches, and a serous in- filtration of the submucous tissue. Occasionally, after death, the injection has entirely disappeared, and the mucous membrane appears pale and bloodless. Swelling of the solitary glands and glands of Peyer is an al- most constant appearance ; they distinctly project above the surface of the mucous membrane. The mesenteric glands also are usually found hyper- semic and somewhat enlarged. The contents of the intestines consist at first of plentiful serous fluid, mixed with detached epithelial and young cells, subsequently of a cloudy mucus, which is adherent to the wall of the in- testine, and contains epithelial structures." The best description that we are acquainted with of the anatomical ap- pearances found in the intestines in fatal cases of diarrhcea, not in children, to be sure, but in adults, is that given by Dr. Woodward in his work on Camp Diseases (Philadelphia, 1863). In that work (page 216), under the head of simple diarrhoea, he says that this form of diarrhoea is to be re- garded as usually the result of irritation of the intestinal mucous mem- brane, produced by the ingestion of improper food, or other causes men- tioned, and expressing itself in increased secretion throughout the intes- tinal tract. The irritation, he goes on to say, may even amount to inflammation. Opportunities for post-mortem examination occur but rarely. "They reveal little that bears on the nature of the disease, ex- cept congestion of the intestinal vessels of variable intensity." At page 246, will be found a description of the histology of the intestinal lesion in chronic diarrhoea, including the changes observed in specimens but moder- ately disea.sed, which latter would probably be the analogue of what we might expect to find in the simple diarrhoea of children we are now de- scribing. We mast refer the reader to the work it,self, as the passage is too long to be quoted in full here; but we cannot help thinking that Dr. Woodward's de-^criptions would apply also to the changes induced in chil- dren by like causes, and leading to similar forms of disease. Symi'TOJLS. — We shall describe first the symptoms of simple diarrhcta in infants, and afterwards those which characterize the disorder in older children. In infants the appearance of the diarrhcea is usually preceded or accompanied by slight disturbance of the temper and comfort of the child. There is some degree of restlessness, peevishness, and disposition to cry; the child sleeps less than usual, and often starts and moans during sleep; all of which symptoms are more marked, as is the case indeed in nearly all the ailnient.s of chihlren, durin'/ tlu* night. Though the symp- 368 SIMPLE DIARRH(EA. toms described are observed from time to time, aod particularly during the night, they are not always present, as the infant will occasionally through the day seem perfectly well and comfortable, with the exception, perhaps, of slight paleness and languor, almost always perceptible upon its countenance. There is no fever in these cases, or at least nothing more than unusual warmth of the hands, feet, and abdomen at night. If a marked febrile reaction take place, there would be reason to suspect the existence of some degree of entero-colitis. The mouth often becomes, after a few days, a little w^armer and less moist than usual ; the tongue is gener- ally moist and only slightly coated ; and the appetite is commonly diminished, as shown by the child's nursing with less eagerness and at longer intervals than before. In very mild cases the stools are at first, and sometimes throughout the attack, feculent; the only differences from their ordinary characters are that they are more frequent, thinner, more copious than usual, and that the odor is changed so as to become acrid and offensive. In severe cases, they contain less feculent matter, become yet more fluid and sometimes watery, and exhibit small particles of a greenish color scat- tered through them ; or the whole of the discharge is of a deep green color, and it is intermixed with portions of mucus. In many of the cases, whitish lumps, evidently consisting of undigested curd, are observed mixed with the other substances upon the napkin. The number of stools varies from two, three, or four, to six or eight in the twenty-four hours. The number last mentioned is seldom exceeded, so long as the diarrhoea remains simple. The abdomen is seldom distended or painful to the touch. The general ap- pearance of the child almost always shows the effects of the malady upon the constitution after a few days. The countenance becomes paler and thinner ; the eyes look some^vhat hollow ; the edges of the orbits are more defined, and often present a pale bluish circle; slight emaciation takes place, and the flesh of the child becomes softer and more relaxed than be- fore the attack. The duration of the disorder is generally short, as it sel- dom lasts more than three or four days or a week. It may terminate in complete restoration to health, without having exposed the life of the child to danger, or, if the causes which gave rise to it continue in action, if the child is of delicate constitution or the treatment not correct, and especially if this is of too perturbating a character, it is very apt to run into entero- colitis and expose the patient to all the dangers of that disease. In older children (after the first dentition), the disease is much -less fre- quent than in infants, and presents a different train of symptoms. Often it is nothing more than a slight disorder of the bowels, amounting to three, four, or five stools, thinner and more abundant than usual, accompanied by slight colicky pains, and unattended by fever or other signs of sickness, which, after continuing one, two, or three days, ceases, and the child re- gains its usual health. Some children are particularly liable to these at- tacks, and suffer from them every few weeks, or after any indiscretion in diet ; whilst in others they are rare, let the diet be what it may. There is another form of simple diarrhoea, however, of which we have seen a number of cases, much more troublesome than the one just described. It occurs in children from two and a half to seven and eight years of age, \ DIAGNOSIS — PROGNOSIS. 369 lasts a considerably longer time, and is much less under the control of remedial measures. This form of the disease has never, in the cases that we have seen, been accompanied by fever, or by any constitutional symp- toms rendering it necessary to confine the child either to the bed or house. The only symptoms besides the diarrhoea which we have observed, have been some degree of paleness and moderate emaciation ; slight weakness, shown by an indisposition on the part of the child to play with its usual spirit, by an inclination to lie about from time to time through the day on the sofa or floor, and by complaints of " being tired ;" irritability of temper and peevishness; irregular appetite; picking of the nose; and restless, dis- turbed sleep at night, attended with moaning, crying, starting, and grind- ing of the teeth ; all of which symptoms generally convince the mother that the child is suffering from worms. The abdomen is sometimes slightly tumid, but remains natural as to tension, and is not painful on pressure. There is no pain except slight colic in some cases. The stools have gener- ally numbered from three to five, and in a few cases as many as six or eight a day. They are semifluid in consistence, often of a very oflfensive odor, and consist usually of feculent matter, which is sometimes clay-col- ored, more frequently dark-brown, and, in other instances, deep yellow or orange in color. They are often also of a frothy character. In some of the cases that we have seen, there was lientery whenever the aliment was otherwise than of the lightest and most digestible kind. In all, the diar- rhcea was evidently greatly influenced by the diet, showing, it appeared to us, a manifest dependence of the malady upon the condition of the stomach, which seemed to have lost to a great degree its digestive power. The cour.*e of the disease in this form is variable. In some it lasts a few weeks, and then, under the influence of diet and remedies, ceases, to recur and run the game course after a short period. In others it may last a much longer time in spite of all treatment that we attempted. We have known it to thus continue between three and four months, with occasional slight remissions, brought about apparently by remedies which a day or two after would lose their effect. DiAf;>'osi8. — The diagnosis of simple diarrhoea will rarely present any difficulties, since there is nothing with which it could be confounded, ex- cept the dirrrhfpa from tubercular ulceration of the bowels, or entero- colitis. From the former it is to be distinguished by the history of the case, and by the signs of tuberculosis in other parts of the economy ; from the latter, by the absence of signs of inflammatory action. Prognosi.s. — The prognosis is favorable so long as the disease remains simple. The physician should never forget, however, the disposition which is inherent in it to pa.ss into entero-coiitis, nor fail to make the possible oc- currence of this transition one element in his prognosis. During infancy it is always more serious than after that period, from the feebler jjower of resistance on the part of the constitution at that age to disease, which un- doubtedly allows this simple afl^ection to prove fatal in some instances, probably from the shock to the nervous system. After infancy it is rarely a dangeroua disorder, both becau.se of the greater stamina existing at that 24 370 SIMPLE DIARRH(EA. age, and from the fact that the disposition ,to the extension of disease is less strong. Treatment. — The prophylactic management of simple diarrhoea is the same as that which is proper for entero-colitis, and as that affection will be treated of at considerable length in a future article, we must on account of our limited space, refer the reader there for information on this point. After the disease is established, the treatment must consist first in atten- tion to the diet, exercise, and state of the gums of the child. In many- cases, careful regulation- of the diet and exercise, and lancing the gums w^hen they are much distended and vascular from the pressure of the ad- vancing teeth, will suffice to arrest the disorder in a few days, without the necessity of resorting to drugs, which ought certainly to be avoided whenever it is possible to do so. If the child is at the breast, we must as- certain whether the milk of the nurse is good, by inquiry as to its appear- ance, specific gravity, reaction, and by examination with the microscope, and by reference to her health, diet, temper, etc., all of which circum- stances more or less affect the mammary secretion. If we conclude that the milk is good, or that it has been disturbed in its healthy properties only by a transient cause, the child must be continued at the breast, with the precaution, however, of not allowing it to nurse quite so much as usual. An infant suffering from any kind of diarrhoea, had better be restricted entirely to the breast, unless it be clear that the supply of milk is quite insufficient. If we determine that the milk is unhealthy, the nurse must either be changed, or the child weaned ; of course the former alternative is infinitely preferable if the child is under a year old, or even under eighteen months, if it seem to have a rather delicate constitution. If the case occiir in a child already weaned, or in one fed partly on artificial diet, the regulation of the kind, preparation, and quantity of aliment is of the utmost consequence. It ought to consist chiefly of milk or cream weakened with water, unless it has been clearly shown by previous trial that these articles do not agree with the child. We prefer before any kind of diet that v/e have ever employed, or known to be employed, that made from cow's milk, cream, arrowroot, and gelatin, in the manner de- scribed at page 332. The proportions of the milk, cream, and arrowroot must vary with the age and digestive power of the patient. As a general principle, during the existence of diarrhoea, or at least in the early stage of it, and before the strength has been reduced by the disorder, the propor- tions of cream and milk ought to be somewhat less than in health. Not only so, but the total quantity of food in the day should be diminished, unless the ordinary amount seems to be really necessary for the sustenta- tion of the strength. If it be found, after patient trial, that the child will not take, or does not digest this kind of food, we may try arrowroot or rice- water, with a little cream, or thin gruel or panada, alternated with very carefully prepared chicken- or mutton-water. If the child is six or eight months old, it often suits well to allow it a piece of juicy beef or a chicken- bone to suck, or from one to several teaspoonfuls of meat of chicken or mutton minced very fine. For older children with a common attack of simple diarrhoea, the diet TREATMENT. 371 should consist for a few days of boiled milk with bread, of gruels made of boiled milk and arrowroot, rice-flour, sago, tapioca, or common wheat flour, aud of small quantities of light broths. Meats are, for the time, improper, aod all vegetables, with the exception of rice, yet worse. In the case of infants it is best to recommend a continuation of the ordinary exercise, unless the weather be cold and damp. Indeed, in good weather, exposure to the air aud proper insolation are more important during the existence of this disorder than even during health. The same remarks apply to older children, with the exception that they ought not to be allowed to fatigue themselves, particularly in warm weather, as this tends to aggravate the complaint. When the disorder occurs in a teething child, the gums ought always to be examined by the physician, and if found swelled, vascular, of a deep red color, and hot, with the outline of the advancing tooth perceptible, they should be freely incised to the tooth. If, on the contrary, the tooth is too deep to be felt, and yet the gum is red and swelled, we would advise only a slight and superficial scarification in order to relieve the tensicm. The therapeutical management of the disease should be as simple as pos- sible. The fewer drugs we can succeed with in the gastro-intestinal com- plaints of infants and children, the better. When, however, the diarrhoea continues for some days in spite of attention to the points already men- tioned, and earlier if the discharges are either large, frequent, very watery, or weakening to the child, we must resort to some of the means which have been found most useful in checking the inordinate action of the bowels. The most important are a careful employment of laxatives, and the use of opiates and astriagents. Formerly we generally commenced the treatment by the exhibition of a teaspoonful of castor oil, containing from half a drop to a drop of laudanum, for young infants, and two drops for older children : but of late years we have usually preferred the spiced syrup of rhubarb, in a teaspoonful dose, with laudanum, as above recommended. Cai«tor oil sometimes purges more than we like ; rhubarb rarely does so. These doses given for two evenings in succession have oftentimes sufficed to eflTect the cure. Dr. West recommends very highly in cases of simple diarrhfpa, in which the evacuations, though watery, are fecal, and contain little mucus and no blof>d, small doses of the sulphate of magnesia and tincture of rhubarb. His formula at one year of age is as follows: B — MHjjne?. Sulphat., r^]. Tinct. Rhei f^ij. Svr. Zingiber.. .... f;:^]. Aqtiee Carui, ....... f3ix. — M. Dose, a teaspoonful. We often use with excellent effect the sulphate of magnesia, with lauda- num, a.s follows: B- — Magnw, Sulphat., 3J. Tr. Opii Deodorat. gtt. xij. Syrup Simp., f^^s. Aquse Menth. vel Cinnamom., ..... f^ij*''. — M. Dose, at one or two years a tcacpoonful every two or three hour*. For older children, the proportion of the magnesia and laudanum should be doubled. 372 SIMPLE DIARRH(EA. If the diarrhoea persists after these means have been used for two or three days, or gets rapidly worse, we must resort to some of the astringents. The one most commonly employed is the chalk mixture, which is officinal in our Pharmacopoeia. A teaspoonful of this is to be given after each loose evacuation, or three or four times a day. If the case prove obstinate, it will be found useful to add to each dose of the chalk preparation, a small quantity of laudanum or paregoric, or some astringent tincture, the best of which is the tincture of krameria. When the chalk mixture fails en- tirely, powdered crab's-eyes will sometimes succeed ; or we may resort to the aromatic syrup of nutgalls. The formulae and doses for both these remedies will be found in the article on entero-colitis. If the discharges are small and frequent, mixed with mucus and somewhat painful, it will be found that small opiate injections (from one to two drops of laudanum in a tablespoonful of starch-water for young infants, and from three to six drops in double that quantity for older children), or the use of Dover's powder in combination with chalk or sugar of lead, will often succeed in arresting the disease. One of the most valuable astringents in the bowel affections of young children is bismuth, which we are much in the habit of giving in the form of subnitrate in doses of from two to five grains, ac- cording to the age, from three to six times in the course of twenty-four hours. For further and more complete information in regard to astrin- gents, we must refer the reader to the article on entero-colitis, where they wull be fully discussed. The chronic form of simple diarrhoea which we have attempted to de- scribe, occurring in children who have completed the first dentition, has always proved difficult to manage. From the experience* we have had, we believe that the best mode of treating it is by proper regulation of the diet, and by the use of tonics and stimulants, and occasionally of opiates. We were led to adopt this plan in consequence of having failed entirely to control the symptoms by the treatment generally successful in simple diarrhoea, and by the opinion which we came at last to form, that the dis- ease depended in great part on a loss of the digestive power of the stomach and duodenum. The diet must be adapted to the idiosyncrasies of the individual ; what we should seek is such a one as will be easily digested by the patient, the materials of which shall not appear in the stools, and one which does not manifestly increase, if it fail to moderate, the frequency of the discharges. The one which we have found to succeed best, consists of boiled milk with stale bread for breakfast and tea, and the tenderest meats, as very fine beef, mutton, chicken, or birds, with rice, as the only vegetable, for dinner. If the child likes flour or rice pap, it may have either in place of the bread and milk. If it will take none of these, it may have milk, warm water and sugar, with bread ; or well-boiled mush with milk, or milk toast. Should it refuse the dinner recommended above, we may substitute delicate soup, or some of the milk preparations. Raw meat, given in the manner recommended in the article on entero-colitis, should also be tried, and will at times prove very beneficial. Between meals it ought to be allowed nothing but dry bread. All rich food, dessert, fruits, all vegetables except rice, candies and comfits, all kinds of cake and TREATMENT. 373 hot bread, iu fact everything except the articles which we have mentioued, or siniihir oues, ought to be rigidly, systematically, and perseveringly for- bidden. Until this has been done for many days, or for several weeks, the disease has always, according to our experience, obstinately persisted. We have already said that we have not found the ordinary remedies for simple diarrha^i to exert much etlect upon this form of the disease. On the contrary, the treatment for dyspepsia, that is to say, a simple but nu- tritious diet, exercise, and the use of tonics and stimulants, has always removed it in a longer or shorter time. The tonics which we have em- ployed are port wine, quinine, and iron. From a dessert to a tablespoonful of port wine was usually given in water three times a day, in connection with iron. The preparations of iron used were Vallet's mass, of which from half a grain to a grain was given in pill three times a day ; the solu- tion of iodide of iron in the dose of first one, and then from two to four drops, three times a day, or the solution of the nitrate of iron in the dose of from two to five drops, three times a day, in water, continued for one or two months. We have sometimes combined with each dose of the solution of iron a drop of laudanum, especially if there were pain ; or the opiate might be given by injection every evening. The quinine was generally administered alone iu the dose of a grain three times a day, for one, two, or three weeks. It has not, however, proved so useful as port wine and iron. Another tonic which we have found very useful in some cases of this kind, of late years, is one containing nux vomica and compound tincture of gentian, as follows : B.— Tr. Nucis Vomic, f^.^s. Tr. Gentian Com p., f.^i'j- Syrup. Symp., I'^v. Aquae, f*ij. — M. D<»e, a teagpoonful three times a day after meals, for children of three or four yean of age. Wine of pepsin, in half teaspoonful doses, three times a day, is also a goochildren. We had almost abandoned the plan followed in our former editions, of devoting a special chapter to this subject, but on further consideration, think it will be best to treat of it separately, since, as stated above, cases do occur in practice in which the stomach is the chief, if not the only seat of disease, and which can be properly designated and described only under the title of gastritis. Causes. — It has already been stated that the most violent and typical cases of gastritis, as a distinct disease, are the result of the application to the organ of some special irritant, as the mineral acids, arsenic, boiling water, or of certain remedial. agents, and particularly of tartar emetic, iierraes mineral, or croton oil. These latter agents, the drugs just men- tioned, cannot produce this effect unless used in large doses, or when con- tinued for too long a time. The quantities of the antimonial preparations formerly administered, were always thought by us to be dangerously large, and we were not at all surprised to find that MM. Rilliet and Barthez, from their experience in former years in the Children's Hospital in Paris, cited them as one of the causes of acute gastritis. In the Journal fur Kinder- kranhheiten, for the years 1859, 1860, and 1861, in the third, fourth, and ANATOMICAL APPEARANCES. 375 fifth aunual reports of the Public Institute for Childreu's Diseases, of Vienna, bv the Director, Dr. Luzsiusky, may bo ftuind in the third report three cases, in the fourth three cases, and in tlie fifth two cases of gastritis caused by the accidental drinking of concentrated lye. The milder forms of gastritis are vastly more common than the ones above referred to. They are generally associated with disturbances of the intestinal tube also, and constitute by far the majority of the cases which come under the observation of the physician. They are caused very gen- erally by improper alimentation ; by the same causes, indeed, as those which determine indigestion. In infants, an unhealthy state of the mother's or wet-nurse's milk, the use of too rich a preparation of cow's milk, milk obtained from an unhealthy cow, or a food composed of too large a proportion of farinaceous material, are the most common causes. In older children, an unwholesome meal, as a surfeit of cakes and candies, tough meats, unripe, or an excess of ripe fruits, the swallowing of a quan- tity of skins of grapes, of orange-peel, of the seeds of oranges, or such like imprudences or accidents, of all which we have seen examples, will sometimes occasion symptoms which we can refer only to acute catarrh of the stomach. In such cases the child may escape any serious conse- quences if it rejects, by vomiting, the improper food, soon after it has been taken. Or it may have an attack of cholera infantum or cholera morbus, and either recover its usual health -in a short time, or pass through a longer or shorter illness, as the result of these disorders ; or, lastly, the unhealthy food* may be retained for a longer time than usual in the stomach, and act- ing as a local irritant on the gastric mucous membrane, may set up a true and more or less severe form of the disease we are considering. Anatomical Appearances. — Death is so rare a consequence of gas- tritis alone, except in the form produced by the direct application of irri- tants to the organ (and even in such, recovery appears to be the rule, since all the eight cases referred to as reported by Dr. Luzsinsky, recovered), that it is difficult to present a description of the lesions characteristic of this variety of the disease. M. Billard, however {Mai des Enjnnh, p. 353), gives a ca*e from M. Deni.s, and one observed by himself. M. Denis found the raucous membrane of a deep brown color, of a fetid odor, reduced here and there to a state of putrilage, and everywhere easily removed in soft- ened strips. A fluid of the color of lees of wine, wiis found macerating the chaoged mucous membrane, and this he could ascribe only to gangrene from excegflive inflammatory action. The case ob.served by Billard oc- curred in a girl three days old, who was brought to the infirmary with a quantity of V>lacki.«h bloofl pasjjcd into the napkins, and also vomited. The child died on the following day. The mouth and resophagus were healthy, but the mucous membrane of the stomach was completely de- 8troye We are indebted to the courtety of Mr. Chambem, the clerk of the Board of Health in thi» city, for the opportunity «'f collating portions uf this table from the m<»niblj rvUim» of mortality calculated by him. 382 ENTERO-COLITIS. Tahle showing the Monthly Mortality for the last Seven Years from Years of Life ; compared with the Total Monthly Mortality Month. 1862. 1863. 1864. 1865. Mortality. Mortality. t It a Mortality. n 1 Mortality. t a 1 — a In ^-2 2 111 Total 5"^ ^ a s « III IP g«5 Total h Total ci ~ ill m Total Jan., 1 2 4 1314 32.46° 3 3 1061 38.25° 1 5 1302 33.28° 1 6 3 1373 26.78° Feb., 1 3 1 1080 32.70° 5 3 2 1122 35° 3 1434 35.97° 2 2 1 1550 32.59° March 2 2 3 1204 40.25° 2 7 1172 37 26° 4 1 5 1894 40.5° 3 1 2 1868 47.94° April, 3 1 4 1213 £0.61° 2 5 6 1488 49.80° 2 2 6 1377 50.58° 5 3 4 1411 56.46° May, 9 4 5 1343 63.70° 5 1 6 1060 64.63° 10 5 8 1529 67.20° 10 6 7 1227 63.39° June, 20 3 8 1002 69.14° 14 2 5 961 68.76° 74 11 14 1245 72° 184 . 10 20 1690 76.73° July, 300 21 31 1767 7523° 313 17 38 1859 77.07° 259 24 32 1643 76.08° 364 52 41 1838 77.82° Aug., 217 19 22 1755 76.70° 464 25 '28 2044 79.46° 250 27 31 1956 79 40° 245 42 23 1759 74.74° Sept. , 60 4 9 1037 69.36° 105 15 9 1453 64.73° 28 16 10 1251 65° 44 14 7 1040 72.68° Oct., 15 5 4 1235 58.32° 14 4 5 1104 56.08° 9 8 4 1144 54 75° 15 12 5 1C84 54.88° Nov., 2 5 1021 45.20° 5 1 1061 47.72° 2 2 1 1212 45.80° 9 8 3 1285 45.35° Dec, 1 2 1124 36.06° 3 2 1 1404 35.41° 2 2 4 1595 36.77° 2 3 1044 37.39° Total, 808 1120 862 1139 1 FREQUENCY — INFLUENCE OF SEASON AND TEMPERATURE. 3S3 Cholera Infantum, Dysentery, and Diarrhcea, during the First Five FROM ALL Causes, and thk Mean Monthly Temperature. 1860. ; 1 1867. 1868. 1^. »; a > 1 ] Mortality. Moktalttt. Mortality. s:2S «2 .i< = - >, 2 il Si = 2 il 2 3 •2 = rt Is? S £c 11 is c u It • I'- r s « ToUl h III rr — "^ ToUl h Total i 1 3i 2 ^ 1 1402' 29.31°i 11376 25.89° 2 1249 30.12° 2 12964 30 87° 4 1 i ^1 1 n 1 3 1 u o 11 5»; 34.14= 2 1042 40.21° 1063 26.65° 2| 1206f 33.89° (» 3 1 3 i 1 3 1 1 21 ' 1082 40.85° 1 1094 38° 1 1096 41.12° n 1344f 40.85° 3 2 1 H 6 1 9 1 4 3 1034; 66 06°' 2 1088 54.13°; 5 1357 48.24° 3 1281 1 52.27° 4 2 1 35 8 7 4 ^ 1 1304 61.37° 2 1260 59.44° 1 917 59.66° 2« 12342 62.77° 4 1 1 3 6 U r>S 38 , 71 67 2 1168 73.04° 6 980 72.19° 8 1201 71.99° 6 1178} 71.97° 10 j 1 5 7 9f 427 ' ' 423 i 423 358a 21 -2047 80.87° 23 1795 76.48° 14 1900 80 94° 24i 1837 77.71° 34 81 32 34j .'■;•'»■. 265 327 3046 ;•) 2401 72.6** 26 11294 75.10° 19 1570 78.42° 27^ 18254 76.62° 41 25 34 291 89 88 128 77^ 16 1862 69.42*» 18 1012 6821° 14 1858 68.80° 13 1215^ 68.31° 13 »! 24 ^^ 55 24 20 152 8 182^ 68.86» 1177 67.66° 2 955 54.08° 4^^ 1218f 56.3° 15 10 3 ^ r, 6 8 81 1087 48» 2 871 47.79° 2 878 46.91° 24 1052} 46.68° 4 6 n 2 1 1 9 2 W2 88.630 2 974 81.78° 1154 32.16° M 1191 34.7° 3 2 8 2? 1252 1040 1057 384 ENTERO-COLITIS. dren that I have seen, occurred in those who had been placed upon this kind of regimen, and, second, that the disease did not occur in any of those observed by me in private practice, for whom I had directed an exclusively milk diet up to four, five, or six months of age." He adds that M. Trousseau had arrived at similar opinions, after studying the same diseases at the Necker Hospital ; and that he, on account of the danger of a system of diet disproportioned to the digestive powers, recommended that children be confined almost exclusively to the breast until after the first dentition is completed. Barrier, speaking of the follicular diacrisis (op. ciL, t. ii, p. 40), states that the artificial food given to children at the period of weaning is a frequent cause of the affection, and that of all the different kinds of food habitually employed at that period, feculent sub- stances are the most injurious. We have frequently known entero-colitis to follow the employment of artificial diet, either alone, at the period of weaning, or in children who were partly nursed. Children fed wholly on artificial diet from birth rarely escape, according to our experience, attacks of the disease, which in many prove fatal. We have, on several occa- sions, seen children recover rapidly from such attacks, after suffering more or less for weeks, by the suspension of a diet consisting wholly or in too large proportion of farinaceous materials, and the substitution of one com- posed of milk and cream, prepared with gelatin, and containing a very small quantity of arrowroot, rice, or wheat flour (see article on thrush, page 332). It is not merely the quality, but the quantity also of artificial food that proves injurious to infants. Overfeeding has always been recog- nized as a fruitful source of bowel complaints in early life. Another cause is the preparation of the food in too thick and rich a manner, thereby overtasking the stomach, intended during the early months to receive only the thin milk supplied by nature. The custom, therefore, of feeding in- fants on thick oatmeal gruel, with but little or no milk, on what is called cracker victuals (pounded crackers with water and sugar, or milk), on thick bread and milk, on preparations of rice of too solid a nature, or, indeed, on any kind of diet not consisting chiefly of milk, and in which feculent substances enter merely as secondary constituents, may safely be asserted to be the most frequent cause of the disease under consideration. An unhealthy character of the milk of the nurse is also known to be a cause both of simple diarrhoea and entero-colitis. When the granule-cells which exist as a physiological element in the colostrum secreted during the first few days after childbirth, continue to be present after that period, the infant is almost certain to suffer from entero-colitis, and not unfre- quently to die, unless weaned or transferred to another nurse. So, also, when the milk departs widely from the normal characters which it should possess, as described at page 338, when the nurse is liable to vivid moral emotions of any kind, or when addicted to intemperance, the child is very apt to suffer either from the disease under consideration, or from simple diarrhoea. That the heats of summer are a most fruitful cause of this disease, no one can doubt who will glance at the table given at pages 382 and 383, where the mortality from cholera infantum, dysentery, and diarrhoea. CAUSES. 385 under five yeai-s of age, in this city, during the seven years from 1862 to 18G8 inclusive, is given. The table shows at a glance, the number of deaths from these diseases enumerated, during the period of life specified, in each month of every year, with the mean temperature of each month, and also the total mor- tality at all ages and from all causes in each year. The reader must not forget what we have already stated, that there is every reason to suppose that a large majority of the cases reported under the head of cholera in- fantum are, in fact, cases of entero-colitis, — at least what we have proposed to call entero-colitis, as opposed to the less frequent choleraic disease to which we restrict the term cholera infantum. It will be seen, in this table, that the two months of July and August furnish by far the largest propor- tion of deaths. In these two months, when the mean temperature is noted between 70^ and 80° Fahr., the deaths from this disease ran up to three and four hundred and upwards; whilst in June and September, when the temperature ranges between 60° and 70°, the deaths average between 60 and 80, and rarely rise over 100; and in January and December, with a temj>erature of from 30° to 40°, they number from between 3 and 5 to 10 and 15. The efl^ect of season is here so striking that it nuist interest all, and can leave no doubt, we think, in the mind of the reader, but that the elevated temperature of summer is the main cause, in this city, of the fatal intestinal disease we are considering. Whether heat alone may act upon the system of the child to produce this result, or whether it acts al- ways by determining noxious gaseous products from the decomposition of animal and vegetable substances thrown into our streets, has not yet been demonstrated. From the well-known fact, however, that those children suffer most who reside in the more filthy and crowded part of the city, whilst the disease is very much less common in the open country, and in the cleaner and better ventilated parts of the city, we may safely conclude that it is not heat alone that usually causes the disease, but that the emanations arising from garbage of various kinds, and the imperfect ventilation of houses built in narrow and crowded streets, have much to do in its causation. We referred, in the general remarks at the beginning of this chapter, to the resemblance of the chronic diarrho'a of our armies during the late great war, in its mode of causation, symptoms, anatomical lesions, and the eflTects of treatment, to the chronic form of entero-colitis in childhood. Any one who will refer to the work of Dr. Woodward, already fpioted, or to the essay on Oimp Dinrrhra and IhjMeufpnj, by Dr. S. B. Hunt, in the United StateJ! &ijutary Commimion Contributions relatinrj to the Causa- tion and Prevention of Disease, and to Camp Diseases, etc. (New York, 1867) ; or to the InreMifjations upon the Diseases of the Federal Prisoners ran fined in Camp Sumter, Anderfonville, etc., by Joseph Jones, M.D., published in the volume just alluded to; will find ample proof that improper diet, with heat, overcrowding, and want of cleanliness, will give rise to chronic diar- rhrea, the essential lesions of which are to be found in radical blood-changes, pers'erted nutrition, and a localization on the alimentary canal in tho form of entero-c(jliti.-, vf*ry niuf}; like the disorder we are describing. Dr. Wood- 386 ENTERO-COLITIS. ward says, in fact, in speaking of the nature of this affection (chronic diar- rhoea), at page 251 : " From the account given above of the pathological anatomy of the disease, there can be little doubt that this affection is to be regarded as consisting essentially of a chronic inflammatory process, in- volving primarily the mucous membrane of the ileum and colon. It may, in fact, be described simply as a chronic ileo-colitis, with a tendency to ulceration." Dr. Hunt {loc. cit., p. 294) says : " The essential fact in the pathology of all these various forms of flux is the same, and autopsies re- veal no distinction between cases of diarrhoea and dysentery. They are alike an inflammation of the colon or of the small intestine, or of both, attended by ulceration of the mucous membrane. The solitary follicles of the colon are seen to be enlarged simply, or ruptured, with punched-out ulcerations following. The intestinal wall is thickened and changed in color to a red, browu, black, or greenish hue." It may seem, at first view, visionary and wild to compare the chronic entero-colitis or inflammatory diarrhoea of childhood to the same disorder in armies and camps ; and yet we think there is a most striking analogy between the two as to causation, symptoms, anatomical lesions, pathology, and the results of treatment. The main causes are the same: improper diet ; elevated temperatures, the high temperature of the summer season in children, and of the Southern States in the armies; overcrowding, with foul air in camps and cities : the symptoms are very much alike, a most obstinate diarrhoea, with great constitutional sufi^ering and emacia- tion; the same lesions are present, only less advanced and extensive in most cases of children ; and very much the same results follow treatment : as in both diet is found to be more important than drugs, and removal North in the armies, and in children removal from crowded cities or low hot regions of the country to more elevated and cooler tracts, are found necessary. In children, as in armies, if, at the beginning of the attack, the patient is removed from the causes which have produced a simple diarrhoea or a cholera infantum, the case is likely to go no further ; but, if the same causes are continued in operation, the simple diarrhoea passes gradually into the chronic inflammatory form of entero-colitis, and at last the patient recovers only when he is removed to a more favorable locality, when the diet is changed to a more healthy one, or, in the child, when he ■drags through a long hot summer, and the cooler weather of October or November, and a diminution of the exhalations caused by the summer heats in cities, bring at last, in the course of nature, the change which was essential to his recovery. After the causes just enumerated, the one which appears to exert the strongest influence is dentition. That the evolution of the teeth, though a physiological process, is a powerful predisposing cause of diarrhoea and enteritis, cannot be doubted at the present time. It is one recognized by many of the most able writers and observers of the day, and by most practitioners. MM. Killiet and Barthez agree with Trousseau in the opinion that the simple diarrhoea so apt to occur in children at the epoch of the first dentition, is often the origin of chronic intestinal lesions which finally reduce them to extreme debility and emaciation. They say that I CAUSES — MORBID ANATOMY. 387 c:irefiil investigation will generally show that nearly all the eases of in- flammation and softening date either from the epoeh of dentition, from the period of weaning, or from the time at which some considerable change in the character of the regimen was made. M. Bouchut states that of 110 children in whom the first dentition was going on, 26 escaped any indis- position, 38 suffered from restlessness, colics, and occasional diarrhani, so mild as to excite no alarm in the parents, whilst 46 had abundant diar- rhcea. In 19 of the last series it appeared coincidently with the fluxion of the gums, occurring at the time of emergence of each tooth, and disap- pearing eniirely in the intervals ; in the remaining 27, in all of which the process of dentition was diflicult, the diarrluva persisted and gradually as- sumed the characters of entero-colitis. M. Legendre and M. Barrier i^Ioc. cit.) both agree in ascribing very great eftect to the influence of dentition in the production of diarrhea and entero-colitis. The former asserts the diseases referred to to be much the most frequent between the ages of six or seven months and two or two and a half years, which includes exactly the period occupied in the first dentition, while they are only met with ex- ceptionally after three years of age. The act of weaning is very apt to result in the production either of sim- ple diarrhoea or entero-colitis, in consequence, no doubt, of the irritation set up in the gastro-intestinal surface, by the change of food made at the time. The diarrhQ?a which occurs at this period was formerly, and is still, not unfrequently, called weaning-brash. Dr. Stokes {Cyclop, of Med., Art. Enteritis ) says of this disease that it " is manifestly an acute enteritis, pro- duced by the change of food, and in which nature seeks to relieve the in- flammation by a supersecretion." Entero-colitis is prone to occur as a secondary affection in many of the acute diseases of children. It is by far the most common in the course of the eruptive fevers, particularly measles, and in that of typhoid fever. It is also a frequent complication of the latter stages of pneumonia. That children of feeble constitution and lymphatic temperament are more disposed to the disease than others, is sutflciently proved by the evi- dence of various observers. Lastly, that the incautious and excessive use of perturbing systems of medication, addressed to the digestive tube, often occasions diarrhoea and entero-colitis, is fully proved by the researches of MM. Rilliet and Barthez, and by our own experience. MoHBiD AxATO-MY. — Seat OF DisEASE. — It has bccn already stated, that the alterations of the large intestine are, as a rule, much more frecpient and serious than those of the small intestine. It appears from the re- searches of MM. Killiet and Barthez, and Legendre, that enteritis rarely exists alone ; whilst colitis by itself, or combined with enteritis, is quite frequent. M. Legendre states that inflammation of the small intestines never occurs without corroponding lesions of the large bowel, while in 28 cases of diarrha^a, he found the large intestine alone diseased in 9. From a table of different intestinal lesions, given by Killiet and Barthez (op. ci7., t, i, p. 692), it appears that they have met with 45 cases of erythematous, pseudo-membranous, ulcerative or pustular enteritis ; with 113 of the same forms of coliti- : with 00 of follicular enteritis; 64 of follicular colitis; 388 ENTERO-COLITIS. and with 28 of softening of the small, and 35 of softening of the large intestine. Dr. J. Lewis Smith (op. cit., p. 367), offers an analysis of the post-mortem appearances in 82 cases of intestinal inflammation in children. The upper part of the small intestine, embracing the duodenum and jeju- num, was found inflamed in 12 cases, while in 51 cases it was free from inflammation and of a pale color. The ileum was inflamed in 49 cases, and the cjBcal portion, including the ileo-csecal valve, was the part in which the inflammation was uniformly most intense, and to which it was often confined ; in 13 cases there was no enteritis whatever, and in 16 there was no inflammation of the ileum, so that the ileum was inflamed in all but 3 cases where enteritis was present. On the other hand, in all the cases ex- cepting one, namely, in 81 out of 82 cases, there were lesions indicating inflammation of the mucous membrane of the colon. In 39 the inflam- mation had affected nearly or quite the entire extent of this portion of the intestine ; in 14 it was confined to the descending portion entirely, or almost entirely; in 28 cases, the records state that colitis was present, but its exact location is not mentioned. We may add, that, in the quite numerous autopsies we have made after death from this disease, we have invariably found the large intestine in- volved, the inflammatory lesions being in some cases limited to it, while in others they also extended into the small intestine. It is, therefore, clearly established, that in the inflammatory diarrhoea of children, inflammation of the large is considerably more frequent than that of the small intestine, and much more apt to exist alone. The lower end of the ileum is the portion of the small intestine which presents the most advanced and severe lesions; while in the large intestine the lesions are most marked in the caput coli, sigmoid flexure, and descending colon. In our description of the lesions of entero-colitis, we shall divide them into those found in the acute and chronic forms of the disease respectively; a division made for the sake of correspondence with the description of the symptoms, although the lesions found in the two stages differ from each other only in extent and degree. Thus, in the acute stage, the lesions consist of increased vascularity, thickening and softening of the mucous membrane of the intestine, and enlargement of the intestinal follicles ; while in the chronic form there is discoloration, thickening, with infiltration and induration of the walls of the intestine, and more or less extensive destruction of the mucous mem- brane from follicular ulceration. In the acute stage, the increased vascularity (inflammatory hypersemia) may present itself as a uniform, more or less intense redness of the mucous membrane; an appearance which may sometimes exist in the duodenum, but far more frequently is observed in the lower end of the ileum and in the colon. More frequently it takes the form of arborescent congestion, occurring in patches surrounding the enlarged follicles. The peritoneal surface may also be more or less vascular, and quite frequently there are little patches of redness and arborescent vascularity, corresponding to the bases of the inflamed mucous follicles. The thickening of the mucous membrane usually corresppnds to the MORBID ANATOMY. 389 degree of vascularity, and Avheii the latter is but slight, may be scarcely appreciable ; while iu other cases, aud especially when associated with much enlargement of the mucous follicles and o?{iema of the submucous tissue, the thickening is highly marked. The inflamed portions of the mucous membrane are also more or less softened, so that they can be detached from the subjacent coats more readily than in health. In some instances the softening is so extreme that it is impossible to raise up the mucous mem- brane in strips at all. These lesions are all mc^t frequent and marked in the lower part of the ileum, and in the descending part of the colon. In addition to these changes in the color, thickness, and consistence of the mucous membrane, the mucous follicles are prominently enlarged. In the normal state, the isolated follicles of the mucous membrane of the intes- tine, in young children, appear as minute grayish-white bodies, and pre- sent a grayish point, the excretory orifice, which is only visible with the aid of a lens. In the course of entero-colitis, however, the morbid devel- opment which they undergo causes them to present the following charac- ters. The isolated glands are enlarged, and seem, therefore, more numer- ous than in the healthy condition ; they appear in the form of lenticular grains seated in the texture of the mucous membrane, sometimes project- ing from its surface, sometimes not, aud in other instances appearing to be situated beneath it ; the excretory orifices of the follicles are often enlarged and tumid, and easily distinguished under the form of a grayish or blackish point in the middle of the gland ; in other cases the orifices cannot be dis- tinguished until slight pressure is made upon the crypts, when a drop of turbid mucus may be seen exuding through the open point. The color of the distended follicles is dull white, rosy, or yellowish ; they are generally from one-third to two-thirds of a line in diameter. Dr. Horner (Amer. Jour. Med. Sci., Feb. 1829) speaks of them, in this state of development, as resembling "small grains of white sand sprinkled over the mucous mem- brane, and about the size of a millet-seed." The agminated glands or patches of Peyer are found in the same state of increaseti development; they are tumefied, and project above the level of the surrounding mucous membrane, and the orifices of the follicles are con- gested, .«o as to appear as dark points, giving to the patch a dotted, punc- tated appearance, which hus been compared to the freshly-shaven chin. A little later the enlarged follicles present minute, oval, or round yel- lowish spoU< upon their summits, which soften down and allow the contents of the follicles to be discharged. The enlarged orifice of the follicle will then admit a small probp, anearance of being ulcerated, but a careful examinatioi] will gener- ally show that this is not the case. The appearance depends upon the en- 390 ENTERO-COLITIS. largemeut of the orifices of the glands, upon unequal tumefaction of the surrounding mucous membrane, and upon the presence, in the patch, of small, irregular grayish points, consisting of pultaceous matter, which makes the patch look more uneven and projecting than usual. If, how- ever, the pultaceous layer be gently rubbed with a piece of linen, it can easily be detached, when the mucous membrane beneath is found red, soft- ened, and thickened, but not ulcerated. In comparatively rare cases, how- ever, there are superficial erosions of the mucous membrane, covering the prominent patch. The exact date at which the ulceration of the follicles begins, is as yet undetermined, and probably varies greatly in diflferent cases. It fre- quently happens, however, that death occurs, especially from the super- vention of a choleraic condition, whilst they are still merely in a state of enlargement. When, on the other hand, the disease passes into the chronic form, the lesions which we have above described become more and more extensive. This is especially the case with the lesions of the large intes- tine, for it is even more true with regard to chronic than acute entero-co- litis, that the chief seat of the disease is in the colon. In chronic enterocolitis, the intestine is often contracted, and the peri- toneal surface may present patches of discoloration. The thickening and infiltration have now affected the submucous and muscular coats, and have been followed by induration of the tissues, so that the walls of the intestine are often abnormally rigid. This is especially true with regard to the lower part of the descending colon and the rectum. The mucous mem- brane is seen to be riddled, not with mere superficial erosions, but with true ulcers, affecting the whole thickness of the membrane. These ulcers, when isolated, are from one to one and a half lines in diameter, oval or circular in shape, and either have sharp-cut edges, as though the piece of mucous membrane had been cut out with a punch, or the mucous mem- brane bounding them is undermined. Frequently, however, these ulcers coalesce, and at the same time extend in depth, so that large, sinuous, ir- regular ulcers are formed, with thickened, slate-gray, undermined edges, and having for their base either the submucous or muscular coats, which may be covered with a pultaceous, apparently pseudo-membranous layer, of a grayish-white color. These ulcers surround and include irregular islets of mucous membrane, which are swollen, infiltrated, vascular, and discolored. That the large and deep ulcerations just described, even when most extensive, take their start from the mucous follicles, is proved by the frequent presence amongst them of other ulcerations of more recent date and smaller size, which present all the characters of the follicular ulcer, and show clearly the origin of the larger and more advanced ulcerations. Occasionally there is a marked deposit of pigment in the bases of the ulcers, and in some cases small coagula of blood have been found adherent to their bases. We have already had occasion to allude to the marked analogy between the disease under consideration, and the form of camp diarrhoea described by Woodward (op. cit.) ; and one of tjje most powerful arguments in favor of the essential identity of the two affections, is the perfect correspondence MORBID ANATOMY. 391 between their anatomical lesions. We present below a snniniary of the niierosoopical changes in the intestine during the (levelo])nient of these lesions, as determined by the careful investigations of Dr. AVoodward (op. cit., p. 246). In the early stage, attended merely with thickening and softening of the mucous membrane, microscopic examination shows marked multiplication of the connective-tissue cells about the base of tlie follicles, and soon the tissue is occupied by great groups of small, rounded, or slightly polygonal cells. The delicate layer of muscular tissue imme- diately beneath the base of the follicles, presents, at first, enlargement and proliferation of its nuclei, whilst later it often ceases to be recognizable, being obscured by the luxuriant cell-growth. In the most intense cases, the cell-growth here described as attained toward the surface of the mem- brane, may take place throughout its whole thickness, and even involve the subjacent muscular layer. A similar proliferation takes place in the connective tissue, which lies between the follicles. The epithelial layer, which invests the mucous membrane, and is prolonged into the tubular follicles, ^either is the seat of rapid cell multiplication, or is exfoliated and replaced by round granular cells from the adjacent connective-tissue cells. The epithelial lining, near the orifice of the follicles, appears to undergo these changes most readily and with the greatest rapidity. The dosed follicles also present rapid cell multiplication, which affects the parenchyma of the follicle, as well as the connective tissue of its cap- sule and the surrounding cellular tissue. Microscopic examination then shows the follicle distended with small, rounded, granular cells, and im- bedded in a luxuriant growth of similar cells, which render it almost or quite impossible to draw the line where the follicle terminates and the sur- rounding connective tissue begins. " Ulceration usually appears to origi- nate in the rupture of one of the closed follicles, and the discharge of its softened contents into the intestinal cavity. This is followed by the lique- faction of the intercellular substance, and the consequent liberation of the broods of minute cells, into which the surrounding connective tissue has been transformed. Hence results one of the punched-out ulcers described above. In the subsequent extension of the ulceration, by which large, irregular, sinuous ulcers are produced, the progress seems to take place chiefly in the submucous connective tissue, the superficial part of the mu- cous membrane resisting the process until undermined, and its nutritive supply cut ofT. Hence arises the excavated undermining character of the edges of the ulcers. From the anatomical point of view, it will therefore be perceived that the morbid prooes.^, in the cases in whi(rh there is no ulceration, is es.sentially the same as in those in which ulceration is present. The one lesion is only a later stage of the other." Not unfrequently there will be found one or more intussusceptions of the ileum. Thf#e are usually readily restored, and have cvid(;ntly oc- curred during the act of dying. .Smith has, however, " in a few instances, found intussusceptions, which sustained the weight of two feet or more of intestine, without being reduced, qju\ which, from being in their interior more vascular than the contiguous membrane, had probably occurred some 392 ENTERO-COLITIS. hours or days before death, but being sufficiently pervious to allow the food to pass, the symptoms of obstruction were lacking." The Mesenteric and Mesocolic Glands are nearly always enlarged, the most marked enlargement corresponding to the lower end of the ileum and the descending colon. The enlarged glands are of a pink color, and rather more soft and succulent than normal. Stomach. — In the great majority of cases the stomach is quite healthy ; in a few instances, however, there may be found congestion of the mucous membrane, slight enlargement of the mucous follicles, or softening of the mucous membrane, probably cadaveric in most cases. Liver. — Many authorities, apparently led by the presence of symptoms supposed to indicate disturbance of the function of the liver, have assumed that there is in most cases of entero-colitis some morbid condition of this organ, but extended observation has disproved this view. Thus Hallowell {Amer. Journ. Med. Sci., July, 1847) found, that in 14 cases, the liver was affected in but 1 case, when it was enlarged ; and Smith (op. cit., p. 370) has published the result of 32 post-mortem exami- nations in regard to this point, which confirm the same conclusion. Thus, he states, " there was no evidence from the post-mortem appearances of the liver in these cases of any congestion, or torpidity, or hyperactivity, or perverted secretion. The size of the liver was in some cases very different in those of about the same age, but probably there was no greater differ- ence than usually obtains among glandular organs within the limits of health. In most of the cases the liver was examined microscopically, and the only fact worthy of note observed was the variable amount of fatty matter. Sometimes it was in excess, sometimes in moderate quantity or rather deficient, and sometimes in greater amount in one portion of the organ than in another." The thoracic viscera present no constant or important lesion, though in a certain proportion of cases, there may be found more or less hypostatic bronchitis with collapse of portions of the lungs. When death occurs during the acute stage, the brain presents no lesions dependent upon the disease. When the case has been protracted and attended with much wasting of the solids and fluids of the body, the brain also diminishes in size, and there is frequently found marked excess of subarachnoid effusion in cases where the foutanelles have closed; while if these spaces still remain unossified they become markedly depressed. These appearances are, however, purely passive in their character, and depend upon the wasting of the brain. Pathology. — The pathology of inflammatory diarrhoea is involved in great obscurity. We are now pretty well acquainted with the physical conditions under which the disorder is most apt to be developed. Early age, the period of dentition, high temperatures, improper food, residence in cities, and especially the crowded occupation of small and ill-ventilated buildings, in narrow courts and alleys, where unhealthy exhalations arise from the decomposition of filth and dirt of all kinds, are the chief condi- tions which precede the outbreak of the disease. But how these conditions act to produce their effect is still a matter of doubt. To attempt to reason % SYMPTOMS — DURATION. 393 upon a matter so full of difficulty seems almost useless, and yet we sliall venture to place before the reader some thoughts we have had upon the subject. There are two broad generalizations which we think may be safely as- sumed to be true. 1. An unhealthy food, one incompetent to furnish to the body what it needs for the purposes of nutrition, as farinaceous food or unhealthy milk, is sure to produce the disorder we are considering, no matter how favorable may be the circumstances, in all other respects, in which the chiM is placed. 2. The best breast-milk in the world, or the most correct artificial diot, will not save a child from this disorder who is located in an ill-ventilated house in a dirty and filthy quarter of a large city during hot weather. Here the heat to which the child is exposed, the heavy air loaded with foul exhalations which it breathes, determines a con- dition of the health in which the digestive organs can no longer digest properly the food offered them. In both cases the same result is produced. In the first, the stomach cannot change the originally improper character of the food into healthy material. In the second, the diseased and en- feebled organ loses the power to digest even proper food. In both the ali- mentary canal is filled with the products of an improperly digested food. Whether these unhealthy products in the alimentary canal act chiefly as local irritants to the mucous membrane, and thus determine the tissue- changes met with ; or whether, as Rilliet and Barthez suppose, some mor- bid condition of the blood is brought about, which of itself gives rise to the changes in the mucous membrane through a morbid action of the dis- eased blood on the nervous system, and particularly on the sympathetic nerve:*, we cannot say. Most probably they act in both ways, and the re- sultant effects are the consequence of the two trains of diseased action set up, the local and the general. In either case a constitutional condition is brought about, the essential feature of which is a slow innutrition or inanition. It is altogether proba- ble, moreover, that a conclition partaking of the scorbutic, must be induced, *o that we have, after the disorder ha.s lasted for several days or weeks, the general debility of a slow inanition, aud blood-alterations which resemble thn-f of scurvy. SvMiTfJMs; Duration. — In infants the arufe form of enterocolitis generally begins with restles.«ness and fretfulness. The mother observes that the child .sleeps less than usual and for shorter periods, and that its gleep is uneasy and broken by sighing or moaning, or by occasional expres- sion.* of pain flitting acros.s the face. It takes the breast Ic^s frequently, and i,« satisfied to nun»e tor a shorter time, showing thereby an evident dimiuution of appetite. At the same time it is apt to reject its milk in larger quantities than usual, and this is often observed to have a very acid smell. After these symptoms have lasted a few days, and sometimes with- out them, the |>eculiar symptoms of the disease, the diarrhcea and othfr ab- dominal symptoms, make their appearance, and are accompanied by febrile reaction in most ca.«»«. In older children the acute form may come on suddenly, with diarrlnea, \o9e of appetite, thirst, sometimc^s vomiting, abdominal pain and fever from 394 ENTERO-COLITIS. the first; or, as happens very frequently, the case begins with slight diar- rhoea, unaccompanied by fever or other signs of sickness, and it is not until after several, or eight, ten, or even more days, that signs of inflammation make their appearance. After the disease is established, the most important symptoms are the following. The diarrhoea, w^hich is the most prominent and characteristic, presents various characters. In order to appreciate this symptom as its importance requires, the practitioner ought always to see the napkins of the child at least once, and often more frequently, in the day. It exists in almost all cases of entero-colitis, in the erythematous and follicular in- flammations, and in the ulcerations and softening which accompany or succeed simple inflammation. It is seldom absent, and yet that it is so sometimes, is proved by the facts mentioned by MM. Rilliet and Barthez, who state that they have calculated, from their cases, that it is wanting in about one of every twelve cases of inflammation or softening of the intes- tine. They add, however, that it is absent only in slight attacks, and is ahvays present when the disease is severe. It varies greatly as to the fre- quency, abundance, and character of the stools. It varies also in its mode of progress, so that it presents great differences as to all these points from day to day, and at diflerent portions of the same day. We may remark, in general, however, that in proportion to the severity of the inflammation, so is the diarrhoea violent and constant, and that it usually increases as the signs of inflammation become more and more marked. It is rare to have severe diarrhoea when the anatomical lesion is of slight extent, though this does sometimes happen. The number of the stools, as has been stated, is exceedingly variable. This depends in great measure upon the violence of the case ; for, while in those which present the symptoms of an inflam- mation of small extent the stools seldom amount to more than six or eight a day, in those in which the evidences of more extensive and severer in- flammation are present, there will be fifteen, twenty, twenty-five, or even more per diem. The consistence of the stools may vary between that which characterizes them in a state of health, and that of the thinnest serous fluid. The materials of w^iich they are composed consist chiefly of mucus, bile, serum, small portions of feculent matter, portions of un- digested casein or other food, and blood. M. Bouchut {loc. cit, p. 219) describes those of very young children as presenting the following charac- ters : 1. They are semifluid, homogeneous, greenish, and similar to cooked vegetables ; neutral. 2. Semifluid, homogeneous and green ; often acid. 3. Semifluid, heterogeneous, greenish, and mixed with yellowish frag- ments of ordinary fseces ; neutral. 4. Semifluid, heterogeneous, greenish, and mixed with fragments of un- digested casein ; acid. 5. Difllueut, greenish, heterogeneous, composed of a large quantity of water, in which float yellowish and greenish or whitish particles ; acid. 6. Diflluent, greenish, like the preceding, and mixed with gas of a mawkish and sometimes sourish smell. SYMPTOMS — DURATION. 395 7. Diffluent, completely serous. 8. Bloody stools are very rare at this age. Such are the appearances of the stools in children who have not com- pleted the first dentition. After the epoch of the first dentition the disease becomes much more mre, and when it occurs, is generally of a milder character, so that the discharges ditfer less from their healthy characters. Under these circumstances, they are usually less frequent, not often exceed- ing six, eight, or ten in the day, and retaining generally their yellow color or becoming brownish ; they are commonly of a semifluid consistence, and may be called bilious. When, on the contrary, more frequent, they be- come fluid, abundant, mixed with mucus, and are either of a light yellow or brownish, or more rarely, of a greenish color. In some cases there are, in addition to the substances mentioned, pus, which indicates ulceration of the lower |X)rtion of the intestine, and fragments of false membrane. Moreover, it is very common in older children to observe traces of blood in the stools, sometimes in considerable quantities. We may remark that we have several times met with stools containing blood in children within the year, but much less frequently than after that age. The presence of blood generally coincides with small and frequent stools, attended with much straining, and often severe pain, and almost always indicates fol- licular inflammation and ulceration of the large intestine. The serous fluid alluded to sometimes constitutes the whole of the dis- charge, so that the napkins are merely wetted through, without any or but a very small quantity of solid matter being left upon them. This kind of stool is very frequent in the cholera infantum of this country. The odor of the stools is important. In the beginning, while the discharges still retain some of their natural characters as to color and consistence, it is often very offensive, but as the case goes on, and the greenish color pre- dominates, it is either sour, or becomes very slight. In some violent cases, in which the discharge consists of a watery, dark-brown fluid, the odor is fetid. After diarrhcea, the most important symptoms arc those which concern the form^ sizCf and tewnon of the abdomen^ and the presence or absence of pfiin or tenderness on pressure. In infants the abdomen is more distended than usual ; but, according to Bouchut, the tension depends on the muscu- lar effort made by the child to resist the hand of the physician. He says that when it is carefully examined, while the attention of the child is at- tracted in some other direction, it is found to be soft and supple, and rarely painful to the touch. In older children it is, in many acute cases, but not in all, enlarged, s<^»metime8 tense and sonorous, and very generally painiul to the touch. The seat of pain is variable, but generally it is one of the iliac fossae or at the umbilicus. It is seldom acute, though the child not unfrequently shrinks away and cries out, as though it were excessive, from fear of the examination. It is easy to distinguish when the pain is real and when apparent, by withdrawing the attention of the child, by some device, from the examination, in which ca«*e it will cease to notice the pal- pation ; or by touching some other part of the brxly, when, if the crying and shrinking depend oo fear or nervous excitation, they will be as violent 396 ENTERO-COLITIS. as when the abdomen is touched. Pain to the touch is an important symp- tom, as it is very generally indicative of acute enteritis. Gurgling is rare, according to MM. Eilliet and Barthez, in ordinary entero-colitis, though very generally present in typhoid fever. Vomiting is very common in young infants, and is generally repeated several times a day. In severe and rapid cases it is a very troublesome and alarming symptom. In older children it is much less common, and is never really violent, except in some of the most acute cases. In them it is confined to the first few days of the attack. After the diarrhoea is fairly established, young infants are almost always either very irritable, peevish, and restless, or weak, languid, and subdued. Their slumber is short, and disturbed, and generally they sleep much less in the twenty-four hours than when in health, unlcvSS under the influence of anodynes. Older children are generally somewhat restless and irritable, but much less so than infants. There is seldom any disorder of the intel- ligence, though in acute cases there is sometimes slight delirium, or head- ache. Fever exists in all acute cases. It is seldom continuous in infants except for the first few days, after which it almost always assumes the remittent type. It is marked by increased frequency of the pulse, which rises to 120 and 140, or in bad cases much higher ; by heat of skin, often intense during the exacerbations ; by thirst and diminished appetite ; and by dryness and heat of the mouth. In older children the pulse is not generally so high as in infants, and in many of the mild cases the fever is very slight or there is none at all. In acute cases, however, it is'sometimes continuous, and marked by rapid pulse and great heat of skin. The tongue is generally normal, though sometimes red on the edges and tip in acute cases. It is seldom dry, except during the fever. The appe- tite is almost always lost, and the thirst generally increased, though to a less degree than in diseases of the stomach. The countenance presents nothing peculiar, except that the features are, according to MM. Eilliet and Barthez, drawn down towards the inferior portion of the face. Emaciation always takes place as the disease pro- gresses, and in very severe cases occurs with the greatest rapidity, so that in a very few days the child will be reduced from an appearance of vigor and strength, to that of the greatest debility. As this occurs the flesh loses its firmness, the skin hangs in folds upon the trunk and limbs, and is dull and dirty in its tint, the eyes become sunken and surrounded with bluish circles, and the whole appearance of the child is that of misery and exhaustion. In infants, it is very common to meet with erythema of the buttocks and thighs, produced by the contact of the acrid stools and urine with those parts. This symptom is said by Bouchut to exist in five-sixths of the cases. We feel quite sure that it does not exist in so large a proportion of those which occur in private practice, though we have met with it in nu- merous instances. When severe it is generally accompanied by papules, which ulcerate after a time and form superficial ulcerations upon the skin. The.e ulcerations sometimes run together, and become of considerable size and depth; In the form of the disease met with in the children's hospitals SYMPTOMS — DURATION. 397 ill Paris, ervthema ami ulcerations of the heels and internal malleoli are also met with, and constitute a serious complication in the case. They are said to de}>end on want of cleanliness, and the rubbing together of the feet of the child, unprotected by covering. We have never met with them in private practice. The duration of the disease is stated by the French writers to be gener- ally about fifteen days, at the end of which time convalescence is usually established. It may be shorter or longer. According to our own experi- ence it is entirely uncertain. Most of the cases that have come under our notice have been rather shorter. The disease subsides gradually. The number of stools diminishes; they become less abundant and more con- sistent, and return to their natural color and odor; the pain on pressure, and the enlargement and tension of the abdomen disappear ; and as this occurs, the fever subsides, the appetite returns, the temper improves, and the child enters into full convalescence. The chronic form of entero-colitis generally follows the acute, though it sometimes presents many characteristic features from the fii-st. It differs from the acute form chiefly in the absence or the much slighter degree of fever and other constitutional symptoms in the early stage. The diarrhoea is less abundant and less frequent. At first the child retains its spirits and many of the signs of health. But gradually its strength fails, the temper becomes irritable, the complexion grows dark, sallow, and unhealthy, the skin becomes dry and harsh, and, in consequence of the emaciation which takes place progressively with the other symptoms, hangs in folds around the shrunken extremities, or is drawn tightly over the joints and other osseous protuberances. The tongue is generally moist and natural, though in some cases red and dry, whilst in others it, together with the lips, par- takes of the pallor which pervades all parts of the body. The abdomen is usually distended and sonorous on percussion, and may be painful or not on pressure in ditfereut cases, or in the same case at different periods of the di."^a*e; it^^ parietes sometimes offer no resistance to the touch, so that the intestinal convolutions may be readily felt by the hand, or even be- tween the fingers ; and in some cases we have seen them so thin and re- laxed, though the abdomen was more prominent than natural, that the outlines of the intestines, and even their peristaltic movement, were visible upon the exterior. The appetite generally persists in spite of the gravity of the disea.«€, and is sometimes increa.sed. The stools, as has been stated, are not .«o frec|uent as in the acute form, .seldom numbering over six or ten in the day and night. They consist of the products f)f an imjierfect diges- tion, and contain not unfrequentiy the alimentary substances in the state in which they were swallowed, mixed with mucus, serum, pus, and some- times blood. Their consistence varies constantly, but they are usually semifluid. Their odor is .seltlom natural, and often extremely offen.-ive. The cowrie of the disea.se is very irregular. Kven in the worst and most prolonged cases intermi.ssions or remi.-wions occur, so that the child will often improve greatly for days or weeks, and then suddenly relapse into as bad a condition as ever. In favorable cases these remissions become more and more frequent, and the symptoms gradually improve, until at 398 ENTERO-COLITIS. length the child is restored to health. In fatal cases death is occasioned by the utter deterioration of the general health which finally occurs, and the child perishes, worn out by long illness, or, as more frequently happens, some complication arises which hurries on the fatal event. Thrush is a frequent complication of chronic eutero-colitis, and doubtless often hastens the death by the impediment which it occasions to the nursing or feeding of the child. Vomiting has almost always occurred towards the close of the fatal cases that we have seen, especially in those in which extensive thrush was present. The duration of this form is of course very uncertain. It may last for weeks or months. We have known it to last two and three months in sev- eral cases, and in two others it lasted with occasional intermissions, in one a year, and in the other eighteen months. Diagnosis. — The diagnosis of acute entero-colitis is not difficult. There is no disease with which it is likely to be confounded. The characteristic features of the malady are the diarrhoea and other abdominal symptoms, and the absence of signs of other disease. The secondary cases are distin- guished by the occurrence of the usual symptoms of entero-colitis during the progress of the primary malady. The chronic form is not likely to be mistaken for any other disorder, unless it be the diarrhoea which occurs in tubercular disease, from which it is to be distinguished by the presence in the latter of the signs of tubercu- losis of other organs. Prognosis. — Acute entero-colitis is always a serious disease in infants. The prognosis will depend in great measure on the circumstances under which the affection has been developed. It is much more unfavorable in a child fed on artificial diet, either wholly or in part, than in one who is nursed at a fine breast of milk. It is more unfavorable also in weak and delicate than in robust and vigorous children, and in those of poor people, who live in crowded and unhealthy portions of cities and towns, whose habitations are small, damp, and ill-ventilated, and whose food is coarse and insufficient, or improper, than in those placed in more fortunate and more healthful hygienic conditions. It is a more dangerous disease in summer than in winter. In hospitals for children it is a very fatal dis- order, owing to the bad hygienic conditions under which the inmates are placed. In children who have passed through the first dentition, the prog- nosis is, as a rule, favorable. The disease is seldom dangerous in such cases when it occurs as a primary affection, while, as a secondary affection, on the contrary, it is much more apt to be serious. The unfavorable symptoms are : great frequency of the stoels ; collapse ; violent vomiting or retching ; and dangerous cerebral symptoms, as coma, rigidity of the limbs, paralysis, or convulsions. Treatment. — The prophylactic treatment is very important. It includes attention to habitation, diet, dress, and exercise. The most frequent causes of entero-colitis are high summer temperatures, residence in an unhealthy locality, and improper diet. A child may have been born of the most healthy parents; ma}'' be living, if an infant, on the most healthy food in the world, the milk of a perfectly sound woman, or, if it have been weaned, PROPHYLACTIC TREATMENT. 399 on the best possible substitute for breast-milk, one selected by the most consummate medical art; and yet, if it be the unfortunate resident of some low, crowded, and unclean part of any of our cities in the summer season, it has but small chance of escaping inflammatory diarrho?a or cholera in- fantum, to be followed by chronic diarrhcra. Or, a child may be living in the best part of these cities, with every advantage that wealth and the medical art can give, and, if in the period of the first dentition, and the summer heats be great, it will be only too apt to have some form of the disease we are considering. Under the latter circumstances, its chance of escaping the disease will be vastly greater than under the first-named con- ditions, but the true prophylaxis is, where the parents are so situated as to be able to do that which is best for the child, removal from the city during' the hot season (from the early part of June to the last week of September) into some cool and healthy region of country. We have long thought that the best region to spend the summer in is a somewhat high and cool part of the country, where the breezes have full sweep, and where the topography is such that water runs off rapidly, or sinks fast into the soil. The seaside, if it be a point where there are no marshes and no malaria, and where the supply of milk and other wholesome food is abundant, is an excellent place. We have seen more remarkable sudden efi^ects from the removal of a dangerously sick child to the seaside, than from a change to the in- terior; but, nevertheless, for a continued residence of three months, we prefer a high interior locality. On the other hand, if a child be placed in the most favorable possible condition as to locality, and the diet be a radically bad one, a deficient or unhealthy breast, improper artificial diet, or a foolish allowance on the part of the mother or nurse to the child of a variety of vegetables, of fruits, and especially of berries like currants or gooseberries (and we have known such things;, it can scarcely escape the penalty of a fit of illness more or less severe. A child who is so unfortunate as to get a sharp attack of entero-colitis in June or July, is very apt to continue more or less sick during the rest of the summer, so that the true prophylaxis is to take it away from the city early in June to avoid this danger, and not to return until after the September heat«< are over. As the reasons for decisive medical action in any disorder cannot l)e too strongly demonstrated, and as this suiyect of removal is a very important one, we think it well to advert here to the results of experience in this matter in the diarrhrea and dysentery of our armies during the late war. Here we have. the experience of intelligent army medical officers in vast numbers of cases, — cases. Uh), so grouped together as to give opportunity for the most accurate observation. In the Ser kind. It is clear, therefore, that to avoid the disease it is necessary that the child should, if possible, be nursed. If this cannot be done, the diet ought to be wisely selected and regulateortion. Therapei'TIcal Tkeatmext. — We liave found a large number of the mild ca.«es that have come under our notice to recover under very simple tn ainif nt. When the patient is an infant at the breast, before the period ot d» iitilion, the f^iraple direction not to allow it to nurse as much as u.^ual ; the use of a warm bath morning and evening, if the skin be heated and the child restlese and fretful ; the administraticm of a small dose of castor oil thalf a teaspoonful to a tea.«poonful;, or of spiced syrup of rhubarb in 402 ENTERO-COLITIS. the same quantity, with a half drop to a drop of laudanum, at the begin- ning of the attack, to remove any undigested food that may be lying in the bowels, followed in one or two days, if the disorder continues, by some simple astringent remedy, generally suffices to effect a cure. When, on the contrary, the case depends on an unhealthy or insufficient milk, when the child subsists entirely on artificial food, and when the disease coincides with the process of dentition, the attack is kept up and aggra- vated by these causes, and it is more difficult to obtain a cure. In the former case the diet is, of .course, of all importance; in the latter the gums must be carefully examined, and if found to be swelled and in- flamed, and the teeth near the surface, they should be freely incised. After these matters have been attended to, the kind of treatment will de- pend on the character of the general symptoms and the violence of the enteritic disorder. When the pain is violent, the discharges frequent, painful, and mixed with mucus, muco-pus, or blood, and the abdomen tense and painful to the touch, moderate local depletion by leeches may be used with advantage and safety in vigorous children. The leeches are best applied over the lower part of the abdomen. About six or eight American leeches, or two for- eign ones, may be applied at the age of one or two years, so as to take about two ounces of blood. Of late years, however, we have not em- ployed depletion so much as formerly, but use instead warm baths, poul- tices to the abdomen, or warm stupes, and refrigerant medicines. Small doses of the sulphate of magnesia and laudanum are very useful ; or we may employ spirit of nitrous ether, or solution of the acetate of ammonia with paregoric or laudanum, or the following mixture : R. -Sodse Bicarb., . . . ^ss. Mass. Hydrarg., Tr. Opii Camph., Syrup. Simp., . Aq. Menth., . . gr. iij. . gtt. L vel f^j . f^xiv.-M. Dose, a teaspoor ifiil every three oi four hours. The warm bath, used at a temperature of 95° to 97°, twice or thrice a day, is most excellent. It is a good plan to wrap the child, immediately on being taken out of the bath, in a warm muslin sheet, and over this a light blanket, and let it lie on the lap or bed for twenty minutes or half an hour. During the past two years, the external use of cold water in febrile diseases has been extended widely, and among the affections in which it has been applied are entero-colitis and cholera infantum. We have ourselves limited the use of water to tepid bathing or cool sponging when the temperature was considerably elevated ; but excellent results have been obtained by some observers, both here and in Europe, by the use of cold baths (72° to 78° Fahr.), repeated several times during the day when the febrile temperature rose to 103° or 104°. If the temperature should remain elevated, despite the use of repeated cool spongings and the warm bath, the cool baths may be tried, though we should not recommend them quite so cold as above mentioned. THERAPEUTICAL TREATMENT — CALOMEL. 403 The hot poultice or stupe recommended above should be covered with oiled silk, secured by a towel pinned around the body, changed every three or four hours, and kept on for the greater part of the day, or for several days. Calomel has been so highly recommended and so long employed in these cases, thai we feel some hesitation in saying how often it has disappointed us. Certainly we have found in many children that it was of no evident use, and in the old-fashioned doses of a grain or half a grain, we think it only adds to the irritation of the bowels, Jn doses of the twelfth and eighth of a grain, with chalk and opium, every two or three hours, we formerly thought it was sometimes useful, but we cannot resist the im- pression which years have given us, that the useful agents in these instances have been the chalk and opium, and especially the opium. We still have conlidence in, and employ, the mixture of blue mass and soda above recommended. It does not irritate, as we have known the larger doses of calomel to do ; but, on the contrary, when given for thirt)''- six or forty-eight hours, under the circumstances mentioned, it is frequently followed by an improvement in both the number and character of the stools. Before quitting this question of the use of mercurials in diarrhoea, we wish to quote the results at which some of the more modern observers have arrived, with the remark, as we pass on, that our own conclusions were much the same ten years ago as those expressed above. We shall do this even at the risk of being tedious, for we think the point a very important one. In the first place, we shall quote the opinion of one of the ablest of the United States army surgeons, as to the use of this drug during the late war. The writer ( Outlines of the Camp Diseases of the United States Armies as observed during the Present War, by J. J. Woodward, M.D., Philadel- phia, 1863), in the article on Chronic Diarrhoea, a disorder closely akin in many of its symptoms and anatomical lesions to the entero-colitis of children, says, at page 262: "Among the remedies liberally employed in chronic diarrhoea is one which can only be mentioneol with disapprobation. This is the mercurials, which are too frequently administered to gentle salivation in the form of blue pill or calomel, combined with opium and ipecacuanha. The authority of some of the most distinguished American medical writers is in favor of the employment of mercurials in the chronic diarrhoea of civil life; yet when it is remembered that even those modern writers, who most warmly advocate their general emplojyment in the treat- ment of inflammation, recommend them to be discontinued as injurious whenever the pro)cess has gone on to ulceration, it would appear that even sound mercurialists would avoid using them in the form of chronic diar- rhoea which is mo»st common in the army. " Practically it will be founol that although in some cases mercurials may succeed, a.s much less dangerous remedies would have done, in cho'cking the progress of the disease, yet that in the majority of cases their employ- ment is accompanieol by an increa>e of the debility, the lo)ss of appetite, the ansemia, and the general constitutional symptoms, without any dimin- 404 ENTERO-COLITIS. ution in the frequency of the stools. They are, therefore, to be regarded as dangerous and inefficient, and their use in these cases has been com- pletely abandoned by those surgeons who are most successful in the treat- ment of the disease." Dr. T. K. Chambers, of London (^Clinical Medicine, Loudon, 1864, p. 517), in considering the treatment of diarrhoea in which the stools exhibit the products of acute inflammation, says: " The drugs I have most trust in are calomel, ipecacuanha, and carbonate of soda. Of the first and second equal quantities, and.a double quantity of the third, may be made into powders, of which from four to six grains, according to the child's age, may be given every three hours. This is a traditionary powder, but it is right to say that I have in a good many instances lately left out the calomel, and the case has done just as well, if not better, without it." Dr. J. L. Smith, of New York {op. cit, p. 379), says nothing whatever about mercurials in his article on the treatment of inflammatory diarrhoea, from which we are led to suppose that he does not use them. He however quotes Dr. E. H. Parker as giving, when the condition approaches that of dysentery, a mixture consisting of about ten grains of blue mass rubbed up in two drachms of syrup of rhubarb, to which is added one half teaspoon- ful of paregoric, and four ounces of chalk mixture. Of this the dose is a teaspoonful every two or three hours. Dr. Parker says that the " blue mass certainly does not act like the calomel, not producing in purgative doses so great prostration, and in small doses it does not lessen the proportion of fibrin in the blood, as is the case with calomel." Dr. Smith's comment on this is : "I have never used this mixture, having been generally satisfied with the effects of the castor-oil mixture." It is unnecessary to say any more upon the use of mercurials, and espe- cially of calomel. We have quoted enough to show that our own opinions find us in very good company. We regard opium as one of the most valuable remedies we have in the treatment of this disease. In a former edition of this work it was stated that some writers objected to its employment in the early stage as injuri- ous, but that we had not been deterred from using it, except in cases pre- senting manifest signs of cerebral irritation in connection with the febrile symptoms ; but that when there has been nothing more than irritability, restlessness, and insomnia, when there was evident pain during the dis- charges, and when the latter have been very frequent, we had always made use of some of its preparations without hesitation, and certainly without injury, but, on the contrary, with very great benefit. Our longer experi- ence confirms us in this view and practice. The propriety of using large doses of opium in the early stages of cholera infantum may well be ques- tioned, as it has come to be by some of the best observers in Asiatic cholera ; but this matter will be considered under the head of that disease. In the disorder under consideration, which is one of an inflammatory catarrhal type, we have never seen the moderate use of opium do anything but good. When the nervous symptoms are very marked, if they be of the kind which denotes disturbance of the reflex functions of the nervous system rather THERAPEUTICAL TREATMENT. 405 than those indicating cerebral disorder, we find nothing which answers so well our purpose as this remedy. When, however, there is unusual quiet, tending towards drowsiness or stupor, with contraction of the pupils, we make use of it only with great caution and in very small doses. We are glad to find that Dr. Stokes also" employs opium without hesitiition. He says, "It is a remedy that requires caution in its exhibition, but one of great utility." It generally lessens the number of discharges, and very often diminishes the heat of skin and frequency of the circulation, by al- laying the irritability of the nervous system, while at the same time it greatly promotes the comfort of the child. We have used it in the form of laudanum or paregoric, given in combination with a laxative early in the case, or by enema, and afterwards in that of the Dover's powder or powdered opium. For a child under six months old half a drop of lauda- num is enough to give by the mouth. Of the Dover's powder about a sixth or eighth of a grain may be administered mixed with two grains of chalk, to be repeated every two or three hours, until three or four doses have been taken, or until the child shows some degree of drowsiness from the action of the opium, after which it ought to be suspended for six or eight hours, and then resumed. Or the opium may be given in the form of laudanum combined with the sulphate of magnesia as recommended above. The old-fashioned castor-oil emulsion, in the proportion of one drachm in a one or two-ounce mixture, with half a drop of the deodorized laudanum to each teaspoonful of the mixture, is often very soothing and beneficial. When there is marked tenesmus, with frequent small evacua- tions, opium may also be used with great advantage by the rectum, either to the exclusion of any in the mixture, or in addition to that, taking care to graduate the quantity by the degree of drowsiness that maybe induced. At one year two drops in one or two teaspoonfuls of water or thin starch- water may be used two or three times a day. In such cases, suppositories are sometimes retained better than enemata. A twelfth to a sixth of a grain of powdered opium, made up with cocoa butter, may be given instead of the injection. Generally speaking the acute constitutional symptoms either subside or disappear under the above treatment, and very often the (liarrhrph. Siilphat., ..... frtjxxxij. Acid.Sulph Dil., Ttjjxv. CursiQoa, f:^!]. Aquae, ........ f^xiv. — M. Dose, a teaspoonful every hour or two hours, at the age of six months to a 3'ear. For older children, the proportions of the opiate and acid must be in- creased. When the nausea subsides or passes away, or when the child becomes drowsy, the intervals between the doses must be lengthened, and as the symptoms disappear, the other remedies necessary for the diarrhoea may be resumed, and so too of the food. Dr. J. L. Smith, of New York, states that the best remedy he has used for vomiting is the neutral mix- ture, as follows: H- — Potass. Bicarbonat., gr. xxv. Acid. Citrir., i^r. xvij. Aquae Amygd. A mar., f^j. Aquae, f5ii. — M. One teaspoonful to a child from eii^ht to twelve months old, repeated according to the nau-iCH or vomiting. Creasote is also sometimes very useful. Dr. Smith says that in the Nursery and Children's Hospital of New York, this remedy is used, given in the proportion of an eighth of a drop in a teaspoonful of lime-water, in a tea«[K>onful of milk or breast-milk, and has been found successful in a certain proportion of cases. Thkatment of Chronic ENTEUO-foLiTi.s. — The management of the hygiene of the patient is more important than any other part of the treat- ment, in this, as in nearly all the diseases of the digestive organs in chil- dren ; for cases will often recover when the diet, drinks, and exercise are properly regulated, without the use of any drugs whatever, whereas, most assuredly, but a small proportion of them would terminate favorably under the best and wisest therapeutical me<]ication, were the hygiene of the child neglected. The remarks that have been made as to the diet most proper in the acute form will apply here. If the child have been weaned only a 410 ENTERO-COLITIS. few weeks before the time at which we are consulted, and the case is at all serious, it is better to advise the procuring of a wet-nurse. We have several times known cases of the disease which had resisted the most care- fully managed artificial diet and therapeutical treatment, recover in a few days after the child had been restored to the breast. It is often, however, impossible to follow this course, from the refusal of the parents to obtain a nurse, or of the child to take the breast of a stranger, and we are obliged to rest content with artificial food. We believe that the kind of diet which suits the largest number of children is one of milk. During a number of years past, we have found the gelatin food, already described, to answer better than any that we have ever essayed. It ought to be made very light and thin. About a scruple of gelatin should be dissolved by boiling in half a pint of water. Towards the end of the boiling, a gill of cow's milk, and a teaspoonful of arrowroot made into a paste with cold water, are to be stirred into the solution, and from one to two tablespoon fuls of cream added just at the termination of the cooking. It is then to be sweetened moderately with white sugar, when it is ready for use. The whole preparation should occupy about fifteen minutes. When cow's milk, mixed with water alone, or prepared in the manner just recommended, evidently disagrees, we have sometimes found cream with water alone, or better still, with the solution of gelatin in water, in the proportion of one part of cream to five or six of the latter, to suit very well. In other cases very carefully prepared beef tea or chicken or mut- ton water, given several times a day or but once, according to the taste and fancy of the child, will answer better. It sometimes happens that the child will refuse everything that has been mentioned, and yet the prostra- tion and emaciation are such as to make it essential to procure some ali- ment that it will consent to take. We have, under such circumstances, given small portions of bread and butter, or stale sponge-cake, with weak brandy and water, if the child is old enough to swallow solid food. If the white of an egg be stirred in a small glass of water, the child will usually drink it freely without recognizing the presence of the albumen, and we are thus enabled to administer a considerable amount of nutritious food by giving the whites of two or three eggs in the course of the day. Some- times the child will eat small quantities of meat, and when this has been the case, we have not hesitated to allow a chicken-bone, with a little meat attached to it, or a piece of ham, or better still, a portion of roast beef, or of the tenderloin of beef-steak, to be held in the hand and sucked ; or we may give the white meat of chicken cut up very fine, or torn into the finest shreds. Of the latter about a teaspoonful is sufficient for the first day, given with a little brandy and water. The quantity can be gradually in- creased afterwards. We have of late years also given small quantities of raw beef in many cases, minced very fine and flavored with salt, or pre- pared in the manner described below,^ and have found it to be readily di- ' The use of raw meat in the diarrhoea either of infants deprived of their mothers' milk, or of weaned children, was recommended by Weisse, of St. Petersburg, as loni; ago as 1840 (Oppenheim's Journal). Of late years it has been extensively used with excellent results, and is highly praised by Trousseau and other eminent I DIET IN THE CHRONIC FORM. 411 gested and to agree well with the little patients. There is another article which we have sometimes given when children have been exhausted for want of food, and when they require constant change in order to be tempted to take it. This is the yelk of a /mr(/-boiled egg, which has the advantage of being very nutritious if digested, and of not being injurious should it happen to pass into the bowel in the crude state, as it falls into a state of fine powder, which is not irritating to that organ. The quantity as well as character of the food is of the utmost impor- tance, and should be strictly regulated by the physician, and attended to by the mother or nurse. As a general rule the child may be allowed as much as it wants of proper food, since the appetite is almost always greatly diminished, and it is not likely, therefore, that too much will be taken. If, however, there is disposition to nausea or vomiting, or if the appetite remain as good as usual, the quantity must be restricted. The difficulty in most ca.>es is to get the patient to take enough, and not to prevent it from taking too much, for we have very often ascertained, upon careful inquiry, that the quantity was entirely too small to support the strength of the constitution. A hearty child six months old, fed solely on artificial food, will generally take a quart of food in the twenty-four hours, while at a year old it will take usually fully a quart or three pints of fluid nour- ishment, besides eating small quantities of solid food. Now, we have fre- quently known children laboring under chronic entero-colitis, not to take more than one or two gills of food in the day, which is manifestly much too little. When this is the case, therefore, we should always endeavor to stimulate the appetite and digestion by means of tonics and stimulants, and by causing to be presented to the child such a variety of food as may entice it to take a larger quantity than before. authorities. The administration of the muscultir tissue itself appears much more useful than any form of beef essence or soup, probably for this reason among others, that these fluids pass too quickly through the intestinal canal. The best moat for the purpose is the fillet of beef, though fine mutton may also be used. It should be cut vcf}- fine, and according to Trousseau, poundod in a mortar and strained through a sieve or cullender ; the pulp, thus separated fr<^)m the cellular texture of the meat, may be rolled into small halls in .salt or powdered sugar. The quantity upon the first day should not exceed three drachms, given in di- vided doges; but it may be doubled on the successive days, until young children may take from six to ten ounces a day. Under this regimen the diarrhcea frequently ceases, and the children quickly recover their jtlumpness and natural spirits. Trousseau calls attention to the fact that the stools are frequently red and fetid at first, even when the nature and abundance of the diarrhoea have already undergone a favorable change. In a second article upon this subject (Jour, fiir Kinderkrankheiten, January and February, 1858;, Wei&.sc calls attention to the fact that in many children who had been treated by raw beef, tapeworms have been developed. As these worms were all specimens of taenia solium, which is not indigenous in St. Petersburg, it is prob- able, as suggested by Von Siebold, that they had been conveyed in the undeveloped state in the flesh of oxen, brought from distant points. We are not aware that this unfortunate consequence has been observed frer^uently in other localities, and cer- tainly in the quite numerous cases in which we have ourselves administered raw meat to children, no entozoa have been developed. 412 ENTERO-COLITIS. In connection with this most important matter of the food, we will again quote from Dr. S. B. Hunt (ojo. cit., page 305), to sho^Y the results of his experience in the use of foods in chronic inflammatory diarrhoea in the army. For the sake of any non-professional reader, we will state that by albuminoid food Dr. Hunt refers to meat, meat-broths, eggs, etc. ; and by antiscorbutic food he means tomatoes, fresh fruits, onions, etc. Dr. Hunt says, " The value of drugs was, perhaps, overestimated in this, as in all other diseases of assimilation, and only a careful avoidance of the original causes of the malady, and an equally careful recognition of their continued existence in the system, could secure any degree of success. The scorbu- tic and malarial taints were almost uniformly present, the former very fre- quently in as pronounced a form as the latter. The bowels, enfeebled by the inflammatory process, were unable to perform their normal function of the digestion of starches, and the diet, therefore, became necessarily albu- minoid. A full nutritious diet of albuminoid and antiscorbutic food as- sumed the first importance in the treatment. Coupled with this came pure air and absolute cleanliness. And, with these hygienic measures alone, when they could be properly enforced, it was possible to treat chronic diar- rhoea and dysentery with a fair degree of success, even in the great heats of a Southern summer." These views confirm what we have said above, that milk, meat, raw or cooked, broths, eggs, gingerbread, tomatoes, bread and butter, and we may add currant-jelly, make the best food for children over two and three years of age. Even in children of eight months and a year or upwards of age, milk and beef or chicken tea ought to form the chief diet. The starches, such as arrowroot, barley, wheat preparations, etc., do not answer, except in very small quantities cooked in milk. We saw one child, a year old, weaned in August in consequence of the illness of the wet-nurse, whose life was apparently saved in dysentery by Liebig's cold extract of beef, and by its fortunately having developed a strong taste for the sucking of large pieces of rapidly and slightly cooked beef- steak. The therapeutical treatment of the chronic form consists principally in the administration of tonics, astringents, and absorbents. Of these the most important are the bismuth, powdered chalk and crab's-eyes, and the different vegetable astringents, which have already been noticed in the re- marks on the acute form. These are to be given in the manner there recommended, and it is therefore unnecessary to repeat what has already been said. In addition to these there are some remedies which are par- ticularly adapted to the chronic form of the disease. Amongst them is nitrate of silver. Dr. Eberle (op. cit., p. 251) says he has found its internal administration to produce the happiest effect in a few instances. His pre- scription was a grain of the nitrate dissolved in an ounce and a half of gum arable w^ater, with the addition of twenty drops of laudanum. The dose was a teaspoonful three times a day. He adds that he has never " known the slightest inconvenience to result from the use of this article in chronic mucous inflammation of the bowels, when administered in a mucilaginous solution and in very small doses." It has been much used of late years in France. MM. Trousseau and Pidoux recommend its internal use in TREATMENT OF THE CHRONIC FORM. 413 the chronic diarrhoeas of children occurring during dentition, after bis- muth, powdered crab's-eyes, and diet have failed to effect a cure. Their formula is a^ follows : R. — Argent. Xitrat., ?•*. j. Aqu:v De.-tillat., ^o^'J- Syrup. Sarsjip., ....... l5ijss. — ^M. To be given in eight or ten doses. At the same time, they employ an enema composed of a grain of the ni- trate in three ounces of distilled water. It is highly recommended also in these eases by Hirsch, of Konigsberg. His formula is as follows : R. — Argent. Xitrrtt. Crystal., gr. J. Aqua? Destilliit., f.^ij. Aciici;e Pulv., . . . . . . • Bij- Sacch. Alb., ^ij — M A teaspoonful of this mixture to be given every two hours, and an enema, consisting of a quarter of a grain of the salt, with mucilage and a little opium, to be administered (Bankliig's Abst., No. vi, p. 61). We have em- ployed this remedy in the proportion of from half a grain to a grain in a gill of water, by injection, morning and evening, for several days, with very decided benefit, in three cases of diarrhoea following summer-com- plaint, in which the stools were frequent, mucous, sometimes streaked with blocKl, and accompanied by tenesmus. We have also given it frequently internally in mucilaginous solution, as above recommended, with excel- lent results. Dr. Woodward (op. cit., p. 264) says, in his article on the treatment of the chronic diarrha^a, which was a true entero-colitis, that "by far the most valuable local measure is the employment of solutions of the mineral a.«tringents as enemata." He mentions sulphate of copper, nitrate of sil- ver, sulphate of zinc, and acetate of lead, but thinks that the sulphate of copper and nitrate of silver are probably the most efficient. The strength he recommends is of one or two grains to the ounce of water, of which from one to six ounces may be thrown into the rectum two or three times a day. He advises that, when the rectum rejects the injection immedi- ately, twenty to forty drops of laudanum bo added to each enema, that the injection be thrown carefully into the bowel, and the nozzle of the syringe be withdrawn a.s gently as possible, in order that the fluid may be retained at least for some little time. We quote these statements, not to induce the use, in children, of solutions of one or two grains to the ounce, but to draw attention to one of the means, the ability and advantage of which bore the test of the vast army experience in this most severe and troublesome dis- ease. In children it is best to begin with a grain to four ounces, and, if this gives no pain, or but little, and does not produce the hoped for benefit, the proportion may be doubled, or, after two or three trials, brought up to that of a grain to an ounce. Another excellent remedy in the «hroiiic diarrlio-as of children, one from which we have sometimes obtained very satisfactory effects, is the 414 ENTERO-COLITIS. syrup of the nitrate of iron. It is given in doses of from two to five drops three times a day, in sweetened water, at the age of one or two years. The following formula is recommended by Dr. Eustace Smith. We have used it ourselves in several chronic cases, and have been much pleased with its effects : R. — Liq. Ferri Pernitrat., .... fgss. Acid. l!s"itric. Dil., f^ss. Syrup. Zinzib., f^j. Aq. Anethae, ad f^iij. — M. A teaspoonful every six hours at one year of age. We have found a teaspoonful every three or four hours not too much at three and four years of age. Creasote also has been recommended of late years, and is highly thought of by some practitioners. It may be given in doses of from a quarter to half a drop every three or four hours at a year old. We have used this remedy in the following combination especially in cases attended with nausea, flatulent distension of the bowels, or a very fetid state of the dis- charges : R. — Creasoti, gtt. viij. I Sodae. Bicarb., . Sp. Lavandulae Comp., Pulv. Acaciae, Sacchari, aa, Aquae, .... gr. L. q. s. q. s. ad f§iij. — M. Dose, a teaspoonful three or four times a day. Bouchut recommends enemata of from ten to twelve grains of extract of rhatany, or six to ten of tannin, in about five to seven ounces of some vehicle. Sulphuric acid has been found very useful in the treatment of this affec- tion, and by some authors as, for instance, Pollak (Trans. Amer. Med. Assoc, vol. viii, p. 260) has been given in large doses as the sole remedy. We have never used it in this manner, but for some years past have been in the habit of employing it in the following mixture with excellent results. In cases of diarrhoea, showing a disposition towards dysentery, as often occurs in entero-colitis, and especially when the stomach has been irritable, so as to bear other medicinal substances badly, we have found this combination very beneficial. R. — Acid. Sulph Arora,, gtt. xlviij. Tinct. 0{)ii, gtt. xij, vel xxiv. Syrup. Krameriae, ..... f.f ss. Aq. Fluvial., fjijss. — M. A teaspoonful every two hours. It should never be forgotten in the treatment of chronic diarrhoea in children, that the most important point of all is the regulation of the diet and other hygienic conditions. We are fully convinced that we have seen several children saved from death by attention to these points, and by the persevering and careful employment of tonics and stimulants. It often TREATMENT OF THE CHRONIC FORM. 415 happens, after the disease has lasted for some weeks or months, that the powers of the stomach are ahnost wholly lost. The child either refuses food or takes so little that the quantity is evidently insufficient to carry on the vital processes, or the greater part of what is taken is rejected by vomiting, or lastly, much of it passes off through the bowels, and appears in the stools in an undigested state, forming what is called lientery. If this condition of things is allowed to continue, the emaciation and exhaus- tion make rapid progress, and the case must soon terminate fatally. Under these circumstances all the ingenuity and skill of the physician are required to find articles of diet of a kind to recall and tempt the child's worn-out and often perverted appetite, and which, at the same time, may be digesti- ble and nutritious, and tend to restore vigor to the digestive function. If the stomach is frequently sick, it is best to abandon all remedies but those which are stimulating and strengthening, and especially to forbid all such as are in the smallest degree nauseous. We would indeed depend entirely on the use of repeated doses of the oldest and most delicate brandy that could be found, of which from one to two teaspoonfuls may be put into a wineglassful of cold water, and the whole given by teaspoonfuls in the twenty-four hours ; or fifteen to twenty drop doses of the elixir of Peruvian bark every three or four hours may be used ; or solution of pepsin, in half teaspoonful doses three times a day ; or, two or three drops of tincture of nux vomica in sweetened water three times a day, if the bitterness does not cause nausea or increase the loathing. In such cases, wine of iron, in doses of twenty drops to a fourth of a drachm, with syrup of tolu and caraway water, will sometimes do exceedingly well ; or the following, which has sometimes succeeded in our hands : R.— Tr. Ferri Chlorid., f^;]. Acid. Acet. Dil., f5J. Liq. Ammon. Acetat., .... f^ij. Syrup. Sirap., f^ss. Aquae, f^'j- — ^^^ Dose at four years, a teaspcK)nful, and under that age, half a teaspoonful, three or four times a day. In some very obstinate cases, especially where there is any reason to suspect the existence of a malarial element in the case, from half a minim to one minim of Fowler's solution of arsenic, with the wine of iron, three times a day, has been very serviceable. Whilst this is being done, an oc- ca.«ional dose of anoon as swallowed, or assuming the form of repeated and ex- hausting retching, even when the stomach is quite empty. In connection with these symptoms there is rapid loss of strength. The child is listless and still between the evacuations and vomiting, or tosses and moans with the jactitation of severe illness. The api>etite is lost, but thirst is extreme, and constitutes one of the marked phenomena of the disease. Water and ice are seized upon with the greatest avidity, and taken almost incessantly, if allowed, though rejected only a few moments afterwards. The abdomen is flaccid or retracted, not tender to the touch usually, and the walls inelastic, so that they can be readily pinched up into folds. 426 CHOLERA INFANTUM. The tongue, moist at first, with a thin white fur upon it, becomes pasty or dryish after a time, and is sometimes protruded from time to time between the lips. The pulse runs up from the first, rising soon to 130, 140, and 150, and being usually small in volume, whilst the temperature remains for a time normal, rises slightly above the natural point, or, in some few cases, the skin becomes hot. The urine diminishes in all these cases, and in very se- vere ones, ceases to flow, or flows only in the smallest quantities. As in true cholera, the degree of suppression of this function is in proportion to the severity of the choleraic discharges. The respiration, natural at first, soon becomes, if the case goes on unfavorably, irregular, unequal, and anx- ious. The temper is irritable at the beginning, the child being restless, peevish, disposed to fret and cry at the least contradiction or disturbance. The sleep is restless and disturbed, especially at night. The child wakes frequently, and almost always with crying. When asleep, the eyes are often but half closed, and the brow contracted and frowning. The coun- tenance soon becomes anxious and distressed. In sudden and severe at- tacks, it is languid and subdued, pale and contracted. If the disease is not soon checked, signs of collapse make their appear- ance, and become more and more marked features. The body becomes cool and then cold, the pulse grows smaller, thready, and very rapid ; the features are drawn ; the nose is sharp and thin ; the eyes shrink within the orbits ; the cheeks become sunken ; the patient passes into a still, quiet, and drowsy state ; the vomiting may cease, but the diarrhoea usually per- sists ; the child falls into a comatose or semi-comatose state, and death occurs quietly in this condition, or may be preceded by slight convulsive movements. According to the researches of Koger {op. cit, p. 399), the reduction in the temperature of the axilla never approaches, in these cases of sporadic cholera, that which is found in cases of the true epidemic form occurring in children. Some very violent cases run their course in a day, a day and a half, or two or three days. We, ourselves, do not recollect to have seen any case terminate sooner than in three days and a half. In favorable cases, after one, two, or three days, the diarrhoea ceases to be so violent ; the stools grow less frequent, smaller in quantity, thicker in consistence, containing a better-concocted fecal matter, and regaining a more natural odor. The vomiting and thirst gradually subside ; food is again taken and retained; the circulation falls, and the child, though weak and thin, and the subject for some days of a simple diarrhoea, may regain its health in great measure, at the end of a week or ten days. More fre- quently, however, the disease assumes the form of a more obstinate simple, or inflammatory diarrhoea, which may last for several weeks, to take on again, perhaps, from a recurrence of the exciting causes, the choleraic form, or to persist in one of the former shapes until the return of cool weather. Such is a picture of the disorder to which we think the name of cholera infantum ought to be restricted. If physicians could agree to limit the title to this true choleraic disease, our mortality returns would soon show the comparative frequency of death from this disorder, and from those DIAGNOSIS — PROGNOSIS. 427 more tedious and chrouic diseases which have already been treated of under the designation of simple and inflammatory diarrha\a or entero-colitis. The duration of cholera infantum, as we restrict the term, is seldom more than two, three, or four days. It may prove fatal in a much shorter time. Dr. Eherle (Dis. of Children, p. 285) says it sometimes runs on to a fatal termination in live or six hours. Dr. J. Lewis Smith i^o]). cit., p. 392) re- ports a case in a child sixteen months old, which ended fatally in less than one day; a second, at seven months, after a sickness of about one day ; and a third, at twenty months, in thirty-six hours. We do not recol- lect, in our own experience, which has been chiefly in private practice, a shorter case than one of three days and a half. In favorable cases the diarrhoea usually pei*sists, as already stated, for several days after the dis- appearance of the choleraic phenomena, and very frequently runs on into a simple or inflammatory diarrhoea, which follows the law of these dis- orders. Diagnosis. — The diagnosis of cholera infantum requires no particular elucidation. The season at which it is most prevalent; the profuse, serous, or at least fluid evacuations; the frequent and severe vomiting; the early exhaustion of muscular strength ; the rapid pulse, with absence of, or a very moderate febrile heat; the threatening or the actual supervention of collapse, marked by cool or cold surface, pinched and anxious countenance, shrivelled skin, sighing or irregular respiration, rapid and feeble or ex- tinguished pulse, diminished or suppressed urinary secretion ; with, finally, the still and limp body, and drowsy or comatose brain, all mark a disorder which is readily recognized after being once seen, or which may be dis- tinguished by any intelligent person who has never yet met with such a case, if only the progression of the symptoms be carefully inquired into, and correlated with the present condition. Pro<;nosis. — Cholera infantum, as we restrict the use of the term, is, of course, always a dangerous disease. Collapse, which either threatens all who are attacked by it, or actually supervenes to a greater or less degree, is well known by all physicians to be one of the most formidable morbid conditions to which the body is liable. The degree of danger in any indi- vidual case must dej^end chiefly upon the ability of the physician to arrest, and of the patient to resist, this state. The probability of the supervention of collapse depends very much upon the hygienic condition in which the child is placed, upon the age of the patient, the stage of the process of dentition, the pre?*ent state of health, the innate vigor of the (;onstitutional force, and also, we may say, upon the period of the disease and the degree of wisdom with which medical means are applied. Children placed in favorable hygienic conditions in the country, or in the healthier parts of cities, in large and well-ventilated rooms, and who have been fed upon proper diet, and who have therefore been attacked by the disease whilst in previous fair health, are much more apt to escape collapse, or to recover from it after it has made its appearance in a more or less marked degree, than those who are placed in conditions the opposite of those we have enumer- ated. Early age, recent weaning, im[)n»f)cr artificial diet, and feeble vital powers from any cause, either inherent or acquired, are amongst the most 428 CHOLERA INFANTUM. unfavorable prognostics. Still, we should never despair until the last mo- ment, since we have seen some most surprising recoveries from apparently desperate conditions in this disease. The prognosis may be stated in general terms to be unfavorable in pro- portion to the frequency and violence of the vomiting, the number of the stools, the severity of the fever, and the more or less marked character of the collapse. When the discharges consist merely of serous fluid, and are copious and frequent ; when they consist of small quantities of deep-green matter, mixed with much mucus or with blood ; when accompanied by straining; when they number from fifteen to twenty-five in the day; when they are very fetid ; and when, with these symptoms, the abdomen is tense and tympanitic, the countenance pinched, the expression languid, the extremities cool, the pulse rapid and small, and the child irritable and rest- less, or, on the other hand, very still and subdued, the prognosis is exceed- ingly bad. If, after the symptoms just enumerated, drowsiness or stupor, and then coma, convulsions, rigidity, or paralysis make their appearance, there is scarcely a hope left. The favorable symptoms in any case are, diminution of the fever; equal temperature of the whole surface ; cessation of vomiting ; decrease in the number of the stools, and a return to their natural color, consistence and odor ; quiet, tranquil sleep ; return of appetite ; and lastly, a restoration of the natural temper and gayety of the child. Prophylactic Treatment. — The danger to which teething children are exposed from residence in this city during the hot months of the year, is now so well understood that most families who can aflfbrd it remove to the country during the warm season, and by this course very generally avoid the disease. It is undoubtedly the best plan that can be adopted, and very commonly succeeds. When this cannot be done, however, the prophylactic treatment consists in a most careful attention to diet, dress, and exposure to the open air. If possible, the child should be kept at the breast until it has passed through its second summer, as there is but little danger from the disease after that period. If the weaning must take place prior to that age, it ought to be accomplished before the hot weather begins, as a change from the breast to artificial food during the warm season is very apt to bring on the disease. If the child is weaned, the diet must be strictly attended to. Up to the age of ten months or a year, the food should consist almost wholly of milk containing arrowroot, rice, oatmeal, or some farinaceous substance in small quantity. A little plain chicken or mutton water, with rice boiled in it, or a piece of beef or chicken to suck, may be given occasionally, but all vegetables and fruits should be strictly forbidden. After the age of ten months, some light soup and small portions of mutton, chicken, or very tender beef, minced very fine, may be given every day in addition to the milk food, which must still form the major part of the child's nutriment. Fruit of all kinds, all vegetables ex- cept rice and potatoes, and the latter are doubtful, ought to be carefully avoided until after the hot season has passed entirely away, or until the child has its full set of teeth. We have found the food prepared with \ TREATMENT. 429 gelatiu, in the manner described, to answer better than anything else for a large number of children to wliom we have prescribed it. The dress onght to be arranged according to the heat of the day. We have not rarely known young children to be kept clothed all summer in this city in thick flannel jackets, and petticoats, and woollen >ocks. This is certainly too much for the hot days which so frequently occur in July, August, and early in September, and is often, we believe, very injurious. A light gauze flannel shirt is the only woollen garment that need be worn during the warm season. On hot days a child should have only this, a muslin petticoat and frock, and the lightest possible socks, or none at all. If, as constantly happens in our climate, a cool day comes, there should be added to these a light flannel petticoat. It is of the utmost importance that children should pass as large a por- tion of the day as possible in the open air. In the country this is easily managed, and parents almost always contrive to accomplish it; but in a city, many people seem to think it of less importance, or their servants are occupied with other things, and it is neglected. It is nevertheless a matter of the greatest consequence ; the child ought to be kept in the air by the nurse for several hours in the morning and evening, either in the garden attached to the house, if there be one, at the front door, walking in shady streets or public squares, or, better still, making short excursions into the neighboring country, taking care, however, to avoid the intense heat of the sun during the middle of the day. We believe that with constant and wise attention to these points, viz., diet, dress, exposure to the air, and exercise, much may be done towards preventing the disease even in families obliged to remain in the city dur- ing the summer. As stated in the account of the symptoms, the choleraic disease often supervenes in children who have already been the subjects of simple or in- flammatory diarrhoea. When, therefore, a child in the city has diarrhcea, if it do not yield readily to treatment, and especially if the stools begin to be thin and watery, with any marked tendency to exhaustion, it ought to be regarded as being threatened with cholera. In such an event, the best prophylaxis in the world is instant removal to some high country locality or the seaside. Treatment of the Attack. — Regarding this disease as a truly chol- eraic one, we shall follow, in the consideration of its treatment, the plan adopted by some of the more recent writers on Asiatic cholera ; and shall accordingly divide our discus.sion of this sul)ject into the treatment appro- priate for the three stages of evacuation^ eollapue, and reaction. Every young child who is attacked with diarrhoea, whether simple or inflammatory, in the sumn)er season, ought to be regarded as liable to cholera, and should be carefully watched to prevent the development of this disease. For the propf*r treatment of such conditions, the reader is referred to the article on those aflections. Should a child, either previously well, or the subject of diarrha?a of the ordinary form, be attacked with sudden, jjrofuse, frequent, and watery dis- charges, and especially, should these be associated with vomiting, with 430 CHOLERA INFANTUM. spasmodic intestinal pain, and with any appearance of general exhaustion, it ought to be presumed to be in the early or evacuation stage of cholera infantum, or in what is the analogue of the evacuation stage of epidemic cholera. Under these circumstances, it has been a prevalent practice here to give a cathartic, castor oil, calomel, or rhubarb. We think the prac- tice wrong, unless there be positive evidence that the attack has followed directly upon the use of some unwholesome article of diet. If it be found that the child has certainly eaten some such food, green apples, currants, gooseberries, or articles of this kind, and that these have not come away in the discharges, it is right to give first a moderate purgative. We pre- fer castor oil or syrup of rhubarb, half a teaspoonful of the former, or a teaspoonful of the latter, with two drops of laudanum at the age of one year, or a teaspoonful of castor oil, or two of the syrup of rhubarb, with four drops of laudanum, or two drops of chlorodyne,^ at two or three years of age. Two hours after this dose, if the stools continue frequent and watery, we use the chalk mixture, with tincture of krameria and lauda- num or paregoric (a teaspoonful of the chalk mixture with ten to fifteen drops of the krameria, and one drop of laudanum, or five of paregoric) every two hours at the age of one year. Thirty drops of the syrup of nut- galls (see article on entero-colitis), with an opiate every two hours, is often very useful. We believe that the great object is to arrest the watery dis- charges by stool. If the above means fail, laudanum may be given by in- jection, and two drops at one year, and double the dose at two years, every two or three hours, may be tried in addition to the above treatment. The quantity of opium must depend on its effects. Children, like adults, bear very different amounts. As soon as positive drowsiness appears, or the pupils become contracted much below their natural size, the doses must be suspended or diminished, or the intervals between them lengthened. Of course, if the stools lessen in frequency, quantity, or fluidity, the same reduction in the amount of the opium ought to be made. When vomiting is severe and frequent, and the above remedies are re- jected, we may use the one proposed in the article on inflammatory diar- rhoea, consisting of solution of morphia, dilute sulphuric acid, and curacoa cordial. This, or some similar remedy, is at times very successful. It is nineteen years since one of us saw a child nine months old, in deep col- lapse from a most violent attack of cholera infantum, who rejected its mother's milk as though it had been tartar emetic, whose stomach was only made worse by calomel, but who began to improve very soon upon doses consisting of two drops of aromatic sulphuric acid, and five drops of solution of morphia, in a teaspoonful of iced water, every hour. Since then we have frequently used the mixture above recommended in such cases, and we think, on the whole, with more control over the vomiting than anything else we have tried. ' The preparation which we prescribe under the name of chlorodyne is not Dr. J, Collis Browne's, but is made by Messrs. Bullock & Crenshaw of this city. It contains one grain of morphia to the fluid drachm ; but, as it does not drop less than 120 to the fluid drachm, the dose for an adult is 10 to 15 drops. It is a very elegant preparation, and has proved most efficient in our hands. i TREATMENT. 431 The experience gained by careful and lengthened observation in the treatment of the evacuation stage of Asiatic cholera, may well be applied to the affection under consideration, so much alike are they. Dr. Good- eve {Inc. cit., p. 177) gives fii*st a full dose of opium (he says that calomel was genei-ally combined with it in India, and though he does not " know that the calomel does good, it does no harm"), to an adult two grains, and half an hour afterwards he begins with an astringent, in his own prac- tice, usually the following mixture : R. — Plumbi Acetat., . . • gr. xxx. Acid. Acet., .... ti^x, Aq. Destillat., . . . . f^vj.— M. et ft. sol. One ounce or half an ounce every half hour or hour. At the end of an hour from the administration of the first dose of opium, if the purging persisted, he gave one grain of opium and continued the as- tringent. A small teas})oonful, or two-thirds of an ordinary teaspoonful of this solution would contain about half a grain of the acetate of lead, and this might safely be given to a child a year old for several doses. We have not used this remedy ourselves, but it comes from a source which commends it^lf to us, and we shall not hesitate to use it when the occasion presents itself. As soon as the frequency of the discharges is arrested, the doses should be given at longer intervals, and when the peculiar serous character of the stools has disappeared, this remedy ought to be suspended, and some more simple one substituted, in order to avoid the possibility of producing the toxic action of lead. If, in spite of the treatment, the stage of collapse should set in, other methods of treatment must be adopted. Here the stools are usually in great measure arrested, or they are few in number and small in amount. The object to be sought after is to produce reaction, or rather to favor the efforts of nature to bring about this change. It is now generally acknowl- edged by men of large experience, that the old plan of pouring in large doses of opium and alcohol is a great mistake. But little is absorbed by the stomach whilst the body is in this condition, and not unfrequently the patient is injured, perhaps fatally, by the sudden absorption of these sub- stances, when the stomach begins to act after reaction has taken place. The opium may cause dangerous or fatal stupor, or may increase or keep up the tendency to suspension of the urinary function, and thus ])r()mote one of the great dangers of the disease, uraimic intoxication. The alcohol, if it ha.s been u.sed in large quantities, would also tend to clog the nervous centres, to cause gastric or gastrointestinal catarrh, and to heighten beyond a safe point the febrile movement which is so apt to accompany the reaction stage. Opium, therefore, should be avoided during collapse, or given only in the smallest doses. Alcohol, though it should never be given in large doses, and reckles.sly, as has so often been done, may be used in small quantities, especially if it be found by close watching, that it promotes the force and volume of the pulse. Ten or fifteen drop doses of old and deli- cate brandy, in a teaspoonful or tablespoonful of ice-water, may be given 432 CHOLERA INFANTUM. every hour or two hours, at oue year of age. During collapse the stomach is still often very irritable, and yet the thirst continues intense. We are glad to find that such men as Drs. Maclean and Goodeve recommend the free use of ice and water under these circumstances. Our own practice, for years past, has been to allow ice and cold water, almost without limit, to children in this condition, and we are much pleased to know that such, too, is the practice of these gentlemen. We never could understand the wisdom of refusing water to patients who were suffering the horrid thirst produced by the immense losses of the water of the body by serous purg- ing. The degree of thirst for water (a natural and not a secondary dis- eased instinct, like that of the drunkard for alcohol) must be the safest guide we can have as to the need of the body for water, and as such, it ought always, it seems to us, to be gratified, unless under very rare and most peculiar conditions. We give water and ice, even though the child vomits from time to time, believing and hoping that some will be absorbed to take the place in the tissues of that which has been drained off through the intestines. This point in the treatment we regard as so important, and one, we think, so much misunderstood by the public and by some medical men, that we make the following quotation from a note of Professor Ma- clean's to Dr. Aitken {Aitken's Practice, vol. i, footnote, page 663) : " Urgent thirst is one of the most distressing symptoms in cholera ; there is incessant craving for cold water, doubtless instinctive, to correct the in- spissated condition of the blood, due to the so rapid escape of the liquor sanguinis. It was formerly the practice to withhold water — a practice as cruel as it is mischievous. Water in abundance, pure and cold, should be given to the patient, and he should be encouraged to drink it, even should a large portion of it be rejected by the stomach ; and when the purging has ceased, some may with advantage be thrown into the bowel from time to time." The use of water by enema, when the diarrhoea is checked, is a point which ought not to be neglected, especially if the stomach con- tinues weak and irritable. A gill of tepid water may be used at a time, thrown slowly and gently into the bowel, in the case of a child one or two years old. If this is retained well, the same quantity may be repeated in one or two hours. Whilst the collapse lasts, but little food can be taken. It is seldom re- tained if used in any quantity, and the stomach has lost, in great measure, its digestive power. The only food we have found at all available has been thin chicken tea, Liebig's cold extract of beef, or weak wine-whey, given in two or three teaspoonful doses, every half hour or hour. It is worse than useless to attempt more than this, as not only is it not retained, but it evidently tends to keep up the nausea and vomiting, and thus retard the natural effort at reaction. As to remedies in this condition, we doubt whether anything better can be done than to use water, as just advised, and small doses of brandy, and, if they can be borne, small quantities of the liquor ammonise acetatis, ten to twenty drops, in cold water, every hour, at one year of age. There is, however, a remedy which has obtained a great reputation amongst the English army surgeons in India, for the pro- motion of reaction in the collapse stage of epidemic cholera, which we TREATMENT. 433 have used ourselves with advantage in adults, but uot in children, though we propose trying it when we next have a good opportunity. It is spoken highly of by Dr. Maclean. The formula is as follows : H— 01. Anisi, 01. Cajeput., 01. Juniper., aa, . . f^ss. ^EihtT., f^ss. Liq. Acid. Hallori, f5^s. Tinct. Cinnumom., ...... f^ij. — M. The dose for an adult is ten drops every quarter of an hour, in a tablespoonful of water. An opiate may be given with the first and second doses, but should uot be con tinned, .for the reasons already given. The liq. acid. Halleri consists of one part of concentrated sulphuric acid to three parts of rectified spirit. The dose of this mixture for a child a year old, ought, we think, to be about one or two drops in a teaspoonful of water, given, as above stated, every quarter of an hour. So much is this valued in India, according to Dr. Maclean, that it is always ordered to be kept in store in the " medical field companion " of armies on the march. It must not be supposed that all children seized with choleraic diarrhoea are necessarily to pass through the collapse stage in all its terrors. On the contrary, many, when judiciously treated early in the disorder, escape collapse altogether, and yet they have had none the less the true choleraic disease. Others suft'er more profuse and exhausting losses of water by the discharges, or their vital power of resisting disease is less, and they pass into more or less deep collapse ; or hang, as we have seen them, on the very edge of that condition, for one or two days, and then emerge from the danger, without having done more than cause the experienced physi- cian the grave anxiety which such suspense must and ought to create. During these doubtful moments of the attack, the child should be kept as quiet and still as possible. He should be made to lie in a constantly hori- zontal position, on a smooth and easy mattress, in the crib, or on a large and roomy bed, and as little as may be on the lap, which is uneven and unsteady, and which must give his weak and exhausted muscles more work to do than they would have on the more solid and even bed. If, however, the nature of the child be such that he clings to the mother's or nurse's lap as his only safety, or if he have been taught (a most ill-judged lesson) to prefer the lap to any other position, we must yield to him, rather than cau.se fretting or unhappiness, when his very life may hang upon the avoid- ance of all disturbing influences. In this case, it is well to ])lace him upon ae firm a pillow as can be found, and let him be held on this in the lap. It is imjwrtant to move him, when this becomes neces.«»ary, as slowly and gently as possible, always keeping the body on a horizontal plane, to avoid the tendency to the syncopal state, which sudden movements, and efspeci- ally the sitting or erect position, are apt to produce. When the tendency to cooling of the body shows it.«elf, and this is usually first noticeable in the hands and feet, ears and nose, he should be kept wrapped in warm, dry, and soft flannels or blankets. Flannels heated at the fire, thus sup- 28 434 CHOLERA INFANTUM. plying dry artificial heat, are of great use here. Bottles or tins filled with hot water, ought to be placed at the feet, under the blanket. A warm, soft, and light poultice of Indian meal or flaxseed, with a little mustard incorporated with it, may be placed over the abdomen, or three or four thicknesses of flannel, wrung out of hot water and whisky, may be laid over the lowest part of the thorax and over the abdomen, and covered with oiled silk, to retain their heat and prevent the wetting of the clothes. Whilst artificial heat is thus made use of, fresh air must not be excluded. On the contrary, as these cases almost always occur in the hottest summer weather, the largest supply of fresh air that can be obtained must be ad- mitted. Warm baths, which were proper and useful during the early stage, especially when fever was present, we have not found useful in these cases. The fatigue and irritation caused by the disturbance of undressing and dressing the child, have seemed to us to do more harm than any good de- rived from the heat of the water compensated for. When the case takes a favorable turn, and the reaction stage begins, it is usually best to do nothing more than supply food and water carefully, and keep the body quiet and tranquil. The food may be cautiously and slowly increased in quantity, if the stomach has become settled. Tablespoonfuls of thin chicken tea, just flavored with salt, or of Liebig's cold extract of beef, or of light beef tea, or of a mixture of wine-whey with two or three parts of thin arrowroot decoction (a teaspoonful to a pint), may be given every half hour or hour. If these are retained several times, and the child shows some little anxiety for food, the same materials may be given in wineglassful quantities. At the same time, water and ice ought to be al- Jowed from time to time, as the thirst may call for them. On the second •or third day of the reaction, we may give, if the child shows a desire for it, a little milk and water and lime-water, one part of milk to one or two of water, with one of lime-water, commencing with not more than two or three ounces of the mixture at each feeding. The milk ought certainly to 'be very much diluted for the first three or four days after it is allowed. When the child has been carried thus far safely, we may gradually return .to its former habits of feeding, allowing meat to suck, a little bread, and •so on, if it is old enough for such habits. As to drugs during the reaction stage, they are not necessary if every- thing goes on well. If, however, the fever run high, we may use small doses of the spirit of nitrous ether, as ten drops, in iced water, every two hours at one year, or twenty drops of the solution of acetate of ammonia, in the same manner, at the same age. If, as often happens, the urinary secretion remains scanty, water, in such quantities as the stomach takes willingly, amkes probably the best diuretic ; or we may use the spirit of nitrous ether, as just recommended, with a grain of acetate of potash and half a drop to a drop of tincture of digitalis, every two hours, for a day or two. When reaction is thus successfully brought about, the child may either improve rapidly and regain its previous health, or simple or inflammatory diarrhoea may set in, and pursue the usual course of those disorders. In the latter event, the child, if the attack of cholera have occurred in the TREATMENT. 435 city, ought certainly to be removed to the country if possible, since it is only too apt to have a recurrence of the choleraic disease if kept in town, or to suHer, at least, a tedious and more or less dangerous attack of the simpler form of diarrhcea. For the proper treatment of either of these se- quences to cholera, the reader is referred to the articles on those diseases, with the warninir, however, that all such patients ought to be treated with every minute care as to hygienic and therapeutic measures that experience and art have taught us, since the health has been so rudely shaken by the sickness already endured. We have now laid before the reader, to the best of our ability, what we think is the best method of treating cholera in children ; but, before quit- ting the subject entirely, we wish to make a few remarks upon points not referred to in the above account. Attention to the state of the gums should never be neglected in teething children. Our experience leads us to believe most implicitly that the pro- cess of dentition, or at least that and other concomitant constitutional con- ditions, are constant predisposing causes of gastro-intestinal disorders in early life, and that the active hyperaemic state, or positive acute inflam- matory condition, which often attends upon the near approach of teeth to the surface of the gum, may become an exciting cause of acute digestive diseases, such as cholera. We think it is always well, therefore, to exam- ine into the state of the month in a choleraic child as in other infantile disorders; and if the teeth are felt distinctly through the gums, and the gums be found swollen, tense, hot, and highly vascular, to cut them freely once. If, on the contrary, the gums are firm, not hot, not redder than usual, and the edges of the teeth cannot be felt, it is foolish meddlesome- ness to cut them. Baths. — In the early stage of cholera, before collapse has begun, and whilst the child is still reasonably strong, and particularly when there is marked febrile heat and dryness of the body, we think that the use of the warm or hot bath, or of sponging with hot water and spirit, are excellent measures. The bath may be used twice, or even three times a day if the child does not resist and scream. The temperature should be 95° to 98°, and the child may be kept in the water from five to ten minutes. It is an excellent plan to wrap the child, directly on lifting it from the bath, in a heated muslin sheet, and to apply over this a blanket, and keep it thus enveloped on the lap for half an hour or more if it is comfortable and disposed to rest. If the child be somewhat weak, whisky, added to the water, renders the bath more useful and safe. When the use of a bath alarms or annoys so as to cause violent agitation, it is best to substitute sponging with hot water and whisky or vinegar, under a light blanket, two or three times a day. Aniiphlogisiics. — It may appear to many, in these modem times, a mere waste of words for us to state that we are opposed to bloodletting, in any form or at any stage of cholera infantum. But if any such will take the trouble to look over the works of writers of ten and twenty years back, he will find reason to think that if this be our opinion, it ought to be ex- pressed. When one of ourselves began to practice, in 1841, it was quite 436 DYSENTERY. the custom to take blood for the nervous symptoms which are present in the early stage, and still more for the comatose phenomena at the close. This was done on the theory that these symptoms were the result of con- gestion or inflammation of the brain, whereas now they are looked upon as the results of exhaustion, of the altered conditions of the blood, or of ursemia. Calomel. — The opinion was expressed in a former edition of this work, that the doses of calomel usually recommended were too large for young children, and were apt to aggravate the existing irritation of the digestive mucous membrane ; and that such doses of a remedy acknowledged to be a powerful sedative, could not be proper in a disease which constantly tended towards exhaustion and collapse. It was also stated that the small doses which we did recommend had been declared by some critics to be entirely too small,, and that to this we could only reply that the larger and more careful, and, we hoped, the wiser our observation had been in the last few years, the more thoroughly convinced were we that the larger doses, such as were formerly recommended and used by nearly all writers and practitioners, were not only unnecessarily large, but most seriously objectionable. We went on to say that the indiscriminate use of this remedy, in nearly all cases of the gastro-intestinal diseases of childhood became with some, we believed, a mere routine habit — that they never tried what might be accomplished without it, but went on pushing the drug in constant doses, when the case, if trusted to simpler means, or even left to the efforts of nature, would often do much better, we had learned to believe, than when these delicate organs were made the receptacle of doses that could not but tend to keep up the nausea, and vomiting, and diarrhoea, which form so important a part of the morbid phenomena. The experience w^e have had since that time has but confirmed us in these opinions. Indeed we have so often been disappointed in obtaining any good effects from this drug, and have so often had reason to think that, instead of allaying nausea and vomiting, it increased them, and added to the exhaustion which is one of the dangers always to be contended against, that we have virtually abandoned its use in this affection. ARTICLE IV. DYSENTERY. It seems to us unnecessary to make more than a few remarks on dysen- tery, since we have already spoken of the morbid conditions of the large intestine, in our article on entero-colitis. Dysentery, however, differs from this latter affection by the fact that it frequently occurs in an epidemic form, and that there is a tendency to more rapid and extensive ulceration of the mucous membrane of the rectum and colon. It is an acute febrile CAUSES — ANATOMICAL LESIONS — SYMPTOMS. 437 disease, characterized by frequent evacuations, attended with more or less severe pain and straining, and consisting of muco-sanguinolent or sangui- neous substances, which are due to ulcerative inflammation of the rectum and colon. The causes of dysentery are but little understood, beyond the mere facts that it occurs as an endemic in some regions of country, and as an epi- demic over large districts. It is frequent, also, as a sporadic disease, and in this form seems to depend upon the same causes as those already cited as productive of entero-colitis. Like cholera infantum, it appears to be more common in boys than girls, since of 39 cases of which we have kept notes, in which the sex is mentioned, 27 occurred in boys, and only 12 in girls. It is most frequent in the second and third years of life. Of 38 cases in which the age was noted, 1 occurred in the first year of life, 15 in the second, 7 in the third, 3 in the fourth, 3 in the fifth, 1 in the sixth, 3 in the seventh, 3 in the eighth, and only 2 from the eighth to the end of the eleventh year. It may be either idiopathic or secondary. As a sec- ondary aflection it is most apt to follow measles and variola. We have often known dysenteric stools to occur in the course of cholera infantum, and in a considerable number of cases such as we have described under the title of entero-colitis. The anatomical lesions are confined chiefly to the large intestine, and are the same as those described under the head of entero-colitis, except that they are of a graver character. The mucous membrane is commonly found thickened, swelled, red, and softened ; the submucous tissue sometimes pre- sents ecchyraosed points ; the follicles are often diseased, their orifices being enlarged and ulcerated, as described under entero-colitis. In grave cases, particularly those occurring under an epidemic influence, there are usually more or less extensive ulcerations, which may implicate only the mucous, or extend to the muscular or even the peritoneal coat. In such instances, pseudo-membranous exudations are often formed, sometimes in large quan- tity, and often covering the ulcerations. The intestine contains sanguino- lent mucus, or at times a brownish or greenish material which is evidently the result of a gangrenous condition of the mucous membrane, pus, and lastly false membranes. In some rare cases, perforation has been known to take place. Symptoms. — The symptoms are much the same as those already described as existing in entero-colitis, excepting that the local symptoms are more severe, and the presence of blood in the stools constant. The disease often begins as a diarrhfra. The stoola at first contain feculent materials, but after a time become very thin, small in quantity, and consist chiefly of mucus mixed with blood. The blood may be black and in considerable quantity, or of a dark rosy red color, or like the washings of flesh ; it is mixed with greenish or yellowish substances, whitish mucus, fragments of false membrane, or purulent fluid. In young children there is evidently pain^ from the restlessness, moving of the limbs, and crying about the time of the evacuations, while in those who are older, there is true fotesmim, like that observed in adults, and severe pain in the anus. The number of stools varies according to the severity of the case. There may be only four, eight, 438 DYSENTERY. or teu in the day, or many more. We have quite frequently known as many as 30 and 40 to be voided in the twenty-four hours, and in fatal cases, the dejections sometimes number three or four in an hour, while between the discharges the child often suffers from most violent and painful tenes- mus. The abdomen is generally distended, tympanitic, warmer than natural, and painful. In mild cases there- is usually no fever, or very little, while in severe at- tacks, there is high fever during the first few days, marked by frequent pulse, hot dry skin, followed after a time, unless a favorable change takes place, by coolness of the surface, contraction of the countenance, hollow, sunken expression of the eye, rapid emaciation, and death. It is useless to give a longer detail of the symptoms, as they are the same as those already described in the article on entero-colitis. The diagnosh presents no difficulties. The frequency of the discharges, the pain in the course of the colon and in the anus^ the tenesmus, the char- acter of the evacuations, and the febrile reaction, all make the disease easy of recognition. The prognosis is favorable in mild eases, unattended with much fever, or very frequent discharges. When^ on the contrary, there is violent fever in the beginning, followed by disposition to coolness and collapse ; when the stools are exceedingly frequent, and attended with severe pain and almost constant straining ; and when they consist of nothing but mucus, mixed with considerable quantities of blood, or with pus or false mem- branes, the prognosis is very unfavorable. Of 36 cases, the termination of which we have recorded, 4 proved fatal. Treatment. — The treatment of dysentery in children is often very un- satisfactory. The mere variety of the remedies recommended by difierent writers and practitioners marks the uncertainty of the effects obtained from drugs. Mild cases so generally get well under any treatment that all methods have had their supporters and advocates, while grave cases, and especially those occurring under the influence of severe epidemic visitations, are so difficult of treatment, and often so little under the evident control of medical means, as to leave the careful observer in great doubt as to what he ought to set down as the evident result of his own interference in the case, and what as the results of the efforts of nature to cure the disease. Mild cases of the disease, in which the fever is not very high, the num- ber of stools not great, and the pain and distress moderate, require little else than rest in bed, a light and unirritating diet, and the use of opium in small quantities either internally or by injection. When there is reason to suspect the presence of unwholesome food in the stomach, or of unhealthy secretions in the intestines, it is necessary to give in the beginning small doses of some mild cathartic. The one generally preferred is castor oil, which may be given either simple, in the dose of a small teaspoon ful con- taining one to four«drops of laudanum according to the age, or in the form of emulsion. The latter is the mode of employing it usually chosen. A drachm of oil should be rubbed up with a scruple of gum, a little sugar, from two to eight drops of laudanum, according to the age of the child, TREATMENT. 439 and seven drachms of some aromatic water. The dose is a teaspoonful every three or four houi-s. If the case continue to improve under the emulsion, it may be continued for a couple of days, but should the stools become more and more frequent, and the pain and tenesmus increase, it must be suspended after one or two days, and laudanum enemata, with or "without the internal use of absorbents and astringents, substituted. The injections ought to consist of four or five drops of laudanum at two years of age, and of ten drops at five or six years, suspended in from half an ounce to an ounce of some mucilage, or thin fiirinaceous fluid, or simply mixed in a tablespoonful of tepid water, which is perhaps the best plan of all. The injections may be given every four or six hours if necessary, or they may be made use of only at night, while small doses of Dover's pow- der are administered every three or four hours through the day. The diet in these cases should consist of arrowroot, sago, tapioca, or some such food, made into thin pap with milk and water ; and the quan- tity allowed ought to be very moderate. Rest in bed, in the cradle, or in the lap, is very important. The child ought not to be allowed to run about, or use exertion of any kind. Where the pain is severe and the fever high, and where there is a good deal of soreness in the abdomen, depletion may with propriety be resorted to, but always with moderation and prudence. A few leeches applied around the margin of the anus, or to the surface of the abdomen, often prove of great service in relieving pain and tenesmus. An occasional warm bath is very soothing and useful. In very severe cases of dysentery the treatment is, as above stated, diffi- cult and uncertain, owing to the dangerous character of the disease, and to the fact that so many different methods have been recommended by dif- ferent writers. In the early stagp of a severe case, whilst the febrile reaction is high and the strength of the patient still unsubdued, depletion by leeches in young children and by venesection in older ones, is strongly approved of by many able practitioners. For our own part we have not resorted to it as a gen- eral rule, from the fact that we have so often found the strength of the child to fail rapidly under the disease itself. In a few of our cases, how- ever, leeching around the anus has been followed by manifest benefit. The remedies most commonly depended upon are castor oil in emulsion with laudanum, mercury, sugar of lead, opium, nitrate of silver, spirit of tur- pentine, and astringents. The castor-oil emulsion, prepared as mentioned above, is useful in the early part of the attack, but ceases to be so, ac- cording to our experience, after the first twenty-four or forty-eight hours. From mercurj' we have not ourselves obtained any very positive benefit, though, in combination with opium and ipecacuanha in small doses, it is much tnought of by many excellent authorities. The only remedy which is used by all, though it is rarely given alone, is opium, and the very fact that it is so univer^ally employed jK)int3 it out as one of the most reliable and valuable means we have at our command. It is certainly the one upon which we most depend ourselves. It may be given either alone or in connection with other substances. Where rnjections can be retained it 440 DYSENTERY. is best given in that way. About five drops of laudanum at two years of age, or ten drops at four or five years, may be given in a tablespoouful of any bland vehicle every four hours. When the rectum rejects the enema as soon as administered, the opium should be given either by the mouth, in the form of laudanum or solution of morphia, or in that of Dover's powder ; or in the form of suppository. We should indeed strongly recommend the administration of opium in this latter form in such cases, since we unquestionably obtain a certain beneficial local action, in addition to its constitutional effect through its absorption. The amount of opium should be about the one-eighth of a grain at two years of age, which, together with any other remedy, such as acetate of lead, if it be desired, should be incorporated with butter of cocoa, a most bland and soothing substance, which dissolves readily at the temperature of the body. When made of this substance, and of proper shape and sufficiently small, the suppository can be introduced without pain, and will usually be retained. They should of course be repeated at intervals, depending upon the effect produced. Opium is almost always employed in connection with some other remedy, and particularly with calomel or acetate of lead. The dose of calomel is from a sixth to half a grain, or, as used by some practitioners, a grain with a twelfth of a grain of opium, or half a grain or a grain of Dover's powder, every three or four hours, for children two or three years of age. The acetate of lead is more relied upon, and has probably higher testimony in its favor than calomel. We have ourselves obtained excellent effects from it in some instances. The dose is from half a grain to a grain every two or three hours at two and three years of age. There are two other remedies not yet mentioned, which have been of more positive efficacy in our own practice than any others, with the exception of opium. These are the nitrate of silver and the solution of the nitrate of iron. The former we have used both internally and by injection, the latter only by injection. For an account of the mode in which these remedies are employed by different authorities, the reader is referred to the remarks on chronic entero-colitis. We have employed nitrate of silver in 14 cases of dysentery. These were all severe attacks, and some of them most violent. Of the 14 cases, three died. The remedy was given by the mouth alone in 7 cases, by injection alone in 5, and by the mouth and by injection both in 2. It has proved most beneficial in its effects, in our hands, when given by the mouth, though its influence over the disease has always been less im- mediate than when used by injection, but it has been more permanent. The dose in which we have used it has varied with the age of the child, and with the severity of the symptoms. For children two years old we have usually employed from one grain to one and a half grains, and for those of five or six years or upwards, two grains dissolved in two ounces of a vehicle, consisting of an ounce each of syrup of gum arable and dis- tilled water. The dose is a teaspoonful every two or three hours. It is well, as a general rule, to add from four to sixteen drops of laudanum, ac- cording to the age of the subject, to the mixture. For use by injection we have commonly employed for each enema two grains for young children, and four grains for older oties, dissolved in four ounces of distilled water. DISEASES OF THE CCECUM AND APPENDIX CCECI. 441 The injections are to be repeated twice or throe times a day. After the nitrate of silver enema has come away, it is a good plan to throw into the bowel a laudanum and starch injection. We have made use of the solution of nitrate of iron, to which allusion was made above, only as an injection in acute dysentery. We have em- ployed it in eight cases, and are quite sure that it was of essential service in six, while in two it appeared to irritate, probably because the quantity given was too large. Our mode of applying it is to mix from ten to twelve drops in four ounces of tepid water for each injection. The injections were given twice or three times a day, and they were followed, as soon as they hatl returned, by a laudanum injection. On two occasions, the nitrate of iron injection remained in the bowel for several hours before being re- jected, and thus restrained for that time the stools, which had previously been very freciuent, and attended with much tenesmus. When the stools continue very frequent in spite of the use of opium in 8ome of its many shapes, when sugar of lead and nitrate of silver have been employed without controlling the frequency of the discharges, we have sometimes found the mixture of aromatic sulphuric acid, laudanum, and syrup of rhatany, before recommended, very beneficial. When the stools, in addition to their dysenteric characters, have been watery, and greenish in color, the chalk mixture, with laudanum and tincture of rhat- any, kino, or catechu, repeated every two hours, with occasional laudanum enemata, has been very useful. The hygienic management of dysentery should be precisely the same as that which was suggested as proper for entero-colitis. ARTICLE V. DISEASES OF THE (XECUM AND APPENDIX CCECI — TYPHLITIS AND PERITYPHLITIS. Synonyms; Definition. — The diseases of the cnecura and of its ver- miform appendix are so important and frequent, and present so many peculiarities, as to demand a separate and detailed consideration. In ap- proaching their discussion, it is neces>ary to bear in mind several important pf>ints in which the ccecum differs from the rest of the large intestine. Thus its peritoneal investment is deficient over the posterior part, which is generally quite firmly attached to the right iliac fossa by connective tissue, containing a small profKjrtion of fat. Its anatomical relations moreover indicate that the .'K?mi-feculent materials passing from the ileum are des- tined to be retained in the ccecum to undergo some important action. The ileum at its lower portion rarely has a calibre greater than one-third that of the co'cum, a circumstance which must materially retard the progress of the couteuts of the latter, and a further detention is caused by the 442 DISEASES OF THE COiCUM AND APPENDIX CCECI. ileo-ea?cal valve, which prevents all reflux, aud by the position of the coeeum, which compels it to force onwards its contents in opposition to gravity. The view that the coeeum is the seat of an important part of the digestive process, either in the appropriation of any remaining nutritious elements of the semi-feculent chyme, the absorption of its watery parts, or the elimination of some excrementitious matter from the system, receives confirmation from the very rich vascular and glandular supply of the walls of this part of the intestine. In addition to this, the coeeum has opening into it, usually at its lower and back part, the appendix vermiformis, a narrow, elongated, glandular process, varying from three to six inches in length, and having an average diameter about equal to that of a goose-quill, although its calibre is quite small. It is usually directed upwards and inwards behind the coeeum, and lies coiled upon itself. Its function appears to be the secretion of a viscid ropy mucus. We thus see in the anatomical and physiological relations of the coeeum strong predisposing causes of many morbid conditions. Among these the most frequent are distension and impaction of its calibre by hardened faeces ; the lodgment of a foreign body or intestinal concretion in one of its pouches or in the appendix, an accident which often excites violent and destructive inflammatory action ; and finally localized inflammation of one or all of the coats of the coeeum or the vermiform appendix. This last condition has received the names of typhlo-enteritis, from Tocploq^ blind, and evrspov, intestine ; typhlitis ; and coecitis, from the Latin word coeeum, also signifying blind. The pericoecal connective tissue is also occasionally the seat of inflam- matory action, constituting a condition known as perityphlitis. Seat and Character. — Clinical experience and the researches of pathological anatomy fully justify us in recognizing the above-mentioned morbid conditions, but the question as to their relative frequency and importance is still far from being settled. By some authorities the diseases of the coeeum are regarded as secondary to morbid affections of the appendix, the latter consisting generally in the presence of foreign bodies, or of hardened, inspissated mucus, which act as the focus and exciting cause of the inflammation of the coeeum. It is probable, however, in regard to the simple form of typhlitis, that both the coeeum and its appendix are subject to a peculiar localized in- flammation, involving all their coats, and due to the temporary arrest of some foreign substance or intestinal concretion in their cavity, or to the action of the causes to be hereafter considered. It is indeed possible that the inflammation excited by the presence of a foreign body may subside, whilst the cause still remains arrested in the appendix or one of the pouches of the coeeum ; but experience would lead us to infer, that, when once inflammatory action has been excited, so long as the foreign substance which has caused it remains in contact with the mucous membrane, the tendency is usually to produce ulceration and perforation of the coats of the bowel. We find this same discrepancy of opinion in regard to those cases at- CAUSES. 443 tended with perforation of some portion of the civcum, and the formation of an abscesi? in the iliac region. Dupnytren, who was the first to call attention to the pathology of these iliac abscesses, attributed them to sup- purative inflammation of the periccecal connective tissue, produced in many cases by extension of inflammation from the coats of the ca?cum, and held that the perforation of the bowel often found in connection, was a secondary phenomenon, and was in fact the mode by which the abscess was discharged. Inflammation and suppuration of the perictrcal tissue does indeed occur as an idiopathic affection, or from extension of inflammation from the caecum, but it is of extremely rare occurrence ; aud there can be no doubt that nearly all cases of iliac abscess are due to perforative ulcer- ation of either the ccecum or appendix. As Bouchut suggests, one proof that most cases of non-puerperal iliac abscess are thus due to perforation of the caecum or appendix, is afforded by their almost constant occurrence upon the right side. Thus of 57 non-puerperal iliac abscesses collected by Grissolle, 9 only were on the left side ; while of 26 puerperal ones, 15 were ou that side. It is necessary, however, to carry this question one step further, and to determine, if possible, the relative frequency of perforation of the ccecum and of the appendix. It has been supposed, as by Ferrall, that ulceration of the coecum is in most cases the starting-point in the development of the lesions. But, while we are in possession of a sufficient number of recorded cases, 12 of which we have collected, where post-mortem examination hhs proved the abscess to have originated in perforation of the ccecum, there is good reason to believe that perforation of the intestine is much more frequently found associated with disease of the appendix than with ulcer- ation of the ca?cum itself. Causes. — In addition to the anatomical peculiarities of the ccecum and ap|)endix, which must be regarded as predisposing causes of these affec- tions, there are other conditions which exert an unquestionable influence. The strumous diathesis has been regarded as a predisposing cause of diseases of the ccecum and appendix. It does not appear, however, that inflammation of these parts is more frequent in strumous subjects, but merely that it has a greater tendency in such patients to run on to ulcer- ation and perforation of the bowel. Age. — The greater irritability and proneness to inflammation which the intestinal canal presents in early life, appears to have its effect upon the development of typhlitis, since a considerable majority of reported cases have occurred under the age of 25 years. This is particularly true of the milder attacks, which are not attended with ulceration. Thus, of 38 cases of typhlitis at all ages, which recovered without perforation of the bowel, 20 occurred at or under the age of 25 ; 9 only were in older persons. Of these 38, 13 occurred in our own practice, and were aged as foUows: 2 under six years; 6 between 6 and 12 years; 5 between 12 and 15 years. Finally, 19 of the 38 cases occurred at or under the age of 15 years. This does not appear to hold true, however, with regard to perforative ulceration of the co'cum and appendix. We have not met with any ca.-e of perforation of the caecum occurring 444 DISEASES OF THE CCECUM AND APPENDIX CCECI. (luring childhood, but of 25 cases collected from different sources, 13 occurred after the age of 25 ; 12 at or under that age. Of these 25 cases, 12 only were verified by post-mortem examination, of which 3 were under 15 years of age, 2 between 15 and 25 years, and 5 above 25 years. Of perforation of the appendix vermiformis, we have met with 3 cases in children, aged respectively 4^, 8, and 11 years. Of 25 other cases, col- lected from various sources, in which the age is stated, 9 were above, 16 below 30 years of age. Of these 16, 3 only were under 15 years of age, so that, including our own 3 cases, we find 6 cases occurring under 15 years, 13 between 15 and 30, and 9 above 30 years of age. Sex. — The influence of sex has been very variously stated by diflferent ob- servers. It appears, however, that males are somewhat more prone to all these forms of disease than females. Thus of 39 cases of typhlitis, which recovered without perforation of the bowel, 23 were in males ; 16 only in females. Of 13 of these 39 cases, which we observed in children, 8 were males and 5 females. Of 25 cases of perforation of the coecum, 13 occurred in males; 12 in females. The sex is stated in 27 of 32 cases of perforation of the appehdix. Of these, 21 were males ; 6 only were females. Of 6 cases occurring under 15 years of age, the sex is stated in 5, 4 of which were males. Occupation. — Various occupations, especially those involving sedentary habits, have been supposed to predispose to these aflfections, as also the practice among females of wearing tight corsets. Experience, however, has not verified these suppositions. Constipation. — A constipated state of the bowels undoubtedly predis- poses to these affections by favoring the production of a distended and impacted condition of the coecum, even if the presence of the hardened fecal matter does not prove the exciting cause of some cases of typhlitis. Rokitansky considers this cause so important that he has given the name typhlitis stercorals to one form of inflammation of the coecum. Exciting Causes. — Cold and Exposure. — The action of these ordinary exciting causes has been denied by some observers on account of the fre- quent absence of a chill or rigor at the inception of the attack, and the development of the local before the general symptoms. It cannot, how- ever, be doubted that typhlitis may be idiopathic, and arise from the ordinary exciting causes, though the cases are comparatively rare. Food. — In several instances the attack appears to have been brought on by the use of indigestible or irritating articles of diet, among which may be especially mentioned unripe acescent fruits. It has been said that the use of oatmeal, which favors the formation of intestinal concretions, is also liable to be followed by this disease. It does not, however, appear that typhlitis is any less frequent in countries where wheaten bread is used, than in those where oatmeal forms a chief part of the food. Blows or Exertion. — There are a few cases recorded in which a blow upon the abdomen, or a sudden violent strain, appears to have been the immediate cause of an attack of typhlitis. Foreign Bodies and Intestinal Concretions. — This class, comprising very CAUSES. 445 various substances, certainly forms the most important and frequent cause of diseases of the civcum and appendix. We cannot be positive as to the amount of intiuence they exert in the milder and more tractable cases of simple typhlitis, though it is quite probable that many of these are caused by the temporary arrest of some foreign substance in the appendix, or one of the pouches of the ca?cum. Thus, in a case reported by Dr. Wynn Williams {Lancet, January 25th, 1862), in a male adult, three mouths after a well-marked acute attack of typhlitis, which yielded to judicious treatment, a large intestinal concre- tion, having a plum-stone for a nucleus, was passed by the rectum. They are, however, the etiicient cause of a large majority of all the cases of per- forative ulceration of the coecum and its appendix. The diseases of this latter part, however, are far more uniformly de- pendent upon the presence of foreign bodies even than in cases of the ctecum ; almost three-fourths of all recorded cases of perforation of the api>endix having been due to this cause. In 6 cases occurring in chil- dren, some extraneous substance was found in the appendix in each one ; in 2 a foreign body was present ; and in each of the other 4, an intestinal concretion. Many of these bodies are true intestinal concretions, having for their nucleus merely a nodule of hardened fieces or inspissated mucus. They vary considerably in size, the majority of them being about the size of a cherry-stone or date-stone, though Habershon mentions having seen one as large as a hen's-egg. They are also of very varying consistence, accord- ing to Volz, as quoted by Hanbury Smith, constituting three varieties : the soft, resembling excrement in appearance and odor, and having a nucleus of hardened fecal matter; the semi-hard, of a grayish-brown color, consisting of shining concrete layers, with a nucleus which is not a foreign body; and the stony, which are of a grayish-white or earthy color, and have a surface from which may be detached delicate scales, or which is smooth, shining, yellowish-white, or brown and studded with calcareous projections. Many of these concretions consist of carbonate and phosphate of lime united with inspissated mucus. Copland also mentions one which con- sisted of cholesterin. In addition to these, however, numerous foreign bodies have been found in connection with the ctecum or appendix, either free or forming the nu- cleu.s of an intestinal concretion. Among these may be mentioned grape- seedri, cherry-stones, date-stones, pins, bristles, fragments of glass, biliary calculi, and balls of worms, either ascarides or lumbricoids. It may not be amiss to remark here, that some intestinal concretions resemble, to a marked degree, the seeds or stones of different fruits, par- ticularly of the cherry, date, and plum ; and there is no doubt that many of the bodies found in the ca*cum or the appendix, and reported as cherry- stones or date-stones, have been in reality intestinal concretions. Whatever be the nature and origin of these bodies, it is probable that in many cases some morbid condition of the mucous membrane of the coecum 446 DISEASES OF THE CQECUM AND APPENDIX CCECI. or appeudix precedes their formation or lodgment, and the development of the grave symptoms which often follow. As Habershon justly remarks, the ordinary calibre of the appendix is so extremely small and so thoroughly lubricated, that it must be very rare for any extraneous substance to become impacted in it so long as it re- mains healthy, A further argument in favor of this view is the fact that the presence of these concretions is attended by the most varying results, since very large and irritating bodies have been occasionally found occu- pying the cavity of the appendix without having produced any symptoms during life, or any inflammation of its surface ; while, on the other hand, minute concretions of semi-solid consistence, and apparently unirritating in character, have frequently been observed to act as the foci of the most serious and destructive inflammatory action. Anatomical Appearances. — In the simple forms of typhlitis, the mucous membrane of the coecum presents the usual appearances of inflam- mation ; the peritoneal investment is also involved, and besides injection and opacity of this membrane, there are adhesions formed between folds of the intestines. When, however, ulceration is present, as often results from th^ presence of foreign bodies, or in strumous subjects, it is a matter of the utmost im- portance which portion of the coecum is involved, since, as such ulcers have a strong tendency to perforate the coats of the bowel, if they occur on the anterior part of the coecum, which has a peritoneal investment, there is the greatest danger of an escape of the contents of the bowel into the peritoneal sac, and the development of rapidly fatal peritonitis. Thus, of 10 fatal cases of perforation of the coecum, in which the seat of the perforation was determined by post-mortem examination, the an- terior wall was involved in 6 instances. If, on the other hand, the ulcer be seated on the posterior part of the coecum, where it is attached to the iliac fossa by connective tissue, and devoid of a peritoneal covering, per- foration is not directly followed by any such unfortunate results. Inflam- mation is excited in the pericoecal connective tissue, suppuration ensues, and the resulting abscess follows one of several courses, precisely as in idiopathic suppuration of the pericoecal tissue. Thus it may reopen into the bowel ; may burrow along the sheath of the psoas muscle, and point below Poupart's ligament ; or it may discharge in the lumbar region, or at any point along the crest of the ilium. In one case the iliac artery was opened, leading to speedy death from hsemorrhage. Occasionally these abscesses discharge themselves by more than one avenue, as for instance through the bowel, and in the groin or iliac region simultaneously. When, as occasionally happens, the inflammation of the coecum passes into a chronic form and the ulcerative process ceases, the ad- hesions of the coecum to the iliac fossa become preternaturally dense, the coecum itself is contracted, its coats thickened, and the mucous membrane almost entirely destroyed, or converted into a retiform and trabecular fibroid tissue. Rokitansky has found in such cases the coecum converted 1 CASE OF PERFORATION OF THE APPENDIX. 447 into a slate-colored capsule, with dense parietes, of the size of a ^Yalnut or a pigeon's egg. The appendix t^enniformis may be the seat of catarrhal inflammation, as- sociated with intiammation of its peritoneal covering. Death does not re- sult from this condition, but the pathological appearances are probably analogous to those found in all cases of localized sero-enteritis. When, however, the appendix has been the seat of ulceration, and death has resulted before perforation has occurred, its cavity is found distended with pus, it5 mucous membrane deeply ulcerated, and in nearly every in- stance, a foreign body or an intestinal concretion is present. The ulceration of the appendix varies in its position and extent, at times being seated at the free extremity, at others occupying the lower third of the appendix, which is perhaps the more frequent seat. In regard to its size, the ulcer and the subsequent perforation may be either very small, or else may involve almost the entire circumference of the appendix. Under favorable circumstances, especially if the foreign body is dis- charged, the ulceration ceases, and the appendix becomes converted into a ligamentous cord, its calibre being entirely obliterated. When perforation of the appendix occui-s, the results vary according to the degree of local peritonitis which has been excited. If the appendix ha^ become strongly adherent at the point where perforation is about to take place, this accident may not be followed by the development of gen- eral peritonitis. The points to which the appendix generally becomes ad- herent, are the ccecum, the anterior abdominal wall, and the right iliac fossa. In the first case, the circumscribed abscess which follows the per- foration of the appendix will discharge itself though the coecum by eflect- ing a perforation of its wall from without inwards, and this is the most favorable termination possible. When, however, the appendix has become adherent to the abdominal wall or iliac fossa, tlie resulting abscess will follow. the course, already described, of abscess from perforation of the ccecum. It is in this connection that the various abnormal positions which the appendix may assume, are of importance, as determining the position in which the abscess will point. Unfortunately, however, the adhesions are rarely strong enough to cir- cumscribe the purulent matters escaping from the appendix, so that these generally find their way into the peritoneal cavity, and excite general peritonitis. We subjoin the histories of 3 fatal cases of perforation of the appendix from intestinal concretions, occurring in children, in all of which some local peritonitis with adhesions had occurred, but had not sufficed to pre- vent the above unfortunate termination. Care 1. Intestinal eoncretioyi in the appendix crrri, canning perforaticn ami Jatal peritrmitui. — T. D. S., a healthy, well-grown boy, 11 years of age, rose on thr- morn- ing of December 25th, I860, apparently quite woll. So<^>n afterwards, however, ho complained of pain in the right iliac and lumbar regions, was chilly, and re- turned to bed. A dose of castor oil was given him. In the course of the day fever c«me on. 448 DISEASES OF THE CCECUM AND APPENDIX C(ECI. Next day he was feverish, with a pulse of 132, a hot and dry skin, and a moder- ately furred tongue. The pain still continued, with tenderness and slight disten- sion of the abdomen on the right side; there was no vomiting. His bowels had been acted upon three times by the oil. Leeches and a poultice locally, and a mix- ture of blue pill with rhubarb syrup internally, were ordered. On the 27th and '28th, the symptoms were much the same, except that the ten- derness and distension increased. The pain was aggravated by coughing, by a full inspiration, and by motion, especially of the right leg. The bowels were slightly moved by the mixture; no vomiting as yet. His fever continued, but the pulse fell to 108, and his skin was somewhat cooler. On the 29th he was worse. All his symptoms were aggravated, and vomiting set in ; his bowels became confined. Small doses of calomel and opium were given, encmata of various kinds were tried, and rhubarb syrup with a little fluid extract of rhubarb was perseveringly employed, but without effect. The abdomen now be- came greatly distended, exceedingly sonorous, and painful ; the stomach grew more and more irritable, rejecting from time to time, towards the last, with a sudden spasmodic effort, everything that was taken by the mouth. The bowels were com- pletely obstructed, so that repeated injections of various kinds elicited no dis- charges, even of flatus. The urine continued to be secreted to the last; and there was at times, in spite of the nausea and vomiting, quite a strong desire for milk and bread. During the last few days wine-whey and beef tea were given in small quantities ; and opium by enema and by the mouth was used to allay pain. On the third day of the treatment a blister four inches square was applied over the seat of tenderness ; but neither this nor any of the other remedies employed seemed to exert the least effect upon the course of the disease. Death took place on the eighth da}', January 1st, 1861. The autopsy was made by Dr. Packard, twenty-four hours after death. Body large, muscular, and well formed ; rigor mortis well pronounced. Abdomen only examined. On making the usual section, several coils of small intestine, very greatly dis- tended with gas, and markedly injected, with flakes of lymph here and there over the surface, at some points gluing the adjacent coils together, were seen concealing the rest of the abdominal viscera. After some search, the colon was found, very much contracted, except at the coecum. The ileum was in like manner contracted, the narrowing beginning at about the end of the jejunum, which formed the dis- tended coils above mentioned. No cause was assignable for the constriction at this point; but a little lymph was thrown out here, and it may have been that the bowel had been twisted. The appendix vermiformis was bound down by peritoneal adhesions. "Within it near its origin, was a mass as large as a small bean, but perfectly oval. Just beyond this mass, at what seemed to have been its position, was an ulcer extending all round the tube, and of a gangrenous aspect. At the distal end of this ulcer was a perfora- tion, by which matter had found an exit into the peritoneal cavity. The rest of the tube looked as if it had been distended by the pus before the opening was formed. After its escape from the appendix, the matter seemed to have caused a circum- scribed peritonitis, in addition to the general one already indicated. The adhesions bounding this peritonitis had extended up to the liver, the convex surface of which was hollowed to a slight depth in an oval shape, the depression being lined by false membrane. The whole quantity of the pus was perhaps l^iv. The liver was pale in patches, but was not degenerated. Kather too large a num- ber of oil-drops existed in a dark, inflamed portion of its substance, just beneath the depression above mentioned ; but even here the quantity was not great. The mesen- teric glands were swollen and injected over the surface. No other lesions were ob- served. Case 2. Intestinal concretion in the appendix coed, causing perforation and fatal TYPHLITIS. 449 periioniHs. — C. B.. *t. 4i years, was taken sick with slight fever, pain in the abdo- men, some vomiting, consiipuiion, and inflation of the abdomen. With these symp- toms there was marked tenderness in the rigiit iliac fossa. After three days the bowels were well opened, and the fever subsided ; the abdomen, however, continued inflated, and a small but distinct tumor had appeared just inside of the right anterior superior spinous process of the ilium. He continued to improve, and was apparently much better, but was strictly con- fined to bed, when on the ninth day, at 3h p.m., he was seized with severe abdominal pain ; symptoms of collapse rapidly appeared, and he died at 2 a.m. the following morning. At the autopsy an intestinal concretion of the shape and size of a date-stone was found in the appendix. The end of the appendix was perforated, and had become attached to the anterior wall of the abdomen, where a small abscess had formed in the cellular tissue between the peritoneum and the abdominal muscles, evidently seeking an outlet through the abdominal parietes. The wall of this had unfortu- nately ruptured into the peritoneal sac, and death had resulted in a few hours from general peritonitis. Case 3. R. P., a healthy girl, aged 7J years, died at the end of the second week of a well-marked attack of perforative disease of the appendix vermiformis. At the autopsy a large, rounded intestinal concretion was found in the appen- dix ccBci, which was perforated, allowing an escape of matter into the peritoneal cavity. There was marked general peritonitis, with the formation of a large quan- tity of pus. Symptoms. — Mere distension of the ccecum by hardened fteces, without actual inflammation of its coats, may be attended with constipation, some vomiting, and the presence of a somewhat sensitive tumor in the cwcal region. According to Copland, when the distension by accumulated matters is great, it may, from rising high in the abdomen and pressing upon the nerves, vessels, and ducts in its vicinity, occasion numbness and cpdema of the right lower extremity, retraction of the right testicle, and derangement of the urinary secretion, so as to be mistaken for disease of the kidney. Inflammation of the innrov.-- membrane only of the coecum, is generally at- tended with a moderate degree of fever, slight pain and tenderness in the right iliac fossa, and some diarrh(pa, with mucous, offensive stools. This condition is not unfrequently chronic, and evinces its presence by no very positive symptoms, unless adjacent parts have become involved in the in- flammation, or an acute attack of typhlitis supervene. TYriiLiTi?-, or inflammation of all the coats of the coecum or appen- dix, usually appears suddenly during full health, or it may be preceded by .«light intestinal derangement, such as diarrhoea or constipation. Pain. — The earliest and most marked .symptom is generally pain in the r.'inon of the ca'cum, which appears suddenly, becomes fixed and con- stant, rarely remitting, and is L'reatly inf-n a-od by a deep in-j)ir:iti()n or hy coughing. This pain is attended from the very iir~r with surh exfjuisite tenderness on pressure in the right iliac region, that the weight of the bed-clothes cannot be borne, and the patient shrinks from the lightest touch. To re- lieve this pain the patient lies toward the right side, with the thighs flexed upon the pelvis, and any attempt to draw the right leg doWn causes ago- 29 450 DISEASES OF THE CCECUM AND APPENDIX CCECI. nizing suffering. These local symptoms are usually confined to the right iliac fossa, though the entire peritoneum may become somewhat involved, and the symptoms of general peritonitis develop themselves. Fulness or Tumor. — Owing to the distended state of the bowel itself, and to the adhesions formed between folds of the intestines, or in some rare cases to an inflammatory effusion behind the coecum in the iliac fossa, there is marked fulness or even a well-defined tumor in the right iliac region. Frequently there will be merely fulness during the first few days of an at- tack, and then a distinct tumor will be developed. In 11 of 39 cases of acute typhlitis, recovering without perforation of the bowel, a distinct tumor was present. In most of the other cases the condition of the coecal region is described as one of fulness or distension. Of these 39 cases, 1 9 occurred in children under 15 years of age, in only 3 of which a distinct tumor is recorded to have been observed. Constipation. — The bowels are almost invariably constipated ; in many cases very obstinately so. This constipation is frequently associated with quite severe tormina and tenesmus, and if the coecum be much distended, there may be pain shooting down the right thigh, or numbness and even oedema of this part, together with retraction of the right testicle. It is important to observe here, that in most cases, when once the consti- pation is relieved, and free feculent stools procured, the most threatening symptoms of the attack rapidly subside. Vomiting nearly always attends in children ; it was present in all of our 13 cases. It is never stercoraceous, and indeed is rarely troublesome unless the constipation is marked, or perturbating treatment has been adopted in the beginning of the attack. Fever. — The attack is not usually ushered in by any chill or rigor ; but marked febrile symptoms soon appear, the pulse becomes accelerated, the skin hot, the tongue furred, and the thirst extreme. These symptoms usually subside under appropriate treatment after a variable time, gener- ;ally from four to twelve days ; the bowels are opened freely, the pain and tenderness diminish, and the fulness in the right iliac region gradually .disappears. This description of symptoms applies to acute inflammation both of the ■coecum and appendix, as there are no well-recognized differences in the symptoms of these two conditions. The only probable points of difference are, that in inflammation of the appendix the pain is more acute, and the thorough evacuation of the bowels is not followed by the same prompt and complete relief Perforation of the Ccecum. — When, however, perforative ulceration is progressing, the symptoms follow a different course. The constipation may be relieved and the vomiting cease, but the local symptoms persist, until the rupture of the bowel leads either to speedily fatal peritonitis, or to the effusion of fecal matter mixed with the products of inflammation into the pericoecal tissue. When this latter event occurs, the constitutional symptoms soon indicate the occurrence of suppuration, and hectic irritation, with rigors or marked chills succeeded by drenching sweats, colliquative diarrhoea, rapid prostration and emaciation, with a dry brownish tongue PERITYPHLITIS. 451 and feeble ruoDing pulse, soou appear. Despite the desperate character of these symptoms, however, recovery may take place if the abscess points externally in the way already described, and does not open into the peri- toneal cavity. It is necessary to be aware that the approach of a fecal abscess to the surface is not attended with the appearances which usually accompany the pointing of an abscess. Thus, instead of the skin becoming tense, prominent, and reddish, with a distinct sense of fluctuation present, the surface becomes doughy and dark-colored, and upon palpation a dis- tinct sense of emphysematous crepitation is often obtained. Upon incising such a point, a discharge of fetid gas and grumous matter follows the punc- ture, and this peculiarity has more than once led surgeons to believe that they had opened a knuckle of intestine. Perforative Ulceration of the Appendix. — The symptoms of this disastrous condition closely resemble those of perforation of the anterior part of the coecum. They are, however, often even more acute, the pain is sudden and violent, and a distinct tumor is more uniformly present ; while, on the other hand, the symptoms of obstruction of the intestine are not so well developed. Constipation and vomiting are not constant in the early stage, and at a later period spontaneous diarrhoea may appear, but without any favorable result. The perforation of this part is, as already said, far more apt to be followed by general peritonitis ; and, indeed, so fur as we know, there is but one well-authenticated case on record of recovery after this accident, which was published by one of ourselves in the Pro- ceedings of the Pathological Society of Philadelj^hia. (See Amer. Jour. Med. Sciences, vol. liv, July, 1867, p. 145.) Perityphlitis, or inflammation of the pericoecal tissue, when it does occur independently of typhlitis, is ushered in by pain, with deepseated tenderness in the right iliac region. There is also some fulness of this part, but not the formation of a distinct tumor, as may frequently be de- tected in typhlitis. There are usually colicky pains in the abdomen, with either constipation or diarrhoea, and with a moderate degree of febrile excitement. This disease, when judiciously treated, frequently seems to terminate in resolution ; when, however, suppuration occurs, the symptoms will approximate those given above, and the abscess which forms may dis- charge itself externally, into the bowel, or into the peritoneal cavity. Duration. — Many attacks of acute typhlitis, when promptly and judi- ciously treated, yield on the second or third day ; though the case is often prolonged to the ninth or twelfth day, and, in violent attacks, it may be many weeks before all local tenderness in the cwcal region passes away, and the function of the bowel is again completely restored. When perforation of the ccccum occurs, the after-duration of the case depc*nds entirely upon the point of perforation. If the ulcer have jhii- etrated the anterior wall, general peritonitis is usually excited, and death resultfl in less than forty-eight hours. But if, on the other hand, the posterior wall be perforated, a fecal fistula may be formed, and continue open for very many years. The duration of i)erforative ulceration of the appendix varies considerably. In 3 cases in children, observed by our- 452 DISEASES OF THE CGECUM AND APPENDIX C(ECI. selves, the du ration was respectively seven, nine, and fourteen days, with a mean of ten days. In 11 cases, at all ages, in which the duration is distinctly stated, the mean duration was nine days, the extremes being two and a half and twenty-nine days. Bamberger, however, gives the duration of seven cases, occurring at various ages, at from twenty to fifty days, with a mean of thirty-one days. It is probable, however, that this last mean is rarely attained in cases oc- curring in children. Prognosis. — Nearly all cases of simple acute typhlitis, without perfora- tion of the bowel, recover under proper treatment. Indeed, there are no cases on record of acute typhlitis proving fatal, in which post-mortem examination did not show the existence of perforation of the coecum or appendix. When the coecum has become the seat of chronic inflammation, how- ever, death may result, either from the sudden development of acute peri- tonitis, without perforation of the bowel, or from such contraction of the coecum as finally to lead to obstruction of the intestine. When perforation of the coecum does not prove speedily fatal from peritonitis, but leads to the formation of an abscess in the iliac fossa, the prognosis of the ease depends, in a considerable degree, upon the course taken by this abscess. Dupuytren regarded the reopening into the bowel as the safest termination of an iliac abscess, and the opening upon the surface of the body as almost universally fatal. Further experience has confirmed the truth of the first portion of this opinion, but has also established the fact, that almost one-half of the abscesses opening exter- nally recover. Perforation of the appendix vermiformis is invariably fatal, so far as our experience goes, if we except the case before referred to, where, in an old man about whose past history nothing could be learned, we found the appendix converted into a solid fibrous cord, with a small opening, near the free extremity, leading to its centre. Diagnosis. — The general diagnosis of most of these conditions is not attended with much difficulty. We have already mentioned that simple excessive distension and impaction of the coecum is sometimes attended with severe pain, some tenderness, constipation, and even vomiting, and that these symptoms are relieved upon free action of the bowels being secured. We do not have here, however, the sudden attack occurring in a state of perfect health, as in typhlitis, nor the marked febrile symptoms, nor are the local signs in the right iliac fossa, and especially the peculiar, exquisite sensitiveness, nearly so well developed. Inflammatory diseas'e, in connection with the right ovary, with local peritonitis, is unquestionably sometimes mistaken for typhlitis. The local symptoms in the former affection are, however, lower down in the abdomen than is usual in typhlitis ; there is not the well-defined tumor nor the ob- stinate constipation ; and, in addition, there is generally the history of some menstrual trouble, or the attack occurs in immediate connection with the period of menstruation. TREATMENT. 453 Paiu in the course of the last dorsal nerve may arise from spine disease, or, in the course of the genito-crural nerve, from the passage of a renal calculus, and, according to Habershon, be confounded with ca^cal disease. It is evident, however, that most of the characteristic symptoms of typhlitis would be absent, whilst a careful investigation of the case would probably educe more symptoms of the existing trouble. The diagnosis of typhlitis from intussusception, an affection which pre- sents many features of resemblance, will be fully considered in the article devoted to this latter disease. Ulceration of the ccecum or appendix may be suspected, if the violent pain and the exquisite tenderness persist in the right iliac region, after the other symptoms of an acute attack of coecal disease, especially the vom- iting and constipation, have been overcome. Ulceration of the crecum is much more apt to have been preceded by bowel complaint for some time ; it is also much more rare than ulceration of the appendix. In cases where we are consulted only after perforation has taken place, with the production of a fecal abscess, we must endeavor, by obtaining a most accurate history of the case, to establish the presence or absence of symptoms of inflammation of the coecum at the beginning. And further, care must be taken to exclude the following conditions, all of which may at times simulate iliac abscess, namely : psoas abscess, or abscess connected with caries of the pelvic bones ; abscesses in the walls of the abdomen, with local peritonitis, resulting from blows ; suppuration originating in con- nection with the right kidney or its enveloj^e ; and finally, some cases of disease of the right hip-joint. The differential diagnosis of these affections of the coecum and appendix from one another is as yet scarcely possible. The following general re- marks contain, perhaps, all that can be surely advanced : Simple inflammation of the appendix presents symptoms of even greater acuteness and severity than those of simple coccitis, and which do not sub- side so promptly after the bowels have been freely acted upon. In ulcerative disease, both of the coecum and appendix, the symptoms also persist after the constipation and vomiting have yielded. Ulceration of the ca?cum, however, is rare, and is apt to be preceded by symptoms of bowel complaint. Whilst ulceration of the appendix, on the other hand, is often terribly acute, advancing from a state of apparent perfect health to perforation and death in forty-eight hours; it is also much more frequently attended with a distinct tumor in the right iliac region. Treatment. — The indications for treatment in the acute stage of typh- litis are clearly to reduce the local inflammation of the peritoneum and intestine, to relieve the pain and tenderness, and to secure free and natural action of the bowels. At the same time, all perturbating and strongly reducing treatment is forbidden, by the knowledge that the attack is fre- quently caused by an irritating foreign body: and that, in a certain num- ber of cases, perforation will occur, in which event the only hoj)e of recovery often rests upon the adhesions which have been formed during the early 454 DISEASES OF THE CCECUM AND APPENDIX C(ECI. stage, and upon the vigor of the constitution to resist a prolonged and ex- hausting process of suppuration. Depletion. — The local abstraction of a few ounces of blood by the appli- cation of leeches to the ccecal region, should be practiced in acute cases. This measure, while it does not seriously reduce the strength of the patient, relieves the pain and tenderness, and probably facilitates the action of the internal remedies employed. Beyond this degree, however, depletion is injurious, or, at least, unnecessary. Purgatives. — The experience of all observers agrees in condemning the use of powerful, irritating purgatives at any stage of typhlitis. In the early stage, they aggravate the pain and inflammation, increase or establish vomiting, and frequently fail entirely in their object ; while, on the con- trary, the constipation which will resist the strongest, most drastic purga- tives, will quickly yield to mild, saline, or vegetable laxatives. It is a good plan to combine a small amount of opium with the laxa- tive ; since, so far from counteracting its operation, it appears, by allaying the intense sensitiveness of the bowel, to promote its painless and thorough action. Burne recommends highly the following laxative draught, the dose of which is arranged for an adult : R- — Sodffi Sulphatis, ^j. Tr. Opii, gtt. V. Inf. Senna3, f^j. Ft. sol. S. — Repeat every four hours until the bowels are freely moved. We have ourselves been led by experience to rely upon the combination of comp. ext. colocynth with opium, given in small and frequently repeated doses. Thus, for a child of from five to eight years, the following pill may be prescribed : R- — Pulv. Opii, ". gr- ij or iij. Ext. Colocynth. Comp., .... gr. xij to xviij. Ft. mas. et div. in pil. No. xxiv. S. — One every three or four hours until free action of the bowels is secured. Enemata. — The action of these laxatives may be furthered by the ad- ministration of large enemata, which may consist either entirely of tepid water, or of water containing a small proportion of some stimulating or laxative substance, such as soap, molasses, or castor oil. In cases where the irritability of the stomach precludes the administration of laxatives by the mouth, enemata become especially important, and at times their use will be followed by the most happy results, the irritating contents of the caecum being brought away, with almost immediate relief to the most threatening symptoms. Mercury. — It is difficult to support the practice of giving this drug in typhlitis. In the early stage, indeed, when it may be supposed that the intestinal canal contains irritating ingesta and secretions, a small dose of calomel or blue pill may be administered ; and, in a large number of the I TREATMENT. 455 sncoessfiil cases ou record, this was done. It is not, however, at all neces- sary. Beyond this, the further use of mercury appears to us injurious, since, if it be given until any constitutional efiects are produced, it Tuust have a tendency to prevent the formation of those strong adhesions which constitute the sole chance of recovery in case of perforation of the appen- dix or the anterior wall of the ccecum. Opium. — "We have already mentioned the way in which opium is most advantageously given in this aliection, in combination with the laxative employed. Its use is absolutely called for, and the violence of the local symptoms, the pain and exquisite tenderness, form the best guide as to the amount required. Poultices and Counter-irritants, — In case even the local abstraction of blood appears undesirable, resort should be had to the frequent applica- tion of mustard plasters or turpentine stupes to the coecal region. Hot fomentations or light poultices, to which some sedative substance may be added, should be kept constantly applied to the abdomen. Vomiting when present, should be allayed by counter-irritation, by swallowing small fragments of ice, by carbonated drinks, hydrocyanic acid, or any other suitable remedy. The diet during the early stage should be fluid, and unirritating in character. When the persistence of the symptoms leads us to apprehend the pres- ence of ulceration, either of the coecum or appendix, all depletory and per- turbating treatment should be abandoned, and we should limit our efforts to the relief of pain, by the use of opium and the continued application of poultices ; to regulating the functions of the intestinal canal, and to the sustentation of our patient's strength. If perforation has occurred, without the speedy development of general peritonitis, our attention should be mainly directed to supporting the sys- tem during the long and exhausting process of suppuration which must ensue. For this purpose a generous, though digestible diet, with as much stimulus as appears necessary, should be enjoined ; and resort may also be had to the various tonics, as quinia or the preparations of bark. If a tumor forms, and it becomes evident that the abscess is tending to dis- charge externally, its approach to the surface should be encouraged by poulticing ; and the moment an emphysematous condition of the skin is detected at any point, a free incision should be made, and the discharge of matter furthered by the introduction of a sponge-tent or a pledget of lint, and the application of a poultice. In those unfortunate cases where the perforation of the bowel has been followed by general peritonitis, all treatment is unavailing. Our main reliance must, however, be placed upon the exhibition of opium, and the use of counter-irritation. 456 ARTICLE VI. INTUSSUSCEPTION. Definition; Synonyms; Forms; Frequency. — Obstruction of the intestinal canal, from one or another of the numerous causes capable of producing it, is an accident liable to occur at all periods of life. But the variety of it which forms the subject of this article is of rare occurrence excepting in early childhood. It has been called ileus, volvulus, miserere mei ; but is best known under the descriptive names of intussusception or invagination of the intestines. It consists in the passage or introduction of one portion of intestine within another, as a small tube might slide into a large one, or, to borrow a familiar illustration, as the end of a glove- finger may be pushed back upon itself into the glove. This simple invagi- nation, however, is not the only element present, for in order that the symptoms of intussusception should be produced, it is necessary that the included portion of bowel should be so incarcerated and constricted as to give rise to more or less complete intestinal obstruction. This has led to a very just division of intussusceptions into such as are slight, unattended by inflammation, or spasmodic ; and such as are grave, or attended by in- flammation and incarceration. The slight form of invagination is found very frequently at autopsies of children who have died of other diseases, and in whom during life there was no symptom of disturbed function of the alimentary canal : it is in all probability produced in the death agony. M. Louis states that the greater part of 300 children dying during the period of dentition ^t the Salpetriere, had 2, 3 or even 4 volvuli without inflammation. Baillie, Cheyne, and BilJard speak of such intussusceptions as being frequently found at the autopsies of children ; and Burns, as quoted by Gorham,^ gives the results of the autopsies of 50 children who had died from diarrhoea, in every one of which they were found. This species of invagination in children occurs almost exclusively in the small intestine ; the invaginated part is usually of no considerable length ; and the very slightest traction suffices to restore it. The grave form, on the. other hand, differs from this alike in the very positive symptoms by which its presence is announced, in the condition of the parts involved, and in the part of the bowel aflTected; and as the form first mentioned scarcely deserves to be called a disease, it is to the latter alone that the following remarks are addressed. Frequency. — Although numerous well-authenticated cases of intussuscep- tion occurring in adults are on record, statistics prove that it is relatively much more frequent during the first four years of life. Thus of 100 cases 1 Guy's Hosp. Keports, 1st series, vol. iii, 1838, p. 330. ANATOMICAL APPEARANCES. 457 given by Duchaussoy' in which the age is mentioned, there were 31 under 4 years of age, 6 between 4 and 10 years, and ()3 adults. Smith's- tables go to show that " this complaint is rare under the age of 8 months, and that the period of greatest frequency is from the third to the sixth month of life, the maximum number being at the fourth month." Thus there were 11, of the 50 cases collected by him, at the age of 4 months, or 21 in all between 3 and 6 months inclusive; 8 from 6 months to 1 year; and only 18 between the ages of 1 and 12 years. We must, however, call attention to the rarity of this disease at any age among us ; for although, in the course of a very exrensive practice among children in this city, we have met with several well-marked illustrations of the various forms and terminations of intussusception, it has been one of the rarest occurrences in our experience. Anatomical Appearances. — Intussusceptions, anatomically consid- ered, may be divided into descending or progressive, and ascending or re- trograde, according to the direction which the invaginated portion takes ; and into central or lateral, according as the entire intestine, or but one wall, is invaginated. Lateral invaginations, however, are exceedingly rare, occurring but twice in 137 cases collected by Duchaussoy. Excepting when invagination occurs as a complication of some other affection, it is almost invariably of the descending form. Thus, of Du- chaussoy's 137 cases, only 16 were retrograde, all of them being compli- cated ; and Haven gives but 3 instances of ascending intussusception out of 59 cases. It is a matter of considerable importance to determine what is the most frequent seat of intussusception in children. Rilliet and Barthez^ declare that in infants the small intestine is almost never the seat of intussuscep- tion, but that ordinarily it is the lower end of the ileum which is invagi- nated into the large intestine. The reasons for this are found in the ana- tomical conditions of the intestines- in infancy: the adhesions of the cnecum to the right iliac fossa being much more limited and less powerful than in later life ; and the muscular coat of the coecum being but slightly developed in childhood, a circumstance which must also tend to favor the passage of the lower end of the ileum through the valve. The statistics of Duchaussoy and Smith confirm this opinion ; as of 31 cases of simple descending intussusception in children under 4 years of age, collected by the former, the large intestine alone, or both the large and small, formed the intussusception in all but 4 cases; and Smith states that he has found no exception to Rilliet's remark, as regards early infancy. In children above the age of 2 years, fatal invagination in the small in- testines may occur in rare cases. In a few cases also, the ileum has pre- gerve^l its normal relations to the ileo-ccecal valve, the cfccum being the first part inverted, and drawing after it the lower end of the ileum. * Ducbnu&soy, Mem. de I'Acad. de 31 ed., vol. xxiv, p. 97 (New Syd. Soc. Year- Book, 1863, p.* 294). ' Smith, Sutistics of Intussusception in Children (Am. Jour. Med. Sci, vol. xliii, 1862, p. 17). ' Ma), des En^nt^, 2^me ed., torn, i, p. 806. 458 INTUSSUSCEPTION. An intussusception, then, is made up of three folds of intestine : 1st, The inner, or contained part, which in descending intussusceptions is always in the natural direction ; 2d, The middle, which is a reflection of the inner, and passes in a direction contrary to the intussusception ; and 3d, The outer, containing part or sheath, which is in its natural position, and in the direction of the intussusception. We find, therefore, the mucous mem- brane of the middle and outer parts in apposition ; and the peritoneal in- vestment of the middle and inner parts in contact. The amount of intestine invaginated and the condition of the parts de- pend, in great measure, upon the duration of the case. If death takes place early, only a small portion of the ileum may have passed the valve; but as the case progresses, the tenesmus or the active peristaltic action of the outer part, brings down more and more of the ileum with its accom- panying mesentery, until finally, the constriction of the ileo-coecal valve preventing the descent of any more of the ileum, the coecum is inverted and forced into the ascending colon. This in turn may be invaginated in the descending colon and rectum, until not unfrequently a portion of the invaginated intestine protrudes from the anus. In rare cases, the whole invaginated mass descends into the intestine below, thus forming a double intussusception of great thickness. It has occurred, in a few rare cases, that the amount of constriction was so slight that the intestine remains per- vious to a certain extent ; so that life has been protracted for many weeks, and death has finally ensued only from exhaustion. But ordinarily the parts are in the following condition : the intestine above the point of con- striction is distended with gaseous and fecal contents, and more or less dis- colored from congestion of its walls. It is rare, however, to find any evi- dences of enteritis either here or in the intestine below the intussusception, which is generally pale and contracted. The invaginated portion itself, at the upper part, where it seems to plunge into the containing portion of the intestine, presents a series of concentric circular folds. The walls of the bowel thus incarcerated are thickened and infiltrated ; their serous invest- ment either deeply injected or discolored by congestion and ecchymosis, so as to be of a deep blackish-red color ; and frequently evidences of local peritonitis are present. The mucous membrane in cases of short duration may be merely thickened and injected, but more frequently it is turgid from congestion, ecchymosed in points, and shows the effects of violent in- flammation by its unequal roughened surface, presenting either ulcerations or grayish false membranes. The capillaries of the constricted portion be- come greatly distended, so that, especially in young children, in whom the vascular rete of the intestines is remarkably rich, whilst the tissues are delicate and yielding, they frequently rupture, filling the invaginated in- testine with blood, and producing bloody discharges. If the case is protracted and the powers of life sufficient, when treatment has not sufficed to reduce the intussusception, nature endeavors to effect a cure by eliminating the invaginated portion. The incarcerated bowel be- comes gangrenous, a line of separation forms, union and cicatrization take place between the part of the bowel above the intussusception and the upper ANATOMICAL APPEARANCES. 459 part of the containing intestine, and the iuvaginated portion is discharged per anum. This process of elimination is extremely rare in infants ; but it is stated by Rilliet to be the ordinary method of cure in children in their second infjincy. In 59 cases reported by Haven/ of all ages, discharge of the intestine per anum took place 12 times, with recovery in all but two cases. The average length of intestine passed in these cases was 23^ inches : in the two fatal cases, the portions passed were respectively 39 and 44 inches long. The earliest age at which we have met with this process of cure, is at 13 months in a case reported by M. Marage. In the report of the Proceedings of the Pathological Society of Loudon, vol. xiii, a specimen is described by Dr. Hare, where this process had taken place. The patient was a female, 41 years of age, and her death resulted from tubercular disease three months subsequently to the passage of the sphacelated bowel, " which was 6\ inches in length, of a very dark purplish-gray color: it formed a perfect cylinder, but the intestine was turned inside out, the exterior of the specimen, as voided, being the mu- cous membrane, and the interior of the cylinder being the peritoneal covering of the intestine." At the autopsy, at the point where the invaginated portion had been separated, about fifteen inches above the coecum, the line of union was found running obliquely across the intestine, " but the union was so per- fect that it could scarcely be detected except by holding up the intestine between the eye and the light, when the thinness of the intestine clearly pointed out the line or seam where the union had taken place. Exactly at the point of union the intestine was notably narrower than natural ; but the intestine above this point was a little dilated." We have jecently had an opportunity, through the courtesy of Prof. A. Stille, of studying a specimen in which a similar process of cure had been effected. The patient was an adult, who died of some chronic disease, and no history could be obtained of the occurrence of the attack of intestinal obstruction, or of the discharge of the sphacelated portion of bowel from the anus. The specimen, however, presented appearances which left no doubt that invagination of a portion of the ileum had occurred, that the invaginated portion had sloughed away, and that union had taken place between the intestine, just above the intussusception, and the upper part of the sheath, so a.s to preserve the continuity of the bowel. The exter- nal surface presented a marked constriction encircling the intestine due to the entrance of the upper part of the bowel into the sheath. There was a layer of organizx'd lymph investing the peritoneum at the line of junction, and firmly uniting the two serous surfaces. Upon laying open this part of the ileum, a narrow rira of indurated tissue, evidently the al- tered intestinal wall, projected downwards into the intestine from the line of constriction, and formed, as it were, a perforated diaphragm across the calibre of the bowel. We thus see that even when the slough is cast off, and the patient re- covers from the intussusception, the cure is not always permanent, since in » Haven on Intestinal Obatruction, Amer. Med. Sci., vol. xxx, 1855, p. 351. •i60 INTUSSUSCEPTION. a small proportion of cases there may be serious contraction of the bowel, caused by the ensuing cicatrization. In addition to the modes of recovery already adverted to, namely, the reduction of the intussusception either by the movements of the bowel itself or by the remedial measures adopted, and the elimination of the in- vaginated portion, there is still a third mode possible, in which the intestine remains invaginated, but by agglutination of the outer folds, becomes per- vious, and undergoes such atrophy and contraction as not to interfere materially with the functions of the bowel. Rilliet and Barthez, as well as other Continental authors, speak of this as of occasional occurrence, but we have not found any well-authenticated cases recorded. There are few morbid changes found in intussusception excepting those pertaining to the intestines. It is, however, worthy of mention, that in some cases the invaginated mass appeal's to produce serious compression of the large vessels of the abdomen. Causes ; Age. — We have already given the statistics which prove that intussusception is relatively very much more frequent during the first four years of life, the period of maximum frequency being between the third and sixth mouths. It is very rare before the age of three months. All forms of invagination, however, do not occur with equal frequency at these various ages. During early infancy, for the anatomical reasons already assigned, the almost invariable seat of the invagination is the lower end of the ileum and the upper part of the large intestine ; while, after the age of two years, invagination of the small intestine alone, though still veiy rare, may occur. Sex. — All statistics agree in giving a majority of males over females, at least in the proportion of 2 to 1 ; while in some tables the proportion is as high as 7 to 1 ; thus Rilliet and Barthez collected 25 cases, of which 22 were boys. Previous Condition. — In by far the majority of cases, intussusception in the infant occurs as an idiopathic affection, appearing during perfect health. In children over one or two years of age, however, it is much more apt to be preceded by some disturbance of the alimentary canal, as constipation, diarrhoea, dysentery, or even by symptoms of imperfect obstruction of the. intestines. Intussusception may also occur during the course of other diseases, as in a case quoted by Rilliet from Legoupil, where the invagination ap- peared during the progress of variola ; the child, 4^ years old, recovered. Exciting Causes. — E.vternal violence, as blows upon the abdomen, or sud- den jerking of the child's body, as in tossing it in the arms, are assigned as the probable exciting cause of a certain number of cases. It has been supposed, also, that violent fits of coughing or screaming, or strong straining at stool, have produced invaginations, especially in very young children. Improper alimentation and sudden changes of diet appear to act quite frequently as efficient causes ; thus in a case reported by Gorham, occur- ring in a healthy infant of four months old, the only assignable cause was the administration of panada for three days preceding the attack. It is, SYMPTOMS. 461 however, frequently impossible to assign any plausible reason for the sud- den production of severe intussusceptions. Gniuting, however, the presence of any of these causes, the question still remains as to the exact mechanism of the invagination. According to Gorham, " it is necessary to the production of an intussusception that there should be either: 1st, A contraction of the part to be intussuscepted ; or 2d, A dih\tation of that part which is to be the outer fold ; or 3d, A natural and sudden inequality of calibre of some portion of the Intestinal tube. The first of these conditions may be produced by spasm ; the second by flatus; whilst the third is always present at the termination of the ileum in the ccecum." It is at this point, accordingly, that intussusception most fre(|uently occui-s, and, from the anatomical arrangement of the parts making it very difficult for restitution to occur, puts on its most dangerous and fatal characters. The invagination having once begun, its increase and persistence are probably due to the active peristaltic action of the outer fold, aided by the spasmodic contractions of the diaphragm and abdominal muscles, Causing the powerful tenesmus so frequently observed. There is one more question in regard to the etiology of this affection, about which various opinions have been expressed ; whether, namely, en- teritis holds the relation of cause or effect to intussusception. Rilliet and Barthez appear to us to have given it its true importance in stating that it sometimes plays one part and sometimes the other. We have already seen that, though in many cases intussusception occurs suddenly in full health, there are a sufficient number of instances where the attack has been preceded by symptoms of intestinal irritation or inflammation, to make it clear that at times enteritis acts as a predisposing or determining cause. And, on the other hand, the pathological anatomy of the disease, showing the inflammation of the bowel to be limited to the immediate vicinity of the invagination, and to be the more intense as the constriction is tighter, proves that enteritis frequently appears as a result of intussus- ception. This becomes especially evident in those cases where the disease has been caused by external violence, and where after death the above conditions have been noticed. Symito3is; Duration; Terminations. — The principal symptoms of intussusception are furnished by the gastro-intestinal apparatus ; and, to- ward.s the termination of unfavorable cases, by the nervous system. We have seen that a considerable diflference exists in the seat of the invagina- tion at different periods of childhome to be almost never present, but we have found it recorded particularly in six of Smith's cases, the same number in which an abdominal tumor was prei*ent in the same series; and in three other cases, altliouL'h no tumor protruded from the anus, the invaginated mass was readily felt by examination per rectum. When the bowel protrudes, it forms an oVjlong tumor, at times even two iuches in length, much congested from the constriction, and smeared with bloofl and mucus. When we pass from these positively diagnostic symptoms, we find little 464 INTUSSUSCEPTION. elsewhere characteristic of the disease. The tongue is normal until in- flammatory action sets in, when it often becomes dry and brown; the ap- petite is impaired or absent, and the thirst is generally but moderate. Rilliet and Barthez call attention to the importance of this last symptom in a diagnostic point of view, as well as to the fact that the emaciation is usually not so marked as in other acute diseases of equal duration and severity. The amount of febrile action is generally slight in infancy ; the surface, cool at first, may at times become hot, or is alternately hot and cold, and as death approaches remains continuously cold. Tiie pulse soon be- comes frequent, though small and feeble. There is no marked disturbance of respiration. In older children there is apt to be more febrile action, the skin being hot until late in the attack, and the pulse frequent and more full. The physiognomy of the little patient is greatly altered from the commence- ment of the attack. The eyes are dull and languid, sunken in their orbits, and surrounded by discolored areolae ; the countenance is expressive of the most profound prostration, so as to have elicited a comparison to the physi- ognomy of cholera patients. Almost all cases, at whatever age, present symptoms of marked disturb- ance of the nervous system, as great restlessness, indescribable malaise, sharp cries, and, toward the close of the case, profound prostration. But in infancy, in addition to these symptoms, the case is more apt to present an attack of convulsions, either as one of the earliest symptoms, or toward death, alternating with coma. Duration. — It is necessary to distinguish here between cases occurring during extreme infancy, when we cannot hope for elimination to take place, and those in more advanced childhood. In early infancy, when the attack is about to take a favorable turn, the symptoms usually yield in from two to four days, owing to reduction of the invagination. In fatal cases, death occurs within five days, as the rule. In some cases, however, where the constriction was not complete, life has been prolonged even for six weeks. In second infancy, where the constriction is complete, and the result fatal, death occurs within seven or eight days in the vast majority of cases. But when elimination is to result, the case is more protracted, and complete recovery is postponed to the third week. Thus, in 7 cases out of. Smith's statistics, which resulted favorably by sloughing, the ages were 5, 6, 6, 9, 11, 12, and 12 years respectively; and the separation of the invaginated portion took place between the ninth and twelfth days, with an average of nine and a half days. After the discharge of this, which is soon followed by the fetid, brownish-black stools already described, the symptoms rapidly disappear, and in one or two weeks the cure is complete ; so that, if we can carry a patient, advanced beyond the first infancy, through the first week of the attack without too much exhaustion, we may each day look for the discharge of the invaginated bowel, the restoration of the function of the intestines, and ultimate recovery. Terminations. — We have already described the favorable modes of ter- mination, namely, by the subsidence of the intussusception, either spon- PKOGNOSIS — DIAGNOSIS. 465 taneously or as the result of treatment; by restoration of the calibre of the bowel by sloughing of the invaginated bowel, and union and cicatriza- tion of the divided edges ; and linally, by agglutination of the outer layei*s of the invaginated portion with subsequent thinning and atrophy, thus rendering the intestine pervious, although the intussusception remains. In those cases in whicii death takes place very early, as on the first or second day, it is frequently produced by cerebral congestion or an attack of convulsions. In the majority of cases, however, it occurs somewhat later, and is preceded by a state of collapse. Even in those cases where the constriction is not at first complete, and where there are daily feculent evacuations for a time, death is apt to occur from exhaustion, or from the invagination becoming more extensive and symptoms of complete obstruc- tion arising. Prognosis. — A single glance at the character of the lesion and the accompanying phenomena, suffices to assure us of the grave nature of intussusception, and of the impotence of all ordinary methods of treatment against it. In young infants, indeed, where the strength of the system cannot be expected to hold out until elimination occui-s, intussusception is almost invariably fatal. In a single instance only has recovery by elimi- nation been noticed so early as the end of the first year. In a few cases, where the symptoms were well developed and threatening, they have sub- sided and the infant has recovered, apparently from spontaneous reduc- tion of the invagination. We must not, however, forget that during the early stage of this affec- tion the diagnosis is somewhat doubtful, since young children frequently present symptoms of obstructed and loaded intestine, such as a distended, hard abdomen, constant unnatural straining, with evident suflering, and yet are entirely relieved after the administration and operation of laxa- tives. Not to refer now to the recent cases of successful abdominal section, a considerable number of cases of cure of undoubted intussusception, by means of inflation, have also been reported even at this early age ; so that, when treatment is instituted soon after the appearance of the symptoms, the case is not absolutely hopeless. In older children, that is to say, above three years of age, the prognosis is much less unfavorable, since treatment offers a certain amount of hope, and there is always the prospect of the occurrence of elimination of the invaginated bowel, if the strength of the patient has been sustained during the first week. Even after elimination has taken place, however, the prognosis should still be somewhat guarded, as the slightest indiscretion in diet may, either by the development of flatulence or by the escape of irritating, undigested panicles into the intestine, cause a rupture of the recently formed cicatrix and speedy death. DiAGNr>iis. — Intussusception has been, until recently, regarded by all authors as an affection of obscure and doubtful diagnosis. With the light, however, which has been thrown upon this subject by the labors of Clarke, Gorham, Smith, and especially Rilliet, the diagnosis in the great majority of cases can be made with precision. It is true, however, as conceded by 466 INTUSSUSCEPTION. Rilliet, that " very rarely in early infancy, more frequently than later, there are certain cases of invagination impossible to distinguish from other forms of intestinal obstruction ; and that at all periods of childhood the diagnosis presents many difficulties." With what diseases, then, could we confound this affection, occurring, as we have seen, suddenly in perfect health ; attended by obstinate, though rarely fecal vomiting ; by marked constipation, but with frequent bloody discharges ; by paroxysmal abdominal pain and tenesmus ; by the presence of a tumor, generally in the left iliac region ; by the protrusion of the in- vaginated bowel from the anus ; and by profound prostration and disturb- ance of the nervous system. It is to be remembered, iudeed, that this group of symptoms, so characteristic when viewed together, are rarely all present ; and that with the exception of the vomiting, constipation, and bloody discharges, there is no single symptom which is not more frequently absent than present. There are, nevertheless, a sufficient number present in nearly every case to enable us to form a diagnosis. The diseases which may most readily be confounded with intussuscep- tion are, 1st, impaction of the intestine with hardened f^ces ; 2d, typhlitis or perityphlitis ; 3d, cholera infantum ; 4th, dysentery ; 5th, intestinal haemorrhage ; 6th, the various forms of internal strangulation ; 7th, peri- tonitis. 1st. When an accumulation of fecal matter takes place in either the coecum or sigmoid flexure, the case may present many symptoms similar to those of intussusception. There is frequently such gastric and intes- tinal irritation, as to lead to occasional vomiting and paroxysmal abdom- inal pain ; the bowels are constipated, and there is frequent and strong tenesmus, so as often to cause protrusion of the bowel. In addition to these symptoms, a well-defined tumor is present in one or the other iliac fossa. These cases, however, often have presented symptoms of intestinal dis- turbance for some time previous to the attack ; the vomiting is rarely so constant as in intussusception; the tumor is quite painless and has a pecu- liar doughy consistence ; bloody discharges from the bowels are very rare ; and we do not notice the profound prostration which exists in well-estab- lished invagination. During the early stage of the case, however, the diagnosis is doubtful ; and when we have reason to suspect the presence of fecal accumulations, we must await the result of the administration of lax- atives and laxative enemata, before deciding upon the nature of the case. 2d. Inflammation of the coecum, appendix vermiformis, or of the peri- ccecal connective tissue, is attended with fulness or a well-defined tumor in the right iliac fossa, with vomiting, constipation, and occasionally tenes- mus, with distension of the abdomen and pain radiating from the right iliac region. There is, however, a marked degree of fever, and the symptoms of local peritonitis appear early in the case ; the patient assumes a characteristic position, with the thighs flexed upon the pelvis, and the right iliac fossa is the seat of exquisite tenderness, so that the slightest pressure cannot be tolerated. The vomiting and constipation are not so marked and obsti- DIAGNOSIS. 467 nate, and excepting in those cases which have been preceded by dysenteric symptoms, there are no bloody discharges, and as we have remarked above, the tumor or fulness is in the right iliac fossa ; whereas when this sign is present in intussusception, it usually occupies the left iliac region. 3d. In cholera infantum, the vomiting is often incessant ; the stools are frequent, with painful tenesmus ; the abdominal pain paroxysmal, and occasionally the intestine protrudes from the anus. It is almost impossible, however, to mistake this affection for intussusception, if we remember that it is almost always accompanied by fever, with insatiate thirst, and prompt and extreme emaciation ; that the abdomen is without tumor, and rarely distended until towards the close of the case, and that the stools, instead of being bloody, are large and fluid. 4th. Dysentery frequently offers a close resemblance to intussusception so far as the characters of the stools are concerned, as they are often small and bloody, or muco-sangu indent. But we do not see in dysentery the sudden inception, the rapid progress, the obstinate vomiting, the moist tongue and moderate thirst, which characterize intussusception. 5th. We have seen that occasionally the amount of blood passed by stool in intussusception is very great, and constitutes a true intestinal hseraorrhage ; thus in the case reported by Marwick,^ it amounted to a large teacupful of pure blood. Intestinal hiemorrhage is a very rare occurrence during childhood, but has been noticed in children in connection with polypus of the rectum, especially by Mr. Bryant ; in typhoid fever, or the hiemorrhagic form of -ome others of the exanthemata, and in the course of purpura. The absence of the other symptoms of intussusception, however, and the presence of the local or general symptoms peculiar to these various conditions, will ?erve to render the diagnosis easy. 6th. Other forms of internal strangulation, such as those produced by a diverticulum from the intestine compressing it, by the adhesion of the vermiform appendix .so as to constrict the bowel, or by a contraction of the calibre of the bowel, produce symptoms so identical with those of intu«su.«ception in second infancy, when the affection more nearly resembles -final obstruction in the adult, as to render diagnosis impossible. The nee of an abdominal tumor, the occurrence of bloody stools, or the protrusion of the constricted bowel from the anus, would be the only diag- nostic signs. 7th. Peritonitis, when diffuse, presents a few symptoms in common with intu*su.«ception ; as the vomiting, constipation, abdominal pain and tender- ness ; and when the inflammation of the peritoneum is localized, there is in addition a well-defined sensitive tumor, which soon appears as the result of the inflamraator}' action. The diagnosis here rests upon the greater frefjuency of the vomiting in intussusception, the more obstinate constipa- tion with bloody discharges from the bowels; the paroxysmal nature of the abdominal paio, with less tenderness ; the less degree of fever, the * London Lancet, July, 1846. 468 INTUSSUSCEPTION. moist tongue, slight thirst, quiet respiration, and only moderately acceler- ated pulse. Treatment. — There is no special plan of treatment for intussusception deserving the name oi preventive, owing to our ignorance of any symptoms which can be definitely regarded as the precursors of the invagination. The fact, however, that various derangements of digestion, such as pain upon going to stool, diarrhoea, or constipation alternating with diarrhoea, have been occasionally noticed to precede the attack, should be an addi- tional motive to urge us to meet these symptoms by the most assiduous attention to the hygiene of the child, and to the regulation of its alimen- tary functions. The curative treatment may be divided into three classes : the medical, mechanical, and surgical treatment. Medical. — Depletion is strongly contraindicated by the tender age of the patients, and by the necessity of preserving the vital powers; since elimina- tion, which affords the principal chance of recovery, does not occur until after the eighth day. In order, however, to relieve the engorgement at the point of constriction, without reducing the strength of the patient, it is ad- visable to apply a few leeches or cups to the abdomen, and preferably to the right iliac region, unless a tumor can be detected, when, of course, they should be applied over its seat. Purgatives were formerly strongly advocated by most authors ; the one most generally advised being quicksilver, which was given with a view of overcoming the obstruction by its great weight and fluidity. The use of this agent is now, however, universally reprobated. In regard to other and less mechanical purgatives, there is still some difference of opinion. During the early stage of the attack, before the symptoms of intussus- ception are very positively developed, we should advise the administration of a mild but thorough laxative, such as castor oil, in conjunction with large laxative enema ta. If, however, at the end of twenty-four or forty- eight hours, the administration of these remedies, aided by the local deple- tion, has failed to produce an evacuation from the upper bowel, these measures should be abandoned, and recourse be had to means of calming pain and nervous disturbance, and to the sustentation of our patient. Among the remedies best calculated to allay the pain, the tenesmus and the nervous irritability are: opium, in doses proportionate to the intensity of the pain ; warm anodyne poultices applied to the abdomen, and warm baths carefully given. These latter are especially serviceable when the symptoms of nervous disturbance are marked, even amounting, as they oc- casionally do, to general convulsions. In endeavoring to sustain the child's strength, attention must be paid to the vomiting, which is generally so severe as to prevent any nourishment being retained. The remedies of most service against this are counter-irri- tants to the epigastrium, opium, hydrocyanic acid, carbonated water, small pieces of ice kept constantly in the mouth or swallowed whole. Nutritious eneraata may also be tried, but are rarely retained. The mechanical treatment consists in the injection of fluids or air into the k TREATMENT. 469 bowel iu such quantities as to distend it; and in the introduction of a h\rge sound, with the view of pushing up the invaginatod portion of intestine. The fluids generally used have been either tepid water or warm gruel, in- jected forcibly into the bowel, until the sudden cessation of resistance in- forms us of the reduction of the intestine. We have already seen that the seat of intussusception in the child is almost invariably the lower end of the ileum, which passes into the coecum and is there constricted ; and, when we reflect that it has been frequently demonstrated that if fluid be forcibly injected into the large bowel, the ileo-ca^cal valve will rupture before any fluid is allowed to j)ass into the ileum, it is evident that we can in this way exert a most powerful pressure upon the invagiuated intestine. Experience shows that this procedure is frequently successful, even in cases where all medicinal treatment has proved unavailing ; and there are now a sufficient number of such cases on record to render a resort to it proper. The fluid may be introduced by an ordinary syringe, or better by a Bow- ditch's syringe, the limbs being held together so as to prevent as far as possible any reflux. It has been recently suggested by Simon that hydro- static pressure might be employed to force fluid into the bowel. For this purpose a glass funnel attached to a long india-rubber tube terminating in an olive-shaped plug is used. The plug is inserted in the anus, and the funnel is held on a level with the body, and water poured in until it is filled. The funnel is then gradually elevated, and more and more water poured in to replace that which is forced by the hydrostatic pressure into the bowel. Owing to the gradual and uniform increase in pressure thus brought about, extreme distension of the entire colon can thus be produced. We have recently employed this mode of treatment with most gratifying success in a very severe case of an infant of 6 months of age. ^ir, also, both on account of its great elasticity and mobility, as well as the great facility of its introduction in sufficient quantity, is to be highly recommended. Indeed, inflation was advised by Hippocrates as a remedy in intussusception, but until within the past forty yeai-s does not seem to have been much practiced. Two cases of obstruction of the bowels, oc- curring in adults, successfully treated by inflation, are reported in the American Journal of Meflical Sciences, for 1883: one by Dr. Janeway, of New York ; the other, which, however, was transcribed from the Gldsrjoiv Medirnl Journal, for 1831, by Dr. King. The following year, in the Bos- ton Medical and Surgical Journal, December 15th, 1834, Dr. J. Wood publi.*hed a ca^, also in an adult, where death seemed imminent, but where the obstruction was readily overcome by inflation, and the patient recovered. Since then, this remedy has been frequently employed in in- tuisusception in children, and with such good results, that it may fairly be said that the prognosis of this affection is less grave since the introduction of this remedial measure. To obtain the best result.e, inflation should be employed early in the case, before any considerable amount of adhesive inflammation has taken place between the sheath and the contained intes- tine. The air is readily introduced by a pair of ordinary' bellows; the nozzle being inserted well into the rectum, and inflation continued until the obstruction yields. The return of the invagiuated intestine is some- 470 INTUSSUSCEPTION. times attended by a clearly audible sound, a species of crack, but it never gives any pain, and has generally seemed to afford relief. The complete restoration of the calibre of the intestine is proved by the copious feculent stools which frequently come away soon after the inflation. A third mechanical means for restoring the displaced intestine has been recommended by Dr. Nissen, and consists in pushing up the invagi- nated portion by means of an oesophageal sound protected by a sponge. This proceeding would probably be readily accomplished, if the intussus- ception occurred far down in the large intestine; but it would appear very difficult to replace in this way an invagination as high up as the ileo-coecal valve. Dr. Nissen, however (in the Journal de Canstatt, quoted by Rilliet and Barthez), gives two cases in which he succeeded in pushing up the in- testine into the ascending colon, with complete relief of the symptoms of obstruction. There are also a few other cases of cure, by this means, upon record in medical literature. The surgical treatment, consists in the performance of the operation of gastrotomy, finding the invaginated portion of bowel and reducing it by gentle traction. When, in our last edition, Ave expressed ourselves in favor of this operation under certain circumstances, there existed much diversity of opinion on the subject and many authors condemned it. Their disap- proval was based upon the grounds of the great difficulty of ascertaining the exact position of the intussusception ; the difficulty of restoring the invaginated intestine even if found ; and finally upon the dangers of the operation. We have seen, however, that in the majority of cases the invaginated mass will be found in the neighborhood of the left iliac fossa ; the lower end of the ileum having traversed the coecum, ascending and transverse colon, and these parts being successively inverted ; that in a certain pro- portion of cases a tumor is readily detectable ; and further, that some idea as to the seat of obstruction may be obtained from the distance to which enemata appear to penetrate. So that in a considerable proportion of the cases, we have the means of localizing the point of constriction, with a certain amount of definiteness. In regard to the difficulty of reducing the invaginated parts, authors differ greatly. It has been remarked, that even if the equivocal and un- certain nature of the symptoms of volvulus were not sufficient to deter us from undertaking the operation, the state of the invaginated parts would entirely banish all thoughts of such an imprudent attempt ; since the dif- ferent folds of intestine become so agglutinated to each other that they can hardly be withdrawn, even after death. Rilliet and Barthez {loc. cit.), however, conclude from their anatomical researches, that in the majority of cases the disengagement of the intes- tines is very easily accomplished ; and accordingly they declare that, "after employing medical treatment during three or four days, and after having made several attempts at inflation, we should not hesitate to perform gas- trotomy." The great danger of the operation is, of course, apparent, but should hardly be considered an objection, when we consider the fatal nature of I TREATMENT. 471 this affection. Nor have the results of operation been such as to destroy hope. In addition to several successful operations previously recorded, the only 3 cases out of the 57 collected by Haven, in which gastrotomy was performed, terminated favorably. ^lore recently, also, the operation has been performed several times by ditierent operatoi*s (J. Hutchinson, Howard Marsh, Legge, and others), and with such encouraging results as to fully justify us in repeating our former advice in regard to its perform- ance. To sum up our remarks upon this subject : after having tried for two or three days the medical and mechanical means recommended, without success, we must forbear and decide whether to trust the case to nature, with the hope of elimination of the invaginated bowel occurring, or to resort to gastrotomy. And in this decision, the circumstances of each case must be taken into account ; for if the case has not yet progressed so far that adhesive inflammation has certainly taken place, and if we are able to detect the exact seat of constriction by the presence of a tumor, the operation certainly has strong arguments in its favor, and should not be hastily rejected. In those cases which have been trusted to nature, and when elimination has fortunately occurred, we must treat the child, during this crisis, with the utmost care. The diet must be rigidly regulated, and the child kept in absolute repose. Nor must we relax these precautious for several weeks, and allow either indigestible food, or too large a meal of even the most di- gestible articles ; since death has been several times known to follow this imprudence, from a rupture of the imperfectly formed cicatrix. CLASS IV. DISEASES OF THE NERVOUS SYSTEM. GENERAL REMARKS. It is a very common opinion, both in and out of the medical profession, that this class of diseases occasions a much larger number of deaths in childhood than any other. Indeed, many persons suppose that, be the primary disease what it may, nearly all children who die, die, as it is said, by the brain. It appears, however, from an examination of the bills of mortality for this city, that this opinion is not well founded. During the five years from 1844 to 1848 inclusive, the number of deaths from diseases of the nervous system was less than from diseases of the digestive system, and though larger than those from diseases of the respiratory organs, not so much so as the popular notion would seem to warrant. The number of deaths from diseases of the nervous system was 3970; from diseases of the digestive system, 4204 ; and from affections of the respiratory system, 3376. M. Barrier, whose observations were made at the Children's Hospital in Paris, says {loc. cit., t. i, p. 35) that, setting aside cases in which the ner- vous symptoms were probably only sympathetic of some other coincident disease, the cerebro-spinal affections were few in number in comparison with those of the thorax, abdomen, and senses, including amongst the latter the eruptive fevers. He states {loc. cit., p. 34) that affections of the thorax constituted two-fifths of all the cases of disease, those of the abdo- men and senses each one-fifth, and of the nervous centres only a tenth. M. Barrier, after combating the opinion so generally entertained, that disorders of the nervous system cause the death of the greater part of the subjects who die before puberty, says {loc. cit., t. ii, p. 233) that there is only one circumstance that in part justifies this opinion, which he opposes " not as false, but as exaggerated," and this is, that the affections alluded to are almost always of a dangerous character, that they are beyond the resources of art, and that they furnish a very considerable relative mor- tality. He says that, according to his experience, the mortality in diseases of the cerebro-spinal system has been as sixty-eight in a hundred, while in those of the thorax, senses (including the skin), and abdomen, it was respectively as forty-eight, forty, and thirty-two in a hundred. Before beginning the consideration of the particular diseases of this class, we are desirous of stating that we shall be compelled, on account of our limited space, to devote attention chiefly tQ those which are most im- portant from their frequency or severity, avoiding or merely alluding to TUBERCULAR MENINGITIS. 473 those which are of less cousequeuee, or which occur in childhood merely in common with adult life. In our earlier editions we divided this subject into two classes, one con- taining all the'diseases attended with and dependent upon, some appreciable alteration of the nervous centres, the second containing those in which no such alteration exists. We have since discardetl that arrangement, princi- pally on account of the minute researches of histologists during the past few years, which have all gone to prove the existence of positive and definite tissue-changes in many diseases previously regarded as purely functional. ARTICLE I. TUBERCULAR MENINGITIS. Definition ; Synonyms ; Frequency. — This disease is characterized by violent cerebral symptoms, dependent upon the existence of tubercular granulations in the pia mater, as the essential anatomical lesion ; accom- panied, in the great majority of cases, by coincident inflammation of that membrane, by softening of the central parts of the brain, by effusions of serum into the ventricles, and in many instances by tubercular deposits in other organs. Formerly tubercular meningitis, simple acute meningitis independent of tuberculization, and simple dropsical effusion within the cavity of the cranium independent of inflammation, were confounded to- gether under the single term of acute hydrocephalus or water on the brain. It has been shown, ho'wever, that a large majority of the cases of acute hydrocephalus of authors are, in fact, cases of tubercular meningitis, and more recent researches have further shown that most of the remaining cases are in reality due to the altered condition of the blood, called uraemia, and are independent either of any material lesion of the brain or of the presence of an excess of serous fluid in its cavities. The term acute hydrocephalus ought to be therefore restricted to the single condition of sudden serous effusion in or around the brain, indepen- dent of any inflammation ; a condition which only occurs in connection with the causes of general dropsy, and especially with renal disease, and is, indeed, merely the most rare form of internal dropsy, and, as such, not to be regarded as a separate disease. A description of the symptoms of this condition will be found in our remarks upon the renal complication of scarlatina. There can be no doubt that tubercular meningitis is of rather frcrjucnt occurrence, though it is difficult to obtain statistic.*? which will enable us to form anything like an accurate idea upon this point. M. Barrier doc. cit., t. i, pp. 34, 36) states that during the periml in which his observations were carried on at the Children's Hospital in Paris, there occurred 576 medical cases of all kinds. In this number there were only 10 cases of tubercular meningitis, whilst there were 83 of pneumonia, 48 of pleurisy, 474 TUBERCULAR MENINGITIS. 24 of typhoid fever, 48 of measles, etc., etc., showing the first-named dis- ease to be much less frequent than many other aifections. We may also form some idea of its frequency in proportion to other diseases, by a ref- erence to the work of MM. Rilliet and Barthez (lere edit.), "who report 33 cases of tubercular meningitis, against somewhat over 245 of pneumonia, 174 of bronchitis, 111 of typhoid fever, 167 of measles, and 87 of scarlet fever. We are of opinion that it is not of frequent occurrence amongst the easier classes of this city, since we have met with less than 60 cases in private practice in the course of thirty-five years. We observe it more frequently, however, in our large children's hospitals, and from what we have been told by other practitioners, it seems probable that it is much more common among the destitute classes, and particularly the blacks, who crowd the southern parts of the city, and who suffer to a great extent from tubercular and scrofulous diseases. It is, however, impossible to ob- tain accurate information in regard to the frequency of the disease in this city, in comparison with other affections of the brain, from a reference to the bills of mortality. Thus during the year 1874, with a total mortality of 16,254, there were 8349 deaths among minors ; of these, 143 are recorded as from hydrocephalus (tubercular meningitis), 382 as from cephalitis, 211 as from congestion of the brain, 83 as from brain disease undefined, and 654 from convulsions. It cannot be doubted that a considerable number of cases of tubercular meningitis are included under these latter vague headings. Predisposing Causes. — MM. Eilliet and Barthez (2eme ^dit., t. iii, p. 511) state that the disease is very rare in the first year of life ; that it be- comes notably more frequent in the second year, but that it is between two and seven years of age that it occurs with the greatest frequency. After this, it diminishes, they say, rapidly from eight to ten, and especially from eleven to fifteen years of age. The influence of sex has not been determined, but it appears probable that boys are somewhat more subject to it than girls. It has been clearly shown by the observation of various writers that the disease usually attacks delicate children, and especially those born of parents who are either themselves laboring under tuberculosis, or in whose families that diathesis has existed to a greater or less extent. Of the 31 cases that have come under our own observation in which we have pre- served notes of the disease, in 20, one of the parents either had phthisis at the time, or died of it subsequently ; in 3, one or the other parent came of a tuberculous family, though in these both parents were living at the time in seeming good health ; in 4, no trace of tuberculosis could be found in the parents or in their families, and in 4 the history of the parents or of their families could not be traced out. It is not uncommon for several children in a family to die of tubercular meningitis. Under these circum- stances, it has nearly always been ascertained that the parents, or some of the immediate relations, have either died of tuberculous or scrofulous dis- ease, or shown unequivocal signs of one of those diatheses. Thus, 4 of the above-mentioned 20 cases occurred in two families, in one of which the father is since dead of phthisis, and in the other the mother has long been ailing with inactive tubercle of the lungs, and slow caries of a bone, in all ANATOMICAL LESIONS. 475 probability of tuberculous oripn. It may fc^llow other diseases, and has been observed particularly alter measles and other fevers, and after the suppression of eruptions. ]M. Barrier {op. cit.j t. ii, p. 379) explains, and we think with good show of reunion, the causes of the disposition on the part of the tubercular dia- thesis in cliildren to localize itself in the brain, as well as the dispropor- tionate violence and extent of the inflammatory action in comparison with the degree of the tubercular lesion, by the physiological conditions of the Dervous system in early life, which are those of great functional energy and nutritive activity. The affection, though much more frequent in childhood, is by no means peculiar to that period of life, and we have met with, in addition to the cases above referred to, a number of cases occurring in the adult, and presenting the same general clinical symptoms and anatomical lesions. As to the excitiufj causes, nothing positive is known. The disease has been supposed to be brought into action by falls and blows upon the head, by violent moral emotions, and by exposure to the sun. These causes, however, are all of doubtful influence. Recent pathological investigations have established the fact that, in many case, the development of true miliary tuberculosis of the cerebral membranes, or of other tissues, is connected with the previous existence of foci of cheesy degeneration, as in an enlarged lymphatic gland, a patch of unabsorbed pneumonia exudation, or otherwise. Undoubtedly such a con- dition exerts its power of infesting the general system, and leading to the development of tuberculosis, especially when, there exists a hereditary pre- disposition to that disease. In a number of instances, we have been able to trace the origin of tubercular meningitis to this cause. Anatomical Lesions. — The tubercles which constitute the essential anatomical element of the disease are very rarely found upon the free sur- face of the arachnoid, but almost invariably beneath that tissue, or in the meshes of the pia mater. They usually appear as more or less opaque gray granulations, the so-called miliary tubercles, and may generally be seen through the arachnoid, scattered about in the shape of small, rounded, or flattened bodiei?, of grayish or yellowish-gray color, and varying in size from two-fifths to four-fifths of a line. When the finger is passed over the arachnoid above them, they may be usually felt as little granular bodies. Their size, however, varies very much, and they are in some cases so small and 8o closely resemble in color the .surrounding parts, that it requires a careful search to detect them. They vary also greatly in number, being in some ca.«e8 thickly scattered over a considerable extent of the pia mater, while in other cases but two or three can be discovered on each hemi- aphere. Frequently they can be detected with most ease upon the processes of pia mater which dip down between the convolutions, so that if we fail to find any granulations upon the surface, we should always strip ofl' the pia mater and carefully examine these processes. Upon a careful examina- tion of the arrangement of the miliary tubercles, it will often be observed 476 TUBERCULAR MENINGITIS. that they are clustered about the small arterioles of the pia mater, and evidently follow in their distribution the branches of these vessels. These granulations are not found upon all portions of the brain equally in cases of tubercular meningitis. On the contrary, they are rarely pres- ent upon its convexity or lateral aspects, while they are uniformly present at the base, and especially about the optic chiasm and the fissures of Sylvius. Upon microscopic examination of one of these granulations, its tissue is seen to be composed of numerous oval cells, with a single nucleus, though there are also some larger cells mixed with these which contain several nuclei. In many instances, as has been observed by Cornil,^ Hayem,^ Bas- tian,^ and ourselves,* the tuberculous granulation will be seen to envelop a small arteriole, whose calibre is obstructed at the point of its development. There is also marked proliferation of the cells of the perivascular sheath of the vessel for a varying distance on either side of the granulation, and it is highly probable that it is from these cells that the granulation has been developed. We think it probable that some of the granulations may also be devel- oped from the cells of the connective tissue which holds together the vessels of the pia mater. These miliary tubercles precede the occurrence of the inflammatory changes in the meninges described below, and sometimes it happens, in very acute cases, that the only lesions discoverable consist of a few gray granulations scattered in the meshes of the pia mater. It is not probable, however, that they exist any great length of time without giving rise to meningitis, since they are usually found associated with more or less abun- dant inflammatory exudation, which surrounds and often conceals them. The chief seat of this inflammation, as of the tubercular deposition, is the pia mater; the arachnoid membrane being, as a general rule, affected only to a slight extent. That membrane sometimes, however, contains a very small quantity of clear or turbid serurn, in its cavity. Its surface is often dry and viscid, and in some instances its whole tissue is opaque and thickened. But it is chiefly in the pia mater that are found the evidences of severe inflammation. In order to detect these changes, it is necessary to examine the membrane not merely upon the surface of the brain, but to tear it off*, so as to bring into view the portions which dip in between the convolutions, and which often exhibit the greatest amount of morbid alteration. The inflammatory lesions vary between mere vascular injec- tion, infiltration with clear, turbid, or gelatinous liquid, and abundant formation of lymph. When the inflammation has gone beyond mere san- guine injection, it is marked by infiltration of the membrane with turbid, whitish, or sanguinolent serum, with pus, or with whitish or yellowish lymph. These products are, like the tubercular granulations which they imbed and often conceal, most abundant at the base of the brain, about 1 Arch, de Phys. Norm, et Path., 1868, p. 98. 2 Etudes sur les Diverses Formes d'Encephalite, Paris, 1869. 3 Edin. Medical Journal, 1867, p. 875. 4 Trans, of Biological and Micros. Section of Acad, of Nat. Sci. of Phila., 1869. ANATOMICAL LESIONS. 477 the peduncles of the cerebrum, the optic chiasm, and in the fissures of Sylvius ; like these granulations also, the products of the iniiammation are most marked along the track of the bloodvessels. In this respect the dis- ease differs from simple meningitis, in which the results of inflammation are usually more abundant and well marked upon the convexity than at the base. The pia mater, which, in a healthy brain, can be readily de- tached from the surface of that oriran, becomes, in cases of meninijitis, particularly in those which are violent, more or less adherent, so that in tearing it oft' portions of the ciueritious substance, which is itself softened, come with it. The proper tissue of the membrane is thickened and indu- rated, the degree of thickening depending on the amount of infiltration. After the changes in the pia mater, the most important anatomical fea- ture is efliusion within the ventricles. This was formerly thought to be the essential lesion of the disease, but recent researches have shown that it is absent in some instances which have followed in all respects the ordinary course of the malady. According to M. Barrier, effusion cannot be sup- posed to exist unless the ventricles contain from one and a half to two ounces of fluid, whilst Rilliet and Barthez assert that the normal quantity is a few grammes (about a drachm). The quantity in this disease is very variable ; sometimes there are only a few drops or a teaspoonful, while in other instances it amounts to three ounces and a half, or much more. It may be so large as greatly to distend the ventricles, rupture the soft com- missure of the thalami, and even the septum lucidum, diminish consider- ably the thickness of the hemispheres, and flatten the convolutions against each other. In such cases the effused fluid passes through the membrane of the ventricle and infiltrates into and softens the substance of the brain, 80 that the latter becomes almost of the consistence of thick cream. The characters of the fluid vary in different cases. It is white, perfectly limpid and transparent, or may be turbid, either from being secreted in that con- dition or from holding in suspension albuminous or purulent flocculi, or portions of the broken-down walls of the cavity. In some rare instances it is sero-sanguinolent. Rilliet and Barthez remark that the effusion which coincides with tubercular meningitis is different from that which accompa- nies tubercles of the substance of the brain. In the former it takes place rapidly, is turbid, exist.s in smaller quantity, and constitutes the condition formerly called acute hydrocephalus. In the latter it is secrcteJ slowly and in considerable quantity, dilates the walls of the cranium, and consti- tutes one form of chronic hydrocephalus. The brain itself presents various morbid alterations. The whole organ often seems enlarged, so that the dura mater appears distenrlcd, and when the latter is cut into, the cerebral substance protrudes in the form of a hernia. At the .same time the convolutions are observed to be pressed against each other, and the anfractuf^ities seem to have disappeared. The compression of the brain depends either upon the di^tcnrling action of the ventricular effusion, or upon sanguine turgescence of the organ. In most cases, but not in all, there is evident congestion of the cerebral sub- stance, shown by a more or less abundant dotted redness, and sometimes by a general rosy tint of the medullary, and vivid redness of the cortical 478 TUBERCULAR MENINGITIS. portion. Softening of the substance of the brain is of common occurrence in connection with the other lesions. We have already spoken of the soft- ening of the walls of the ventricles where there is much effusion, and which in some cases appears to result from the macerating influence of the fluid. In many other cases, however, microscopic examination of the softened brain-tissues shows the effects of inflammation in the presence of numerous granule-cells, free granular matter, and a disintegrated condition of the nerve-fibrils. In addition to this, as figured by Rindfleisch {Syd. Soc. edit, vol. ii, p. 312), the proper vessels of the cortical substance of the brain frequently present tubercular degeneration of their walls. The lining mem- brane of the ventricles also presents abnormal appearances in a majority of cases. In some these consist merely in injection with loss of polish and transparency ; in others, however, by viewing the surface sideways, we can detect a very finely granular condition, as though the membrane had been sprinkled with fine sand. Loschner (Aus devi Franz Joseph Kinder- spitcde, 1860, Prague), has found this appearance to be due to a prolifer- ation of the cells of the ependyma, the minute granulations consisting of rounded nucleated cells. In Dr. West's minute analysis of 61 autopsies of tubercular meningitis, also, the lining membrane of the ventricles pre- sented evidences of inflammation in a large proportion of the cases. We have also referred, very cursorily, to the softening which exists under the inflamed portions of the membranes, and which occasions adhesion of the pia mater to the brain beneath. In the latter cases the softening may be either red or white, and does not penetrate more than a line, and often less, in depth. In addition to the changes already described tubercles of the brain itself may be occasionally met with, having no connection with the meninges. These are found in various parts of the organ, and differ greatly in size, varying generally between that of a millet-seed and hazel-nut, but reaching sometimes the volume of a pigeon's or hen's egg, or even that of half the fist. We have but few words to say in regard to the lesions of other organs. It is undoubtedly true that in the vast majority of cases tubercles are found in other parts of the body. Of all the cases of tubercular disease observed ^y Rilliet and Barthez, amounting to 312, in only one was the deposit •confined to the meninges (op. ciL, lere edit., t. iii, note, p. 49). M. Valleix (op. cit, t. ix, pp. 196, 197), states, that in all the cases, without exception, of tuberculosis of the meninges in adults, tubercles exist also in the lungs, and that the same is true, in the vast majority of cases, in regard to chil- dren. The organs in which the deposit is most apt to exist are the bron- chial glands, lungs, mesenteric glands, pleura, and peritoneum. Another very frequent lesion is softening of the stomach. This may affect only the mucous or all the coats, so that a slight degree of force will suffice to tear the organ. Dr. Gerhard (Am. Jour. Med. Sei., vol. xiv, 1834) states, that lesions of the stomach existed in six of the ten cases detailed by him, and in four-fifths of others not detailed. Before quitting this subject, we would call the attention of the reader to the fact mentioned by M. Valleix {op. cit, t. ix, p. 214) that all the i| SYMPTOMS. 479 symptoms about to be described as constituting the disease under consider- ation, with the exception of paralysis, may depend on simple tuberculosis of the meninges. Several cases have been cited, in fact, in which the only lesion found after death consisted of granulations in the pia mater. No traces of inflammation were observed. It is clear, therefore, that the evi- dences of the disease, or symptoms, depend not merely on inflammation caused by the tubercular deposits, but on the presence of that morbid pro- duction. The paralysis, which is one of the important symptoms, depends partly upon the inflammatory changes in the brain-tissue itself, and partly upon the pressure exerted on the structures at the base of the brain by the exudation which forms there. Symptoms; Course; Duration. — The disease has been divided by authors into different stages, founded on the predominance of certain symptoms at particular periods of its course. These divisions are all imperfect and unsatisfactory, because the disease is in fact a continuous one, and for this reason some writers have avoided attempting any classification of the symptoms. We can, however, obtain a more faithful picture of the disorder by adopting the division made by M. Valleix, which, though arbitrary and imperfect, because of the want of a natural line of demarcation, seems warranted by the very great diflJer- ences in the character of the symptoms at an early and late period of the afllection. We shall therefore describe first the invasion of the malady, and then two stages or periods of the symptoms after the disease is con- firmed. The invasion of the disease may be either insidious or sudden. In a large majority of the cases, the onset is preceded by a well-marked pro- dromic period. The length of this period varies greatly in different sub- jects. Its duration is stated by ^DI. Rilliet and Barthez to be, as a general rule, between fifteen days and three months, scarcely ever less, and rarely more. During this period, the symptoms presented by the child are those which are ur^ually held to be indicative of a failure in the general health. The nutritive functions especially show disorder. The appetite diminishes, or becomes capricious, there are alternations of constipation and diarrhoea, the boearances of optic neuritis often become visible. These lesions are indeed more frequent in this disease than in simple meningitis, since the inflammation and resulting exudation are more apt here to involve the base of the brain, and cause a greater degree of obstruction to the circula- tion. Enlarged experience has convinced us of the high value of these retinal lesions in establishing the difl^erential diagnosis of tubercular meningitis. It is true that they cannot be regarded as pathognomonic of the existence of this disease, and are therefore only valuable as confirmator3'of the gen- eral symptoms, still in certain cases the development of the ocular lesions before the appearance of the more characteristic symptoms enable the dixig- na«is to be made at an earlier date than would be possible without oph- thalmoscopic examination ; while in others where the general symptoms leave it for the time doubtful whether the case is one of typhoid fever or of tubercular meningitis, the use of the ophthalmoscope renders invalua- ble aid. During the first stage the coloration of the face ought to be noticed. It is generally paler than natural, though from time to time a sudden flush of redness may be seen to pass over it. The condition of the sens&s is natural, except that the acuteness of the eye, ear, and sometimes that of touch, are exalted, so that the child avoids the light, starts at sudden or loud sounds, and cries when it is touched or moved. The rejtjnration becf)mes unequal and irregular, and is interrupted by sighing or yawning. Cont'uhionji rarely occur in the first stage. MM. Rilliet and Barthez conclude that meningitis without complication of tuberculous disease of the cerebral substance, never begins with convulsions. In one of the cases that came under our charge, a severe and prolonged convulsive seizure did occur, however, on the very first day of the attack of the disease. The ruhject of the case was a boy between four and five years old. The death took place on the eighteenth day. and the autopsy showed no tubercular 484 TUBERCULAR MENINGITIS. disease of the cerebral substance. It is proper to state, however, that the child had eateu on the morning of the day that he was attacked, a most unwholesome meal, and it is very possible, as we in fact supposed at the time, that the convulsions were caused by the presence in the stomach of undigested food. When they do occur in tubercular meningitis, they may be limited to the extremities, upper lip, eyeballs, or they may be general. Sometimes the child dies in a convulsion. They are generally much less important as a symptom, according to M. Valleix, than in simple acute meningitis. The tongue remains moist ; the appetite is not entirely lost ; thirst is moderate ; the constipation continues, unless removed by treatment ; the abdomen becomes retracted, so that its walls approach closely to the spinal column, and allow us to feel the pulsations of the aorta without using more than very slight pressure. The latter symptom comes on gradually, and is generally well marked by the sixth day or a little later. MM. Rilliet and Barthez regard it as a very important sign, and state that they have observed it almost exclusively in cerebral affections. They think it depends not upon contraction of the abdominal muscles, but upon re- traction of the intestines. We can corroborate by our own experience, the evidence of the above authorities as to the value of this symptom. It has been very marked in most of the cases that we have seen. The state of the circulation is of the utmost importance in forming the diagnosis. So true indeed is this, that Dr. Whytt, of Edinburgh, whose description of acute hydrocephalus, published in 1768, has been most highly commended by all recent -writers as a singular instance of accurate observation, makes three stages of the disease, each of which is character- ized by the state of the pulse. In the early part of the attack the pulse is accelerated, rising to 110, 120, or, according to Whytt, in a few^ cases to 130 or even 140. At the same time it is neither full nor tense, as a gen- eral rule, but rather soft and compressible. This condition of the pulse changes, as we shall find, in the middle period of the disease, and again shortly before the fatal termination. The heat of the skin is usually moderate and sometimes quite natural, at this time, as might be supposed from the state of the circulation. Frequently the temperature will not during this period exceed 100° to 100.5°, though occasionally marked and rapid changes in it are observed. It is especially to be noted that the temperature does not follow the regular mode of development so char- acteristic of typhoid fever. Second stage. — This stage begins about the time the more marked ner- vous symptoms show themselves. The headache generally subsides or ceases at the beginning of this period and gives place to delirium. This occurs usually somewhere between the sixth and twelfth days. The de- lirium which occurs has been generally supposed to be always mild and calm. MM. Rilliet and Barthez state, however, that in one-third of their cases it was intense, and accompanied with cries, agitation, and frequent changes of position. In most of the cases, however, it is mild, and is mani- fested in older children by their muttering unintelligible words, by in- attention to what is going on around them, by an expression of wildness I SYMPTOMS OF THE SECOND STAGE. 485 and astonishment, and by their giving hesitating answers to questions. In chiklren under two years of age there is no proper delirium. There is, however, an analogous condition, which is characterized by disorder of the two faculties of attention and perception. The delirium seldom lasts more than two or three days, and generally alternates with somnolence, so that the child is either dozing and sleeping, talking in its sleep, or fre- quently waking with loud cries, and restlessness. The general sensibilityf which may have been exaggerated in the early period of the disease, is diminished in the early part of the second stage, or about the seventh day, and completely abolished towards the end. The face in the second stage is almost always pale, or pale and flushed alternately. During this stage, and especially during the latter part of it, it is very common to see sud- den alterations in the color of the face. Sometimes without any apparent cause, but more frequently from disturbances of any kind, as from pain, or from external influences acting upon the child, such as moving it, or the administration of food or medicine, the face becomes suffused of a more or less deep pinkish or scarlet tint, the color beginning faintly at first and gradually deei)ening and expanding until it covers the whole face and forehead, and then as gradually fading away. It is during this stage also that another symptom, which we have often noticed, and to which M. Trousseau has called attention, may usually be observed. M. Trousseau refers to it as a red line or spot remaining upon the skin of the forehead or abdomen when the finger has been drawn across it, and has given to it the name of ''tache meningitlque," or "tache cercbrale." We had often re- marked, before knowing that M. Trousseau had drawn attention to this phenomenon, that the slightest pressure with the finger on any part of the face or forehead, caused the appearance at the point of pressure, of a spot of a j)eculiar pink or rose color, which, like the flush above referred to, began faintly, became more or less deep in tint, remained a few moments, and then as gradually faded away. This symptom is undoubtedly due to the extreme modification of the innervation of the minute bloodvessels of the skin. There is no doubt that it is nearly always present in cases of tubercular meningitis, and thus may be said to possess a diagnostic impor- tance. We have, however, so frequently met with the same phenomenon in cases of typhoid fever, and more rarely in cerebral pneumonia, that we must warn against its being regarded as a pathognomonic symptom of tubercular meningitis. Occasionally contractions pass over the features, giving rise to grimaces, after which the countenance resumes its expres- sion of indifference and stupor. The eyelids are generally only partially closed, and between them the globes of the eyes can be seen to oscillate and move in various directions, as though by some automatic force. A.S the case progresses, the nervous symptoms become more and more marked ; somnolence gradually deepens into coma ; the delirium becomes less and less frequent ; and the child no longer observes what is going on, nor answers questions. As the somnolence and coma increase, various lesions of motility make their appearance, consisting, in order of frequency, of paralysis, which is generally partial ; contraction with rigidity of the limbs; stiffness of the muscles of the back of the neck, causing retraction 486 TUBERCULAR MENINGITIS. of the head ; stiffness of the trunk ; spasmodic closure of the jaws ; car- phologia ; subsultus tendinum, and convulsions. The paralysis is almost always partial and of very limited extent, affecting, for instance, the jaw, the orbicularis muscles of the eyelids, the levator of the upper eyelid, the tongue, or one side of the face. It is very rare to see one of the limbs paralyzed. Contraction with rigidity of the muscles is an important symptom, but is not always present. When it exists it generally appears at an advanced period of the attack, commonly between the seventh and thirteenth days, and is usually partial. It may affect either the extremities, back of the neck, trunk, or inferior maxilla. It is seldom permanent, but after lasting one or two days, disappears, to reappear at a later period. The carphologia, subsultus, and chewing motion of the under jaw generally occur only a few days before death, and lasts but a few days. The decubitus, in the early part of the second stage, is generally lateral, with the thighs flexed upon the pelvis, the legs upon the thighs, the arms applied against the thorax, the elbows bent, and the hands placed in front, the decubitus called by the French " en chien de fusil,'' or gun-hammer. At this time the child will still occasionally move its position with facility, showing that strength is not by any means entirely lost. At a still later period the decubitus is dorsal. In the latter part of the first and early part of the second stage, the pulse, which we have ascertained to be ac- celerated at the invasion, falls to the natural standard, or becomes slow, and at the same time irregular. From 110 or 120, as it was, it now sinks to 90, 80, 60, or, as happened in one instance to M. Guersant, to 48 in the minute. Coincidently with this change it almost always becomes irregular. The irregularity affects both its force and frequency, so that a strong pulsa- tion may be followed by a feeble one, or the rhythm may be regularly or irregularly intermittent. The irregularity varies greatly at different pe- riods of the day, or within short spaces of time, so that the pulse is found to be very slow at one moment and much more frequent the next. On this account it is necessary to examine it on different occasions. Slowness and irregularity of the circulation are important as a means of diagnosis, since it has very rarely been met with as a permanent condition, except in the tuberculo-inflammatory affections of the brain and its appendages. To- wards the termination of the disease, generally speaking two or three days before death, the pulse rises again in frequency, so that it counts at first 112 or 120, and gradually increases to 140, 160, or even 200 the day be- fore, or that on which death takes place. Simultaneously with this change it also becomes extremely feeble and small, and often ceases to be percep- tible at the wrist on the last day. The respiratory movements also show marked irregularities. During the early stage of the disease they are frequent, though we think rarely so much so as to preserve the normal ratio to the pulse. But during the stage we are now considering, the breathing becomes unequal and irregu- lar, and deep sighing respirations alternate with quick superficial ones. We have called attention lately^ to a very peculiar modification of respira- 1 Remarks on Cheyne-Stokes Respiration, especially in connection with tuber- cular meningitis, by William Pepper, Phila. Med. Times, May 27th, 1876. I DIAGNOSIS. 487 tion, which has been frequently observed by ourselves and others in the exudative stage of tubercular meningitis. The following description may serve to give an idea of its general character : " The breathing is from time to time interrupted by periods of apncea of varying length (five to thirty secondsX between which occur a series of respiratory acts, which begin by very feeble and barely perceptible movements, and gradually grow fuller and stronger until they reach a climax, when they occasionally end by a long- drawn sigh, or more commonly, pass through a descending scale of move- ments, each growing more and more feeble until they end with barely per- ceptible respirations, such as marked the beginning of the series. This period of respiration, which also occupies from five to thirty seconds, is followed by a second period of complete apna?a, which is in turn succeeded by a group of respirations similar to the first." {loc. cit.) This disturbance of respiration, together with the interference with the heart's action, depend upon the pressure of the exudation upon the pneumogastric nerves; and, as they are not found in the affections which may simulate tubercular meningitis, must be regarded as possessing considerable diagnostic value. The heat of skin, which has fallen with the reduction in the frequency of the pulse, generally increases with its acceleration. This is not invariable, howes'er, since in some cases the temperature remains but moderately ele- vated, about 101° or 102^, until death ; and in others an algid condition precedes death, in which the temperature falls as low as 79.4°. {Reynolds's Syst. of Medicine, vol. ii, p. 379, art. Tuberc. Meningitis.) On the other hand, in some cases the temperature increases irregularly as the fatal re- sult approaches, and may attain an extreme height. Thus Roger (op. cit., p. 323) has observed on the day of death in an attack of tubercular men- ingitis, a temperature of 108.5° F. During the last few days the surface is often covered with an abundant perspiration; the tongue becomes dry; the teeth and gums are fuliginous; the exhaustion increases; the respira- tion becomes stertorous, unequal, difficult, and anxious, and at the very last attended with groat dyspncea ; and the urine and stools are discharged involuntarily. Death finally occurs in this condition, or is hastened by an attack of convulsions. In some cases it is most lingering. In one instance we expected the death of a young child in this disease every day for eight in succession. The duration of tubercular meningitis is exceedingly variable in different cases. As a general rule it lasts between eleven and twenty days, though it may continue a considerably longer time. Riliiet and Barthez have never known death to occur before the seventh day. Di.\GNr>tis. — The diseases with which tuberculosis of the meninges is most likely to be confounded are simple meningitis and typhoid fever. It might also be confounded, though this is much less probable, with the cerebral symptoms which complicate the exanthemata and some local dis- eases, especially pneumonia, and to which symptoms, as a group, M. Bar- rier has applied the term pseudo-meningitis. The diagnosis between tubercular and simple meningitis will be best understfX)d from the following synoptical table, ba^ed upon the one con- tained in the last edition of the work of MM. Killiet and Barthez. 488 TUBERCULAR MENINGITIS. SIMPLE ACUTE MENINGITIS. I. The subjects of acute simple menin- gitis are usually robust and well-devel- oped, and present no trace of either in- ternal or external tubercular disease. Born of healthy parents. II. The disease may prevail epidemi- cally. III. Condition prior to invasion. — The disease begins in the midst of the most blooming health, or, if secondary, it oc- curs in the course of, or during the con- valescence from, some acute non- tubercu- lar disease, or it follows an external cause. lY. Mode of invasion. — Violent con- vulsions attended with intense febrile movement, and with very hurried respi- ration in young infants; or very acute frontal headache, accompanied by fever, bilious vomiting, and towards the end of the first, or in the course of the second day, at the latest, excessive restlessness, preceded or not by somnolence ; most violent delirium ; formidable ataxia. Y. Symptoms. — Very intense headache, ofts^ma^e vomiting, morfera^e constipation, violent fever, high delirium. YI. From the beginning, the aspect of a grave disease of ataxic form. YII. Course rapid, aggravation pro- gressive and continuous; convulsion after convulsion, or else violent delirium, ex- treme agitation, violent fever, etc. Duration. — Disease of short duration, ending sometimes in 24 or 36 hours, but lasting generally from three to six days, and seldom more. REGULAR TUBERCULAR MENINGITIS. I. Subjects of tubercular meningitis delicate, puny, exhibiting often precoci- ous intelligence and sensibility. Have sometimes had, in infancy, enlarged glands or chronic cutaneous eruptions ; the parents, or brothers and sisters, often present the signs of tubercular disease. II. Disease always sporadic. III. Condition prior to invasion. — For some months or weeks the patients grow languid, lose their strength, become pale, emaciate; their temper changes, they are dull, they lose appetite, the digestion is deranged, etc. Absence of prodromie symptoms is rare. lY. Mode of invasio7i. — Never with convulsions at the onset ; the change from the prodromie to the acute stage sometimes imperceptible. It takes place by a progressive increase of the symptoms before mentioned, and by the setting in of headache ; in other cases, the acute stage is better marked by headache, vomiting, and constipation ; generally, the intelligence remains clear ; no ataxia. In the rare cases in which there is ataxia at the onset of the acute symptoms, the prodromie stage, above described, has been observable, or the meningitis has occurred in the course of advanced phthis- is. In cases in which no prodromes exist, the meningitis begins with vomit- ing, constipation, moderate headache, and slight febrile movement ; ataxia, if it is to appear, occurs later, and a mis- take is impossible. Y. Symptoms. — 'N ot very intense head- ache, vomiting less frequent, very obsti- nate constipation, very moderate fever, slowness and irregularity of the pulse, delirium usually mild. V I. Invasion insidious, with the aspect of a mild disease. YII. Course slow, preservation of the intelligence to an advanced period, fever slight, and some slowness and irregularity of the pulse, sighing, changing color of the face, eye dull or ecstatic, etc. Duration. — Always much longer in the regular form. DIAGNOSIS. 489 We will remark in regard to this table, which is, in most respects, admir- able, that we have never met with more intense and persistent headache than we have in some cases of the disease nnder consideration. In some of our cases this has been a most prominent and striking symptom. Before quitting the subject of the diagnosis of these two affections, it is desirable to state for the information of the reader, that some of the high- est authorities acknowledge it to be sometimes nearly or quite impossible to distinguish between them. This is the expressed opinion of ]\IM. Guer- sant, Rufz, Barrier, and Valleix. From typhoid fever, tubercular meningitis is to be distinguished by the antecedent history of the patient, which often reveals the existence of a tubercular diathesis in the latter affection ; by the symptoms of the inva- sion, which in meningitis consist of severe and persistent headache, frequent vomiting, and constipation, whilst in typhoid fever the headache is less severe and less persistent, the vomiting much less frequent, and the consti- pation replaced by diarrhoea, or at least by an unusual susceptibility to the action of laxatives ; by the diflfereut characters of the febrile move- ment, which, in typhoid fever, is more marked, and attended with a fre- quent, full, and regular pulse, while in meningitis it is less marked and is accompanied after a few days by slowness and irregularity of the pulse, and by irregularity of respiration ; lastly, in meningitis, the constipation is usually marked, the abdomen is retracted, and there are various impor- tant and characteristic lesions of motility, and the special senses ; in ty- phoid fever there is diarrhoea, the abdomen is distended and meteoric, there are characteristic rose-colored spots, whilst there are no considerable lesions, either of motility, or of the special senses. Much assistance in the diag- nosis can also be obtained by a careful study of the course and changes of the temperature in the two diseases. In tubercular meningitis, instead of the gradual progress in development, with moderate evening exacerbations, which is so characteristic of typhoid fever, the temperature presents great and irregular variations; it is specially marked by a period of reduction, even to 97° or 96^ (Roger), corresponding to the middle stage, and then by a final rise, which may continue increasing until the last day of life, or may be replaced by an algid state, with great lowering of the heat of the .surface. In doubtful cases, the use of the ophthalmoscope will often be of great value. We have already mentioned the retinal changes which are frequently seen in tubercular meningitis, whilst in typhoid fever no lesions will be detected. Although the above general remarks apply to the majority of cases, it must not be imagined, however, that the diagnosis between the two affec- tions is always ea«y or even possible in the early stages. This is largely due to the fact that the typhoid fever of children presents as many irregu- larities and departures from the typical course which it more frequently follows in the adult. Thus it is not very rare to have epistaxis, diarrh(i*a, and even the peculiar eruption ab.sent in typhoid fever in young children, and if, when this occurs, the tache clribrale be developed by drawing the nail over the skin, it is evident that it will be difficult to decide whether the irregular fever, with cerebral disturbance, be the result of the one or the 490 TUBERCULAR MENINGITIS. other of these affections. The symptoms of most value in such obscure cases, are irregularity and slowing of the pulse, with unequal and irregu- lar respirations ; and strabismus, diplopia, or changes in the optic nerves or retina. When these appear, as they usually do in the second stage of tubercular meningitis, the diagnosis can scarcely possess any further diffi- culty. It is unnecessary to do more than allude to the possibility of confound- ing the disease with the exanthemata, or with local diseases accompanied by cerebral symptoms, and particularly with pneumonia in very young children. The resemblance of pneumonia of the apex of the lung in the early stage to tubercular meningitis, has been referred to in the article on pneumonia. The diagnosis must be made by careful consideration of the symptoms peculiar to each, and in the case of a local disease, by accurate physical examination of all the important organs of the body. Occasionally, also, cases are met with where, in connection with gastro-- hepatic disturbance, there is probably some cerebral congestion, and which may simulate the early stage of tubercular meningitis. For instance, we were called to see a boy eight years old who had been suffering for two weeks with violent frontal headache, frequent vomiting, constipation, slight fever, and somnolence. We feared that the case might prove to be one of tubercular meningitis. However, a large dose of calomel, follow^ed by castor oil and free leeching to the temples, relieved him in two days per- fectly, and he has remained well ever since, though this was a number of years ago. Prognosis. — M. Barrier, in speaking of the prognosis of this affection, says : " The gravity of tubercular meningitis is not surpassed by that of any other disease. Thoracic and abdominal phthisis, though almost con- stantly fatal, pursue a slower course, and last a longer time. We may even allow as proved, that in a small number of cases, they are suscepti- ble of cure, or may remain stationary for months or years. Unfortunately it is not so in regard to tubercular meningitis." MM. Rilliet and Barthez, in their second edition, do not express the same entire hopelessness as to recovery from the disease, that they did in their first. They say, amongst other conclusions (op. cit., t. iii, p. 510), that there are on record incon- testable examples of the complete disappearance of the symptoms, but remark, that such cures have occurred in the first stage, or in the first half of the second stage, after seven or eight days of sickness, rarely later, and after alternations of amelioration and aggravation. They state also that, in excessively rare instances, a return to health has been obtained even in the course of the third stage, after many weeks of illness. They are of opinion that the disease often returns and proves fatal in from one to five years and a half after the recovery. The cause of the relapse is to be found in the fact that the local lesion remains, and that the diathesis has not been eradicated. M. Valleix is of opinion that after having acquired the conviction that a case is really one of tuberculosis of the meninges, we should regard the patient as lost; "for the exception that I have men- tioned (a case belonging to M. Billiet, then unpublished), even did no doubt as to the exactness of the diagnosis remain, ought not, standing by t PROGNOSIS. 491 itself, to impart to us auy real security." M. Guersaut (Did. de Med. t. xix, p. 403\ seems to think it possible that the disease may sometimes ter- minate tavorably in the very early stage, but adds that " such cases are always more or less doubtful, and seem to us to belong rather, for the most part, to simple meningitis." During the second period (^that of slowness and irregularity of the pulse\ he has scarcely seen one child in a hundred survive, and even then they perished at a later period of the disease, or of phthisis pulmoualis. Of those arrived at the third stage (^marked by re- newed frequency of the pulse, coma, and lesions of motility and sensibility), he has never seen any recovery, even momentarily. Dr. George B. Wood (Prac. of Med., vol. ii, p. 365), states that he has " never seen a well-marked case of tuberculous meningitis end favorably." Dr. Robert Whytt ( Works of JRobcrt Whytt, published by his son, quarto, Edinburgh, 1768, p. 745), says : " I freely own, that I have never been so lucky as to cure one patient who had those symptoms which with certainty denote this disease ; and I suspect that those who imagine they have been more successful have mistaken another distemper for this." In the quarterly abstract furnished by Dr. A. Wiltshire in the Brit, and Foreign Med.-Chir. Bev., for April, 1876, at page 465, it is stated that Dr. Clifford Allbut has known of two cases of recovery from tubercular men- ingitis, in which the diagnosis made with the aid of the ophthalmoscope was verified some years later at the autopsies of the patients. And at the same place is quoted another case by Dr. Rinteln (Berl. Klin. Wochnschr., No. 21, 1876, p. 287), where recovery occurred after all the recognized symptoms of tubercular meningitis had been present, and where this diag- nosis with a consequent fatal prognosis was made by all the physicians who saw the patient. Our own experience coincides with the mass of evidence given above as to the almost hopeless fatality of the disease. All the undoubted cases that we have seen have proved fatal. A case, however, came under our observation, in 1850, which might, perhaps, be classed as a recovery from tuberculosis of the meninges, though not from tubercular meningitis, since there were no well-marked signs of inflammation of the membranes of the brain, though there was every reason to suppose that the symptoms depended on the deposit of tubercles in those membranes. The case was as follows : A girl botwcen four and five years old, whoso mother was then hiboring undor tubercular disease of the summit of one lung (which has since proved fntnl), and who had lost several brothers and sisters with consumption, had had nearly con- stant cough during the winter of 1849-50, During the months of April, May, and June, of 1850, she had exhibited all the signs of induration over the upper two or three inches of the right lung, before and behind, — marked dulness on percussion and bronchial respiration, but no rale. For these symptoms she had been treated with cod-liver oil, iodide of iron, opium for the coutrh, and good diet. From the middle of June she complained frequently of headache, had occasional vomiting without any gastric derangement, and was much disposed to be constipated. iSho bad no appetite, grew thin, and was very languid, listless, and weak. On the 27th of June the mother thought she observed some squinting. On the 2fUh we found that the child had lodt all power over the right muscles of the right eye, so that 492 TUBERCULAR MENINGITIS. when she looked towards the right hand, she squinted dreadfully. She was dull and heavy, and vomited two or three times a da}'. The pulse was 62 to 75 or 80 ; there was a slight hitch in its beat, but no decided intermittence. The child said that she sometimes saw two things instead of one From this time until July 7th, she con- tinued in much the same state. On the first July, finding that the eyes were quite yellow, and that the child was constipated, we ordered half a grain of calomel morn- ing and evening. After three doses she was purged. This relieved her a good deal, there being less headache, more appetite, and an improvement in color afterwards. But still there was ever}' day some vomiting, complaints of headache, and more or less listlessness and heaviness in the morning, while in the afternoon she would brighten up and seem better. The intelligence continued perfect ; the temper was rather irritable, but not very much so. The treatment after the 29th of June was calomel, given as above stated, from time to time, to keep the bowels soluble; cod-liver oil, a teaspoonful twice or three times a day, as the child would take it; mustard foot-baths ever}' day or two ; and meat, bread, and ice cream for diet. On the 5th July we ordered half a grain of iodide of potassium, three times a day, in addition to the oil. On the 11th Jul}', she was taken, by our direction, to the seaside, where the use of the oil and of the iodide of potassium was to be continued. On the 7th of August she was brought back from the seaside, and we saw her on the 8th. We were astonished to see how well she looked. The strabismus had en- tirely disappeared. We were told that it had begun to diminish two weeks after her arrival at the sea, and had then gradually disappeared. She had grown some- what, though not very much, fatter. Her whole appearance was very much im- proved. The coloration of the body, the expression of the face, were both much better; she was much stronger, running about, in fact, all day ; she ate well, and with the exception of a little cough, and a rather delicate frame, looked very well. Except one day, she was well all the time at the seashore. On that day she was feverish, had much headache and vomiting, and laid abed. The cod-liver oil and iodide of potassium were ordered to be continued. The child remained pretty well throughout the winter of 1850-51. There was no return of either the strabismus or the vomiting. She was thin, pale and delicate- looking, coughed occasionally, and the solidification of the summit of the lung con- tinued, but she was not confined to the house. Late in the winter she went south with her mother, and there, after having become quite stout and healthy during their travels, died of dysentery in April or May. The mother died in 1852, of phthisis, with large cavities in both lungs. Another case, in which the early symptoms of the disease were well marked, and in which recovery took place, will be detailed in the remarks on prophylactic treatment. In the following case, also, the diagnosis was of tubercular meningitis in the early stage : The patient was a boy eight years of age, whose father had died a few years be- fore of phthisis, the younger brother died of tuberculous meningitis, and the sister of hooping-cough, with the lungs filled with miliary tubercles, as ascertained by a post-mortem examination. The child, after having had fair health previously, was seized, towards the end of March, 1865, with frontal headache, very slight fever, occasional vomiting, constipation, hesitating pulse, languor, willingness to lie abed, and a tendency to somnolence. He was treated with rest, milk and beef tea in alternate doses, and mustard foot-baths morning and evening ; the bowels were kept moderately open, and he took tincture of the chloride of iron in combi- nation with dilute acetic acid and solution of the acetate of ammonia every three PROGNOSIS. 493 hours. Under this treatment he improved, and in ten days had quite recovered. His mother removed from this city to Washington, where he died on the 30th of June of the same year, after an illness of twenty-one days, of what was called water on the brain. In another ca^e to which one of us was called in consultation, a boy whose mother had died a few years before of diabetes mellitus, and whose father's family was tuberculous, presented a series of symptoms which we could explain only as the result of slow thickening of the membranes at the base of the brain, in all probability the result of a tubercular deposit. This child had, for several weeks, violent frontal headache, constipation, loss of flesh, lassitude, a peculiar one-sided or lateral gait in walking, strabismus, and great impairment of vision, so that he could see a small ob- ject only by bringing it almost in contact with the face. There was scarcely any disturbance of the circulation, and only slight febrile heat at night. He was treated at first with rest, nutritious food, minute doses of bichloride of mercury in combination with iodide of potassium, three times a day, and then when he began to improve, with tincture of the chloride of iron and cod-liver oil for a long period. He finally recovered his health, grew stout and strong, but has remained ever since so blind that he reads with great difficulty, but manages to pick his way through a room or the street, with only occasional stumbling. The illness occurred several yeai-s ago, and he is still living in good general health at this time. Are we then to abandon all hope of deriving any good from medical means in the disease under consideration ? To this most serious question we ought clearly to respond in the negative. The grounds for entertaining hope are first, the evidence of M. Guersant that he has seen cases which appeared to be tubercular meningitis recover in the first stage. Let it be supposed, even, that they were cases of simple inflammation. But they were undistinguishable from the tubercular disease by one of the most celebrated of modern physicians. Surely, therefore, it may happen to men of inferior skill to meet with the same difficulty, or if we may so speak, to make the same mistake, if a mistake was made. It is said by M. Valleix that M. Rufz, after determining at the autopsy, that a case which he had witnessed was one of simple meningitis, asserted that it would have been impossible to distinguish it from the tubercular disease during life. Again, M. Rilliet has, according to M. Valleix, seen one case of recovery from what he believed to be the tubercular affection, and MM. Rilliet and Barthez, in their second edition, a.s above quoted, a.«sert its occasional cura- bility. To these authorities must be added the valuable evidence of Dr. CliffVjrd Allbutt, already quoted ; and it would be possible to cite still further instances, if it were necessary. We know of the occurrence of a case in this city, under the charge of one of our friends, than whom we be- lieve no one can be more competent to make a correct diagnosis, in which, after the child had presented in regular order all the early symptoms of the di.*ease, and had arrived at the last and most hopeless stage, f)erfect recovery, to his utter amazement, gradually took place. This child, when our friend last heard of it, three months afterwards, was in all respects stroDg and hearty. No doubt the probabilities are that the case was one 494 TUBERCULAR MENINGITIS. of simple meningitis, but who could have known this at the time ; and should it not deter us from abandoning all hope, and, as a consequence, all active treatment, when we seem to have under our hands a case of this dreadful malady? Our own cases, given above, also go to prove that the disease is sometimes curable in its early stages. It is important, in tubercular meningitis, to avoid making a positive prognosis as to the period at which death will occur, notwithstanding that the patient may present every mark of an immediately fatal termination. We have already adverted slightly to this subject. On one occasion we expected the death of a patient with this malady for three days in succes- sion, and on another, we visited a child for a week, during every day of which it seemed as though existence could not endure until the next. It had during this time profound coma, subsultus tendinum, and enlarged pupils; the eyelids were half open, the eyes constantly oscillating, or else rigidly distorted, and both corneas dimmed and slightly eroded, from con- stant exposure to air and light. Convulsions occurred from time to time, the pulse w^as variable, and at times exceedingly frequent, and indeed everything threatened a speedy termination. MM. Killiet and Barthez say, " Often have we inscribed upon our notes death imminent, and been astonished the next day to find still alive, children to whom we had allowed scarcely two hours of life." The symptoms which most positively indicate the near approach of death are, livid color of the face, sweats occurring about the face, glassy expression of the eye, dry and incrusted nostrils, and especially a very rapid pulse, and the various nervous symptoms mentioned, as carphologia, subsultus tendinum, and general convulsions. Treatment. — In the early editions of this work we took the ground that it was proper in the early stage of the disease to employ bloodletting. Further experience and knowledge compel us to retract this opinion. We believe now^, that abstraction of blood should not be resorted to unless when the diagnosis between this disease and simple meningitis is very un- certain. Where there are no marked signs of active inflammation, where, from the family history, from the absence of marked fever, and the peculiar state of the pulse, we have every reason to believe that the low-typed in- flammation present is the result of the presence of tubercle, we deem it safest to avoid all lowering measures. The case is so critical, so almost hopeless from its very nature, that we prefer a treatment based on the theory of promoting a retrogression of the tuberculous deposit. The only measures which, in an experience of over thirty years, we have found to delay and, in the cases referred to in the article on prognosis, to cure the disease in part, have been the following : quiet of body and mind, obtained by means of rest in or on the bed, in a pleasant room, with attendants who know how to soothe and still the child. We always insist upon a nutri- tious diet: and one consisting mainly of milk and cream, or the two mixed, with beef tea, bread and butter, if the patient will take it, or milk- toast, in moderate quantities every three or four hours, a soft-boiled egg, or the yelk of a hard-boiled egg, once or twice a day, is what we usually endeavor to get the patient to take. A mustard foot-bath two or three II TREATMENT. 495 times a dav, is always safe, and we think useful and tranquillizing. The bowels should be moved gently once a day, or every two days, by means of an enema or some sim})le laxative, as simple syrup of rhubarb. Active purgation we have found of no use. As remedies, we prefer the following : R.— Tr. Forri Chlorid., f^j. Acid. Acot. Dil., f^j. Liq. Amnion. Acetat., ..... t^ij. Syrup. Simp., . . . . . , . f^}. Aqua?, ^S'jss. — M. A teaspoonful at five years of age. every three or four hours. In connection with this, we give half a teaspoonful of cod-liver oil in emulsion three times a day. Calomel we have abandoned of late years entirely, as it has utterly failed in our hands to do any good. Iodine has been very much employed as a remedy in this disease, both in the forms of Lugol's solution and iodide of potassium. Perhaps the strongest argument which exists in its favor is the benefit which often fol- lows its employment in other scrofulous and tuberculous diseases; though there are several cases in which it is asserted to have been successfully u.sed in tubercular meningitis. Iodine itself is comparatively little used. M. Rilliet {op. cit., t. iii, p. 308, 1847) states that it has entirely failed in his hands in the tubercular form of the disease; the only influence which it seemed to exert was to cause the immediate suspension of the coma. This was its efl^ect also in a case in which we employed it, that of a girl seven years old, to whom we gave two drops of Lugol's solution three times a day, from the thirteenth to the twentieth day, when she died. The day before her death she seemed to improve somewhat, and we were in hopes that it had been of some service. The amelioration did not con- tinue, however, and we are now disposed to believe that the change was one of those which often take place naturally in the disease. Iodide of potassium was recommended more than twenty years ago by Roeser {HufelatuVs Journal, April, 1840), as a remedy of special power in this disea.se. It has since then been very widely employed, and there are quite a number of cases in which it is asserted that its administration ha.s been followed by successful results. Dr. 'WesKop.cit., 4th Amer. ed., p. 97) thinks that he has seen good from its employment, "and that in one instance of what seemed to be ad- vanced tubercular liydrocephalus, under the care of my friend and former colleague, Dr. Jenner, recovery took place under its employment." Niemeyer (op. cit., vol. ii, p. 218 j speaks as follows of its use : "On the strength of two successful cases, opposed, it is true, by a large number of unsuccessful ones, I recommend large doses of iodide of potassium, con- tinuod for a long time." Dr. J. Lewis Smith (op. rit, p. 145; al.«o recommends its use through- out the entire disease, beginning as early as possible in the premonitory period. Successful cases of its administratioD are also reported by Drs. Bourrose 496 TUBERCULAR MENINGITIS. de Lafore, Coldstream {Edin. Med. Jour., Dec. 1859), and Carson (Med. Times and Gaz., March 5th, 1857). We have ourselves frequently administered it, either alone or in combi- nation with small doses of bichloride of mercury, but have not yet been fortunate enough to arrest the progress of any case when once the second stage has been fully developed. In a few cases, however, the use of the following combination : R. — Potass. lodidi, ^j. Hydrarg. Chloridi Corrosivi, gr. j. Syr. Simp., f^j. Aqu8e, f^^i'j- Ft. sol. Dose, a teaspoonful three times a day at five years of age, has seemed to delay the march of the disease, in one some weeks, and in another, the one already mentioned, it seemed to have a positive effect in promoting the absorption of the exudation upon the membranes at the base of the brain. It is improbable, also, that in all of the reported cases, errors of diagnosis were made, and simple meningitis taken for the tubercular form ; so that there is no remedy from which so much benefit may be hoped for in this almost hopeless disease, as iodide of potassium in full doses, and it should tlierefore be faithfully tried whenever opportunity offers. We have been in the habit of giving it in doses of one or two grains every three or four hours, to children two years of age. It has, however, been given to the extent of a drachm in the course of a single day to children of that age. It ought to be begun with early in the case, and continued in con- nection with counter-irritation and cold to the head. We must remark, however, that it sometimes irritates the bowels too much, causing diar- rhoea ; and here the dose ought to be greatly reduced, or the remedy with- drawn. Bromide of Potassium, on account of its undoubted power in cases of active cerebral congestion with great nervous excitement, may be advan- tageously associated with the iodide, and we are in the habit of combining from three to five grains of the former with the dose of the latter above recommended. The treatment which has just been described is that which we have been led by our convictions as to the nature of the disease, and by our personal experience of different plans, to adopt as the most reasonable and the best. It is proper to state, however, that we have never seen it, nor any other method, of any avail after the disease has passed into the latter part of the second stage — when coma, dilatation of the pupils, marked strabismus, paralytic or convulsive phenomena, show the presence of in- flammatory exudation under the membranes, and of serous effusion into the lateral ventricles, or the peculiar lesions of the substance of the brain which exist at that period of the malady. It is also proper to add that other means have been recommended by high authorities, and to these we shall now devote some remarks. Counter-irritation in different forms has been employed, and apparently with success, though it has failed in our hands. Blisters to the nucha, be- TREATMENT. 497 hiud the ears, or over the whok^ scalp, liave been used. At one time, in this citv, it was a comniou practice to cover the scalp with a blister, but it was found to fail so constantly, and was so j-wiinful a sight to the relations of the child, that it has been very much abandoned. Surely, if it had succeeded in any considerable proportion of the cases, it would have been received as a boon, however revolting to the sight. We have, ourselves, in past vears, blistered the nucha, the back of the ears, and the temples in a number of Ciises, but have always failed to obtain any evident good from them. Within a few years it has been claimed that pustulating the whole sinciput with croton oil has been of great service. The last case of tuberculous meningitis we saw, occurred in an adult, and here we had nearly the whole of the crown of the head shaved, and pustulated with the oil, but it was of no use whatever. Cold applications to the head have been very much used. We have employed them ourselves, and still use them whenever the head is hot, or when their use relieves the headache or soothes the patient, but we confess that they have not seemed to us of much use except as palliatives. They may consist of cloths wet with cold water, of affusions with cold water, or, as has been proposed by M. Guersant, of irrigation as employed in sur- gery. M. Guersant prefers this mode of applying cold to any other, be- lieving it to be the most convenient and comfortable to the child, and from its continuous action, the most efficacious. To make use of it, the hair is to be shaved or closely cut, and the child placed upon a mattress without a pillow, and with its head near the edge of the bed. The head is then covered with compresses of soft rag, or, better still, of patent lint, while under it is placed a piece of oiled silk or india-rubber cloth, so ar- nged as to keep the thorax from being wet, and doubled into a gutter ve to convey the water off into a vessel placed on the floor. A bucket r basin filled with fresh, cool water, is placed near the head of the bed, d from this a siphon made of lint or lamp-wick is so arranged as to convey a stream of water upon the compresses covering the head. If the heat of the whole body falls so much as to threaten collapse after the irri- gation has been continued for some time, the stream of water should be stopped, and compresses, merely wet with water not quite so cool, kept on the head. The latter precaution is necessary in order to prevent injurious reaction from the sudden and total removal of so powerful a sedative as irrigation proves to be. Some practitioDers prefer the use of ice in a bladder. This seems, how- ever, too severe a remedy to be long continued, and we should therefore rather use only cloths wet with iced-water, or irrigation. Dr. Abercrombie is of opinion that the application of cold is by far the most powerful local remedy that we have. M. Gendrin recommends cool or cold affusions over the whole surface, the temperature to be proportioned to the heat of the skin. When there is but little heat of head, only a slight febrile movement, and the headache is not relieved by cold applications, ( Juer- saot recoromeDds the substitution of warm poultices to the scalp, in the place of irrigation or cold applications. We have already stated that calomel has not succeeded in our hands, so 32 498 TUBERCULAR MENINGITIS. that we have abandoned its use We deem it right, however, to lay be- fore the reader the opinions of others upon this point. Thus, it is highly recommended by many of the English writers on acute hydrocephalus, and is asserted to have effected cures when it has been pushed to such an extent as to produce salivation. But little dependence, however, can be placed on these assertions, as in all probability the reported recoveries oc- curred in cases of simple meningitis. The French writers speak of hav- ing used it in very large quantities without any success. It was given to many of the patients of MM. Killiet and Barthez, in the quantity of from six to ten, increased to twenty grains, in twenty-four hours, in connection with frictions with mercurial ointment, of which two drachms and a half were used at first, and the quantity afterwards doubled and trebled. They state that salivation did not occur in any of the cases, though fetor of the breath and inflammation of the gums were of frequent occurrence. Cal- omel may be given, as has been remarked, in purgative doses, at the be- ginning, and for the purpose of procuring its specific, effects. With the latter view the dose may be from a quarter of a grain to a grain, every hour or two hours. Mercurial inunction, in conjunction with the internal administration of the remedy, has been highly recommended by several writers as an efiicient means of procuring the full effect of the drug upon the constitution. About a drachm of the ointment is to be rubbed into the insides of the arms and thighs morning and evening, and the quantity gradually increased if no effect is produced. For our part, we will merely state that we have never known calomel given in large quantities, in order to procure salivation, of the least benefit in the disease. On the contrary, we cannot but think that the violent irritation of the digestive mucous membrane which it has determined, whenever we have used it largely, and the inflamed, irritated condition of the mouth which it caused in one case, must have been a serious aggravation of the state of disease under which the constitution was laboring. Mercury is well known to be an in- jurious and dangerous remedy in the tubercular diseases of adults, having for its effect to increase the dyscrasia of the constitution, which already exists, and thereby to hasten the progress of the malady. Why it should have a different effect in children is difficult to understand. It may be said, to be sure, that in the disease we are considering, it is given to over- come the inflammatory element of the malady, which, for the time, con- stitutes the danger of the case, and also to allow the patient the chance of its beneficial operation should the disease happen to be one of simple meningitis. In support of the views just expressed, we will quote the opinion of Dr. John Abercrombie (Diseases of the Brain and Spinal Cord, Philad. ed., 1831, pp. 173-6) : "Mercury has been strongly recommended in that class of cases which terminates by hydrocephalus, but its reputa- tion seems to stand upon very doubtful grounds. In many cases, espe- cially during the first or more active stage, the indiscriminate employment of mercury must be injurious. ... In the preceding observations, I shall perhaps be considered as having attached too little importance to mercury in the treatment of this class of diseases, particularly in the treatment of hydrocephalus ; but in doing so, I have stated simply what is the result TREATMENT. 499 of an extensive observation, . . . and I confess, the result of my observa- tions is, that when mercury is useful in affections of the brain, it is chiefly as a purgative." It has been recommended, within a few yeai-s, by Sir B. Brodie, to em- ploy mercurial inunction as especially applicable in using mercury for children. He advises that a drachm or more of the ointment be spread upon one end of a flannel roller, which is to be applied, not very tightly, around the knee ; repeating the application daily. " The motions of the child produce the necessary friction ; and the cuticle being thin, the mer- cury easily enters the system." The editors of the journal in which this communication is made {Braith. Metrosp. of Med., vol. iv, 1846, p. 147, from Quart. Med. Bev., July, 1846, p. 169), state that they tried this plan in a case of acute hydrocephalus, in which some of the most urgent and fatal symptoms were present, " such as very dilated pupils, constant con- vulsions, hemiplegia, and more or less stertorous breathing ; in short, so violent were the symptoms, that we considered the case perfectly hopeless ; but on reflecting on Sir Benjamin's method, we ordered strong mercurial ointment to be smeared on each leg every twelve hours, and covered with a stocking made to tie tightly above the knees. The symptoms soon began to abate, and by following this up with small doses of iodide of potass., frequently repeated (gr. i, every three or four hours), the head symptoms vanished. " In a second case, the same set of symptoms were approaching, but were stopped by the same mode of treatment." When the convulsive symptoms are violent and distressing, they may often be moderated by the use of a warm bath, which must be carefully given, and by the administration of some of the antispasmodics. AVe prefer for this purpose the fluid extract of valerian, of which from ten to twenty drops may be exhibited every two or three hours to young children, and a larger dose to those who are older. Bromide of potassium has also been recommended on account of its peculiar sedative action, and M. Bazin ( Gaz. de Hopitattx, 1865) narrates a case in which large doses of this remedy were successful in checking the progress of tubercular meningitis, in a lad who presented at the same time the symptoms of pulmonary tuberculosis. As a general rule, narcotics of all kinds are to be avoided, from their effect of increasing the constipatioD, and exciting more or less the cerebral circulation. When, however, neither antiphlogistics, evacuants, nor cold or warm applications relieve the sufferings of the child, it would be proper to employ small laudanum poultices or opium plasters upon the forehead or temples, or we may use morphia by the eudermic method. The treatment described in the preceding pages, is that which is proper for cases of the disea.«e occurring in subjects previously in good health, or evincing but few signs of the tubercular cachexia. When, on the con- trary, it occurs in children with extensive tubercular afl^ections of other organs, by which they are already weakened and exhausted, the treatment must of course be modified to meet the circumstances of the case. It ought to consist chiefly of cold applications, and of an early use of cod- liver oil, of iodine, or of the iodide of iron. We should recollect that 500 TUBERCULAR MENINaiTIS. experience has long since shown the weakness of our art in such cases, and for that reason avoid such a degree of interference as might possibly abridge the little span of life allowed the patient by this relentless malady. Prophylactic Treatment. — It must be evident that the prophylactic treatment is of especial importance in a disease so little amenable to curative means as the one under consideration. When, therefore, there is reason to suspect a tendency to tubercular meningitis in a child, either from the fact that other children in the family have perished with it, or from a bad state of the general health, and frequent complaints of head- ache, it becomes proper and necessary to regulate both the moral and physical education with a view to its prevention. For this end the hygienic management of the child ought to be such as is best calculated to prevent the formation or development of tubercles in the constitution. During infancy, such a child should be nursed, if this be possible, by a strong, hearty woman, with an abundant flow of milk. If the mother is not possessed of these qualities, if there be, indeed, the least doubt upon the point, she ought without hesitation to give up the pleasure of nursing the child herself, and procure for it a wet-nurse of the kind described. This alone will, in all probability, often make a difference between a vigorous and a fragile constitution. When the time for weaning arrives, the change ought to be made with the greatest care and circumspection. During and for some time after weaning, the diet must consist principally of milk preparations and bread, and of small quantities of light broths, or of meat very finely cut up. As the child grows older, the meals ought to be arranged at regular hours, and should consist of four in the day. The principal food must be bread and milk, well-chosen, well-cooked meats, and rice and potatoes as almost the only vegetables. After the first den- tition is completed, a moderate use of ripe and wholesome fruits may be allowed, but always with care, in order to avoid injury to the digestive organs, and also so as not to mar the appetite for more wholesome and nutritious food. Coffee and tea ought to be forbidden at all times ; since, as we have often observed, when the palate of a child is taught, by habit, to become accustomed to these more highly sapid substances, it is very apt to abandon the use of milk, which ought to constitute a large proportion of its food, at least up to the age of twelve or fifteen years. In no circum- stance of life is the old saying, " where ignorance is bliss, 'tis folly to be wise," a better rule of action than in regard to the diet of our children. The child should not taste improper articles of food, so that it may escape the torment of desiring what is improper. After diet the most important points in the treatment are air and cloth- ing. The child should inhabit, if possible, a large, dry, well-ventilated room, which ought to be kept as cool as possible in summer, and moder- ately warm in winter. Not a day should be allowed to pass, unless the weather is totally unfit, without the child's being sent for several hours into the open air, and we believe that it is much better for it to walk than drive, unless the weather be very hot. The clothing ought to be suitable to the season, cool in summer and warm in winter. In our country there is a great inclination to harden children by dressing them very slightly in PROPHYLACTIC TREATMENT. 501 cold weather ; so that they frequently suffer from catarrh, pneumonia, and spasmodic croup brought on by improper exposure. This cannot but be wrong in a child who shows the least evidence of a tendency to tubercular affections. For our own part we are fully convinced from what experience we have had of the diseases of children, that by far the most certain and effectual means of preventing the development of a tubercular, or indeed any other cachexia in a child, is to have it brought up in the open country, or in some healthy village, until the epoch of puberty has passed by safely. A very good plan for parents whose occupations compel them to live in cities or large towns, is to have their residence a few miles in the country, and to come to town every day. Children brought up in this way have a far better chance of obtaining strong and vigorous constitutions, than those reared entirely in the close and confined dwellings and streets of crowded cities. When a child, who, from the health of its parents, or from its own ap- pearance, may be suspected of having any tubercular or scrofulous taint in its system, becomes subject to frequent attacks of apparently causeless headache, and especially when such headaches are associated with a con- stipated habit of body and with occasional vomiting, it ought to be looked upon as threatened with tubercular disease of the brain. Under these cir- cumstances we would advise, in addition to the measures just now recom- mended as to diet, dress, exercise in the open air, and a residence in the country, that it be put at once upon the use of cod-liver oil, iodide of iron, and mild laxatives, and that these be persevered in for several weeks or months, until in fact the strength and general health are restored and the headaches cease. When the appetite is poor, and the digestion is imper- fect, in such a case we may use with advantage, besides the above reme- dies, solution of pepsin, a teaspoonful three times a day with the meals, or tincture of nux vomica, three or four drops in a mixture of syrup and compound tincture of gentian, or in a teaspoonful of elixir of cinchona three times a day. If the child is of an age to be going on with its educa- tion, this should for the time cease, or be carried on in such a way as to avoid all excitement or fatigue. A case occurred to one of us in the course of the year 1852, which showed, we think, very clearly the utility of these measures. A boy between seven and eight years old, whose mother had died of well-marked pbthis>i<< a few months before he was put under our charge, had been losing flosh and flrength, and suffering from occasional headache for some time before we were called to see him. We found him in bed complaining of severe frontal headache ; so severe at times, and usually in the afterqiart of the day, as to cause great distress, with crying. The intelligence was perfectly natural. The child was rather dull and listless, from suffering and from weakness, but not from any want of a health- ful stale of the mental of»eralions. There was no sign whatever of spasmodic or paralytic affection. In the morning the skin was cool and natural, but in the after- noon it became warm and dry, but not very hot. The pulse was 02 to G8, and though not actually irregular, it was halting or hesitating. There was occasional, but not frequent, unpinivoked vomiting, and he complained often of sick stomach, even when be did not vomit. The bowels were very much constipated, and had 502 TUBERCULAR MENINGITIS. been a good deal so for some weeks previous to his falling actually sick. There was no cough, no sore throat, and no soreness about the abdomen. The tongue was moist, soft, slightly furred, and not red nor gashed. The urinary secretion was healthy. Physical examination showed the lungs and heart to be without disease. The treatment during the first week was small doses of calomel and rhubarb, half a grain of the former to two of the latter, given for a day, and followed by syrup of rhubarb and fluid extract of senna, until the bowels were copiously evacuated. After this the bowels were kept soluble by the administration every day, or every other day, of doses of Seltzer powder, sufficient to produce the effect. Blisters were applied behind the ears. In the after-part of the day, when the head and body became heated, cooling applications were made to the head, and the feet were put into mustard-water, once, twice, or three times. Two grains of iodide of potassium were ordered to be given three times a day. The diet was to be light but nutri- tious. It was to consist of bread and milk and a soft-boiled egg in the morning, oysters or light meats with rice for dinner, and milk with bread in the evening. Of these he was to have any reasonable quantity that he might desire. Under this treatment he improved slowly, with occasional drawbacks for a week, when the iodide of iron was substituted for the iodide of potassium. The bowels continued very costive, requiring daily doses of the Seltzer pow.dcr ; the headaches dimin- ished in frequency, duration, and severity ; the pulse went up to 72 and 78, and became more free and even ; the appetite had improved, but the child remained still very weak, pallid, and quite emaciated. After another week, as he continued to mend, and the stomach had become stronger, cod-liver oil was ordered in addi- tion to the iron ; a teaspoonful was to be taken three times a day in a wineglassful of table-beer. As he gained strength, the amount and kind of food was increased. He was, indeed, encouraged to eat heartily of plain and digestible substances. He now improved gradually in health. The headaches subsided, and finally ceased ; the bowels became soluble ; the appetite grew hearty and strong, and all feeling of nausea disappeared ; he regained his strength, flesh, and color, so that at the end of two months we saw him looking quite fat and well. The iodide of iron and cod-liver oil were, however, to be continued for a month longer. He is now (1869) a young man in very good health. He has passed several years in Germany pursuing a scientific education, and has returned lately to this country, and is about to marry. As to the particular means likely to be of service in preventing a direc- tion of the tubercular cachexia towards the brain, such as might produce tuberculosis of that organ, we have only to propose the course recommended by different writers, viz., to keep the head cool by not allowing it to be very warmly covered, and by keeping the hair short ; to keep the extremi- ties warm ; to avoid stimulating the intellectual faculties to any consider- able extent by education, until after eight or ten years of age ; and to use every means to preserve the general health in a sound and pure condition. Some recommend the long-continued employment of a powerful derivative from the brain, as a small blister on the arm or a seton in the neck. We think, however, that such remedies ought not to be used unless there are positive symptoms of a tendency to cerebral disorder. The caution not to interfere much by powerful local applications, with eruptions which nature may have thrown out upon the scalp, is, we believe, wise and prudent ; though there can be no objection to the administration of suitable internal remedies with a view to their cure. I SIMPLE MENINGITIS. 503 ARTICLE II. SIMPLE MENINGITIS. Definition; Synonyms; Frequency. — By this term is understood in- flararaatioii of the niembraues of the braiu, iudependeiit of tuberculosis of those tissues, or of other organs of the economy. The disease was for a long time confounded with tubercular meningitis under the titles of water on the brain, dropsy of the brain, and acute hy- drocephalus. It has also been called arachnitis ; and more rarely phrenitis. Its frequency is much less than that of tubercular meningitis. West (op. cit., 4th Amer. ed., p. 100), states that he has seen seven cases of fatal acute meningitis, in five of which post-mortem examination was made and confirmed the diagnosis. Vogel i^op. cit., p. 359) speaks of it as being much rarer than the tubercular form, and states that it is no more frequent in children than in adults. It appears that MM. Rilliet and Barthez, during their researches, met with only five cases of this disease, while they report thirty-three of tubercular meningitis. Bouchut states that he has met with two cases of simple meningitis to six of tubercular disease, whilst Barrier reports only four of the former in nearly thirty autopsies of menin- gitis. He states, however, that he has met with three cases of recovery, all of which he believes to have been instances of the simple form. Fabre and Constant met with nine cases of simple to twenty-seven of tubercular meningitis in a period of two years, at the Children's Hospital of Paris. {Bibliothtque du Med. Prat., t. vi, p. 166.) Causes. — The causes of simple meningitis are not very clearly ascer- tained. It would appear, however that the disease is more common in infants than older children. M. Rilliet. who published a very valuable paper on this affection (Arch. Gen. de Med., t. xii, 1846), divides it into two forms, the convulsive and phrenitic, the former of which he believes to be most common under two, and the latter between five and fifteen years of age. This author is disposed to think, from the fact that the dis- ease is most frequent in the first and ninth years of life, that the process of dentition has something to do in its production. It appears also to be more frequent in boys than girls, and in robust than in weak constitutions. Exposure to extremes of temperature predisposes to attacks of acute men- ingitis; and, in particular, rontinuod exposure to the direct rays of the 8UD has been known to act as an immediate cause. Guersant has known it to follow such exposure in several instances par- ticularly in young infants; MM. Rilliet and Barthez report a case of the game kind, and Rilliet (he. cit.), another. Other caus&s cited by authors are injuries upon the head, such as blows, falls, and wounds. It also occurs as a consequence of extension of inflammation to the membranes of the brain, and usually from the internal car in cases of otorrhea. The disease seems to have sometimes occurred in an epidemic form. There is reason to believe, however, when we consider the purely sporadic 504 SIMPLE MENINGITIS. nature of its recognized causes, that the reported epidemics have for the most part been of cerebro-spinal meningitis, a disease which we shall treat of in its appropriate place, among the acute specific febrile affections. Anatomical Lesions. — The dura mater is generally much injected, and its sinuses, together with the large cerebral veins, contain coagulated or semi-coagulated blood, sometimes in large quantities. On opening the dura mater, the w^hole, or nearly the whole of the convex surface of both hemispheres, or in some instances of one only, are found to be covered with a yellowish or greenish-yellowish layer, which consists of fluid or concrete pus, or of false membranes. These deposits exist also on the internal sur- faces of the hemispheres, on the upper surfaces of the cerebellum, and often also at the base of the brain, though in some cases the latter presents none whatever. The inflammatory products are seated in the pia mater, and sometimes in the cavity of the arachnoid membrane, but in much smaller quantity than in the tissue beneath that membrane. The arachnoid membrane which covers the brain seldom participates in the inflammation, but remains smooth and transparent. Its cavity, how- ever, sometimes contains inflammatory products, which, when death occurs early in the attack, consist of a small quantity of pure pus, or of larger quantities of a turbid, yellowish serosity, consisting of serum and pus mixed together. "When death has occurred later in the disease, — after five, six, or seven days, — the pus is mixed with lymph, or else true false membranes are found. The pia mater is observed to contain fluid or semifluid pus when death occurs before the fourth or fifth day ; while in less acute cases there are patches or large layers of lymph, which sometimes dip into the anfractuosities, and give to the membrane under consideration a swelled and thickened appearance. These appearances are more marked on the superior and lateral, than on the inferior surface of the brain. Where the deposits exist the membrane presents a vivid injection, which is more marked in proportion as death has taken place earlier in the disease. The pia mater is generally easily detached from the cerebral substance, par- ticularly when the fatal termination has occurred early. The substance of the brain is firm, and but slightly colored, in rapid cases. When the course of the disease has been slower, the cineritious portion is generally of a bright rose color, and the medullary substance abundantly dotted with red, showing that the inflammation has involved the superficial layer of the brain. In the latter class of cases the surface of the convolutions is usually softened, and the pia mater adherent. In very young children the whole brain is sometimes soft. The ventricles do not, as a general rule, contain transparent serum, ex- cept at a very early age, when serous effusion takes place with great facility. They, often, however, contain one or two teaspoonfuls, and rarely more than one or two tablespoonfuls, of pus or purulent serum. The serous membrane of the ventricles and the plexus choroides exhibit signs of inflammation in some instances. They are of a bright red color, uneven, rough, and very much softened, in children who die early ; and pale, opaque, slightly thickened, and rough, in those who die at a later period. I SYMPTOMS. 505 The central parts of the brain often retain their firmness, bnt are some- times softer than natural, or even diffluent. This softening is particuhirly apt to exist in very young children, in connection witli large efiusion into the ventricles; though it also occurs in those ^vho are older, and in whom there is only slight effusion of ])us or purulent serum. In the former case it is probably due to the macerating effect of the effusion, ^Yhile in the latter it is more likely to be owing to inflammatiou. lu some cases, and especially those of the epidemic form of the disease, the membranes of the spinal cord are found to present the same inflamma- tory appearances which have been described as existing in the cerebral meninges. Tliese cases are, therefore, more correctly designated by the name cerebro-spinal meningitis. The other organs are healthy except in secondary cases. Tubercles, which so constantly exist in various other organs in tuberculosis of the meninges, are never found, according to M. Eilliet, in this form of menin- gitis. This author believer himself entitled from his researches to formu- late the following law of pathological anatomy: "That general meningitis and meningitis of the convexity of the brain ocoir only in non-tuberculous children, whilst meningitis of the base of the brain without inflammation of the lining membrane of the ventricles, belongs exclusively to tubercu- lous children." ( Op. cit., t. iii, 1846, p. 408.) This law cannot, however, be adopted without exception, since we have already seen, when speaking of tubercular meningitis, that there are, in a large proportion of such cases, evidences of inflammation of the lining membrane of the ventricles. Symi»toms. — The following account of the symptoms of the disease is taken chiefly from the paper of M. Rilliet. That author describes two forms of the affection, the convulsive and phrenitlc; the former of which is characterized by a predominance of convulsive phenomena, and the latter by disorders of the intelligence. The disease may also be idiopathic or secondary, simple or complicated, sporadic or epidemic. The convulsive form generally occurs in children under two years of age. The disease usually begins suddenly or after a restless night, with a violent and prolonged attack of convulsions, oftener general than partial, and is accompanied by violent fever, and sometimes by considerable quickness of respiration. The existence of headache cannot be ascertained at this early age. Vomiting is often absent, and the boweh generally continue regular in thjs form, though they are sometimes constipated. After awhile the con- vulsions cease, and the child remains for the time in a state of quiet, som- DoleDce, or coma, when they return with renewed violence. The returns of the convulsions generally take place at intervals of one or two hours or more. In the intervals between the crises the child is restless or drowsy, or in a state of partial stupor, attended with tremulous movements of the extremities ; there is strabismus, contraction of the jfupils, trismus, and some- times hemiplegia. The skin retains its warmth, the pulse is accelerated, irregular, and unequal ; the face is pale ; the stools are spontaneous or ea.«ily procured by remedies. It is unusual to see the child regain its con- 506 SIMPLE MENINGITIS. sciousness so as to recoguize objects in the intervals between the convulsions, or after the appearance of coma and other cerebral symptoms. Death occurs during coma or in a violent attack of convulsions. This form seldom lasts more than four days. Occasionally this form begins in a different manner. The convulsions, though they still predominate, do not occur until later in the disease, and the whole course of the affection is slower. Such cases begin with a violent febrile movement, lasting several days, and accompanied by acceleration or uneveuness of the respiration, or by almost constant drowsiness, pre- ceded or followed by agitation, screaming, staring expression of the eyes, and dilatation of the pupils ; vomiting and constipation are sometimes present, at others absent. After a time, however, convulsions make their appearance, and the case follows the course already described. The du- ration of this form may be the same as that of the first, or it may last about two weeks. The phrenitie form of simple meningitis generally begins suddenly with fever, which is sometimes preceded by a chill ; the skin is warm and dry, and the pulse, in idiopathic cases, full and accelerated. In secondary cases the pulse has been found slow and irregular ; in all it becomes ir- regular, small and very rapid the day before death. Simultaneously with the fever there is frontal headache, which is often so violent as to draw cries from the child, and, according to M. Killiet, is more severe than either in tubercular meningitis or typhoid fever. It is also more constant, and lasts generally one, two, or three days, until the appearance of rest- lessness, delirium, or coma. At the same time there is great sensibility to light and noise, and abundant vomiting of bilious matter. The latter symptom is one of the earliest ; it generally ceases after a few days, but sometimes continues to the very end. Constipation exists in some cases, but is much less constant and more easily overcome than in the tubercular disease. The appetite is lost, and the thirst very acute. The abdomen is flattened and retracted, especially towards the end, while in secondary cases of this form, and in very young children, it retains its usual shape. About the end of the first day, generally, or, in rare instances, after two or three days, appear various disorders of the intelligence. The first symp- tom of this kind is observable in the expression of the face, w^hich becomes a little wild or wandering, and sometimes grimacing. Soon afterwards occur restlessness, which is sometimes extreme, and, in succession, delirium, somnolence, and later in the attack, coma. The restlessness and somno- lence often alternate early in the case, though the former generally pre- dominates and soon passes into delirium, which is usually violent. When in this condition the child seldom recognizes any one, and either refuses to answer questions, or answers incoherently. In connection with the dis- orders of intelligence there exist also trismus, grinding of the teeth, sub- sultus tendinum, partial convulsive movements, stiffening of the extremi- ties or trunk, retraction of the head, strabismus, contraction first and then dilatation of the pupils, and in some cases violent convulsions, followed by deep coma. Death sometimes occurs at this period. In other instances, the disease continues longer, and other symptoms declare themselves. DIAGNOSIS. 507 Vomiting generally ceases ; constipation increases ; the abdomen is re- tracted ; headache is no longer complained of; the fever continues, but the pulse becomes irregular; the respiration is uneven and irregular, being sometimes more and at other times less frequent than natural ; the face is distorted and extremely pale, or there may be a purple flush on the cheeks; the restlessness is excessive, and accompanied by subsultus, car- phologia, or partial convulsive movements ; tlie delirium, at first so violent as to make it necessary sometimes to hold the child in bed, subsides into a state of coma and collapse, in which general sensibility is obtunded, and special sensibility extinguished ; the respiration becomes stertorous, and at length asphyxia, coma, or a severe attack of convulsions terminates the scene. The course of the disease is generally continuous. In very rare cases, however, occasional remissions occur, so that the child recovers its intelli- gence for a short time, and recognizes persons around. The duration has varied between a day and a half and nine days. Diagnosis. — The convulsive form may be confounded with the essential or symptomatic, and with the sympathetic convulsions of children. The mistake may generally be avoided by attention to the following points. In essential convulsions, the attacks are usually less violent, seldom last more than a few moments, occur from some evident cause, and do not recur often. When they have ceased, the child generally soon regains its con- sciousness and health, or exhibits slight drowsiness, or derangement of movement for a short time only. In such cases the respiration is not per- manently accelerated, as in convulsive meningitis ; the pulse, if it has been increased in fcequency, soon falls to the natural standard, and special sen- sibility remains undisturbed. It is to be distinguished from sympathetic convulsions by the characters just described, aided by a reference to the disease which may have caused the attack of eclampsia, and which may be one of the eruptive fevers, en- teritis, indigestion, pneumonia, or any other acute affection. In some instances, however, the distinction cannot be made except by attention to the progress of the attack. The phrenitic form may be confounded with tubercular meningitis, with congestion of the brain, or with the early stage of the eruptive fevers. The distinction between it and tubercular meningitis has already been consid- ered under the head of the latter disease. It i.s sometimes difficult, as pointed out by Rilliet, to distinguish between simple meningitis and cerebral congestion and partial encephalitis. In congestion, however, there is not the same intense headache, the ' :!c movement is not so marked, vomiting is usually al)sont, and the -v iopment of delirium or coma, or of convulsive or paralytic -ynijjtoms is more sudden or even instantaneous. Partial encephalitis is even more rare in children than sim|»l<; m< iiin- gitis. It may be distinguished from the latter by the less severity of the headache, by the less marker! delirium, by the comparative infrequency of vomiting, and by the less activity of the febrih- movement, and the more gradual course of the case in encephalitis. 508 SIMPLE MENINGITIS. From the invasion of variola, it is to be distinguished by attention to the contagious and epidemic nature of that malady, by the inquiry as to whether the patient has been vaccinated or has had a prior attack of that disease, by the absence of pains in the loins in meningitis, and by a con- sideration of the period at which the delirium makes its appearance, which, in variola, rarely occurs before the third day. To make the diagnosis between meningitis and malignant scarlatina, we must attend chiefly to the epidemic and contagious character, to the thick coating upon the tongue, redness of the throat, elevated temperature, and nasal respiration, which exist in the latter. Prognosis. — The prognosis of simple meningitis is very grave, but much less hopeless than in the tubercular form. M. Valleix is disposed to think that most of the recoveries reported by M. Guersant were cases of sanguine congestion or effusion. M. Rilliet {loc. cit.), who has studied the subject more carefully than any other observer, cites several instances of recovery, but states that death is much the most frequent termination. Treatment. — It must be evident, it seems to us, that but little depen- dence can or ought to be placed on any but prompt and powerful anti- phlogistic treatment. Bloodletting, therefore, mercury, cold applications to the head, purgatives, counter-irritants, and the most rigid diet, ought to be employed from as early a period as possible, and in the most energetic manner. Venesection ought always to be preferred to local bleeding, even in the youngest child, unless it is impossible to find a vein, or unless this is evi- dently too small to bleed well. When venesection cannot, from any rea- son, be employed, blood should be freely drawn by means of leeches or cups. It is customary to apply the leeches to the temples or behind the ears. We may remark that MM. Rilliet and Barthez object to the appli- cation of leeches to the head, and propose that they should be placed rather about the anus or on the inferior extremities. The quantity of blood to be drawn must depend upon the age and constitution of the subject, and the violence of the attack, in some measure. It should always, however, be large, as much or more, we think, than is necessary in any other of the acute affections of childhood. In a child two years old, of good consti- tution, from two to four ounces would not be too much at first, and should the symptoms not moderate in six or eight hours, as much more may be taken. Should these detractions of blood fail to produce a good effect upon the dangerous symptoms, it would be proper, unless there were evi- dent and unmistakable signs of exhaustion, to take still more, either lo- cally or generally. We are disposed to believe that in such a disease as this, bleeding is by far the most powerful remedy, and it is perhaps the only one which offers us any real chance of success, at least in those rapid cases in which extensive layers of pus and false membranes are found on the surface of the brain, in the pia mater, or in the subarachnoid tissue, in from two days and a half to three or four days after the commencement of the disease. While the bleeding is being performed we should direct the preparation of means for the application of cold to the head, which constitutes another TREATMENT. 509 most efficient remedy iu inflammations of the brain and its membranes. These means may consist of a bh\dder containing water and pounded ice, which is perhaps the most convenient and powerful, of cloths wrung out of iced or very cold water, to be constantly renewed, of cold affusions upon the head, or lastly, of irrigation as recommended by M. Guereant, and described in the article on tubercular meningitis. Purgatives ought to be employed so as to empty the bowels thoroughly, and produce a decided revulsion upon the intestinal mucous membrane, but not in such quantity as to occasion inflammation of that tissue, which would be very apt to prove the case were the drastic substances and large doses recommended by some writers used. The remedy usually given and most highly recom- mended is calomel, which is chosen for its sedative alterative properties. About four grains may be exhibited alone, and followed in one, two, or three hours by castor oil, jalap, or infusion of senna and manna, sweetened with syrup of rhubarb. These doses ought to be given until the bowels are freely moved. It is always useful to employ a strong purgative enema immediately after the bleeding, without waiting for the operation of the internal remedies. After the purgative doses have been given, it is impor- tant to continue the mercury in smaller quantities, with the view of ob- taining it5 specific influence upon the inflammation. The doses may con- sist of from a quarter of a grain to a grain every hour or two hours. Some writers also recommend very highly the use of mercurial inunction. Vogel {op. cit., p. 361) states that a mercurial treatment is decidedly effectual, and adds that the only two children he has seen recover from this disease, were treated exclusively with mercury, internally and externally. Counter-irritants are useful as adjuvants to the more powerful remedies already indicated. During the first day or two they should consist chiefly of sinapisms and mustard poultices, applied from time to time to the trunk and extremities. Authorities difler somewhat as to the effect of blisters, and as to the time at which they ought to be applied. M. Valleix (op. cit.j t. ix, p. 187j, opposes their employment in this affection as often inju- rious and still more frequently useless. We think the advice given by Dr. Abercrombie, as to their employment, is probably the most prudent. This is, not to apply them in the early stage, but to wait until the active symptoms of the disease have been subdued. They may be applied to the head itself, to the nucha, or to the extremities. We believe that we have seen them most useful when applied to the neck and inside of the calves of the legs. Nevertheless, there is high authority in favor of their good effects when applied upon the head itself. M. Rilliet (loc. cit.) recommends a vigorous revulsion upon the scalj) when the disease has followed the suppression of an eruption. He proposes with this view the employment of pustulation by croton oil, and relates a ra>e of recovery which followed this treatment under a most unfavorable train of symptoms. To make use of it the head must be first sliaved ; from fifteen to twenty drops of the oil are then to be rubbed over the scalp with a glove four or six times a day. Before making the friction, the eyes of the patient must be covered with a band to prevent the intro- duction of any of the oil into them, as this would be apt to occasion severe 510 CEREBRAL CONGESTION. ophthalmia. In the case reported by him, a considerable number of pus- 11 tules were produced in twenty-four hours, and in a few more hours the eruption was general, so that the head was covered with a kind of cap of a fine yellow color. ARTICLE III. CEREBRAL CONGESTION. Cerebral congestion implies a condition in which the bloodvessels of the brain contain an excessive quantity of blood. It occurs under the two forms, of active congestion, where there is an increase in the amount of ar- terial blood, and of passive congestion, where the quantity of venous blood is excessive. While it can no longer be doubted that the amount of blood circulating in the brain is thus liable to vary, and that such variations are of frequent occurrence, and are attended with very important symptoms, it is difficult to determine the relative frequency of cerebral congestion at different pe- riods of life. Dr. West, whose publications upon the diseases of children are amongst the most valuable that the English press has afforded us, long ago claimed for cerebral congestion in childhood the position of a very important and frequent condition of disease. According to some more recent authors, also, it is much more frequent in childhood than at any later period of life. We are inclined, however, to regard this latter view as probably an overestimate, because, in our opinion, the symptoms which are detailed in this article as dependent on congestion of the brain, are, in some cases, rather due to mere excitement and undue rapidity of the cir- culation, and in others to the irritation of the brain caused by the circu- lation through it of blood vitiated by the poison of some of the acute specific diseases. Rilliet and Barthez assert (lere edit., t. i, p. 649) that they have found in children dying of different diseiases, and who had presented no cerebral symptoms, congestion precisely similar to what they found in others who had exhibited more or less dangerous idiopathic or secondary nervous symptoms. They are not disposed, therefore, to attribute to cerebral con- gestion any large share in the production of eclampsia or other nervous phenomena. Other writers of the French school, also, as Valleix and the authors of the Bibliotheque du Med. Prat, express the view that it is rare to meet with true pathological and idiopathic congestion of the brain, either in the first or second infancy (t. vi, p. 118). We have alluded to this diversity of opinion not to depreciate the importance of this condi- tion, but to show how much want of agreement exists among high authori- ties as to th^ explanation of symptoms (delirium, somnolence, coma, con- vulsions, etc.), which we believe are too often, in this country, set down as unquestionably dependent on cerebral congestion. CAUSES — SYMPTOMS. 511 Causes. — Active congestion may occur during the process of dentition, or may result from exposure to the sun, from falls or blows on the head, or from excessive excitement or fatigue iu child reu who are predisposed to the affection. The cerebral symptoms occurring at the outset of the erup- tive fevers have been, by West and others, attributed to the development of intense cerebral congestion. AVe feel, however, that the nervous symp- toms just alluded to ought, most frequently at least, to be regarded as the result of the presence in the nervous centres of a diseased and vitiated blood, rather than of congestion. That congestion does not always pro- duce them is shown by the statement of Rilliet and Barthez (op. cit., t. ii, p. 620) in regard to the cerebral symptoms of scarlet fever, " that a more or less sanguine congestion (of the cerebro-spinal apparatus) is the only alteration generally, but not ahcays found, and sometimes the congestion is not more marked than in other diseases in which there had been no cere- bral symptoms." In reference to the cerebral symptoms which less frequently occur in in- flammations of important organs, as, for instance, pneumonia or entero- colitis, we are not yet in possession of sufficient facts to determine whether they result from reflex irritation, from the elevated temperature and ac- celeration of circulation, or from changes in the quantity of blood circu- lating through the brain. Probably all three of these elements take part in varying proportion in the production of such symptoms ; we do not, therefore, feel at liberty to regard them, in the majority of cases, as ac- tually depending on cerebral congestion. Passive congestion results from such causes as offer an impediment to the reflux of the venous blood from the brain. Among them may be mentioned the mechanical obstruction caused by the pressure of an en- larged thymus gland, or of enlarged cervical or bronchial glands, or by the partial or complete occlusion of a large vein or sinus from the forma- tion of a fibrinous concretion (thrombosis) in its cavity, or from the pres- sure of a tumor upon its walls. Passive congestion occurs also in affec- tions which, like hooping-cough, are attended with violent paroxysms of cough, during which the return of venous blood from the brain is greatly impeded. Finally it often appears that the state of feeble, languid circu- lation, depending upon want of pure air or of sufficient and nourishing food, strongly predisposes to, or actually induces, this form of cerebral congestion. Symptoms. — Recognizing that cerebral congestion may occur at the outset or during the course of various acute diseases, it is evident that the symptoms due to the congestion itself must frequently be complicated by those of the primary affection. We may, however, give the following brief sketch of the symptoms which may be attributed to the two forms of cerebral congestion. The active form usually appears suddenly, though it may be preceded for a few days by a state of indisposition, with irritability and peevishness, some fever, and a disordered state of the bowels generally, l)ut not always consisting of constipation. The chief symptoms of the attack are great heat of the head, and complaint", in older children, of headache, intolerance of 512 CEREBRAL CONGESTION. light and sound, nervousness, with startings during sleep and twitchings of the muscles. The pulse is frequent, the carotids throb, and if the skull be still unossified the anterior fontanelle is tense and prominent, or the brain is seen and felt to pulsate forcibly through it. If these symptoms be not relieved by appropriate treatment, or, in some cases, without any premoni- tory stage, the child may pass into a state of more or less profound stupor or coma ; or, on the other hand, an attack of partial or general convulsions may occur. In passive congestion the symptoms are apt to be less suddenly devel- oped, but when marked they resemble in many respects those which we have described as indicative of the active form. There is, however, less febrile excitement, and the force of the arterial pulsation and the promi- nence and tension of the fontanelle are notably less. Still there are usually present great irritability, restless, disturbed sleep, muscular twitch- ings, or even convulsions ; or, on the other hand, deepening indifference to surrounding objects, resulting in profound stupor. The duration and termination of these symptoms are very variable. If the anatomical condition present has been only one of great vascular dis- tension, and appropriate treatment is promptly employed, the threatening symptoms subside in the course of two or three days. If, however, the congestion has been so extreme or has lasted so long as to lead to serous effusions or even to minute extravasations of blood, the symptoms may continue to deepen in gravity until the fatal result occurs, or else the at- tack subsides but leaves behind it some evidence of injury to the brain- tissue in the form of more or less lasting paralysis. Occasionally, how- ever, complete recovery takes place, contrary to all expectation, after the grave symptoms above described have continued but slightly modified for days or even weeks. The diagnosis of cerebral congestion must be based upon the symptoms above detailed, as well as upon the general considerations with which we ^ prefaced this article. The reader is also referred to the remarks made under the head of diagnosis in the article on simple meningitis. It is, of course, essential not only that the existence of cerebral congestion should be recognized, but also that the form in which it presents itself should be determined, as this has a most important bearing upon, the treatment to be employed. Treatment. — Active cerebral congestion is to be treated like the first stage of simple meningitis, with cathartics and purgative enemas, calomel, cold applications to the head, baths, revulsives, full doses of bromide of potassium, low diet, and confinement to a cool dark chamber. We desire to lay particular emphasis upon the employment of bromide of potassium, as its power of lessening active congestion of the nerve-centres is estab- lished by very positive evidence. Belladonna, which exerts a similar action, may be associated with it. If the symptoms do not promptly yield to these measures, and there is no special contraindication, we should recommend the use of local depletion by leeches or wet cups to the temples or some part of the head. In the treatment of the passive form, particular attention must be given CEREBRAL HAEMORRHAGE. 513 to the relief or removal of the primary cause. Unfortunately, however, in many instances this is not possible. The urgent symptoms themselves must be promptly treated by coki applications to the head, by active re- vulsion, by strict attention to the diet and the state of the bowels. If great danger exists, and the nature of the cause and the condition of the child justify it, mild local depletion may be cautiously employed. If, on the other hand, the case be associated with enfeebled nutrition, it may be necessary to employ quinia, ammonia, as nourishing a diet as can be di- gested, and small amounts of stimulus. If the congestion terminate in extravasation, the treatment for this con- dition and the paralytic symptoms which may result, must be such as is i recommended under the head of cerebral hiemorrhage. ; ARTICLE IV. CEREBRAL HEMORRHAGE. We shall consider haemorrhage of the brain under two heads, that of the substance, and that of the membranes ; the former is usually desig- nated as cerebral, and the latter as meningeal apoplexy. Both these forms of hiemorrhage are of rare occurrence in childhood compared with other diseases of the brain, and with their frequency during adult life and old age. Of the two kinds, that of the meninges is the most common. Definition; Frequency; Forms. — By cerebral apoplexy or haemor- rhage is understood an effusion of blood into the substance of the brain. By meningeal apoplexy or hiemorrhage is understood an effusion of blood between the dura mater and cranium, into the cavity of the arachnoid membrane, beneath the arachnoid, or in the meshes of the pia mater. Cerebral haemorrhage is a very rare affection in childhood. This is proved to be the case by the facts that MM. Rilliet and Barthez met with only eight cases in their extensive experience, and that M. Barrier saw but one in 576 cases of disease of all kinds. Meningeal apoplexy is of more frequent occurrence, since MM. Rilliet and Barthez report eighteen cases. M. Barrier. met with one case of this form in the 576 cases referred to. Dr. West (London Med. Gaz., June 18th, 1847, p. 1062) says he has only twice met with distinct extravasation of blood into the substance of the brain in children. We have ourselves met with two cases of hiemor- rhage into the substance of the brain, and with several of meningeal apo- plexy. Haemorrhage into the substance of the brain occurs in two different forma: one in which the effused blood is contained in a cavity cau.-ed by a laceration of the tissue of the organ, and der^ignated apoplexy in a cavity; and the other in which the blood is effused in a multitude of little points of different sizes, and designated capillary apoplexy. In addition to thi.s, as in a remarkable case published by Dr. Dulles (J'], ',!.,. hi. Med. Times, July 22d, 1876;, the hiemorrhage may occur into the veDtricles of the brain, completely filling these cavities. 33 514 CEREBRAL H JilMORRHAGE. In meningeal hsemorrhage the blood may, as we have stated, be effused between the dura mater and the bone. This form, however, is very rare, so rare, indeed, that several writers deny its existence. It is proved, how- ever, to have occurred, by a case reported by MM. Rilliet and Barthez, which is the only one they have met with. In by far the most common form of the disease, the blood escapes into the cavity of the arachnoid membrane. Of this form the authors just quoted report 17 cases, while, according to the authors of the Bibliotheque du Med. Prat. (t. vi, p. 193). the effusion always occurs in this situation. That this is not invariably correct, however, is proved by the case of effusion exterior to the dura mater already referred to, and by the fact that it sometimes takes place be- neath or in the meshes of the pia mater. The latter class of cases is very rare, however, in proportion to those in which the hsemorrhage occurs within the cavity of the arachnoid. MM. Rilliet and Barthez did not themselves meet with a single instance of that kind, but they quote two from other writers ; and M. Valleix refers to a memoir by M. Prus, in •which others are given. It appears, therefore, that in the great majority of instances, the effusion takes place within the cavity of the arachnoid membrane. Causes. — The causes of cerebral hsemorrhage are very obscure, so much so, indeed, that some writers have not attempted to ascertain them. They appear to be the same in both forms of the affection. Amongst the as- cribed causes are the sudden disappearance of eruptions of the scalp, ob- served in two cases by MM. Rilliet and Barthez, in one of which this effect is stated to have been produced suddenly by medical treatment, while in the other it followed the application of poultices to a favous eruption upon the same part. This cause must, however, it appears to us, be regarded as purely illusory. The disease is stated by M. Legendre to have followed in one case a violent fit of anger. It is said also to have been produced by various causes which acted as impediments to the circulation. The obsta- cle may be situated within or exterior to the cranium. To the first class belong cases in which the sinuses and large venous trunks of the head have been found obstructed by coagula of blood, or by the pressure of tumors, generally of a tubercular nature ; to the latter, those in which there is in- tense engorgement of the superior cava produced, as in prolonged parox- ysms of hooping-cough, or in obstructive cardiac disease, or where there is compression of this vessel by enlarged and tubercular bronchial glands. Another cause is thought to be the existence of confirmed cachexia and general debility from any diseased condition whatever, in which the blood having become thin and lost its plasticity, escapes from the vessels with great facility. This last condition is one which almost always exists in connection with the causes cited as acting through the agency of obstruc- tion to the circulation, and tends of course to augment their dangerous effects. Occasionally, also, aneurisms of the cerebral arteries, especially of the middle cerebrals, occur at an early age (several cases are on record at the age of 14 years), and by the rupture of the sac give rise to excessive and rapidly fatal cerebral hsemorrhage. We have met with one case of extensive hsemorrhage into the left corpus striatum and adjoining tissue in a boy of 13, evidently connected with ad- ANATOMICAL LESIONS. 515 vanccd granular degeneration of the kidneys, resulting from a previous attack of scarlatina. In some instances the haemorrhage occurs in the healthiest and most vigorous constitutions, and cannot be accounted for in any way. It appears that meningeal apoplexy is most frequently met with in very young children, according to MM. Rilliet and Barthez, between the ages of one and two and a half years, whilst M. Legendre did not meet with a single case after three years of age in 248 autopsies. Cerebral and ven- tricular ha}morrhage, on the contrary, are much more common after three years of age than before, which is just the reverse of the law in regard to meningeal effusion. Anatomical Lesions. — The description of the lesions of hcemorrhage into the substance of the brain need not detain us long, for they are much the same as those observed in the adult. When the blood is eff'used into cavities (apoplexy in cavities), the latter are usually small in size, seldom exceeding from one to two-thirds of an inch in diameter, though in rare cases they have been found much larger. The cavity is formed by a lacera- tion of the substance of the brain, and is filled with soft, dark coagula, or sometimes with fluid blood; the walls of the cavity consist sometimes of the •ubstance of the brain, which may be of a rosy color and natural consist- ence, or yellowish and softened, while in other instances they are formed of more or less numerous points of capillary apoplexy. The capillary form of eflfusiom occurs in the shape of a number of points, scarcely so large as the head of a small pin, and of a dark or brownish color, which contrasts strongly with that of the cerebral tissue. These points evidently consist of true coagula, which are sometimes surrounded by small yellowish areolae. The substance of the brain around the effiision is either white, firm, and perfectly healthy, or softened, and of a whitish, reddish, or yellowish color. The capillar}' effusions are generally limited within a space of from a third of an inch to an inch and a half in size, but they have been found scat- tered over a large portion of the hemispheres. Both forms of hiemorrhage are much more common in the cerebrum than cerebellum, and occur more frequently on the left than right side. In addition to the sanguine effusion there is generally considerable con- gefstion of the pia mater, of the venous sinuses, or of the substance of the brain itself. In describing the lesion? of meningeal apoplexy, we shall confine our re- marks to the effu.-ion which occurs into the cavity of the arachnoid, this being, as we have already remarked, by far the most frequent form of the di.«ease. The appearances presented by the cavity of the arachnoid into which the effusion has taken place vary greatly in different cases, according to the age of the child, the quantity of the hiemorrhage, and the period of time which may have elapsed between the accident and the death of the patient. It is very uncommon to find pure liquid blood, though this has been met with. In the case published by Dr. Dulles (loc. oH.), which occurred at the age of six months, the lateral ventricles were filled completely with firm and partly organized clots, a large firm clot filled the third ventricle. The surrounding brain tissue was deeply stained, but was not lacerated. 516 CEREBRAL HEMORRHAGE. In most instances, there is a bloody serum mixed with thin, reddish coag- ula, contained in a soft and very delicate membrane lining the internal surface of the arachnoid. Sometimes the effusion is thin, limpid, and more or less yellowish in color, while at other times it is thick and brownish, or chocolate-colored. In some rare cases it is perfectly transparent and color- less. The fluid, in whatever state it exists, appears to be the result of transformations undergone by the effiised blood. The solid portion of the blood or clot is found either in the condition of more or less recent coagula, or changed into false membranes, which sometimes resemble very closely the arachnoid itself, and sometimes a true fibrous membrane. The coag- ula are found in the form of thin membranes, varying between one or two lines in thickness, and an inch and a half to two inches in size. They are thickest generally in the centre, where they measure between a fifth of a line and two lines, and are brownish or greenish in color, and of variable consistence, according to their age. These coagula may exist upon any portion of the brain, but, according to MM. Rilliet and Barthez, are most frequently met with upon its convex surface. The coagula just referred to undergo in some instances a curious change, of which we shall give a short description. In the course of time, the fibrinous portions of the blood are deposited upon the internal surfaces of the cavity of the arachnoid, in the form of a new membrane. When death occurs soon after the onset of the attack, the parietal layer of the arachnoid is found to be completely lined with this raembraniform production, whilst the visceral or cerebral layer is covered by it only in certain points. When the case has lasted a longer time, on the contrary, the visceral as well as the parietal layer of the arachnoid may be covered with the new produc- tion, and when this happens there is formed a true sac or cyst, destitute of opening, which lines the whole interior of the arachnoid, and contains within its cavity bloody serum and coagula. At first this new membrane is reddish in color, elastic, and of a stronger texture than might be sup- posed from its apparent thinness and softness. Its thickness is generally about a tenth of a line. At a later period the walls of the cyst become so thin and transparent that they have been mistaken for the arachnoid it- self They differ, however, from the latter in being rather less transparent and thin, and particularly in the circumstance of presenting numerous vas- cular arborizations. When death occurs at this stage, which M. Legendre (whose description we chiefly follow) calls the second period, or that of complete organization of the cyst, the external surface of the latter is found to adhere intimately to the parietal portion of the arachnoid membrane, by very delicate cellular tissue, though not with so much force but that it may be detached by traction. The internal portion of the new membrane, on the contrary, which is lubricated by the serosity of the arachnoid tissue, is very slightly adherent to the layer of that membrane covering the brain. So long as the cyst formed by the new membrane, or, as it is called by MM. Killiet and Barthez, the 'pseudo-arachnoid membrane, contains an amount of fluid sufficient to keep its surfaces separated, its cavity is single. When, on the contrary, the walls of the cyst have come into contact, either because of the partial absorption of the contained fluid, or because the fluid has accumulated at the lowest points, or wherever there is the least resist- SYMPTOMS. 517 ance, the cavity becomes multilocular iu consequence of the cohesion of its walls at certain points. The size of the cyst varies exceedingly. Sometimes it covers the greater part of the convex surface of one hemisphere, sometimes the whole, while in other instances it extends to the base, forming in that case a nearly com- plete shell for the whole brain. The quantity of fluid varies in diftereut cases. Sometimes it amounts only to a few large spoonfuls ; in others, to one or two, or eight or nine ounces; in one case observed by MM. Rilliet and Barthez there was upwards of a pint on each side, or more than a quart in all. In most instances the hremorrhage occurs into both halves of the arachnoid membrane, so that there is a cyst for each hemisphere. More rarely it occurs only on one side. In the second stage, and when the effusion is very large, which rarely happens except in young children, and prior to ossification of the fonta- nelles or sutures, the lesion constitutes a form of chronic external hydro- cephalus, and the symptoms are such as will be detailed under the head of this latter disease. The vault of the cranium is enlarged by the un- natural prominence of the frontal and parietal bones ; the sutures are more open than usual, and the anterior fontanelle is distended and pro- tuberant. When the etfusion occurs thus early in life before complete ossification of the skull, the brain does not appear compressed or flattened, as it does when the disease occurs at a later period. The visceral portion of the arachnoid is often thickened, opaque, and more resisting than natural. The pia mater is frequently infiltrated with a good deal of serosity, which sometimes has a gelatinous appearance. When death has occurred in the first stage of the disease, the brain usually presents signs of hyperemia. The veins on the surface of the hemi- spheres are enlarged, the cortical substance is of a bright rose-gray color, and the medullary ix)rtion is dotted over with drops of blood. Sometimes the cellular substance beneath the arachnoid is slightly infiltrated with serosity, at other times not. The ventricles contain a very small quantity of fluid. The exact anatomical cause of the cerebral hiemorrhage in children is still subject to some doubt. It appears probable that it usually results from intense determination of blood to the head, or from extreme passive congestion, which lead to the rupture of vessels so minute as to escape notice, or possibly in some cases to the transudation of blood through the capillar}' walls without actual rupture. We are not aware that any care- ful micrascopic examination has yet been made of the condition of the walls of the vessels in such cases. In some rare instances, however, as in one witnessed by M. Legendre, the effusion is the result of the rupture of a vessel of some size. In the case observed by him, death took place in twelve hours from the attack, and the left hemisphere was found covered with a layer of coagulated blood, which had escaped from a ruptured vein. {Biblioth. du Med. Prat., t. vi, p. 192.) Symptoms; Duration. — The symptoms of htrmorrhage into the smbatance of the brain in the child are, as a general rule, extremely obscure and un- certain, though in some few cases that have been observed, they were as characteristic as those which occur in adults. In obscure cases, the chief 518 CEREBRAL HEMORRHAGE. symptoms that have been noticed were restlessness, delirium, headache, violent fever, grinding of the teeth, and, after a time, complete abolition of the intelligence, fixity of the eyes, invariable dilatation of the pupils, stertorous respiration, and general insensibility. Of three cases reported by M. Valleix (CUnique des Mai. des Enf,), the nature of the disorder was easily diagnosticated in one by the existence of complete hemiplegia, while in the two others the only marked symptom was entire immobility. The only certain symptom of the disease, therefore, would be a sudden attack of hemiplegia, either as the primary symptom, or following coma or con- vulsions, and lasting for at least several days. An attack of general paralysis would not be by any means so certain, as this may exist in sev- eral other diseases of childhood. In a case which came under our charge, we believe the attack to have been one of apoplexy of this kind. Case. — A girl, two years and a half old, apparently in the enjoyment of excel- lent health, was suddenly, and without ascertainable cause, attacked with violent general convulsions and entire insensibility, which lasted with very slight remis- sions of the convulsive movements, but without any return of consciousness, for twelve hours. At the end of that time the convulsions ceased entirely, and she very soon regained her consciousness, remaining merely peevish and languid. She was, however, completely hemiplegic on the left side, so that she could neither rise in bed, nor turn towards the right side. The paralysis diminished rapidly, but regularly, so that at the end of three days she could sit up in bed, and in a few weeks was perfectly well. This child remained well, with the exception of rather unusual excitability, and some peevishness of temper, for three years, when she died of scarlet fever. No autopsy could be made. The obscurity which exists in these cases will be clearly understood by any one who will read two examples given by Dr. West (Joe. cit., p. 1062). With a short quotation from the work of MM. Rilliet and Barthez, we shall pass on to the subject of meningeal apoplexy. These authors remark {op. cit, t. ii, p. 54), in speaking of this affection, that " cerebral symptoms have been observed to exists but of so unusual a character, and so different from what have been assigned by writers to apoplexy, that they could not lead to a diagnosis of the disease." We shall describe the symptoms of the meningeal form of haemorrhage under two heads : first, as they present themselves in the acute, and, sec- ond, as they occur in the chronic or second stage of the affection. Unfortunately the symptoms of the acute or first stage are not much more certain and distinct than those of cerebral haemorrhage. The disease may begin with fever and some convulsive movements, or, as happened in a case reported by M. Valleix, with violent general convulsions. Vomit- ing sometimes occurs at the beginning, but is usually very slight. It is difficult to know whether headache exists or not at the early age at which this disease commonly occurs. The convulsive movements generally af- fect particularly the eyes, and are followed by some degree of strabismus. The appetite is lost from the first ; the thirst is moderate ; there is no constipation. Soon after the symptoms just described, appear permanent contractions of the hands and feet, which are followed by attacks of tonic 11 SYMPTOMS OF THE MENINGEAL FORM. 519 or clonic couvulsious, during which sensibility and intelligence are abol- ished. Between the attacks of convulsions there is somnolence, which, though slight at fii^st, becomes more marked as the case goes on. The attacks of convulsion become more and more frequent as the case pro- gresses, until at last they are nearly constant. The tonic convulsions aftect the limbs and trunk both, but particuhirly the former, whilst the clonic spasms occupy sometimes one side of the body, sometimes the up- per extremity alone, and at other times the whole body, but even then are usually stronger on one side than on the other. Paralysis is rarely noticed in the disease ; it occurred only in one out of nine cases observed by M. Legendre, and in one out of seventeen observed by MM. Rilliet and Barthez. Dr. West remarks (p. 1061): "The absence of paralytic symptoms, however, is not the sole cause of the obscurity of these cases, but the indi- cations of cerebral disturbance, by which they are attended, vary greatly in kind as in degree. The sudden occurrence of violent convulsions and their frequent return, alternating with spasmodic contraction of the fingers and toes in the intervals, appear to be the most frequent indications of the effusion of blood upon the surface of the brain. I need not say, however, that such symptoms, taken alone, would by no means justify you in infer- ring that an effusion had taken place." Dr. West adverts particularly to the fact that apoplexy in the child is especially apt to occur in those who are weakly and feeble, and gives to this form of the disease the appella- tion of the cachectic form of cerebral haemorrhage. It must be remembered that in cases of valvular disease of the heart, embolism of one of the cerebral arteries may occur from the detachment of a fragment of a vegetation. We have observed this accident in a young girl, eight years of age, where the symptoms which marked the occurrence of the embolism were brief unconsciousness, followed by complete left-sided sudden hemiplegia. The diagnosis may be made in these rare cases by the detection of the physical signs of organic disease of the heart, and by the less severe cerebral symptoms which, as a rule, attend it. The hemi- plegia which follows embolism may be partial or complete. In our cases it persisted, with contraction of the paralyzed members, until death. The chronic form presents most of the symptoms which exist in acquired chronic hydrocephalus from .serous effusion into the ventricles. The cra- Dium is verj' large in proportion to the face ; the sutures are not ossified ; there is strabismus, with dilatation of the pupils ; the sense of sight is generally but not always retained; the face loses its expression; if the child was old enough at the moment of the attack to .show signs of intel- ligence, the latter are found to dimini.«h rather than increase, and some- times they are lost entirely, as the size of the head augments ; and the child is apt to utter loud cries, particularly during the night. The cutane- ous .sen.*?ibility is in general neither lost nor diraini.shed. The power of motion usually remains, though it was entirely lo.st in one ca.se. The apj^etite and thirst persist. The durnfion of cerebral apoplexy is very irregular. In one ca.se quoted by MM. Rilliet and Barthez, it was a quarter of an hour; in another, an hour ; in a third, forty-eight days; and in one reported by M. 520 CEREBRAL HEMORRHAGE, Valleix, in a very young infant, recovery was nearly perfect in a little less than two months, when the child was seized with pneumonia and died. The duration of meningeal apoplexy is also irregular. According to M. Legendre, all the recent cases seen by him in the Children's Hospital, died in from eight to twelve days, apparently rather from intercurrent diseases than from the primary affection itself, whilst cases occurring in subjects placed in better hygienic conditions, and not attacked with intercurrent affections, passed into the second or hydrocephalic stage of the disease. The second stage lasted, according to the same author, in the four cases which he witnessed, from eight to thirty months, and then death was the result, not of cerebral symptoms, but of complications affecting the thoracic organs. Diagnosis. — The diagnosis of cerebral haemorrhage is, as we have already stated, very difficult, unless hemiplegia exist. When the case commences, as it often does, with convulsions or with inflammatory symp- toms, it is often impossible to distinguish it from acute or tubercular disease of the brain. The diagnosis of meningeal hsemorrhage is also very often extremely difficult. Not uufrequently it occurs in the course of other diseases, and is then entirely latent. In acute, primary cases, the most important and distinctive symptoms are the early age of the subjects, between one and three years generally ; the violent fever from the commencement, marked by full, frequent, and regular pulse ; the absence of constipation ; the fre- quency of the convulsive attacks, and particularly the permanent contrac- tion with rigidity of the feet and hands. The diagnosis between the form of hydrocephalus which follows men- ingeal apoplexy, and ventricular serous hydrocephalus, is exceedingly obscure. The only circumstances which seem to have any real value are the acute commencement of the disease with the symptoms above detailed, and the early age of the patient. MM. Rilliet and Barthez state that they have never known a child of two years old, or younger, to die of ven- tricular serous hydrocephalus from tumors, whether tubercular or not, of the brain ; in all such cases the effusion has been the result of a haemor- rhage. Prognosis. — The prognosis of both forms of the disease is very grave. It is impossible, however, to ascertain the prognosis with any certainty, so long as the symptomatology of the two affections is so obscure as we have found it to be. That cerebral haemorrhage is susceptible of cure, however, is proved by the case reported by M. Valleix, already referred to, in which the child had nearly recovered, when it was seized with another dis- ease which destroyed it. Recovery from meningeal apoplexy is certainly extremely rare ; we believe, however, that we have met with one case in which this affection terminated favorably. Treatment. — The treatment must depend on the diagnosis and the special character of the symptoms in each case. In a sudden and severe attack, occurring in a strong and hearty child, in which the symptoms of congestion of the brain are strongly marked, and where we are not yet certain that actual haemorrhage has taken place, we should immediately resort to a general or local bloodletting. It was formerly customary to i TREATMENT. 521 employ venesection in all such cases, but we believe that equal relief can be obtained by freely cupping or leeching the back of the neck. When, however, we have every reason to believe that blood has been effused either in the niembmnes or into the substance of the brain, it is evident that bloodletting can produce but little effect, and that only in reducing the general fulness of the cerebral vessels. In such cases we should certainly limit ourselves to the application of a few cut cups or leeches to the nucha. It must further be remarked, however, that in many cases of cerebral or meningeal apoplexy, depletion in any form is entirely contraindicated ; since, as has already been stated, the efiusiou of blood occui*s frequently in feeble and weakly children, and either in the course of some acute or chronic disease, or as a consequence of previous diseases which have ex- hausted the forces of the constitution and induced a state of dyscrasia and diffluence of the blood. In such cases as these we must depend upon the use of rest, cold applications, purgatives, and counter-irritants as recom- mended below. Cold applications should be immedfately made to the head, either by wet cloths, the ice bladder, or by cold affusion. At the same time, or as early as possible after the invasion, a dose of some purgative medicine must be given. The best is calomel, either alone or combined with jalap or rhubarb. If given alone, it ought to be followed in an hour or two by castor oil, infusion of senna and manna, salts, magnesia, or some active cathartic. When the symptoms are very urgent, it is well to open the bowels still more speedily by a purgative enema. Counter-irritants are always useful adjuvants to the remedies already mentioned. They should consist at first of mustard plasters applied to the extremities, and shifted from place to place. When the symptoms do not yield after proper depletion and the use of sinapisms for some hours, it is well to apply blisters to the calves of the legs, and to the nape of the neck. The diet must be very strict, and should consist only of barley or arrow- root water, for a few days. The temperature of the room should be kept cool ; and the child sliould be placed with the head and trunk somewhat elevated, and kept profoundly quiet. For the paralysis which follows apoplexy in children, we believe that the most important, and indeed the only treatment necessary, is attention to the general health of the patient, in order to give to nature time and opportunity to effect the absorption of the clot which has been thrown out into the .substance of the brain, or into the cavity of the arachnoid mem- brane. This prrK-ess may, however, be aided and hastened by the prolonged administration of iodide of potassium with the iodide of iron. In cases of meningeal apoplexy, when the disease a-ssumes the chronic form, occasion- ing the kind of hydrocephalus we have described, there is little more to be done than to attend to the general health of the child, and to endeavor to promote absorption of the fluid by the internal administration of diuretics, and the preparations of iodine. It has been proposed also to get rid of the fluid by tapping, as has been done in congenital hydrocephalus, and it is 522 CHRONIC HYDROCEPHALUS. indeed in cases of the form we are now considering, when the fluid is en- tirely external to the brain, and where no malformation or organic dis- ease of the brain exists, that this operation has been found most successful. (See treatment of chronic hydrocephalus.) ARTICLE V. CHRONIC HYDROCEPHALUS. This term is applied to an affection characterized by an excessive accu- mulation of serous fluid, either within the ventricles of the brain or the sac of the arachnoid. The names internal and external have also been applied to it, in accord- ance with the position of the fluid : the former being given to those cases where the ventricles are the seat of the morbid collection, and the latter indicating that the fluid has accumulated in the cavity of the arachnoid and consequently surrounds the exterior of the brain. Chronic hydroce- phalus may either be congenital or acquired, the latter variety presenting the most interest in a practical point of view, since congenital hydrocepha- lus is usually associated with some malformation of the brain which renders extra-uterine life almost impossible. In either form it is a comparatively rare disease in Philadelphia. Our more recent experience however has furnished us with numerous oppor- tunities for studying its symptoms, treatment, and pathology. Morbid Appearances. — There are indeed few diseases in which it is of more importance to correctly establish the exact nature of the morbid process and the resulting lesions, since, as we shall see in a later part of this discussion, questions of the utmost practical value hinge upon the de- termination. Internal Hydrocephalus. — In this condition the amount of fluid is often very large, and varies from half a pint or a pint, to even as much as a gallon. Trousseau mentions a case where the fluid weighed 30 pounds, and Frank one in which it weighed 50 pounds. The formation of this ac- cumulation being gradual, the cavities of the brain accommodate them- selves to it, the ventricles become distended, and the communications be- tween their cavities are all enlarged; and occasionally the septum lucidum is perforated. This distension is usually most marked in the lateral ven- tricles. The hemispheres of the brain yield to the pressure of the increas- ing collection in the ventricles ; their convolutions are unfolded and flat- tened, so that the interval between them is only marked by a sinuous shallow groove, and the hemispheres are so thinned out as to form a layer not exceeding a few lines in thickness. It is not unusual, however, even when the distension of the brain has proceeded to this extreme degree, to be able to trace the cineritious and white layers, preserving their normal relations. The consistence of the expanded brain-substance varies in dif- ferent cases ; usually, however, it remains normal, or is even increased, though in some cases it has been found so soft as to tear upon the slightest ANATOMICAL APPEARANCES. 523 traction. The structures at the base of the brain present the same changes in consistence. One of the most important questions in this rehition, as bearing upon the causation of the affection, concerns the condition of the lining mem- brane of the ventricles. The analogy of all other serous membranes would lead us to infer that in those cases where no mechanical obstruction to the circulation exists, such as a tubercular tumor pressing upon the sinuses of the brain, we should look for the cause of the serous accumulation in a morbid state of the lining membrane of the ventricles. This view is fully confirmed by the study of fatal cases of internal hydrocephalus, since in many cases this membrane is found much thickened, and either softened or roughened and granular. The granular condition of the membrane presents many degrees : in some cases it is merely a slight irregularity of the surface, while in others there is an unevenness as marked as that of shagreen, or even a formation of granules, which, at times, measure one-third of an inch in diameter, or even become distinctly pedunculated. Occasionally, a false membrane is found lining one or both ventricles, as the result of the chronic inflammation of the lining membrane of these cavities. Even when the symptoms of hydrocephalus have not appeared until some time after birth, the brain may be found to present positive evidences of congenital malformation, in the retarded development of some of the structures at its base. The veins of Gralen and sinuses of the dura mater are usually found in a healthy state, with their calibres quite free ; a fact which is of im- portance in considering the mode of production of internal hydrocephalus. In external hydrocephalus, the collection of fluid occurs in the sac of the arachnoid, or in a pseudo-cyst resulting from the transformation of a blood-clot, as described in our remarks on meningeal apoplexy : the brain is separated from the cranial vault and compressed against the base of the skull, as the lung is forced back against the spinal column by the fluid of hydrothorax. The superior cerebral veins, passing from the surface of the brain to the longitudinal sinus, traverse the fluid, and at times are so much stretched as to raise the surface of the brain into p<^)ints. Excepting in cases, however, where the disease is congenital and coinci- dent with some original malformation of the brain, there is no absolute diminution in the size of this organ. The character of the fluid varies considerably in different cases, and probably de|)ends to a great extent upon the cause. In an analysis by Spengler of the fluid evacuated in a case of hydro- cephalus by puncture, the fluid was clear and colorless ; specific gravity 1010, of acid reaction, and contained no albumen. It also contained chlorides and phosphates of soda and jKitassa, but no sulphates. It ap- pears, therefore, in such cases as this, that the fluid is not the result of inflammation, but rather due to a passive dropsy. It is, we believe, espe- cially in cases of external hydrocephalus, where the fluid results from the transformation of a sanguineous efiusion, that it possesses these characters. 524: • CHRONIC HYDROCEPHALUS. On the other hand, the fluid frequently contains a large amount of or- ganic matter, and closely resembles the effusion in pleurisy or pericarditis. Thus, in a case reported by Battersby, which was tapped eight times, the fluid always contained varying, and sometimes very large, proportions of albumen. Causes of Internal Hydroeephalus. — The opinions of the highest authori- ties and most experienced observers still difier widely upon this important point. We have alluded to the fact that not unfrequently the brain is found to present evidences of congenital malformation, and this fact has led to the opinion that internal hydrocephalus is almost invariably the effect of ar- rested development of the brain. Rilliet and Barthez place the eff'usion in this affection in the class of pas- sive dropsies, and express their belief that most frequently the cause of internal hydrocephalus is to be found in compression of the veins of Galen or ventricular veins, caused by the development of a tumor in the cranial cavity, and usually in the lobes of the cerebrum. The unfavorable influence which either of these views would have upon the prognosis and treatment of this disease, is of course evident. On the other hand, however, the opinion is advanced that the starting- point of internal hydrocephalus is, in fact, a morbid condition of the lining membrane of the ventricles. We have briefly described the appearances of this membrane which have now been observed in numerous well-authenticated cases of internal hydro- cephalus, and which plainly indicate the pre-existence of a chronic inflam- mation, so that we are led to believe that in a certain number of cases, at least, the effusion is due to a slow inflammatory action in the lining mem- brane of the ventricles. Those cases in w^hich these appearances have been found associated with retarded development of the brain, may be readily explained upon the supposition that the inflammation has been excited at a more or less advanced period of intra-uterine life, and that the resulting eff*usion has so compressed the structures at the base of the brain as to pre- vent their normal development. We may add that many eminent authori- ties, as Trousseau, now adhere to this view. In a very interesting case of this form which we have lately had under observation, the mother, a very intelligent and healthy woman, had quite a severe fall about the fourth month of pregnancy. In addition to this, however, she lost a favorite brother-in-law from a violent attack of cerebro- spinal meningitis about the same time. She nursed him constantly during his illness, and was very deeply impressed with the unnatural appearance of his face and head which had been shaved. This became so fixed an impression that more than once, between the time of his death and the birth of her child, she said it would not be strange if something were to prove wrong about the baby's head. We attributed the hydrocephalus which did actually develop in her infant to inflammatory changes, perhaps induced by the fall ; but the powerful maternal impression above men- tioned certainly constituted a curious coincidence. In cases, however, where the effusion into the ventricles depends upon the SYMPTOMS. 525 development of a tumor in the cranial cavity, the growth ^Yill usually be found to occupy the cerebral lobes iu such a mauner as to compress the veins of Galen, which pass along the under surface of the corpus callosum, and are indeed the only true ventricular veins. The causes of extenialhydrocephahis are perhaps less obscure and uncer- tain than those of the internal form. In some cases, the effusion in the sac of the arachnoid is evidently due to a rupture of some portion of a brain distended by accumulation of fluid iu the ventricles, and hence is merely a sequel of internal hydro- cephalus. According to the able investigations of Legendre, and Rilliet and Bar- thez, one of the most frequent causes of external hydrocephalus is ha?mor- rhage into the arachnoid space ; the effused blood undergoing changes which result in the presence of large quantities of clear fluid, as described at length in our remarks on meningeal apoplexy. We have alluded to the fact that in many cases of external hydrocephalus the diminution in -ize of the brain is comparative rather than real; but there are instances where this form of the disease is found associated with malformation of the brain, which appears as a small, misshapen mass, pressed against the anterior part of the base of the skull. In such cases, it appears as though the fluid were ix)ured out to fill up the vacuum between the skull and atrophied brain. It is also possible that these conditions may be pro- duced by the occurrence of haemorrhage into the arachnoid space during intra-uteriue life, and before the brain had attained its normal develop- m'-iit. r^YMPTOMs; Physk AL Appearance. — The unusual size of the head is one of the most striking symptoms of hydrocephalus. In many cases associated with atrophy or retarded development of the bones of the face and the rest of the body, this enlargement appears even more monstrous than it in reality is. The diameters of the cranium are, however, very much enlarged; cases being on record in which at the age of a few weeks the circumference of the head has been twenty-three inches, or even more. The increase in the size of the head is not, however, invariably the earliest sign of the disease, being frequently preceded by marked symp- toms of nervous disturbance, or of impaired nutrition. The bones of the cranial vault which contribute to this enlargement are the frontal, the parietals, the occipital, and the squamous portions of the temporals. When the disease makes its a])pearance before the ossification of the sutures and fontanelles has been completed, the gradual increase of the fluid sejmrates these bones more and more widely. The occipital bone thus is pushed backwards, the parietals outwards and backwards, the fron- tal upwards and forwards. The increase in the size of the head is thus effected by the widening of the sagittal and coronal sutures, and by en- largement of the anterior fontanelle. The displacement of the frontal bone gives rise to a marked prominence of the forehead, which overhangs the diminutive features: while at the same time the pressure of the fluid depresses its orbital plate into an ob- 526 CHRONIC HYDROCEPHALUS. lique position, contracts the orbital space, and gives rise to the character- istic appearance of the eye, the globe being prominent but directed down- wards so as to be buried beneath the lower eyelid, which conceals almost the entire cornea. The membrane which covers in the enlarged sutures is often distended and prominent, or remains on the normal level. A distinct sense of fluc- tuation is readily obtained by palpating one of these spaces, and in some cases, principally in young infants, and where the collection is very large, the head is absolutely translucent. When life is prolonged, and the dis- ease arrested, the ossification of the cranial vault is effected by the de- velopment of numerous supernumerary bones, or ossa triquetra, in the membranous spaces. These little bones are consequently found in the largest numbers in the coronal and sagittal sutures, where the deficiency is greatest and most wide. When, on the other hand, the disease does not begin until the sutures have united and the fontanelles ossified, it is rare for the head to attain any very large size. In a few cases, however, oc- curring in children of even nine years of age, the sutures have reopened under the continuous pressure, and the bones have been found separated as much as half an inch. More usually, however, in such cases, the pressure seems to expend itself in thinning the cranial bones, which become reduced to mere shells of light, fragile compact bone. Occasionally, so far from inducing thin- ning of the bones, actual hypertrophy occurs, and the bones of the cranial vault acquire an unusual thickness, and at the same time are dense and indurated. The early symptoms of the disease vary much. When it is congenital, there are nearly always evidences of cerebral disturbance either from the date of birth, or appearing within a few days. These symptoms are occa- sionally slight, consisting merely in an unnatural expression, with oscilla- tion of the eyes or strabismus : or, on the other hand, there may be attacks of convulsions frequently repeated. These symptoms speedily become associated with enlargement of the head and the characteristic alteration of physiognomy. When the dis- ease is strictly acquired, the early symptoms are even more varied. In one set of cases they are those of haemorrhage into the arachnoid ; in another the evidences of inflammation of the serous lining of the ven- tricles, of more or less acute character, are present ; whilst in numerous cases the only symptoms which precede the enlargement of the head are those of failing nutrition. Usually the aspect of children suffering with this affection is tranquil, or they may even present a certain unnatural gravity and apathy of ex- pression. Cerebral Symptoms. — At times the intelligence of the child, though per- haps poorly developed, remains intact, and there is no marked cerebral disturbance. In other cases, however, the advance of the disease is attended with a gradual failure of the intelligence, and impairment of the special senses, and especially of vision. DIAGNOSIS. 527 In addition to the displacement of tlie globes of the eyes and alterations in the pupils already mentioned, the accumulation of fluid rapidly causes obstruction to the return of venous blood through the sinuses, so that even at an early stage, ophthalmoscopic examination shows marked changes in the fundus of the eyes. These consist in increase in the number and size of the veins of the retina, with later serous infiltration or even atrophy of the optic papilla. The nervous symptoms are at times much more marked ; and there may be frequently recurring convulsive attacks, or, as West mentions having seen in several cases, spasmodic attacks of difficult breathing, with a crow- ing sound in inspiration (^laryngismus stridulus). According to Rilliet and Barthez, the common sensibility of the sur- face is often impaired ; and there may be more or less complete paralysis, or contraction with rigidity of the extremities. It is, of course, difficult to estimate the amount of suflfering experienced by the little patients ; ordinarily it does not appear great, and indeed in -orae cases it has seemed chiefly due to the opposition offered by the cranial walls to the distension of the brain. In one case of MM. Rilliet and Barthez, the development of acute pain coincided with the ossification of the fontanelles. The general condition of children suflfering with chronic hydrocephalus varies greatly. In some cases they preserve their aj^petite and digestion, and appear well-nourished and strong to a late period in the attack ; but more fre- quently they present marked evidences of impairment of nutrition. The appetite may indeed remain, but the child loses both flesh and strength ; the bowels are irregular ; usually constipated, but alternating with temporary attacks of diarrhoea. In the majority of cases, perhaps, these symptoms are not sufficiently pronounced to establish the character of the attack, until the increasing -ize of the head becomes manifest, and the child acquires the distinctive physiognomy of hydrocephalus. Even after marked enlargement of the head has occurred, however, the advance of the case is far from being uni- In almost every instance there are pauses of the most variable : /lency and duration, during which the child seems free from pain, improves in general condition, and the development of the head is tem- porarily arrested. Death is frequently directly induced by .some intercurrent affection, wholly unconnected with the disease of the brain : while, in other case**, it immediately follows a violent attack of convulsions, or is preceded by .symptoms of an acute exacerbation of the cerebral di.sorder. In some rasf-s, also, the patient« sink into a condition of atrophy, and die worn out by the protracted suffering and malnutrition. DiAGNO*is. — During the early stage of the disorder, if the nervous symptoms are slight, consisting merely in occa-^ional attacks of heat of the head, attended with pupation or tension of the anterior fontanellf, and rf-tlessness, and crying, the diagnosis must remain uncertain. Art<'r the enlargement of the bead has progressed to any considerable degree, the 528 CHRONIC HYDROCEPHALUS. expression of the little patient, taken in conjunction with the other symp- toms, is usually perfectly characteristic and conclusive. The morbid condition with which it is most likely to be confounded, is rickets of the skull. In fact, in some cases, the enlargement of the head, which results from these two affections, is quite identical. Usually, how- ever, this is not the case; and the hypertrophy of the rachitic bones takes place irregularly, so that the skull acquires a square instead of a rounded form ; the orbital plates of the frontal bones are not displaced ; so that, although the forehead may be large and overhanging, the axes of the eyes are not disturbed ; the fontanelles are not widely open, prominent, or dis- tended ; and, finally, of course, fluctuation on palpation is never present. In addition to this, the evidences of rickets in other portions of the body, and the peculiar symptoms of that affection, as detailed in the article de- voted to its consideration, nearly always enable the diagnosis to be readily made. We have already mentioned the changes which ophthalmoscopic exami- nation shows in the retina in this disease, and as a similar examination reveals no lesion whatever in cases of rachitic enlargement of the head, it is evident that the use of the ophthalmoscope may be of material aid in establishing the diagnosis between these affections, which is, despite all the points of distinction above referred to, obscure and difficult in some few cases. ' In doubtful cases assistance may possibly also be derived from cerebral auscultation ; the presence of a bruit over the anterior fontanelle being thought by some authors to be a valuable indication of the rachitic nature of the enlargement of the skull. The significance of this cephalic bruit is, however, so much disputed, that it is at present impossible to assign any definite value to it. The only other pathological condition with which chronic hydrocepha- lus is apt to be confounded, is hypertrophy of the brain, an extremely rare affection, due to an increase of the interstitial connective tissue of the brain, the so-called neuroglia. In hypertrophy of .the brain, however, the symptoms do not usually ap- pear so early as in chronic hydrocephalus, nor is the cerebral disturbance so marked as in the latter affection. The enlargement of the head, also, which is the most characteristic feature of both conditions, is not so great in hypertrophy of the brain, and, instead of being uniform and assuming a rounded form as in hydrocephalus, occurs especially at the occiput. There is, further, no depression of the orbital plates of the frontal bones in hypertrophy of the brain, so that the axes of the eyes are not disturbed, and the globes are not displaced in the way we have already described as so characteristic of hydrocephalus. Finally, the sutures are not so widely open, nor the fontanelles tense and prominent as in hydrocephalus ; and, of course, the fluctuation which can be detected on palpation in some cases of this latter disease is never present. Prognosis. — Chronic hydrocephalus still ranks among the most fatal diseases ; so much so that Rilliet and Barthez — who, however, attribute TREATMENT. 529 its production usually to the presence of a tumor in the brain — express their belief that it is invariably fatal. Indeed, it must be borne in mind that in many cases treatment must necessarily fail from the coexistence of some extensive congenital malformation of the brain. We should suspect the presence of this complication when there is serious disturbance of the nervous system, such as paralysis, or frequent and apparently causeless convulsions. Unfortunately, however, these hopeless cases cannot always be distinguished. While the prospect of a complete cure is very slight, it must be remem- bered that even a high degree of hydrocephalus is not incompatible with considerable prolongation of life. Thus cases have been known to attain the age of 15, 20 or even 25 years, with the maintenance of a fair degree of mental and bodily power. The prognosis in cases of external hydrocephalus, especially when of acute origin, is less unfavorable than when the effusion takes place into the ventricles. Whatever be the seat of the effusion, however, and the size of the head, the case must not be regarded as hopeless and beyond reach of remedial measures, so long as the functions of the brain are well performed, since there are well-authenticated cases of complete recovery from chronic hydro- cephalus, even when congenital. In a case we have recently had under observation, the symptoms of hydrocephalus, apparently of congenital origin, advanced rapidly up to the age of three and one-half years, at which the enlargement of the head was arrested, the mental and physical powers of the child developed reg- ularly, and at the age of seven years it seemed probable that complete recovery would result. Treatment. — It must be sufficiently evident, from the previous consid- eration of this affection, that there are numerous cases in which all treat- ment must prove unavailing, from the serious organic disease of the brain which accompanies it. Under any circumstances, however, the nature of the treatment and its efficiency will be much influenced by the early stage at which it is instituted. In regard to the utility of various sj)ecial remedies, also, there is the .Teatest diversity of opinion ; and, indeed, there is no plan of treatment vhich possesses so much evidence in its favor as that originally proposed by Profess^>r Golis, of Vienna. If the disease be in its incipience, and the constitution and hereditary tendencies of the child free from taint, this distinguished physician recom- mends that the head should be shaved, and one or two drachms of dilute mild mercurial ointment rubbed daily into ita scalp. While this treatment is being carried out, the head should be constantly protected by a flannel cap. At the same time, calomel should be given in doses of one-sixth to >ne-fourth gr. twice daily, unless it irritate the bowels, when the inunction alone should be continued. If after pursuing this treatment, conjoined with the most careful atten- tion to diet and all hygienic precautions, for five or six weeks, there is 530 CHRONIC HYDROCEPHALUS. marked improvement in the condition of the child, the mercurials may be gradually discontinued. The iodide of potassium has been highly recommended as a substitute for the mercurials above mentioned, and several cases of apparent recovery under its use are on record. It should be given in large doses, and for a considerable length of time. Trousseau, who recommends its use, joins to its internal administration the external application to the head of lotions containing iodine. Should the disease remain uninfluenced at the end of this time, it is proper to add to the treatment diuretics and counter-irritants, in the form of issues in the back of the neck, which may be kept open for several weeks. Dr. West recommends the frequent application of blisters as a substitute for the use of issues. During the employment of this or any other mode of treatment, it will be occasionally necessary to have recourse to antiphlogistic remedies, to subdue the exacerbations of heat and restlessness which occur more or less frequently, and threaten the development of an acute inflammatory con- dition. Nor should we fail to pay attention to the proper performance of all the functions ; to the maintenance of the appetite and digestion by the use of tonics ; and in case of the existence of a scrofulous diathesis, to the administration of cod-liver oil, iodide of iron, etc. When, despite the most careful employment of well-directed measures, the disease is clearly advancing, it is worse than useless to persist in any plan of treatment which annoys or absolutely pains the doomed child ; our I only endeavor should then be to subdue any intercurrent disorder which! might hasten the fatal result. More than twenty-five years ago, the use of compression of the head, toj prevent its yielding to the accumulating fluid, was urged by Barnard, and experience has shown it to be a valuable adjunct to other treatment, though! it is inapplicable while any acute symptoms are present, and according tol West is best adapted to cases of external hydrocephalus succeeding to haemorrhage into the arachnoid space. M. Trousseau recommends the following mode of applying this pressure : Strips of adhesive plaster, about one-third inch wide, are passed from each mastoid process to the outer part of the orbit of the opposite side ; from the nape of the neck along the longitudinal sinus to the root of the nose ; across the whole head, intersecting at the vertex ; and finally are kept se- curely in position by a strip passed thrice around the head, the ends of the previous strips being turned up over the first coil of this strip, and secured by the succeeding turns. It becomes necessary to loosen these strips instantly, if any symptoms of compression of the brain develop themselves, since the increasing pres- sure of the accumulating fluid may produce irreparable injury to the base of the brain, or even, as happened to M. Trousseau, detach the ethmoidal bone from its connections. The unfavorable results of all strictly medicinal treatment, impelled physicians, at an early date, to resort to active surgical interference in Li TREATMENT. 531 chronic hydrocephalus, by puncturing the cranium and evacuating the fluid. The operation should be performed with a delicate trocar and canula, the puncture being made in the coronal suture, about an inch or an inch and a half from the longitudinal sinus, — and in a majority of cases, no evil consequences appear to follow the operation itself Much difference of opinion still exists, however, as to its curative influence. From a rigid analysis of oG reported cases in which this operation had been performed, Dr. West came to the conclusion that in only 4 had a permanent cure been effected. Other successful cases have been since reported, so that the oper- ation must be recognized as at least a justifiable one in certain cases. The circumstances favorable to its performance are, when the hydro- cephalus is external ; or when internal, is due to previous inflammation of the lining membrane of the ventricles ; when there is no reason to believe that the disease is congenital, and attended with arrested development of the brain; when, though the head may be very large and increasing in size, the cerebral functions are not seriously impaired ; and, finally, when the nutrition of the child is still good. Until, however, the treatment previously recommended has been faith- fully tried, and unless the disease be evidently advancing, a resort to this operation would be incurring grave risks with but slight prospect of success. Brainard, of Chicago, has recently recommended the injection of solu- tions of iodine into the cranial cavity, after puncture and evacuation of the fluid. He has employed this in at least two cases, without the devel- opment of any severe symptoms as a direct consequence of the treatment. One of the cases died at the end of eight mouths ; the other, at the date of the report, only thirty-five days after the oj^eration, had shown no un- favorable symptoms. He advises the use of an aqueous solution of iodine, in the proportion (of one-third gr. with one gr. of iodide of potassium, to f.5j distilled water; of this from f5j to fsj, may be injected ; the strength of the solution and Xhf amount injected being increased at subsequent punctures. In one of his cases, twenty-one injections were practiced in the course of seven months. Injections of this strength are usually followed by no symptoms of in- flammation whatever ; and this exemption has led to the employment of much stronger solutions. Thus Dr. Tournesko of Bucharest Cquoted by Bouchut), injected f^iij tr. iorline in f^v distilled water, immediately after having drawn off by puncture f5xxiv of serum. The operation was followed by slight febrile eicitenient ; but, at the expiration of fifleen days, the child seemed in exeellent health, the circumference of the head having diminished from 06 i to 43 centimetres. i 532 ECLAMPSIA. ARTICLE VI. GENERAL CONVULSIONS, OR ECLAMPSIA. General Remarks. — The word convulsions is a generic term applied to different forms of spasmodic disease, very dissimilar from each other in many of their characters. Writers make different classifications of convulsions according to their peculiar notions in regard to the nature and causes of these disorders. The best division is, it seems to us, that adopted by most French writers, who arrange them by their supposed causes, making three classes, idio- pathic or essential, sympathetic, and symptomatic convulsions. The first two classes are unaccompanied by appreciable lesions of the nervous centres, while the third is called symptomatic, because it includes cases of convul- sions which are the sign or symptom of an appreciable lesion of the cerebro- spinal axis, as for instance, those which occur in the course of meningitis, tubercular disease, hydrocephalus, apoplexy, etc. In idiopathic or essen- tial convulsions, the cause of the attack acts directly upon the nervous centres, while in those to which the term sympathetic is applied, the cause lies in the influence or effect upon the brain or spinal marrow of disease of some other organ ; to the latter class belong the convulsions which occur in the course of pneumonia, bronchitis, the eruptive fevers, etc. We shall not pretend to give an accurate account of symptomatic con- vulsions in this article, as they have already been treated of under the head of the different organic diseases of the brain in the course of which they occur. We shall refer to them in the present article only so far as may be necessary to elucidate the pathology, diagnosis, prognosis, and treatment, of idiopathic and sympathetic convulsions. There is a form of eclampsia occurring in children, which we shall de- scribe separately, as it differs in many of its characters from ordinary con- vulsions. This is the disease known by the names of spasm of the glottis, thymic or Kopp's asthma, laryngismus stridulus, and eclampsia with suffo- cation. Definition; Synonyms; Frequency. — By the term convulsion is meant a paroxysm of variable duration, usually attended with unconsci- ousness, and followed by stupor, and characterized by a primary involun- tary tonic contraction followed by irregular clonic spasms of the affected muscles. In general convulsions, to which the above definition especially applies, the entire system of voluntary muscles is usually affected ; though, as will be described hereafter, the attack may be a complete and genuine one of eclampsia, and yet the convulsive movements be limited in their extent to a single group of muscles, or even a single muscle. The only synonyms which it is necessary to mention are epilepsia puer- ilis, insultus epilepticus, and eclampsia. The latter term, eclampsia, is, we believe, preferable to any other, and we would gladly introduce it instead CAUSES. 533 of convulsions, which is too general a term to express the form of disease under consideration. The frequency of eclampsia is very great. During the two years 1873-74, 1392 children under fifteen years of age died in this city of convulsions; whilst, during the same time, 1973 died of infantile cholera, and 893 of pneumonia. It must be recollected, however, that a very large number of these cases of eclampsia ought, beyond doubt, to have been returned under other titles, a:? manv of them must have been a mere result of organic dis- ease of the cerebro-spinal axis, or of other acute local or general diseases. Predisposixg Causp^. — Essential and sympathetic convulsions are much the most frequent before the age of seven years, which is the case also in regard to symptomatic convulsions, though the latter often occur after the age mentioned. We have ourselves met with not less than 200 cases of convulsions, though we have preserved records of but 96. Of these, the age is noted in 91 cases, 19 of which occurred in the first year, 26 in the second, 20 in the third and fourth, 23 between the fourth and ninth, and 3 between the ninth and thirteenth years of life. Dr. West {op. ciL^ p. 42 I states that according to the Fifth and Eighth Reports of the Regis- trar-General, the deaths from diseases of the nervous system in London, under one year of age, bore a proportion of 30.5 per cent, to the deaths from all causes ; from the first to the third year, the proportion was 18.5 per cent. ; from the third to the fifth year it was 17.6 per cent. ; from the fifth to the tenth year, it was 15.1 per cent. ; whilst from the tenth to the fifteenth year it was only 10.6 per cent., and the total above fifteen years was but 10.4 per cent. Again, to show the very great influence of age upon the predisposition to convulsions. Dr. West states that, within the first year, the deaths from convulsions constituted 73.3 per cent, of the total mortality from diseases of the nervous system ; between the first and third years, the proportional mortality from convulsions to the total mor- tality from aflTections of the nervous system, was 24.9 per cent.; between the third and fifth years, it was 17.8 per cent. ; between the fifth and tenth years, it was 9.9 |>er cent.; while between the tenth and fifteenth years it had fallen to 2.4 per cent. ; and above fifteen years it was but 0.8 per cent. It is jrenerally stated that convulsions are more common in girls than boys. MM. Rilliet and Barthez found this to be the case in their private practice, whilst in the hospital, .sympathetic and symptomatic convulsions were most frequent in boys. According to our experience, they have been alrooet efjually frequent in the two sexes, since of 92 cases that we have Been in which the sex was recorded, 47 occurred in boys and 40 in girls. It has been generally supposed that a delicate and nervous constitution is a powerful predisposing cause to convulsive attacks. Thid has been de- nied, however, by .several recent writers, whose observation is very careful and accurate. We are disp^>sed to believe that it is not so murh a feeble or delicate constitution that preflisposes to convulsions, as it is one charac- terized by a highly .«»u.sceptible, irritable, and nervous temperament, which often exi8t«t, in our opinion, in connection with a healthy and vigorous phy-ir-al organization. Of 96 children in whf)m we have seen convulsive attaf k-, and in whoni this point was noted, these occurred more than once 534 ECLAMPSIA. in 13. Of the 13, nine presented every appearance of strong and vigorous health, with the exception that when laboring under any kind of sickness, as dentition, indigestion, the fever accompanying simple angina, in two the invasion of measles, and in one that of erysipelas, they immediately be- came extremely restless and irritable, or heavy and drowsy, and at a very early period, and sometimes with very little warning, were seized with con- vulsions. In one, a well-developed infant in its first year, the convulsions occurred every month or six weeks, without any appreciable cause. Three of the 13 were delicate : one was puny and feeble until after the comple- tion of the first dentition, when it grew strong and hearty ; one had had an apoplectic attack when an infant which had caused partial loss of power of one side ; and the third was very weak at birth, then grew stronger, and died in its second year of hydrocephalus following scarlet fever. The number of convulsions varied in the different subjects. In 1 there were five different attacks, in another four, in 4 there were three, and in 5, two. In two the attacks were very numerous, recurring frequently, and from very slight causes, or without any appreciable cause. They all recovered but two, and are still living. Of the 11 now living at various ages, all but one are free from anytl?ing like epilepsy, and that one, though liable during three years to attacks of an epileptiform character, became gradu- ally less and less subject to the seizures, and has now been for several years perfectly well in all respects. We have another patient, a boy, whose case is not included amongst the above, now five years old, who has had ten different attacks of convulsions. These attacks were all produced by some disturbance of his health. Sev- eral of them have occurred at the outset of a febrile reaction caused by a simple catarrh of the upper air-passages, — the convulsions ushering in the catarrh just as they sometimes do an attack of measles or scarlet fever. On other occasions, the seizure has evidently been the result of a febrile movement caused by indigestion or gastric irritation. After having had nine different attacks, he remained free from them for a whole year, and then had the tenth at the very beginning of a catarrh of the larynx, fauces, and nasal passages. This child has never as yet exhibited any symptom whatever of disease, either acute or chronic, of the cerebro-spinal axis, and as the convulsions have always been connected with a febrile movement, there is every reason to hope that they are not epileptic. Another patient, likewise not included amongst the above, a girl now five years old, has also had frequent attacks, but as they are of short duration, always coincident with the fever of catarrh, or digestive disorder, and on one occasion that of measles, and as between the seizures her health is excellent, there is but little reason to fear epilepsy. It is generally believed that the predisposition to convulsions is some- times hereditary. We have remarked in regard to this point, that several children in the same family sometimes suffer from the disease, and that the nervous temperament to which we alluded above, appeared in some in- stances to have been inherited by the child from its parents. In one family that we attend, out of six children, all but one have had attacks of convulsions : one of these children had but one attack, and that I CAUSES. 535 was at the age of ten years, and was caused by a fit of indigestion occur- ring during convalescence from pneumonia. The other four children had each several attacks, occasioned always by the febrile movement result- ing from some of the numerous disorders of infancy. In none of these has there been any reason to suppose that the attacks were settling into epilepsy. Some very interesting evidence confirmatory of this view has recently been furnished by Dr. Robert P. Harris, of this city, in an article read before the Philadelphia Obstetrical Society (see Amer. Jour, of Obstet., vol. ii, No. 2, August, 1869). His record embraces 38 cases of eclampsia, 37 of which occurred in 13 families, in which, collectively, there were 55 children who lived long enough after birth to prove their liability or exemption ; 4 having died too early to determine whether they were subject to convulsions or not. All of the individuals included in the statistics were descendants of the first, second, or third generations, of two pairs of ancestors ; of the pres- ent rising generation (the second) there are 31 members, only one of whom has as yet married ; twenty of the 31 have had convulsions. The exciting causers of convulsions are exceedingly numerous and dis- similar. Amongst the causes of essential convulsions are cited vivid moral emotions, violent pain, high temperature, exposure with the head uncov- ered to the sun, and sudden exposure to cold. In many cases, however, the exciting cause cannot be detected. The exciting causes of sympa- thetic convulsions may be almost any of the diseases incident to childhood. Amongst them we will cite as the most frequent, hooping-cough, pneu- monia, catarrh, scarlatina, measles, violent fever from any cause, dentition, and indigestion. It will be observed that many of the causes here assigned for convul- sions are also regarded as inducing cerebral congestion, either of the ac- tive or passive form. It is accordingly held by some authors that the way in which such influences act is to cause congestion, and that the con- dition of cerebral congestion is the cause of the convulsions. In our arti- cle on congestion of the brain will be found a brief statement of the considerations which lead us to doubt the propriety, in many cases, of as- cribing to that condition the convulsive and other nervous symptoms which occur so frequently in connection with the acute local or general diseases of childhood. In regard to some of the other causes above men- tioned, however, there can be no doubt that they are likely to induce extreme cerebral congestion. We have seen that in both the active and passive forms of such congestion, convulsions are of frequent occurrence. It is proper then to say that congestion of the brain, of either form and however produced, is among the frequent causes of eclampsia in chil- dren. Of 06 cases of convulsions, of which we have preserved notes, we havft regarded only 4 as essential, while 70 were sympathetic, and 22 sympto- matic. Of the 4 essential ca.ses, we could not detect the exciting cause in any. Of the 70 sympathetic ca,ses, it was scarlet fever in 12 ; pertussis in 9; indigestion in 13; pneumonia in 3; the fever of simple angina in 6; 536 ECLAMPSIA. cholera infantum and bronchitis, each 3 ; dysentery, 4 ; measles and den- tition, each 6 ; enteritis, the fever and irritation caused by a burn upon the back, and the onset of erysipelas, each 1 ; an o.verdose of castor oil (5vj) given to a young child with a slight cholera, 1 ; and lastly, fecal accumu- lations in the large intestine, 1. Symptoms. — Frodromic Symptoms. — It has been asserted by some writers that most attacks of convulsions in children are preceded by prodromic symptoms, which indicate to the experienced eye their approach. This does not agree exactly with our own experience, at least in regard to the essential and sympathetic forms, since of the cases of the former variety, well-marked prodromes did not occur in any, and of 64 cases of the latter, in which the early symptoms were noted, strongly-marked precursory phe- nomena occurred only in 8. We do not mean to say that there were no symptoms in the other 56 cases which might have indicated to an expe- rienced eye the probability of an approaching attack of convulsions, but merely that there were none that were strikingly characteristic, none which pointed out clearly and decisively that such a crisis was close at hand. In many of the 56, there were symptoms that might be regarded as indicating, with various degrees of probability, the approach of the convulsive seizure; but, inasmuch as they were such as constantly exist in children not predisposed by temperament or constitution to eclampsia, without the development of the disease, they scarcely deserve to be called precursory symptoms. The precursory symptoms of idiopathic and sympathetic convulsions are, therefore, difficult to describe because of their variable and uncertain character. They consist in general, however, of whatever indicates a highly disordered condition of the nervous system. The most marked symptoms are unusual drowsiness, excessive irritability, a peculiar physi- ognomical expression, general tremors, and the drawing of the thumbs into the palms of the hands, or rigid flexion of the toes. The drowsiness which precedes an attack of eclampsia, is almost always accompanied with some restlessness. The sleep is light and easily disturbed ; the child moves and turns, or starts and moans ; often it seems to have frightful dreams, and will scream out or wake suddenly bewildered and terrified, and when roused is generally exceedingly irritable, crying violently or fretting at the slightest contrariety, or without cause. The face, and particularly the eyes, often exhibit a peculiar expression, altogether diflTerent from their usual appearance. The expression which has most struck us, and which we have seen on several occasions, is a fixed and staring look, lasting but for an instant, as though the child were looking intently at some object, while in fact it is gazing at vacancy ; at the same time the fexpression is entirely without meaning. The child seems, in fact, for a moment, to be in a state of ecstasy. In some instances a sardonic •smile is seen to pass over the countenance just before the attack. The tremors or tremblings alluded to above, occur both in the sleeping and walking state, but particularly in the former. Flexion of the thumbs and toes has been noticed by different observers, but is, we believe, a sign SYMPTOMS. 537 rather of the approach of symptomatic, than of essential or sympathetic convulsions. The precursory symptoms of symptomatic convulsions will depend on the nature of the disease in the course of which they occur. Not unfre- quently the convulsions occur at the very outset of the disease of the brain or spinal marrow, when of coui"se there will be no prodromic symptoms whatever. According to Dr. Marshall Hall (Diseases of the Xervoiis Sys- tem, p. 149 ), the first and most frequent sign showing that the excito-motory system is becoming complicated in diseases of the brain is vomiting, after which come strabismus, a contracted state of the muscles of the thumbs or fingers, or some unequivocal spasmodic or convulsive atiection of the re- spiratory muscles, or of the muscles of the limbs. Symptoms of the Attack: — "With or without the precursory symptoms just described, the convulsion itself usually begins suddenly. The child often utters a cry ; loses consciousness and is seized with powerful tonic contrac- tion of the voluntary muscles ; the eyes are for a moment fixed and staring, and then drawn obliquely upward under the upper lid, so that the white portions of the balls alone are visible for an instant between the partially open lids; the trunk is rigid and stiff, the thorax immovable, the respira- tion suspended by rigid spasm of the respiratory muscles ; the face, for a moment pale, usually becomes livid and congested, and the veins of the neck are distended. This state of tonic spasm is followed quickly by the stage of clonic spasm, in which involuntary and most irregular convulsive movements occur. The eyes are rarely fixed in one position, but are constantly agi- tated in various directions, from side to side, or upwards and downwards; very often there is the most violent strabismus ; the eyelids are sometimes open, at others shut ; the pupils may be contracted or dilated. The mus- cle-: of the face next enter into contraction, and occasion the most hideous contortions of the features. The mouth is distorted into various shapes, the lips are often covered with a whitish or sanguinolent froth, and the jaws tightly clinched together by tonic spasms, or agitated by convulsive movenienUs, so as to produce grinding of the teeth. The trunk of the body is also sometimes variously contorted by clonic convulsions. The head is usually strongly retracted upon the trunk, but in other instances is drawn to one side, or violently rotated. The muscles about the front of the neck enter into action, and alternately elevate and depress the larynx ; the tongue, when it can be seen, is observed to be moved in difll*rent direc- tions, and is sometimes caught between the teeth and severely bitten. The extremities, particularly the superior, are more violently convulsed than any other part«. The fingers are drawn into the palms of the hands, the forearms are flexed and extended upon the arms by short, rapid, and gen- erally rhythmical movement**, the hand is quickly pronated an«l supinated upon the arm, or finally the whole upper extremity is twisted and distorted into various positions, which it is impossible to describe. The inferior ex- tremities undergo similar movement*, but almost always in a less degree than the upper. The respiration during the attack is irregular, sometimes suspended by rigid spasm of the respiratory muscles, and sometimes accel- 538 ECLAMPSIA. erated. A spasmodic contraction of the larynx, producing noisy inspira- tions, has been noticed by several writers. We shall find when we come to consider the nature of this disease, that Dr. Hall was of opinion that a more or less complete closure of the larynx is the most important feature of the convulsive crisis. The face is often livid and deeply congested, especially when the respiration is embarrassed ; the head is hot, whilst the extremities are cold; the pulse becomes large and full, or frequent and small, and sometimes cannot be counted in consequence of the contractions of the muscles of the forearm. The face is not always however congested. We have sometimes seen it perfectly white, while the convulsions were severe, and the child profoundly insensible. The action of the heart is tumultuous, and sometimes irregular or intermittent. When the attack is very violent, the urine and fseces are occasionally discharged involun- tarily, but these are rare symptoms. Deglutition is seldom impossible even in the severest fit. In severe, and especially in long-continued attacks, intellectual consciousness, and general and special sensibility, are all abolished. In milder cases, though consciousness is destroyed, some of the special senses still respond to irritants, whilst in still slighter cases, the intelligence also is more or less preserved. As the termination of the attack approaches, the convulsive movements become more and more feeble, until they finally cease entirely, and the child falls into a state of deep sleep, or of more or less profound stupor. Convulsions are not always, as we have just described them, general. They may be circumscribed or partial, aflTecting one side of the body more than the other, or one side alone, or a single arm, or in some cases, indeed, only a single muscle, as the biceps. Sometimes they implicate the eyes only. The inferior extremities are rarely afiected alone. Of the partial convul- sions the most frequent are those in which some parts of the face and upper extremities are attacked. In this form of the disease, the disorders of the circulation and respiration, the congested tint of the face, the froth upon the lips, and the derangements of intelligence and sensibility, are much less strongly marked than in general attacks. In still other cases, which have been by various authors grouped together under the objectionable title of " inward convulsions," the spasm affects chiefly the muscles of respiration ; at times being limited to the muscles of the larynx, and constituting the affection we shall describe in a special article under the name of laryngismus stridulus ; at others affecting prin- cipally the diaphragm and the thoracic and abdominal muscles of respira- tion. The duration of an attack of eclampsia concerns both the length of the convulsive crisis and the continuance of the disposition to renewals of the "crisis. Both of these are very uncertain. We have known the attack to last in all its violence eight hours and a half in one case, and twelve in another, and it is said to have lasted much longer in some instances. When the spasmodic movements continue during a long period, they are almost always interrupted by remissions. As a general rule, the duration is much shorter than the periods above mentioned, — from a few minutes to half an hour. When the attacks cease and recur, as they often do, II 'I NATURE OF THE DISEASE. 539 several times a day, thev leave the patient during the intervals in a state of more or less perfect consciousness or somnolence, restlessness or delirium, or finally of coma. The period durim; which the disposition to recurrence continues, depends principally upon the cause of the convulsions. If this continue in action, they will be apt to return until it is removed. Idiopathic and sympathetic convulsions generally consist of a single attack, though there are sometimes several, which occur at intervals of «ome hours, or of one or two days. Sympathetic convulsions usually occur cither at the beginning or termination of the disease which they compli- cate, and much less frequently during its middle period. Of 40 cases of this form observed by ourselves, complicating measles, scarlet fever, ery- sipelas, pneumonia, bronchitis, cholera infantum, simple angina, and dys- entery, in which the period was carefully ascertained, they occurred at the invasion alone in 25, at the termination alone in 15, at the middle period alone in 3, and at the invasion and termination both in 3. It is curious to remark, that of the 25 cases that occurred only at the invasion of the disease, all but 7 recovered ; that the 3 occurring in the middle period alone, also recovered ; that of the 3 occurring both at the invasion and termination, 2 died ; and that all of those which occurred at the ter- mination alone, proved fatal. MM. Rilliet and Barthez state that half the cases of symptomatic con- vulsions observed by them, occurred at the commencement of the ence- phalic disease. This form seldom consists of a single crisis ; the attacks, on the contrary, are repeated from time to time. The authors just quoted state that whenever the convulsive attacks have recurred repeatedly within a period of a few days, they have proved symptomatic of disease of the brain. Nature of the Disease. — One of the most important contributions which has been made towards a plausible and satisfactory explanation of the pathology of convulsions in children, was afforded us in the writings of Dr. Marshall Hall ; and, although more advanced knowledge of the physiology of the nervous system has shown that the part of the cerebro- spinal axis involved in the production of convulsions is not limited, as he supposed, to the b-ue spinal system, his theory of excito-motor action fur- nishes the most ready explanation of very many ca.«es of eclampsia. Dr. Flail says (Diseases and Derangements of the Nervous System, p. 145) : "That the whole class of convulsive diseases consists of affections of the true spinal system, there is no longer any doubt. But these diseases do not all originate in this system." All convulsive disorders are, according to this dfK-trine, affections of the tnie spinal or excito-motory system. The causes of these di.sorders may be of incident origin, acting upon excitor nerves; of centric origin, seatefl in the brain or spinal marrow; or of reflex origin, acting upon reflex or motor nerves. They are called, therefore, according to their causes, central or centric, when they depend on disease of the nervous centres; centrifxjtal when they are excitrd through excitor nerves; and centrifugal when they depend on disease of the motor nerves. Dr. Hall, as is well-known, ascribed great importance to the condition 540 ECLAMPSIA. of the glottis in convulsions. He says (p. 323), in speaking of epilepsy, " The second symptom is a forcible closure of the laryrix and expiratory efforts, which suffuse the countenance and probably congest the brain with venous blood." At page 327, he says: "A spasmodic affection of the larynx has obviously much to do in this disease (epilepsy), as well as in the crowing inspiration or croup-like convulsion of infants ; so much, in- deed, that I doubt whether convulsion would occur without closure of this organ." In describing the croup-like convulsion or laryngismus stridulus (p. 180), he says : " I must repeat the observation that the respiration is actually arrested by the closure of the larynx ; and there are forcible ex- piratory efforts only or principally in the actual convulsion." In a later publication, Dr. Hall says: "Without closure of the larynx, extreme laryngismus, and the consequent congestion of the nervous centres, there could, I believe, be no convulsion ! This closure of the larynx must be complete in the affection under consideration (laryngismus stridulus), as in all others, before convulsions can take place." (^Braith. Ret. from Lancet, June 12th, 1847, p. 609.) It is, however, evident that the obstruction to respiration exists not only in the larynx, but in the thorax, the muscles of which are rigidly contracted. Nor can we at present admit that this spasm of the muscles of respiration is more than coincident with the other phenomena of the convulsive attack : and, indeed, there are reasons for believing that the accumulation of venous blood in. the nervous centres which follows the ob- struction of respiration, so far from causing the convulsion, has a tendency to arrest it, and to induce a state of coma. It is, however, easy to comprehend the mode of production of sympa- thetic convulsions by reference to these doctrines. They evidently depend upon morbid impressions conveyed to the cerebro-spinal axis through the exciter nerves having their origin in the diseased organs, probably con- joined with a state of undue reflex excitability of certain parts of the nervous centres. Thus it is easy to understand why inflammation of the parenchyma of the lung in pneumonia, of the bronchial mucous mem- brane in bronchitis, of the mucous membrane of the bowel in entero-colitis or dysentery, or the pharynx in angina ; why the pressure of a tooth upon an inflamed gum during .dentition, the presence of a foreign body, as news- paper (in one of our own cases), or crude food, in the stomach, or fecal, or lienteric accumulations in the intestine, should produce a degree of irrita- tion in exciter nerves, sufficient, when transmitted to the sensori-motor ganglia, to occasion the convulsions we have been considering. It is more difficult to explain the mode in which continued fevers, mea- sles, scarlatina, etc., give rise tq convulsions. To us, however, their occur- rence is explicable by the morbid effect produced upon the nervous centres by the blood, which is known to be more or less changed in these affections from its healthful condition, and also by the mere fact of the existence of fever ; for we have met with a number of children in our own practice, who are almost certain to have a convulsive seizure, whenever the circula- tion becomes greatly excited in force and frequency by the existence of fever, no matter what be its cause. DIAGNOSIS. 541 The explauatiou of the production of idiopathic or essential convulsions is not always so easy, because we are sometimes unable to detect any cause, either centric, centripetal, or centrifugal, to account for the excitation of the nervous system. It seems probable, however, that they must depend, like those of the sympathetic form, upon some unhealthful, and therefore irritating condition, acting upon the excito-motory system of nerves. The cause may be so slight as to escape the notice of the physician, and yet >ufficient to produce a convulsive crisis in a child predisposed to eclampsia. It may be an unnoticed dentition, some undigested food in contact with the stomach or intestines, or accumulations of unhealthy fecal substances, or of vitiated secretions, in the intestines. When convulsions have fol- lowed a vivid mental emotion, as passion or vexation, they are evidently a result of the influence of that condition upon the nervous centres. Acute pain, which is said to have occasioned essential eclampsia, as well as exposure to violent heat or severe cold, must produce their effects through their action upon incident excitor nerves. There is also in all }>robability, in most children who suffer with convulsion, a state of preter- natural mobility and increased reflex excitability of certain parts of the cerebro-spinal axis, which predisposes to disorderly nervous action, even upon trifling causes. There can be no doubt that this irritability of the nervous system is frequently inherited, though it may be acquired in the course of chronic debilitating diseases. Although we have described these convulsions under the title of essential and sympathetic, we do not mean to assert that they are absolutely independent of any material changes in the nervous centres, but merely that, up to the present time, no appre- ciable lesions have been detected as their causes. It is indeed true that, in a certain number of instances, after death from eclampsia, there are found eugorgement of the vessels of the membranes and of the substance •jf the brain, serous effusion into the cavity of the arachnoid or the lateral ventricles, or even actual cerebral haemorrhage. In a certain proportion of cases, undoubtedly, cerebral congestion acts as the direct cause of eclami)sia, a.s we have stated in our article on the former subject. But in the majority of cases, the lesions above mentioned cannot be considered as the caiLses of the convulsive attack, but on the other hand must be re- garded as the direct result of the convulsion, and due to the intense vas- 'ular engorgement caused by the spasm of the resj)iratory muscles and the consequent arrest of the venous circulation. And indeed it is the danger of the occurrence of such lesions which imparts much of the grav- ity to the prognosis in all severe attacks of eclampsia in young children. All symptomatic convulsions belong, of course, to the class of centric diseases. These need no further remarks. Diagnosis. — There arc two important points to be considered in treat- ing of the diagnosis of eclam|>sia : the diseases with which it may be con- ? 'in-led, and the causes which may have produced the convulsions, or, in other words, their distinction into essential, symjiathetic, and symptomatic. The only disease with which eclampsia is likely to be confounded, is f nilf'psy ; the mistake could only be made when the former is violent, and v;.» n it is accompanied and followed by unconsciousness. In epilej)sy, 542 ECLAMPSIA. however, the invasion is more sudden, the convulsions are accompanied with greater rigidity, there is always frothing at the mouth, the duration of the crisis is shorter, and it is generally followed by more marked stupor. If the convulsive attack have occurred under the influence of an appreci- able cause, if the parents are not epileptic, and if the child is very im- pressionable, it is probably eclampsia. Again, the younger the patient, the more likely is the case to be one of eclampsia; whilst if the child is approaching towards puberty, if the attacks are frequently repeated, and yet not dependent on fever, and if they are followed by complete restora- tion to health in the interval, the disease is much more likely to be epilepsy. The diagnosis of the form of the attack, whether idiopathic, sympathetic, or symptomatic, is exceedingly important, as upon this must depend in great measure the prognosis and treatment. It is often very difficult, and sometimes impossible, to determine at the moment to which class the con- vulsions belong. The most difficult points in the diagnosis are the follow- ing : first, when a child previously in good health, is suddenly seized with the disease, to determine whether it is essential ; whether it is sympathetic and occasioned by disease which, up to this instant, has been latent, or by the invasion of some one of the acute local diseases, or of one of the continued fevers; or lastly, whether it is symptomatic, marking the in- vasion of a disease of the cerebro-spinal axis : second, when the convulsion occurs in the course of a disease not primarily implicating the nervous centres, to determine whether it is merely sympathetic of that disease, or whether it is symptomatic of an intercurrent affection of the brain or spinal marrow. It is impossible for want of space, to treat of all these points in detail. The enumeration of them, however, will be useful in calling the attention of the reader to their importance. An essential convulsion is only to be distinguished by careful study of the antecedent history and present condition of the patient. If, after a thorough examination of all the organs, no diseased point can be detected, and if the child recover perfectly from the convulsion, we must conclude that the case has been an idiopathic one, in which the cause is beyond our reach. We are disposed to believe, however, as has already been stated, that in most such cases there has been a source of irritation in some of the organs of the body, which has acted as the excitant to the excito-motory system, and which, if we could but detect it, would warrant us in classing the case amongst sympathetic convulsions ; and on this account a search- ing physical examination should be made in every case, as a matter of course. The sympathetic and symptomatic forms of eclampsia are to be diag- nosticated by the same careful attention to the antecedent history and present condition of the child. If the latter is teething at the time of the fit, and there is no other cause to explain the attack, and should there be nothing in the consecutive symptoms to render such an explanation inad- missible, we may refer it to that condition. We may remark merely, that, as a general rule, eclampsia depending entirely upon the irritation of den- tition, is seldom either violent or long-continued, and that the return to PROGNOSIS. 543 consciousness and health is speedy. The probable dependence of the attack upon indigestion is to be ascertained by the absence of other causes, and by our learning upon inquiry that the child had eaten of some indigestible substance within a few hours or a day or two before the attack. Its de- pendence on intestinal accumulations is to be arrived at by the same neg- ative or exclusive method, and by learning that the patient is usually, or has been of late, of a constipated habit. When the attack occurs in the course of some other disease, as pneu- monia, catarrh, enteritis, pertussis, scarlatina, or measles, it is almost certainly sympathetic. It may possibly, however, be indicative of an in- tercurrent attack of cerebral disease. This can be determined only by attention to the consecutive phenomena. If the attack be short, and soon followed by complete restoration to consciousness, it is in all probability sympathetic. If, on the contrary, the convulsive crisis be long and se- vere, if the recovery from it be slow and imperfect, if it be followed by violent agitation, somnolence, or coma, or by some persistent lesion of mo- tility, there is every reason to fear an attack of disease of the brain. iSympathetic convulsions, occurring at the invasion of different local or general diseases, are to be distinguished only by observation of the symp- toms that follow the crisis, which will be those belonging to the particular malady whose approach has caused the attack of eclampsia. Symptomatic eclampsia is characterized by various signs of encephalic disorder, which soon follow the convulsive attack. The most important of the^e are severe and continued headache; diminution or exaltation of general or special sensibility ; dilatation or contraction of the pupils ; ir- regular movements of the eyes ; flexion or stiffness of some of the limbs, or of the fingers or thumbs; disordered intelligence ; or the symptoms which have already been described in the articles upon the diseases of the brain. Prognosis. — The prognosis of essential convulsions must depend on the nature of the cause and the violence of the attack. When the cause has been slight, or one which soon ceases to act, or can be readily removed, the prognosis is much more favorable than under opposite conditions. If the convulsive crisis is short and of moderate severity, if the pulse and respi- ration are but slightly disturbed, if there be but little congestion of the face, and no stertor, there is every reason to hope a successful issue in the case. Of the three cases of thia class that we have seen, two recovered and one died. Sympathetic is more dangerous than es-sential eclampsia, but much less so than symptomatic. The prognosis will depend chiefly on the nature of the diseaiKJ which it complicates, and on the stage of that disease at which it occurs. Thus, in scarlatina, convulsions, especially when they occur in the first few days of the disease, are almost always fatal, in measles much less so, and in other diseases in various proportions. They are very apt to terminate unfavorably when they occur after the malady which they com- plicate has been in progress for several days. This is a renuirk made by various authors, and we have already stated that of 46 cases of this form in which we carefully ascertained the period of their occurrence, 25 ap{)eared at the invasion, of which all but 7 ended favorably ; .'i at the 544 ECLAMPSIA. middle period, which all recovered ; 3 both at the invasion and at a later period, 2 of which were fatal ; and 15 after the cases had been progressing for a considerable time, all of which proved fatal. In addition to these important elements for making the prognosis, we must consider, also, the duration and degree of violence of the paroxysm, the state of the patient after the fit as to its cerebro-spinal functions, and lastly the age and con- stitution of the child. The prognosis of symptomatic convulsions must depend very much upon that of the disease of which they are the symptom. It may be stated, as a general rule, that, like those of the sympathetic class, they are less dan- gerous when they occur at the beginning than at a later period of the dis- ease. They are always, however, very dangerous. Of 22 cases that we have seen, 19 were fatal. It frequently happens, however, that although life is not destroyed by the convulsions, certain grave sequelae remain, among which the most fre- quent are paralysis, disorders of the mind, and defects of speech or vision. These symptoms are, it is true, far most frequent in cases of symptomatic convulsions, where they depend upon the same lesion of the brain which occasioned the fit. They may, however, succeed convulsions which we are still obliged to call essential, although there very possibly is some minute alteration or defect in a part of the nervous centres, which our means of observation do not suffice to detect. In such cases these sequel se probably depend upon some lesion of the brain, such as cerebral haemorrhage, which has occurred as a result of the convulsion. Hemiplegia, which is the form of paralysis which most frequently follows eclampsia, is most apt to occur when the fit has been limited to one side of the body ; it is often temporary, and passes away in a few days, though it may reniain persistently. Dr. J. Hughlings Jackson suggests that, in the absence of evident disease in such cases of unilateral convulsion and palsy in children, the symptoms may depend upon the plugging of very small vessels in the brain. Treatment. — We shall copfine our remarks upon the treatment of eclampsia to the essential and sympathetic forms of the disease, having already treated of that of the symptomatic form in the articles upon the cerebral diseases which give rise to it. We think that the treatment of eclampsia in children may be simplified if we pay attention to two distinct conditions of disorder, which appear to exist in every case. These are the condition of morbid irritation or de- rangement of the excito-motory system of nerves, and the cause which oc- casions that derangement. The condition of irritation or disease of the cerebro-spinal axis exists in all cases, and is always the same, diflTering only in degree and extent ; whilst the morbid cause of that irritation differs in each case, being in one dentition, in another pain, in another constipa- tion, in others pneumonia or indigestion, pleurisy, catarrh, or angina, scar- let fever, measles, fright, or other violent emotions. If this view of the subject be correct, it is clear that in treating a case of convulsions we have to attend to the two morbid conditions referred to, and we shall be care- ful, therefore, in the course of our remarks, to treat of the remedies most TREATMENT. . 545 proper for the removal of the cause, whatever it may be, wliich acts a? the irritant to the nervous centres; and of those calculated to subdue or allay the deranged condition of those centres and the effects of that derange- ment. There are some general rules to be followed in the treatment of convul- sions which apply to all cases, and of these we shall tirst speak. They are, to place the child in a large urll-vcnfilated room, if such can be procured ; if it have been seized in a little close room, where the atmosphere is dense and impure, removal to another room, or exposure to fresh air before an open window, has sometimes sufficed to terminate the crisis. At the same time the clothes of the child should be loosened, in order to prevent all constriction, and, if necessary, taken off, to allow of a careful examination of the whole body. We believe it is a good rule always to place the child, DO matter what be the cause of the convulsion, if it be a severe one, in a mrm-bath (OG^ or 97^ F.). This has frequently proved an efficient remedy, according to our experience. It is easily procured in most cases, and we are quite confident that we have never known it to do harm, though we have used it in almost every case. The patient should be kept in the bath -ome ten, fifteen, or twenty minutes, or until the convulsive movements cease; when taken out it is most convenient, and at the same time useful, to envelop it in a small, light blanket, or flannel, for a short time, before the clothes are readjusted. In cases where the attack of eclampsia is limited to a single convulsive seizure, we rarely have an opportunity of instituting any treatment for the paroxysm itself, since it is usually over before we reach the patient. In - 'i instances, bloodletting is unnecessary. If, however, the opportunity -, and if the convulsion occur in a strong and vigorous subject; if it be violent, and accompanied by a deep red, or yet more by a livid flush of the face, and distension of the veins of the head and neck ; if it last more than a few minutes, or is re^jeated after short intervals of quiet, we would, without hesitation, recommend the use of hloodiettlng. The detraction of blood is called for, in our opinion, for the same reasons as in puer- peral convulsions, and indeed in every violent convulsive attack, — to save the nervous centres from the effects of the paroxysm, which are, in all severe cases, excessive congestion, and, in some, fatal effusions. There are, however, many cases, in which we would not advise depletion ; as, for instance, those in which the convulsion depends upon an auajmic con- dition, and in which it is contraindicated by a naturally feeble, or by a ']^ ilitated state of the constitution; those in which it is clearly unneces- sary, from the slight severity or short duration of the attack; or those which occur in the course of other diseases, and particularly at their ter- mination, and in which a resort to it is rendered evidently improper by the circumstances of the concomitant afiection. The quantity of blood to be taken, and the method, must depend on the circumstances of the case. W.' must be guided as U) the quantity by the age and constitution of the ; .' nt, the violence and duration of the paroxysm, and the cause of the attack. In a strong, hearty child, two or three years of age, in whom the attack is violent, and produced by some cause not likely to continue long 35 546 . ECLAMPSIA. in action and thereby exhaust the strength, we may take from two to four ounces at the first bleeding ; and should this fail to exert an influence upon the paroxysm, a rather smaller quantity may be taken in one or two hours afterwards. In younger children, and those who are somewhat feeble or delicate, the amount drawn ought to be less. Usually speaking, venesection is to be preferred ; but when a general bleeding cannot, from any cause, be employed, we may resort to cups and leeches to the temples or back of the neck, or, as advised by some of the French writers, to more distant parts. We believe it is useful in all cases of essential and sympathetic convul- sions, which resist the employment of a warm bath and bleeding, and also when bleeding is not resorted to, to make use of an emetic of some kind. The act of vomiting alone is often sufficient to break up a paroxysm of convulsions which has resisted various other means. This we learned first from the advice of an old and experienced practitioner, who was in the habit of employing emetics in all cases of eclampsia of children, and we have since seen it tested on numerous occasions. Dr. Hall recommends the induction of vomiting in the treatment of the paroxysm of the croup- like convulsion or laryngismus stridulus, and as a means of prevention in epilepsy. In the former he employs irritation of the fauces by tickling with a feather ; in the latter, ipecacuanha. He says that a new mode of action is induced in the true spinal system by the act of vomiting, so that the disposition to closure of the larynx, and expiratory efforts, is exchanged for sudden acts of inspiration. The emetic which we employ is ipecacu- anha. The employment of emetics is generally advisable, even when there is no evidence that the attack is due to the presence of undigested or irritating substances in the stomach, since in cases of sudden eclampsia the cause is so frequently some gastric irritation. Of course, when there is special reason to suspect the presence of such a condition, the indication for the administration of an emetic is even more positive. in addition to warm baths, bleeding, and emetics, cold applications to the head will be found proper and useful in nearly all cases which are of any considerable violence. Their use would be improper, however, when the surface is pale, the features contracted, and the pulse small and feeble ; .but whenever the skin, especially that of the head, is deeply colored and turgid, and the pulse full and strong, they ought to be employed from the beginning. While the child is in the bath, its head may be wrapped in a cloth wet with ice-water ; or, after it has been removed, cold water may be poured from pitchers or a tea kettle upon the same part. If the latter is done, enough should be employed to prevent the sudden reaction which inevitably takes place when but a small quantity is used. During the after-treatment of the case, the cold applications ought to be continued so long as the head remains unnaturally heated. The administration of a purgative dose is proper and useful in most cases of convulsions; particularly when it is found upon inquiry that the child has been constipated prior to the attack; when it is suspected that .the bowels may contain crude food or some foreign body ; when it is de- sirable to produce an evacuant effect in a strong plethoric child, or a TREATMENT. 547 derivative action from the brain, and wlien the attack is attended with violent determination of blood towards that organ. The best purgative in severe cases occurring in hearty children is calomel. It is advantageous because of its e^sy administration, its speedy operation, and the powerful sedative influence which it exerts upon the whole economy. The dose should be from three to six grains, according to the age. It ought to be followed in one or two houi-s by some other cathartic, which may be either castor oil, rhubarb, jalap, or salts. The best of all is castor oil if it can be given. When the attack is slight or the patient weak and delicate, cas- tor oil is particularly applicable, as it operates with so little irritation to the intestine, or we may employ a mixture of castor oil and spiced syrup of rhubarb. Whatever the remedy may be, it should be given only in such quantity as to produce complete evacuation of the bowels and a moderate derivation upon those organs, without the risk of occasioning a degree of irritation sufficient to increase the disturbance of the nervous system already existing. In many, indeed, in most cases of eclampsia it will be found that purga- tive enemata are of great service. They may be administered immediately before or after the bath, and not unfrequently have the etlect of stop})ing the paroxysm. They may consist of water holding in suspension or solu- tion castile soap, common salt, molasses, castor oil, sweet oil, or spirit of tur[)entine. If the fii-st fails to operate in ten or fifteen minutes, another or even a third ought to be given. Bevul^ives are of the utmost importance in the treatment of convulsions. They should be employed from the very first, or immediately after the use of the bath. In slight attacks, they alone are often sufiicient to suspend the paroxysm, or at least the fit often ceases under their use. Mustard is the most useful and convenient form of application in the great majority of cases. It may be used either in the form of sinapisms, which are to be -hifted from place to place, or in that of the foot-bath. When sinapisms are used, they should always be covered with gauze or fine muslin, to avoid the danger of leaving any of the mustard upon the skin after they are taken off. We once saw very bad ulcerations upon the feet of a child from the II' L'lf'ct of this precaution. In the hurry and bustle of the moment, the 1- . ; were not washed when the plasters were removed, and the mustard that remained produced vesications which ulcerated. In obstinate attacks, the revulsives ought to be reapplied from time to time, taking care to shift their position in order to avoid vesication. Antispasmodics are very valuable remedies in eclampsia, but as they are somewhat slow in acting, we should first resort to the means already de- tailed. We should then give full doses of one of the antispasmodics r mmended below, and should continue its use so long as may bo i; i^'ht desirable after the attack has passed over. They should also be used as a means of prevention in children threatened with eclampsia. The bromides of potassium and of soear to be somewhat rare. MM. Rilliet and Barthez (2erae 4dit.) speak of having seen nine cases. At the time of publication of their first edition, they had met with only one case, and then stated that they were acquainted with only one other, published by ^I. Constant in the Bui/etin de Thcrapeutique. M. Blache (article N^vrose du Larynx, Diet, de M(d., t. xvii, p. 590) adyerts very cursorily to one case. M. Val- leix ( Guide du Med. Prat., art. Asthme Thymique") doubts its existence as a distinct disease. In Germany, on the contrary, it would seem to be a rather frequent disease. In England it cannot be very infrequent, since Merriniau says it is by no means uncommon. Copland {Stridalous Laryn- r/ic Snfiocntio)} in Children, Diet, of Prac. Med.) speaks of numerous cases that he has seen, and states that he has had as many as three under treat- ment at the same time. Ley speaks of having met with considerably above twenty cases. Dr. Marshall Hall remarks that " within the short space of one month, I have seen five cases of croup-like convulsion." Dr. Charles West (4th edit., p. 162) mentions thirty-seven cases of which he has pre- served some record. The statements of more recent English writers indi- cate that it continues to be of quite frequent occurrence. We do not think it is a common disease in Philadelphia, though it is certainly not extremely rare, since we have either seen ourselves or heard of the occurrence of a comparatively large number of cases. Predisposing Causes. — ^lye. — It is generally acknowledged that the disease occurs most frequently during the period of the first dentition, though it has been known to occur as late as six or seven years of age. Of oO cases .selected indifferently from our practice and from authors in which the age is given, 13 were six months or less of age, 11 between six months and one year, 4 between one and two years of age, 1 of two, and 1 of four years of age; so that of the 30, 24 were under one year. It is evident, therefore, so far as these cases go, that the majority occur within the first, and very few after the second year. Of the 37 cases mentioned by Dr. West, 31 occurred in children be- ' n six months and two years of age. All the cases seen l)y MM. liil- nnd Barthez were in children under two years old. Those authors 'tate that the seven subjects observed by M. H6rard were more than two years of age, and that two of them were between three and four years old. From the statements made by authors in general, it would seem to be most frequent between the ages of three weeks and eighteen months. It has been known, however, in one very rare instance, to occur as late as seven years of age. Ser. — It is most frequent in the male sex. Of 50 cases (4o from authors, and 5 by ourselves), 39 occurred in boys, and 11 in girls. MM. Itilliet 552 LARYNGISMUS STRIDULUS. and Barthez state that of 16 cases observed by themselves and by M. He- rard, 12 occurred in boys, and 4 in girls ; of 183 cases collected by M. Lorent, in which the sex was noted, 125 occurred in boys, and 58 in girls. Constitution. — It seems established that it sometimes occurs in the most healthy and vigorous subjects, being then probably dependent upon reflex nervous irritation. It is, however, far most frequently met with in chil- dren who are delicate and feeble, and especially in those of scrofulous or rickety constitutions. The very frequent association of rachitis with laryn- gismus has been more and more prominently developed during the past few years. Some high authorities, since the publication of Elsasser's re- searches, in 1848, have even asserted that this connection is a constant one, and that laryngismus is essentially dependent upon craniotabes or rachitic disease of the skull. There are certain cases in our own expe- rience, and others which are reported by careful observers, which do not allow us at present to admit that this connection is an invariable one, but there can be no doubt that in the great majority of cases laryngismus oc- curs in rachitic children, and particularly in those who have craniotabes, or "soft spots" in the occiput. It not unfreqently attacks several chil- dren in a family. Ley quotes four instances from other writers, in which three children in each family had the disease, and in one all three died. He states that his own experience fully confirms this fact. MM. Killiet and Barthez (2eme edit., note, t. ii, p. 527) state that Davies and Henrich have met with four, and Torgord five children of the same family affected wdth the disease. They quote from Reid the curious fact that Powell saw one family of thirteen children, not one of which escaped the disease. Amongst the causes of the disease, in addition to those already men- tioned, must not be forgotten dentition and imioroper food. These two are, indeed, probably the most influential of all in the production of the com- plaint. The age at which it occurs most frequently, the last half of the first, and the first half of the second year, the very period during which the process of dentition is most active, would alone go far to show that this must constitute one of its most powerful predisposing, if not exciting, causes. The opinions of writers on this point are also conclusive as to the great influence of this vital process. Improper food, and especially early weaning, and the attempt to bring the child up by hand, is clearly a potent predisposing cause of the disease. This has been clearly shown in the cases that have come under our own observation, and especially in one in which contraction with rigidity followed the symptoms of laryngismus. The details of this case will be found appended to the article on contrac- ture. Dr. James Reid, in an excellent work on the disease (see Brit, and For. Med.-Chirurg. Rev., July, 1849, p. 163), gives the following conclu- sions as to its etiology: " 1. That for the occurrence of this complaint, the cerebro-spinal system is required to be in a peculiarly excitable state, which then acts as a predisposing cause. The period of teething is the most likely to produce this condition. 2. That during this irritable state of the nervous centres, the two most frequent (and in the majority of in- stances the combined) causes are the improper description of food which is NATURE — CAUSES. 553 administered to the infant, and the impure and irritating atmosphere which it breathes." It must not be forgotten that while in some oases these causes act in producing kiryngismus by reflex irritation from the gums or mucous membraneof the alimentary canal upon a weak and over-sensitive nervous system : in other cases, the laryngismus is essentially connected with rickets, which has been induced by improper feeding. XATrRE AND ExciTiNG Cai'ses ; FoKMs. — ^Nluch difference of opinion has prevailed in regard to the nature and exciting causes of laryngismus stridulus since the disease has attracted the particular notice of the pro- fession. Kopp and other German authors ascribe it to compression of the respiratory organs by an enlarged thymus gland, while others of that na- tion, and some of the English and French writers, class it amongst the neuroses. Dr. Hugh Ley supposed it to depend on compression of the par vagura nerves by enlarged cervical and bronchial glands. Dr. Marshall Hall considers it to be a disease of the reflex system of nerves. Amongst the French writers, ^IM. Killiet and Barthez regard it as a neurosis; Val- leix and Trousseau treat of it as one form of convulsions in children ; Blache ( Diet, de Med., t. xvii, p. 584) speaks of it as a neurosis of the larynx, which may be either symptomatic or idiopathic. Many recent authors, as already stated, are disposed to regard it as dependent upon the irritation of the brain due to the existence of craniotabes. Before examining in detail the different opinions quoted above, which we propose doing, we will refer to the anatomical appearances of the malady. The mucous membrane of the air-passages, as a general rule, is found perfectly healthy, presenting neither redness, inflammatory swelling, oedema, nor accidental products of any kind. The lungs are usually of the natural color and density, and crepitant. M. Herard (Bib. du Mid. Praf., U V, pp. .319, 320) observed that in several autopsies made by himself, they always presented one marked change from their natural condition, however, which was a very high degree of emphysema, more general and strongly marked than in any other disease. This alteration is believed to depend, as it does in hooping-cough, upon the impediment to respiration which exists during the disea.se. MM. Killiet and Barthez state, however, that emphysema was not pr&sent in any of their autopsies. The heart and great ve?jsels of the thorax often, but not always, contained more bhmd than usual, as in asphyxia. M. H^rard states that he has made very minute researches in regard to the condition of the nervous system, examining the brain and spinal mar- row, the pneumogastric, recurrent, and diaf)hragmatic nerves, and tliosf; of the extremities even, to their terminations, without, however, findifig im- portant lesions in any cai»e. He exceptij only .serous effusion in small (juan- tity, and evidently consecutive, in the ventricles and particularly in the memltranes of the lirain, and slight venous congestion of the same kind. The tisf*ue*» of the brain and spinal marrow retained their ordinary' consist- eoce, and pre*»enteo8fd it to be a matter of little conscqupnee, she did not Rend for me until the next day. The child was well grown, and except a rather too groat pale- ness, looked strong and healthy. It was playful and good-humored, nursed freely, had no fever, and between the par<»xy»nis presented the appearances of perfect health. The crowing fits occurred frequently in the course of the day and night, •ometimes two or three times in an hour, or not so often. They ofien waked the little thing suddenly from tranquil sleep. They con^if»ted of a succession of long and difiScult inspirations, accompanied by a {*«culiar whistling or crowing sound, 666 ' LAKYNGISMUS STRIDULUS. such as might be supposed to depend on the passage of air through a narrow aper- ture. During the attack the face assumed an expression of great anxiety, the re- spiratory muscles contracted with violence, and there seemed to be for the time im- minent danger of suffocation. After several seconds or a minute the shrillness of the sound diminished, the struggling subsided, and soon the respiration became perfectly natural, and the child seemed well. The paroxysms were usually fol- lowed by fits of crying, which, however, were easily pacified. The paroxysms gradually dim nished in frequency and violence, and ceased en- tirely after the 13th of April. The treatment consisted simply in careful atten- tion to the general health, and in the frequent use of warm baths and mild nau- seants. The child remained perfectly well, with the exception of a slight attack of chol- era infantum, until the following November, seven months after, when the disorder recurred. Several paroxysms occurred between the 12th and 17th of the month; but as they were slight and unattended by other symptoms of illness, the mother was not alarmed, and paid but little attention to them. On the 17th of the same month, the child was sitting on the floor amusing itself with some playthings. There were no persons in the room except young children. They saw the little thing stoop forward suddenly, as though in play, and did not therefore regard it immediately. As it remained in that position, however, they went to it, took it up, and found it dead. It had perished suddenly, no doubt in one of the paroxysms of laryngismus. An autopsy was made, in which the larynx and thoracic organs were examined, but nothing was found to explain the cause of the disease or the sudden death. In the following interesting case, communicated to us by the late Prof. William Pepper, the attack consisted of persistent laryngismus stridulus, accompanied by frequently recurring internal convulsions affecting the diaphragm and other respiratory muscles, and by tonic contraction of the muscles of the arm?. Case. — A boy, aged four months, remarkably healthy and well developed, after suffering a few days with slight catarrhal symptoms, was suddenly seized with a peculiar stridulous crowing respiration. I saw the child about half an hour from the commencement of the attack, and found it with a pulse of 140, pale face, and livid lips. The pupils were contracted, and the hands firmly clenched ; the crowing sound was very loud, and attended every act of inspiration. At times the respiration and circulation would be en- tirely suspended for many seconds, followed by great lividity of the surface and coldness of the extremities. Eight or ten leeches were applied behind the ears, the feet placed in warm water, and a dose of castor oil administered, to be followed by saline enemata. Four hours from the commencement of the attack, all the symptoms were greatly aggravated ; the wrists and fingers were firmly flexed, these spasms coinciding with the arrest of the circulation and respiration ; there was now perfect insensibility. The child was placed in a warm bath, cold water was applied to the head, and a sinapism along the spine, without, however, affording any relief to the crowing inspiration, or other spasmodic symptoms. At the suggestion of Dr. C. D. Meigs, the child was now placed on its right side, with the shoulders elevated; this position to be maintained at least six hours. At the end of that time the child was in no respect improved, and accordingly, at the suggestion of Dr. M., six leeches were applied over the cardiac region ; f^] of lac. assafoetid. was thrown into the rectum, and a blister applied to the back of the neck. The child expired at midnight, about ten hours from the commencement of the II CONTRACTION WITH RIGIDITY. 567 attack, the crowing respiration, with more or less asphyxia, having: per-istod throughout. Auiopsv, ihirfy-six hours after Deaih. — Mucous membrane of the larynx injected, but in other respects natural. Thymus gland three and a half inches long, two and a half wide, and at its upper part three quarters of an inch thick ; its weight was 620 grains, or 10 drachms and 1 scruple. Lower lobes of both lungs greatly congested. Heart natural. The brain, unfortunately, could not be examined. It will be observed that, in the above case, the laryngismus and other spasmodic symptoms appeared after slight catarrhal symptoms had ex- isted for a few days ; and it may be possible that the irritation of the mucous membrane acted as the exciting cause of the convulsive attack. A recent author' has, however, alluded to the case in such a connection and manner, as to at least suggest that he may have mistaken it for one of spasmodic laryngitis. A careful consideration of the symptoms and course of the case will, however, sufficiently show its essential difference from this latter affection. ARTICLE VIII. COXTKACTION WITH RIGIDITY. This is the disease called by the French contracture. We shall treat of it a.s idiopatic contraction with rigidity. It has been little studied until of recent years, since then a number of cases have been placed on record, especially by French writers. We have ourselves met with but one well-marked example of it in an independent form. This case, of which we shall give a sketch at the end of this article, and the one of laryngismus stridulus communicated to us by Dr. Benedict, and appended to the article on that disease, furnish very good examples of contraction coexisting with the former affection. We have seen also two other ca.se8 in which the contraction was decided, but in which it lasted but a short time. The di.sease is evidently one of the forms of excito-motor disturbance, which prei?ent themselves under such a variety of shapes during infancy and childhood. Though it generally exists as an idiopathic and distinct malady, it is in other cases as.«ociated with, or follows laryngismus strid- ulus or spasm of the glottis, and in others again is combined with attacks of general convulsions. Definition. — By idiopathic contraction with rigidity {cmitrnriure of the French writers), is meant the involuntary tonic contraction of differ- ent flexor muscles of the extremities, particularly those of the fingers and toe?, but .sometimes of the forearms and arms also, existing independently of any appreciable organic disease of the cerebro-spinal axis. It has ' Dr. J. Lewis Smith {op. eit, p. 199). 568 CONTRACTION WITH RIGIDITY. been described by different English writers in connection with laryngis- mus stridulus, under the title of " carpopedal spasms," " cerebral spas- modic croup," " croup-like convulsions," etc., etc. We believe, however, that it will be useful to describe it separately from that disorder, for though of the same nature, and sometimes associated with it, it often exists as an independent aifection. Causes. — It is most common between the ages of one and three years. It is much oftener sympathetic than essential, and its most frequent causes are dentition, disordered states of the digestive function dependent upon improper alimentation, anaemia and its accompanying nervous excitability, brought about by digestive and nutritive derangements, pneumonia, bron- chitis, masturbation and other forms of irritation of the genitals, and un- favorable hygienic conditions. In some few cases, the disease is truly essential, since no pathological cause for it whatever can be detected. It is merely necessary to say that it is also often symptomatic of disease of the brain, but of that form of the affection nothing will be said in the present article. Nature of the Disease. — It appears to consist in a functional de- rangement of the motor tract of the cerebro-spinal axis, occurring with- out any cause that can be detected, or determined by the existence of some irritation affecting incident excitor nerves. We once saw a child two years of age, who, after a restless, uneasy night, presented in the morning tonic contraction of the flexors of all the toes of both feet, so that the insteps were swelled, and looked smooth and polished. There was no other sign of sickness except peevishness. Learning on inquiry that the bowels had been somewhat constipated for several days, and that the materials of the scanty stools which had been discharged were dark- colored and very offensive, we ordered a dose of castor oil containing two grains of calomel. The contraction continued unyielding until six o'clock in the afternoon, when a very copious, dark-colored, viscid, and offensive stool occurred, and the contraction immediately ceased. Here the cause of the contraction was evidently an accumulation of unhealthy fecal matter in the intestine, which, by irritating certain sensitive fibres of the excito- motory system, caused a reflex motor action that gave rise to permanent muscular contractions. In other cases the disturbance of the excito- motory system depends on the reflex irritation occasioned by the process of dentition, by indigestion, by diarrhoea, pneumonia, pleurisy, etc. In other instances, again, to which the term essential must be applied, it seems to depend simply on general debility and anaemia, which are well known to be productive of functional disease of the nervous system. Symptoms; Course; Duration. — The disease rarely attacks children previously in good health, but generally those already suffering from some disorder of the general health, or a severe local affection. When sympa- thetic, the first symptom noted is the contraction which constitutes the disease. When essential, on the contrary, the onset is sometimes marked by various nervous symptoms, such as giddiness, headache, or somnolence, which soon pass off, leaving the simple contraction with rigidity as the only morbid condition. In most cases, however, the attack begins with the mus- I SYMPTOMS — COURSE — DURATION. 569 cular contractioD, which generally affects the superior extremities first, and gradually extends to the inferior. When the disease is fully developed, the thumbs are drawn down into the palms of the hands, and the fingers, strongly flexed at tlie metacarpo- phalangeal articulations, cover and conceal the thumbs. At the t^nme time that the metacarpo-phalangeal articulations are flexed, the phalanges them- selves remain extended and the fingers are separated from each other. The contraction genemlly afiects the wrist-joints al:?o, so that tlie hands are strongly flexed upon the fouearras, and in some rare cases the latter upon the arms. The disorder usually affects the inferior extremities likewise, the toes being in a state of tonic flexion or extension, the foot rigidly extended upon the leg, and its point sometimes drawn inwards. The spasm very rarely extends to the knees. Children old enough to describe their sensations generally complain of stiflhess in the affected parts, with more or less severe pains darting along the course of the nerves. The contracted muscles are hard and rigid to the touch, and sometimes enlarged so as to appear in strong relief under the skin. In slight cases the contractions can be overcome by very moder- ate force and without pain, whilst in those which are more severe, the at- tempt to overcome the contraction is productive of acute pain in the rigid parts. The backs of the hands and the insteps present a swollen appear- ance, and the skin over these points is smooth and polished. In the case communicated by Dr. Benedict, appended to the article on laryngismus stridulus, and likewise in our own case, the skin under the thumbs had assumed the appearance of mucous membrane, from the long and close confinement of the member. In addition to the symptoms already enumerated as characteristic of the malady, there are others which require attention. The child is of course unable to walk or perform any prehensile movement. The intelligence and senses always remain perfect in simple, uncomplicated cases. The nervous system shows signs of disorder in the form of restlessness or lan- guor, and irritability, with crying and peevishness. In the great majority of instances, these are the only nervous symptoms, though in some there are general or partial convulsions, strabismus, and diminution of sensi- bility. Of these the most frequent are convulsions, which generally come on a few days after the attack, or precede the fatal termination. In the case of Dr. Benedict, referred to above, there were occasional choreic nioveraeuts of the face, arras, and body. The simple disease is unaccom- panied by any febrile movement, and the organic functions go on naturally. In the sympathetic form, on the contrary, we have the various symptoms of the disease which acta as the cause of the contraction, whether that be abflominal or thoracic. The most common train of symptoms, in young children, is the same as that which accomjianies gastric or intestinal de- rangement, morbid dentition, etc. The course and duration of the disease are very irregular and uncertain. When once developed it may last from weeks to months, either slowly increasing in severity, or remaining station- ary for a length of time. As a general rule, after it has lasted for some time, it becomes intermittent, sometimes diminishing or even disappearing 570 CONTRACTION WITH RIGIDITY. entirely for a period, then reappearing or increasing, to subside or cease again, and so changing without regularity or evident cause, until at last recovery gradually takes place, or death occurs from the concomitant dis- ease, or in a paroxysm of convulsions. Diagnosis. — The only difficulty in the diagnosis of idiopathic contrac- tion is to distinguish it from symptomatic contraction, or that which depends upon cerebral or spinal disease. The kinds of cerebral disease which most frequently occasion contraction are tubercle of the brain, and meningeal haemorrhage. The distinction can generally be made with con- siderable facility, however, by attention to the various disorders of intel- ligence and sensibility, to the fever, constipation, vomiting, and different modes of invasion and progress which characterize the symptomatic form. The following table, taken from MM. Rilliet and Barthez, will assist in the diagnosis. SYMPTOMATIC CONTRACTION. ESSENTIAL CONTRACTION. Cerebral symptoms, special functional Similar cerebral symptoms, but only disorders (convulsions, strabismus, dila- in exceptional cases, sometimes accom- tation of the pupils, etc.), preceding or panying, but never scarcely preceding accompanying the contraction. the contraction. In many cases irregularity of the pulse. No irregularity of the pulse. Generally partial, and commencing Binary, commencing in the fingers usually in the elbows and knees, and in and toes. a single extremity. Almost always permanent. Eemarkably intermittent. Prognosis. — The prognosis must depend on the cause of the malady. The contraction itself has no influence whatever on the termination. The fatal termination has always resulted from the anterior or concomitant disease. Six cases observed by M. Barrier all recovered. The case com- municated to us by Dr. Benedict, which was connected with laryngismus stridulus, and one very severe one that occurred in our own practice, also terminated favorably. The prognosis is favorable, therefore, when the attack occurs in a child of naturally good constitution, and when the cause of the disease is not a permanent or incurable one. The possibility of the occurrence of fatal convulsions should always lead us to make a guarded prognosis. Treatment. — The treatment must depend on the circumstances under which the disease has made its appearance. When it occurs in the course of an acute local affection, the treatment must of course be that which is proper for the concomitant disorder. When it depends on dentition, or on gastric or intestinal derangement induced by improper diet, the treat- ment is the same precisely as that recommended for laryngismus stridulus dependent on the same causes. It may be stated that, as a general rule, all violent remedies, as bleeding, calomel, except in very minute doses as an alterative, drastic cathartics, and blisters, can scarcely fail to be injurious, unless manifestly necessary in the treatment of the concomitant affection. It is proper in almost all cases to combine with the treatment already J CASE OF CONTRACTION. 571 recommeuded, the employment of antispasmodic remedies, particularly when the contractions persist after the removal of the primary disease. The best remedies of this class are the warm hath, used every day ; bel- ladonna ; couium ; bromide of potassium ; the fluid extract of valerian ; assafa^tida, and camphor. We would further recommend the use of rem- edies calculated to improve and invigorate the nutrition, and particularly cod-liver oil and iron. The diet ought generally to be nutritious and strengthening, particularly when the patient is weak and delicate. In conclusion we may state that the treatment should be very much the same as that proposed for laryngismus stridulus, and we therefore refer the reader to that subject for more detailed information. CASE BY DR. J. F. MEIGS. Case — The subject of this case was a girl nine months old. The parents were healthy persons, but the mother, owing to some idiosyncrasy, had made but a jioor nurse for the preceding child, and I had strongly advised her, therefore, at the birth of this one, to give it a wet-nurse. This was not done, however, and it was found necessary to feed the infant a great deal from its birth. During the early month.s of its life it had some slight attacks of disorder of the digestive system, but being taken to the country for several months in the summer, it there improved very ranch. On being brought back to town I saw it, and found it pretty well devel- oped, but very pale, and, on the whole, delicate-looking. It was still nursed by the mother, but not to any very considerable extent, as it was obliged to be fed several times each day. The food consisted of different farinaceous substances made with cow's milk. On the left forearm of the child there was situated a congenital aneurism by anas- tomosis, which had grown, by the age of nine months, to be as largo as a tivo-cent piece. It was deemed necessary to remove this tumor, and, accordingly, on the lllh of January, 1852, a surireon tied it with a needle and double liLjature. The child bore the operation very well, was soon quieted, and was cheerful and ate well until the evening of the loth, when it was attacked with fever, which lasted all night, and was accompanied with a good deal of cough and some gurgling in the fauces. On the following morning, at about 7^ o'clock, it had a slight convulsive seizure, lasting a few moments, and marked by stiffening of the body, and a star- ing expression of the eyes. In the middle of the day, it was seized again, and during that and the next day (17th), up to 10 p.m., it had twenty-four convulsions. These lasted from three to ei:;ht minutes each ; they were general, and consisted of flexions of the limbs, working of the face, and were attended with unconsciou.?- nes.s. There was no opisthotonos during the attacks, no extensions of the limbs, and no contraction of the jaw. Between the seizures, the child nursed perfectly well, sucked the finger, had no 6tiffne.«s of the lower jaw, and was perfectly con- scious. There was, during these two days, some fever, as the skin was too warm, and the pulse between 101 and 180. The respiration was ra(»re frequent than natu- ral, there was a good deal of cough, some caturrhal r&les in the chest, and also •ome gurgling in the fauces. The stools were scanty, pasty, and white. There was a well-marked but rather faint rash on the limbs and trunk, like erythema or mild scarlet fever, and the lymphatic glands on both sides of the lower jaw were some- what swelled, and quite hard. The treatment directed was one-sixth of a grain of calomel every two hours; two drops of solution of morphia with five of fluid ex- tract of valerian, to be given also every two hours; warm immorsion baths, and mustard fool-baths. On the second day, blisters were applied behind the ears. On the 19th, the child was better. There was no convulsion ; she noticed well, smiled a little, nursed heartily, and took some arrowrool-watcr. 572 CONTRACTION WITH RIGIDITY. During all this time the tumor in the arm was not at all inflamed. It was neither red, sore to the touch, nor swelled. It was suppurating slightly. Under the idea that the convulsions might depend in part on the operation, and in order to promote suppuration,- a warm poultice was kept constantly applied over the tumor. The child continued better, with the exception of slight angina and severe cough, until the morning of the 22d, when it waked early, crying violently as though in severe pain, and I found the fingers of both hands strongly flexed at the meta- carpal articulations over the thumbs, which were themselves drawn into the palms of the hands. The phalanges, though bent, as just stated, at the metacarpal ar- ticulations, were stifily extended at the phalangeal articulations, and at the same time separated from each other. The bands were flexed at the wrists. The toes were flexed, and the feet stiffly cramped at the ankles, and the insteps, as also the backs of the hands, looked swelled and cushiony. Any attempt to open the hands was painful and caused crjnng. The pulse was frequent and small, the skin pale, and very slightly too warm; the intelligence was perfect. The jaw was open, and the act of sucking was performed, but with some difficulty. On the previous day the bowels had been opened three times, and on this day once; the stools were scanty, pasty, and white. At 9 a.m. I ordered two drops of solution of morphia, five of the fluid extract of valerian, and twenty of milk of assafoetida, to be given every two hours. 4 P.M. — Same state, except that the contraction is stronger. There is more heat of skin, much crying, and a restless, distressed motion of the head. At 4J o'clock, two drops of laudanum were given with assafoetida. A teaspoonful of the follow- ing mixture was ordered every hour : R. — Mass. Hydrarg., gr. iij. 01. Kicini, f^iij- Syr. Khei. Aroraat., f^v. — M. 10 P.M. — Has taken three doses of the mixture and had one large, whitish, pasty stool. Much easier. Has slept a good deal. Contractions not so strong, as the hands can be opened more easily, and with very little pain. Skin soft, of natural temperature, and moist. Ordered one or two more doses of the mixture, and a repetition of the laudanum and assafoetida, in case of restlessness. During all this time the tumor has not separated. A process of ulceration is going on around the ligatures, but there is no inflammation of any consequence; the arm is not swelled, and there is neither redness nor soreness to the touch. January 30th. — The contracture diminished very much for two days, and then returned, so that during the 27th, and 28th, and 29th, it was very marked, the fore- arms being flexed on the arms, and the hands strongly flexed on the forearms. The feet also were very stiff", and strongly flexed. The head was occasionally but not constantly retracted upon the trunk. The child evidently suffered very much, as it cried constantly and was very restless, except when under the influence of anodynes or antispasmodics. The bowels are sluggish, but have been kept open by the oil and rhubarb mixture. The dejections were generally whitish and pasty, but occasionally there was a healthy yellow stool. On the 28th the following mix- ture was ordered : R.— Ext. Valerian. Fluid, Sp. JEtheris Comp., Liq. Morph. Sulph., Syr. Tolutan., Aquae, .... A teaspoonful to be given every hour or two, when there is much suff'ering or J restlessness. fSJ- f^ss. gtt. Ix. fJij.-M. I ! CASE OF CONTRACTION. 573 On the evening of the 29th the ligatures were removed, as they had become en- tirely loose, though without cutting off the tumor. The diseased point was not much inflamed, nor was it very tender. The child is still nursed and fed. Since the 29th it has had goat's instead of cow's milk. On the evening of the 30th the patient was more tran'^uil, the ex- pression was more placid and open, and the contracture not quite so strong. Up to February 7th, there was no decided -change in the symptoms. They con- tinued quite as severe Jis before. The dyspeptic symptoms, the torpid state of the bowels, the want of appetite, and the white, pasty state of the evacuations were never relieved, except momentarily, by means of cathartics. On the 7lh a wet- nurse was procured, but only after the most persevering and urgent solicitation and argument on our part, I having long been convinced that the cause of the con- tracture lay in the disordered state of the digestive functions, produced and kept up by artificial diet, and perhaps by an unhealthy state of the mother's milk. The parents, however, had always thought that the operation had been the cause of the convulsive disease, and for a length of time would not consent to a wet-nurse. After the child had been suckled by the wet-nurse for two days, the stools, which, since the beginning of the sickness, now twenty-three days, and to a greater or less extent since birth, had been very unhealthy, became yellow, homogeneous, and natural in character ; while the bowels, instead of being obstinately constipated, so as to require large doses of cathartic medicine, were moved spontaneously two or three times a day. On the 10th we noticed strong divergent strabismus, and the child looked very badly. The left leg was drawn up, whilst the right was stiffened. The left arm was more used than the right, the left hand being carried often to the mouth, while this was never done with ihe right. It was difficult to measure the degree of the intelligence, but the child occasionally looked at and evidently noticed objects, but during most of the time it was dull and inattentive. On the 13th there was an evident improvement, the previous night having been very good. The face was improved in color and expression, and was not quite so thin. The contraction was about the same. 14th. — Some diminution of the contraction, the forearm being a little extended upon the arm, and the wrists, though still very rigid, not quite so much drawn. The child looks better; she nurses a great deal, taking all that the mother, and most also of what the wet-nurse, a hearty woman, has. February 20th. — Doing very well up to last night, when she became more rest- less, cried a great deal, rolled the head on the pillow, and had slight retractions of the whole trunk of the body. Occasionally she coasod to cry, scarcely broath('refingers rather extiuded. Bowels natural. Ordered fifteen drops t)f brandy, and a very small pinch of the Quevenne's metallic iron in powder, three times a day. loih. — Condition about the same. On the 2'2d of March, the first wet-nurse, under whose charge the child had improved so rapidly, was changed, on account !' some objection to her personal appearance, and another one procured in her J lace. This one was a healthy-looking woman, with milk enough, but she was red-haired, irritable, and excessively high-tempered, and the child has been losing ground ever since her arrival. Under the idea that her milk did not suit the child, a third nurse was by my advice obtained to-day (loth), a calm, placid, fat, and comfortable-looking woman, with an abundant supplv of milk of ten months old. 17th. — The child has improved very much She is fatter already, has a contented, tranquil expression, t«kes more than she did from the previous nurse, and njects much less of the milk. The stools are now regular, occurring twice daily without aid, and of a natural appearance. The sleep of the child is better now than it has been at any lime since the first wet-nurse was dismissed. The attacks of laryngis- mus are already much less frequent, and less severe. The hands are very nearly n a natural condition. The child is less nervous, not starting now as formerly at zjunds. To continue the brandy and iron. From this period the child continued to improve regularly in health. She was removed to the country during the summer months, and when brought back in the autumn, was entirely well, with the exception that she was less forward in walking than mc»st children, but not more so than might have been expected in one who had been dangerously ill for so long a time. Her intelligence was good in all respects. February 6th, 1853. — We have seen this child to-day, and find her in very good health, except that she is rather smaller in size than is usual at her present ag<'. ^he has been weaned now fi.»r alnjut six weeks, and eats heartily and digests well most ordinary f«x)d, as milk, meat, potatoes, etc. The weaning was borne very well, except that the appetite was rather deficient and capricious, for about a woi-k after the departure of the nurse. .She can stand up when placed in the erect posi- tion, and can walk feebly when well 8upfK>rted, but not alone, nor can she rit^e up from a sitting posture. Her intelligence i."*, in all respects, perfect, but «he does not talk as yet. There is no vestige of her former sparmfxlic symptoms, when she is in good h«nlih ; but any little turn of sickness reproduces some contraction of one b-g, and a >lig1it flexion of the hands. Some months after this, the child was unfortunately seized with hooping-cough. ■^he did well for several weeks, but one day, being seized with a fit of coughing while t<'nied upon the floor playing, died instantly, doubtless-from asphyxin, caur«pd by Complete closure of the glottis by »|»asm. This i» the only case of booping-<'ough that we have ever known to prove suddenly fatal in this way. There ii» every reason to »uppo»e that the fatal suspension of rcnpiraliou was caui^ed by the unnatural ex- citability of the sphincter muscle uf the glottis, left by the previous attack of laryngismus stridulus. 576 TETANUS NASCENTIUM. ARTICLE IX. tetanus nascentium. Definition ; Synonyms ; Period of Occurrence ; Frequency. — Tetanus nascentium is a most fatal affection, occurring principally during the first two weeks after birth, usually running an acute course, and char- acterized by a more or less general tonic contraction of the voluntary muscles, with paroxysmal exacerbations, and usually without any period of complete relaxation until the close of the malady. From this definition it will be seen that the affection does not differ in its essential nature from tetanus as it occurs in adults ; though there are so many peculiarities in its causes and symptoms as to demand a special discussion. This disease has also been described under the names of tris- mus nascentium or neonatorum, in accordance with the prominence and frequency of contraction of the muscles of the lower jaw; but as the spasm is rarely limited to these muscles, but usually involves the other muscles of the face and those of the extremities, the more comprehensive name of tetanus seems more appropriate. It most frequently makes its appearance between the third and tenth days after birth, although there are cases on record in which it set in fifteen hours after birth (West), and others where it did not manifest itself until the twelfth or fifteenth day. Causes. — The causes which have been assigned for the production of tetanus nascentium are very numerous ; they may, however, be generally divided into tlie groups of general and local. Among the local causes, the various morbid conditions of the umbilicus and umbilical vessels hold the most prominent place. These are, however, far from being constantly present, and yet the weight of evidence is at present in favor of regarding diseases of the umbilicus, and more especially of the umbilical arteries, as occasional causes of tetanus nascentium. In other cases, the disease has been attributed to some blow or accidental injury which the infant had received. It is, however, still a vexed ques- tion as to how much influence should be ascribed to those purely mechan- ical impressions in the production of this affection. One of the most powerful efforts yet made to establish their importance was by Dr. Marion Sims,^ who published a series of articles to prove that " trismus nascen- tium is a disease of centric origin depending on a mechanical pressure exerted on the medulla oblongata, and its nerves ; and that this pressure is the result, most generally, of an inward displacement of the occipital bone." This displacement is physiological during the parturient state, but its persistence after birth is dependent, according to his theory, chiefly upon the improper position in which infants are allowed to lie, resting upon their occiput for days together. 1 Amer. Jour, of Med. Sci., April, 1846, p. 363; July, 1848, p. 59; and October, 1848, p. 355. GENERAL CAUSES. 577 Further experience, however, has uot confirmed this view, nor justified the admission of injury to the cmnial bones into the list of common causes ; and yet there are a few cases on record in which tetanus un- doubtedly appears to have been developed from this source. Gexeral Causes. — Vicissitudes of temperature appear to favor the development of tetanus', since it is frequent in many countries where a hijih temperature during the day is succeeded by great cold during the night. In the same way, exposure of the infant to wet and cold, as by putting damp clothes upon it, may be productive of the disease. The most frequent and well-established cause of tetanus nascentium, however, is a vitiated state of the atmosphere ; whether engendered by a filthy con- dition of the bedding or house, or by imperfect ventilation; and it is to this that we must attribute the frequency of the affection in such dissimilar localities as the Western Hebrides, Iceland and the neighboring islands, Minorca (see Cleghorn, Obserr. on Epidemical Diseases of Minorca, London, 1768, p. 81), and some of the Southern States of America, where it was formerly not at all unusual for 50 per cent, of all infants born to perish during the first two weeks from this cause alone. It was formerly sup- posed that certain localities, pre-eminent among which are those just men- tioned, were peculiarly favorable to the development of this disease, but it is probable that no predisposition exists excepting the fluctuations of the climate and the filthy habits of the people. The very great importance of filth and deficient ventilation .as a cause of tetanus nascentium is, however, most forcibly shown by the great reduc- tion in the frequency of this disease in large lying-in asylums, effected by the introduction of more thorough ventilation and a greater regard to cleanliness. This was conclusively demonstrated in the Dublin Lying-in Asylum towards the close of the last century. Previously to the year 1782, of 17,650 infants born alive in the asylum, 2944, or almost one-sixth, had died within the first fortnight, and in almost every one of these the cause of death was tetanus nascentium. During the next seven years, after Dr. Clarke had simply introduced a much more complete system of ventilation in the wards, of 8033 children born, only 419 in all died, or about 1 in 19, or 5ith per cent. Our comparative immunity in this part of America, even among the ji r in our cities, is probably due to the greater degree of cleanliness in tilt ir houses, and to the improved construction of our hospitals and a.sylums. In New York, however, according to Dr. Smith,' there are more »!• aths from tetanus during the first year of life than at all other ages I _ ther. The mortality returns of this city indicate that tetanus, although com- ' paralively frequent among infants, is much lam so than in New York. Thus during the 9 years from 1860 to 1868 inclusive, the returns show a total mortality fless still-born), at all ages, of 127,563, and under 1 year of 36,765. During this period there were 233 deaths from tetanus at all BL'.-; 61 of which were during the first year of life, and 157 after that > Amcr. Jour, of Med. Sci., July and October, 1866; and op. cit., p. 168. I 87 578 TETANUS NASCENTIUM. age. Thus the proportion of deaths from tetanus to those from all causes was, after the age of one year, as 1 to 598, and during the first year of life, as 1 to 602. During this same period, the number of births in Philadelphia amounted to 146,895. Pathological Appearances. — We have already alluded to the mor- bid conditions of the umbilical vessels or umbilicus occasionally found in tetanus uascentium ; it is evident, however, that if these lesions have any connection with the disease, they merely act as exciting causes. The only characteristic lesions of this affection are presented by the nervous system. The brain and its meninges are frequently found intensely congested, though this is not so uniformly present as a similar condition of the spinal cord; according to numerous observers, however, it is more frequently present than absent. In some cases, this congestion has led to an actual effusion of blood, either between the skull and dura mater, into the arach- noid cavity, or into the ventricles. In some cases, instead of haemorrhage, there has been found serous effusion into the ventricles or into the sub- arachnoid space, accompanied with a diminution of consistence of the cere- bral substance, as reported by Matuszynski. The morbid appearances found in connection with the spinal cord are the same in character as the above, but more constant and even more marked. The vessels of the spinal meninges and of the substance of the cord are intensely congested, and there is frequently effusion of blood into the cavity of the arachnoid. The value of these appearances was formerly underestimated from a sus- picion that they might be partly, at least, due to the mere gravitation of the blood after death. This suspicion has, however, been entirely re- moved by the observations of Weber of Kiel, and Finckh of Stuttgardt, who placed the bodies of infants dying with tetanus in various positions before examining them, and yet invariably found the above-mentioned con- ditions. There is, however, a further source of doubt as to the significance of these lesions. We have already seen, in speaking of eclampsia, an affec- tion in which no appreciable material lesion has as yet been detected, that, in a certain proportion of cases, congestion, serous effusion, or actual haem- orrhage might be present not as causes but as effects, and due merely to the intense venous engorgement caused by the embarrassment of the respi- ration and venous circulation during the convulsion. It is, indeed, it seems to us, highly probable that a similar interpretation may be placed, in many cases at least, upon the morbid appearances above mentioned as being found after death from tetanus nascentium. We have thus enumerated the lesions of the nervous system which are readily discoverable in many fatal cases of tetanus; and yet these lesions are, it will be observed, almost without exception concerned merely with the vascular supply of the brain and spinal cord, and we are as yet with- out any accurate investigations into the condition of the nervous tissue itself. Within the past few years, the wonderful advances of microscopi- SYMPTOMS. 579 cal science, as applied to pathological anatomy, have revealed structural changes in the nervous system in connection with more than one disease, whose pathology has heretofore been utterly obscure, and it is not too much to hope that at no distant period the question of the presence of any defi- nite structural change in the brain or spinal cord in cases of tetanus nas- centium will be positively settled. In connection with this suggestion, especially in consideration of the analogy between this disease and tetanus in the adult, we append the results of the investigations of Rokitansky and Demme upon the microscopical appearances in the si)inal cord in fatal cases of this latter affection/ 1. The constant anatomical character of tetanus appears to be prolifer- ation of the connective tissue (of the cord); the most striking peculiarity of this lesion is the extent over which it is found. 2. The product is a viscous mass, abounding in nuclei; it remains at this stage of development in both acute and chronic cases, never progressing to the formation of fibres. 3. This change is found almost exclusively in the white medullary sub- stance ; the gray matter seems to suffer only secondarily, and then from compression rather than interstitial deposit. 4. The proliferation is not always followed by corresponding swelling of the white matter ; it can often be recognized only by means of the micro- scope. 5. It was principally found in the medulla oblongata, the crura cerebri, the inferior peduncles of the cerebellum, and in the greater part of the spinal cord. 6. This lesion of the connective tissue appears to be due to long-contin- ued or repeated congestions. 7. The |)eriod at which it occurs probably varies in different cases. These observations, which were originally published about 1860, have V>een confirmed in all essential particulars by Wagner (Syd. Soc. Year-Book, 1862, p. 219) ; and still more lately by J. Lockhart Clarke, who published in the Med.-Chir. Tram., vol. xlviii, the results of the microscopic examin- ation of the spinal cord in six ca.«es of tetanus, in all of which structural i' -i'-ns were discovered ; and by Dr. Dickinson {Med.-Chir. Tratin., vol. li, p. -2^)0). Symptoms. — There are rarely any premonitory symptoms of the attack, but the onset and development of the disease are usually gradual. The earliest symptom noticed is, in most ca.ses, difficulty in nursing ; the infant ipp<*aring anxious to nurse and eagerly pressing its mouth against the nip- ple, but being unable to fully take it into the mouth or to suck, from a rigid condition of the raa-sseter muscles. At the same time it utters a whimpering, whining, unnatural cry. The tonic muscular contraction very rarely remains limited to the mas- -eters, but soon invades the other muscles of the face, and those of the trunk and extremities. The expression of the face thus produced is indicative of great suffering ; > Schmidt's Jabrb., vol. tii pn New Syd. Soc. Year-Book, 1864, p. 232j. 580 TETANUS NASCENTIUM. though it is impossible to say how truly this represents the sensations of the patient. The face is drawn into wrinkles and furrows, and has a strange appear- ance of age. The condition of the mouth, however, is most characteristic ; the jaws are firmly fixed, the lips slightly separated and pressed firmly against the gums, and the angles of the mouth drawn backwards and down- wards in the well-known risus sardonicus. During this time, the other voluntary muscles gradually become rigid. At first, their contraction can be overcome by the use of a moderate de- gree of force, but in the course of twelve or twenty-four hours the period of maximum rigidity is attained. The head is drawn backwards, and firmly fixed ; the arms are flexed, and the hands clenched, with the thumbs drawn across the palms. The thighs may be flexed upon the pelvis, or the legs crossed ; the great toes are usually adducted and separated from the rest, which are flexed. The contraction of the dorsal muscles frequently produces opisthotonos ; and the entire body is at times rendered so rigid that it can be raised, with- out bending, by placing a hand under the heels and head. This extreme degree of spasm of all the voluntary muscles may never be developed in some cases ; or, when present, it often is not so persistent. When the infant is quiet or sleeping, there is usually a certain degree of relaxation. It is a marked peculiarity of the aflection, however, that exacerbations of the tonic spasm are produced by the slightest exciting causes, as an eflfort at deglutition, a sudden noise, a puff of air, the most delicate touch, or even the alighting of a fly upon the surface. During these paroxysms or clonic spasms, the muscular rigidity and contraction attain their greatest height, and produce the most painful distortion of the face and limbs. The fit, according to West, may be ushered in by a screech. During its continu- ance, there is serious interruption of respiration and circulation ; the sur- face becomes livid, and epistaxis may occur. It is during this condition, too, that haemorrhages- into the brain or spinal cord, or their meninges, may result. These paroxysms recur at irregular intervals, but usually, in fatal cases, occur with increasing frequency until either the child expires suddenly during one of the fits, or passes into a state of coma. The pulse does not present any characteristic change ; in some cases it has been found accelerated, but in others has continued normal, or has even fallen below the healthy rate. The condition of the bowels is not uniform. Diarrhoea is frequently present, but is probably due to irritation of the bowels from the irritating nature of the ingesta, or to some accidental cause ; particularly as the bowels are occasionally constipated in well-marked cases. The appetite generally appears to continue, but we have already alluded to the fact that any attempts to feed the child bring on violent spasms, which expel the greater part of the food taken into the mouth. Owing principally to this obstacle to the nourishment of the infant, the emaciation is more rapid and marked in this than in almost any other affection of infancy. PROGNOSIS — DURATION — PREVENTION AND TREATMENT. 581 The state of the pupils in tetanus nascentium has not been noted \vitli sufficient frequency or accuracy to aHow any deductions to be drawn with regard to it. Smith has seen the pupils contracted in the last stage of the disease. Prognosis. — The majority of authors state that they have never met with a case of recovery from fully established tetanus nascentium. Dr. Smith has, however, collected 8 cases of recovery, in the histories of which he calls attention to two important peculiarities ; that the chil- dren were all about a week old when the initiatory symptoms appeared, and that there were fluctuations in the symptoms of the disease. The only circumstances, then, which would lead us to form a less gloomy prognosis than usual, are the late appearance of the disease, and the mildness and intermitting character of the symptoms. Dr. Hiittenbrenner (quoted in Bo.'ifon Med. and Surr/. Jour., Feb. 12th, 1874) has lately published the results of more recent clinical experience in regard to this disease, from which it appears that although the prognosis is very unfovorable, it must not be considered absolutely fatal. The dioffuosis of this affection presents no difficulties, being readily made by attention to the persistent muscular contraction, the inability to suck or to take food, and the exacerbations which are produced by the slightest causes. DrRATiON. — In fatal cases, the duration rarely exceeds forty-eight or >eventy-two hours, and death frequently occurs during the first day. There are instances, however, in which its course has been prolonged to the sixth, or even the ninth day ; and Smith refers to two remarkable fatal cases, recorded by Underwood and Elsiisser, in one of which the duration was six weeks, and in the other thirty-one days. Dr. Wells has reported (Brit. Med. Jour., Dec. 2l8t, 1861) the follow- ing ca.ae of chronic trismus: The child died at the age of one year — hav- ing been, from its birth, in a state of tonic spasm or trismus ; it was always restless, and appeared ill nourished, though there was no reason for this. All treatment was unavailing. It was suggested that the child's state might proceed from irritation due to the mother's milk ; and the child was wpf\nerl, but without benefit. At the post-mortem examination, there was fuiiiid a considerable opalescent eflTusion over the surface of the brain ; the cerebellum was harder than usual, and on being cut into presented a homo- geneous appearance. The arbf)r vita? was entirely wanting. In favorable cases, the duration varies from a few days to one month, or even more. In the 8 favorable cases collected by Smith, the duration was, in 1 case, two days; in 1, a few days; in 1, fourteen days; in 2, fifteen days ; in 1, twenty-eight days ; in 1, thirty-one days ; and in the remaining case, about five weeks. Pp.Er\*ENTToy AND TREATMENT. — It is fortunate that we can by wise hygienic measures do much to prevent the occurrence of a disease of such fatality, and in which, when once fully developed, treatment is so unavail- ing. We have already alluded to the vast diminution in the number of deaths from this disease, which followed the introduction of free ventilation 582 TETANUS NASCENTIUM. and cleanliness into the wards of the Dublin Lying-in Hospital. Nor are the good effects of this practice limited to public institutions, but it has been found that wherever the disease has prevailed to ^ny extent, as on the Southern plantations, its progress can be arrested by insisting upon the observance of cleanliness in bedding and clothing, of mother aud child ; by cleaning, disinfecting, and freely ventilating the houses ; by care in dressing the umbilical cord ; and, finally, by attention to the food of the infant, and the condition of its bowels. Even when the disease has made its appearance, these same measures should be carried out with equal care, since by removing all possible causes, so far as we are acquainted with them, we may mitigate the severity of the attack. In addition to the removal of the causes, the strictest quiet should be enjoined, and all care employed to avoid exciting the violent paroxysms, which are so readily induced. It would be well, in addition, to examine the occipital region, to dis- cover if the occipital bone be unnaturally depressed, since in one or two cases this has appeared to act as the exciting cause of the attack. If such depression be found, the position of the child should be varied by placing it on its side, in accordance with the recommendation of Dr. Sims. The application of leeches to the nape of the neck or along the spine, appears indicated in the early stage of the disease. Dr. West advises the practice, though he has had no experience in its use. Collins, however, states he has tried frequent leeching aloug the spinal column, without the least benefit. Purgatives are only useful to the extent of maintaining regular action of the bowels. The remedies which have been most highly recommended as directly curative, are ether and chloroform, and various narcotics and antispas- modics, as opium, hydrate of chloral, belladonna, aconite, cannabis Indica, conium, woorara, tobacco, and assafoetida. Anaesthetics have been employed frequently in tetanus of the adult, and occasionally in the affection under discussion. Despite, however, the great expectations which were entertained in regard to their utility, their action cannot be considered directly curative. They relieve suffering, however, and by temporarily allaying the spasmodic contraction of the muscles, enable us to administer food or remedies, and thus prolong life, and give time for other agents to act. " So long, therefore, as the patient is able to take food and to obtain periods of comparative quiet, the use of anaesthetic inhalations is not desirable. Great advantages may, however, be obtained from them if he be unable to open the jaw sufficiently to permit of taking food, or if the tetanic spasms are without remission. Ether appears to have stronger facts in its recommendation than chloroform." (J. Hugh- lings Jackson, and Hutchinson's Report on Tetanus, Med. Times and Gaz., April 6th, 1861.) The evidence in regard to the superior efficacy of any particular nar- cotic, is highly conflicting. Opium has, until recently, been the one usually relied upon, and several recoveries have occurred under its use. PREVENTION AND TREATMENT. 583 Of late yeai*s, however, various other narcotics have been emjik^yed, especially in traumatic tetanus in the adult. Thus belladonna and its alkaloid atropia have been used, the latter hypcKlerniically, with occasional good results. If the sulphate of atropia is used hypoderniically in infants, the first dose should not exceed the sijjth or t.' jth of a grain, so that its effects may be tested carefully. One-half grain of the salt may be dis- solved in a tiuid ounce of water, and four to six drops injected under the skin along the spine. The various preparations of cannabis Indica have also been extensively used. Dr. Gaillard reports two cases of recovery from tetanus nasceu- tium under this treatment; in one of which the infant, aged eight days, took as much as f5ss. of tincture of cannabis Indica in a single day — being equivalent to about eleven grains of the pure extract. This quan- tity, however, appears excessive. Woorara has been given in twenty-two cases, according to Demme, with eight cures. It has been recommended by Harley, Spencer Wells, Broca, Vella, Chassaignac, and others. The dose in which this poisonous sub- stance has been given, is from one-eighth to one-half a grain to an mhtlt. The great objection, however, to both this remedy and cannabis Indica, is the great want of uniformity in the strength of their preparations, which necessitates the utmost caution in their use. More recently still, oumerous cases of tetanus in the adult have been treated with the various preparations of conium, and with its alkaloid conia, and also with hydrate of chloral, and the results have been of a decidedly encouraging character. Hiittenbrenner (he. cii.) especially recommends hydrate of chloral, which, according to his observations, is preferable to all other remedies in this disease. Among the antispasmodics most frequently used, are assafretida and tobacco, either given internally or by enema, or added to a warm bath. There is no very positive evidence, however, of their eflSciency in this disease. Baths, either of warm water or vapor, should be repeatedly given ; they tend to act favorably as sedatives, by relaxing the muscular spasm, and. in addition, excite the action of the skin. The free u. and S. Weir Mitchell report that they havo ob- served that ch<»rea occurs more frequently and in a more .severe form in the spring than at any other sea.«on ; and also that relapses of the di.«ease a^ most apt to take place at that time. They think this is probably at- tributable to the condition of weakness of the system which exists in the spring. An altered and anrcmic state of the blood has also been 8uppo.«ed, as by Ogle ' and Barnes,' to be the efficient and exciting cause of the affection. * Brit, and For. Med.-Chir. Rev., Jan. and April, 18«8, pp. 208, 466. * Chorea in Pregnancy, Proc. of Obstet. Soc. of London, vol. x, 1868, p. 147. 586 CHOREA. Killiet and Barthez/ also, when speaking of rheumatism as a cause of chorea, say that, " while admitting the existence of rheumatic chorea, it must not be forgotten that the disease is frequently of a different nature, and that we meet in authors with incontestable examples of chorea con- secutive to chronic diseases that have produced a debilitated condition of the economy, ... as chlorosis, anaemia, and tuberculosis." Constitution does not seem to exert much influence in its production, though it is generally thought to be most apt to occur in children of deli- cate, excitable, and nervous temperament. The belief in hereditary pre- disposition seems to be unfounded save in rare cases. The disease appears to commence more frequently in spring and summer than in winter, and yet it is scarcely known in tropical climates. Rheumatism, however, is unquestionably the condition in connection with which chorea occurs more frequently than with any other. The evi- dence of all observers of experience is unanimous upon this point. M. See (Joe. cit.) asserts, after much examination of this subject, that one-half the cases of chorea are dependent upon the rheumatic poison. Thus of 109 cases of rheumatism admitted into the Hopital des Enfants, he found that 61 were complicated with chorea. Trousseau^ also states that in his experience rheumatism was undoubtedly the most marked cause of chorea. M. Henri Roger^ asserts their connection even more strongly, and states that " the coincidence of chorea and rheumatism is so common a fact that it ought to be regarded as a pathological law, just as much as the coinci- dence of heart disease and rheumatism." In England, also, this connection between rheumatism and chorea, both of the mild and severe or fatal form, is positively stated by numerous authorities. Thus in 104 cases of the list collected by Dr. Hughes,* " where special inquiries were made respecting rheumatic and heart affec- tions, there were only 15 in which the patients were both free from cardiac murmur, and had not suffered from a previous attack of rheumatism." Hillier {op. cit, p. 236) " believes there is a very close connection between these diseases." West (op^ cit., 4th Am. ed., p. 188) says : " Be the exact relation then what it may, it does seem that rheumatism, or the rheumatic diathesis, is a very powerful predisposing cause of chorea." Dr. H. M. Tuckwell, in a valuable article^ on the pathology of chorea, strongly up- holds their frequent connection, and cites 17 cases of his own, in 11 of which the previous occurrence of rheumatism was allowed, while it was denied only in 6. Dr. Chambers found that out of 33 cases of chorea in his books, in 6 the affection either began during rheumatic fever, or followed immediately after it, or else rheumatic fever succeeded to the chorea. In 80 cases of non-fatal 1 Op. cit., 2eme ed., t. ii, pp. 565-598. 2 Clin. Med., 2eme ed., t. ii, pp. 160-198. 3 Arch. Gen. de Med., 1866, vol. ii, p. 641; and 1867, vol. i, p. 54; and Gaz. Med. de Paris, March 7, 1868. * Guy's Hospital Rep., 2d series, vol. iv, 1846. 6 St. Barth. Hosp. Rep., vol. v, 1869, pp. 86-105. RHEUMATISM AS A CAUSE. 587 chorea recorded by Ogle/ it appears that in 8 case^ rlieuraatic fever had existed. On the other hand, several Grerman authoi-s of liigli authority on the valves or some part of the endocardium. In 2 cases only was the pericardium > Lumleian Lectures, 1849. ' Medical Gazette, 18o0. > London Jour, of Med., 1851. * Edin. Med. Jour., 1852. • Brit, and For. Med.-Cbir. Rev., Oct. 1867. 590 CHOREA. diseased. In the 14 fatal cases collected by Hughes (loc. cit), vegetations were found on the valves of the heart in not less than 11. The results of careful auscultation, during life, come to support those of post-mprtem examination. Hillier states (op. cit, p. 236) that, " of 37 cases in my note-books there was probably organic disease of the heart in 25, and in 4 others there was evidence of functional derangement, whilst in 8 only was there no sign of cardiac disturbance." Jules Simon writes from a large experience, and says : " I have been almost always able to detect well-marked evidence of cardiac affection in chorea, in the shape of organic murmurs, hypertrophy of the heart, etc."^ In our own experience, evidences of rheumatic heart disease have very frequently been present in cases of chorea ; and also in cases which have come under our care for organic disease of the heart, there has frequently been a history of previous attacks of chorea. It is sufficiently evident, therefore, that in a large proportion of cases of chorea, some morbid condition of the endocardium is present. The particular lesion which has been usually found, consists of fine bead-like vegetations, which either fringe the border of the mitral valve, or are seated upon the auricular surface of its leaflets. These vegetations are in most cases readily detached from the valve, by lightly brushing them with the tip of the finger, or with a camel's-hair brush ; and it has been supposed by some observers, as Ogle and Barnes, that they consisted merely of the fibrin of the blood, deposited in the agony of dissolution. We believe, however, both from the previous oc- currence of valvular murmurs in cases where such vegetations have been found, as well as from a careful study of the anatomical descriptions of their appearances, and the occasional presence of the positive results of embolism, that these vegetations are produced by a process of endo- carditis. We will, however, discuss the question of their connection with chorea, when we come to speak of the nature of that disease. In regard to the condition of the nervous system in fatal cases of chorea, there is at times no lesion appreciable, even on microscopic examination, while on the other hand there is not uufrequently marked disease, either of the nervous tissue or of the meninges. Thus, in the 14 fatal cases collected by Hughes, the brai7i was healthy in 4, only congested in 3 cases ; there was softening of the brain, with or without opacity of the membranes and serous effusion in 6, and in the seventh with opacity and congestion of the dura mater. In 11 of the 35 fatal cases collected by Tuck well, the brain was found softened, and in 9 only is it reported as healthy. In the 16 fatal cases re- ported by Ogle, the brain was healthy in 6, much congested in 8, softened in but 1, and ansemic in 1 also. It appears, therefore, that in a notable proportion of the cases upon 1 Nouv. Diet, de Med. et de Chir. Prnt., Art. Choree (quoted by TucUwell, St. Barth. Hosp. Rep,, loc. cit., p. 101). SYMPTOMS. 591 record, positive organic disease of the brain, and especially in the form of softening, has been discovered. In a few instances embolism, or occlu- sion of the vessels by fibrinous masses, has been observed, either in the carotid artery (Ogle), or in the minute arterial branches leading to patches of softened brain-tissue (^Tuckwell). We need, however, a large series of careful observations to determine more positively how frequently lesions of the brain occur, and especially in what proportion of cases em- bolism is present. The spinal cord has also been found softened with or without opacity and thickening of its membranes, though in a much smaller number of cases, probably in part because it has not been so frequently examined in such case:? as the brain. Of the 16 fatal cases reported by Ogle, it5 tissue was congested in 5 ; there was slight softening in 2 ; in 1 the upper dorsal region of the cord was completely broken down and almost difiiuent. In 2 cases the cord was examined by Mr. J. Lockhart Clarke, who found in one {he. cit., p. _'21) that "in the lower part of the dorsal region, at the ninth dorsal nerves, the anterior columns were swollen, and formed a convex protu- berance of considerable size. In a transverse section of the cord carried through this part, and examined under the microscope, it was very evi- dent that extensive morbid changes had been going on, the white substance had been softened, .... and in two or three places there were circum- scribed effusions of blood, surrounded by granular exudations, which had probably occurred before the effusions." Similar appearances were dis- covered in the lower dorsal region in the other case (he. eit., p. 507). In a case already referred to, observed by Tuckwell, of rapidly fatal maniacal chorea in a lad of seventeen years of age, in addition to several patches of embolic softening of the brain, there was marked softening of the spinal cord in the middle dorsal region. In 3 fatal cases reported by Steiner {he. cit.), there was increase in the connective tissue of the spinal cord ; serous eff'usion in the spinal canal ; and congestion or effusinn of blood in the membranes at the exit of the ner\*es. Finally, in the cases where embolism of the brain was observed by Tuck- well, there was also minute embolism of the kidneys. In a case of fatal chorea reported by Monckton,' embolism of one brachial arter}' occurred, and, after death, large vegetations were found on the aortic valves. We will have occasion to refer again to these various anatomical ap- pearances when speaking of the nature of chorea. Symptoms; Course; Duration. — The disease may be general or par- tial : in the first case, it affects all the limbs, the face, and some of the mu>cles of the trunk ; in the second it implicates only one side, the uf)per ' xt rem i ties, a single memljer, or a certain group of muscles. It liap- peus not rarely that the choreic movements are limited to one side of the body : thus in 80 cases of non-fatal chorea reported by Ogle {he. cit.^ p. > Brit. Hed Jour., 1866, No. 806. 592 CHOREA. 488), the right side alone was affected in 24, whilst the left alone was af- fected in 20 ; and in 25 both sides were affected, though in some instances one or the other side was more involved than the opposite one. Of the 30 cases reported by Gerhard {loc. eit.), no less than 15 were strictly uni- lateral, the choreic movements being confined to the right side in 10 in- stances, and in 5 to the left. In a large majority of the recorded cases of unilateral chorea, the right side was the affected one. It occasionally happens, as noted by Russell (^Med. Times and Gazette, 1868 and 1869) and Gerhard {loc. cit.), that a chorea, which begins as unilateral, may subsequently invade the opposite side and become general. Of 7 cases that we have seen, in which this point was noted, it was general in 4, and confined entirely to the right side in 1, and to the left in 2. We shall de- scribe first the prodromes of the disease, then the invasion, and afterwards the symptoms as they exist in fully developed cases. Prodromie Symptoms. — It is doubtful whether there are, as a general rule, any well-marked prodromie symptoms. The only ones that have been mentioned with any authority are irritability and peevishness of the temper, an unusual degree of impressibility, languor, debility, disturbance of the organic functions, exhibited by deranged appetite and an irregular state of the bowels, and, after a time, a certain quickness and irregularity of the movements, which mark the commencement of the characteristic symptoms of the malady. Invasion. — The onset of the disease is, as already stated, either sudden or gradual, so that there may be several days or more before it reaches any considerable degree of severity, or it may, particularly when the case has been of a sudden and energetic nature, reach its height in a few hours. In most cases, however, it begins with some unusual and singular move- ments in one of the upper extremities. The choreic movements are often observed first in the fingers, and at the same time, or soon after, in the face. Sooner or later they increase in severity, and extend to the other arm, to the legs, and to the tongue, and the disease is fully developed. Sym])toms of Confirmed General Chorea. — When the disease has become fully confirmed, the movements are exceedingly diversified and irregular. The limbs are agitated by involuntary contractions of the muscles into every attitude possible for them to assume. The fingers are opened and shut, brought together or separated, without any regularity. The hands are flexed and extended upon the forearms, or pronated and supinated, whilst the forearms are flexed or extended upon the arms, and the arms moved at the shoulders into every imaginable position. Such are the irregularity and rapidity of the motions that it is often with great difficulty that the patient can seize anything with the hands, and when once the object is attained, he frequently cannot do with it what he wishes. This imperfect control over the hands and arms sometimes prevents the patient from carrying food and drink to the mouth, excepting with the utmost difficulty, and may make it necessary to feed the child. The inferior extremities are affected in the same way as the arms. Walking is always more or less difficult, and in some severe cases imprac- ticable. The patient totters from side to side, or walks rapidly a short SYMPTOMS. 593 distance, and then suddenly stops. Sometimes the progress is accom- plished in a zigzag direction, ami at others hy tits and starts as it were, whilst in othei^s again the walk is rapid and sudden, almost a run. The hild often falls while walking or running, either from meeting a slight obstacle, or in consequence of the irregular and imperfect muscular action. In some instances standing is impossible, the knees bending suddenly under the weight of the body. It was no doubt the peculiar irregular and dancing movements of the inferior extremities during the attempts to walk and stand, that gave to the disease its original name of St. Vitus's iance. The convulsive movements of the face and head are not less singular than those of the limbs. The face is distorted into all kinds of expres- sions, so that it assumes by turns that of the most opposite emotions, — sadness, terror, joy, or grief. The mouth is opened and shut, or its corners Irawn apart, with the greatest irregularity; the tongue is occasionally protruded between the teeth, and sometimes moved rapidly in the mouth, so as to cause a clacking sound ; the lower jaw is depressed and elevated, or moved in a lateral direction, and with such violence perhaps as to injure the tongue or teeth. In consequence of the irregular motions of the tongue and mouth, articulation becomes difficult, and the child either stutters, or speaks slowly and badly, or can pronounce only monosyllables. In a case that occurred to one of ourselves, the movements of the mouth and tongue were so violent and uncontrollable that the patient, a boy nine years old, lost for three weeks all power of speech. He was at the same inae unable to open or shut the mouth at will, or to swallow at the proper noment, so that in the act of feeding him, which became necessary from ;]is entire want of control over the arms, the food was constantly sj)illed and spluttered about as though by an 'diot. The act of mastication also ^as quite impossible, so that he could take nothing but fluids for a number f weeks. In another case also that occurred to one of ourselves, in a girl between eight and nine years of age, and which moreover was a relapse, the patient exhibited the same inability to feed herself, and the same diffi- ' ulty in regard to mastication, so that she had to be nourished for several ~ on soft fo<^)d. The speech was likewise greatly affected, it being lifficult to understand her muffled, thick, and indistinct utterance. Whilst the face and limbs are contorted as above desc-ribed, the head •^ ved rapidly from side to side, or backwards and forwards, or under- onstant rotation, and, in some instances, as in two that came under ■jr own notice, all power over the muscles of the back of the neck is lost, ind the head falls from side to side, or forwards, as in an infant. In -evere cases the choreic movements affect the trunk also, so that the !it cannot lie upon a l)ed, but rolls and twist* about the floor with violence as to bruise and excoriate the skin. Deglutition is some- slightly embarra.ssed, and the child is obliged to swallow with great i«,M.iity; in some few ca.«e8 a peculiar loud cry, like that which occurs in i bysteria, dependent apparently upon spasm of the ]ar}'nx, has alsear under the influence of treatnicjit, or in the natural course of the malady. It has been frequently noticed that when an acute febrile or inflammatory disease is developed during tlie coui^ of chorea, the spasmodic movements are very apt to diminish or entirely cease for the time. In fatal cases the symptoms are constantly aggravated ; the movements become so violent as to make it necessary to secure the child in bed, or in a strait-jacket ; the patients, deprived of sleep, become feeble and emaciated; the respiration becomes difficulty intelligence is abolished ; the pupils are contracted ; and the child dies. The duration is irregular, varying in acute cases between one and three months. The average duration is probably about six or nine weeks. In very slight attacks it may be much less. The duration of chronic cases is from months to years. In fatal cases the duration is sometimes very short. In one it was only nine, and in another twenty-seven days. The local forms of the disease are often peculiarly intractable, and last many years. Jiehpses. — Relapses are quite common and are said by Trousseau to be shorter than the original attack. We have, however, in a few cases, ob- served that the relapse was much worse than the first attack. In one case in particular, the relapse was one of the most violent and prolonged attacks that we have seen. MM. Rilliet and Barthez state they occurred in six out of nineteen cases seen by them. The relapses in these cases occurred once, twice, and three times. ^I. See (loc. cit., p. 408) says that it is not uncommon, after some weeks of respite, or several months of apparent recovery, to see the disease reappear with renewed intensity, and be thus repeated twice, thrice, and even seven times in succession. Out of four patients, at least one, he states, remains thus under the influence of the di.sease. Of 158 cases he counted 37 relapses, of which 17 were arrested after the second attack ; 13 suffered a third, and 6 a fourth attack ; and, lastly, one had seven distinct seizures, each one of which was separated from the following by a well-marked interval. In 46 of Ogle's* cases in which this point was noted, previous attacks had occurred in 25 ; in 5 of which there had been 2 previous attacks, and in 1 no less than 7. Accord- ing to Gerhard, relapses, like the primary attacks, occur most frequently in spring. Nature of Chokea. — In considering the essential nature of chorea, it is evident that there are two point« of importance to be determined, Damely, the precise portion of the nervous system involved, and the nature of the morbid change in this jiart. Before alluding to the views which have been entertained in regard to the first of these questions, we would refer to the very great irregularity which exists in different cases in the extent and distribution of the choreic movements. Thus it frequently hapi)ens that the disease is strictly con- fined to one or the other side of the Uniy, or it may be entirely symmetri- cal. In other cases the muscles of the head and neck may almost or (juite escape, while both legs and one or bf)th arms are affected. Or, on the other hand, the choreic movements may first appear and remain most 596 CHOREA. severe in the muscles of the face, mouth, and tongue. It seems probable to us, therefore, that there is no one special portion of the motor centres which is exclusively the seat of lesion in all cases of chorea. In the great majority of cases, however, the symptoms are so far uniform that the mus- cles of the face and tongue, as well as those of the extremities, are affected, and the only peculiarity is that the irregular movements may be confined to one or the other side, a circumstance susceptible of ready explanation. Marshall Hall considered chorea as an affection of the true spinal sys- tem, and possibly in some cases where the choreic movements are limited to the extremities and symmetrical, this supposition may be correct. In the vast majority of cases, however, it is undoubtedly necessary to locate the seat of disturbance in chorea at a higher point in the cerebro- spinal axis, one above the decussation of the anterior pyramids, and prob- ably in or near the corpora striata. Among the arguments which lead to this view, many of which have been advanced by J. Hughlings Jackson^ and Broadbent,^ who strongly uphold it, may be stated the following: That the muscles of the face are very frequently affected by the choreic movements ; that in the great majority of cases the movements cease during sleep ; that the affection is frequently limited to one side of the face and body, and that the spasmodic movements not rarely terminate in complete hemiplegia. In a footnote {loc. cit., p. 93) Tuckwell says : " It is just to Dr. Todd's memory to add, that he long ago (^Lancet, 1843, vol. ii, p. 463) showed that the choreic phenomena cannot be explained by the hypothe- sis which refers them to irritation of the spinal cord. He says : ' The hemiplegic tendency is utterly inexplicable according to that view. The affection of one-half the body would alone refer to some point above the decussation of the pyramids as the seat of irritation.' " The supposition of Carpenter and others that the cerebellum is the seat of the disturbance in chorea, was based upon the view that that organ possessed the chief power of co-ordinating muscular movements. Recent researches into the functions of the cerebellum, as well as the arguments which have been ad- duced above, render this supposition untenable. The further question now remains as to the condition into which the af- fected part of the motor centres is brought, in order to produce the phe- nomena of chorea. And it is especially in regard to this point that the investigations of Jackson and Broadbent, above referred to, are of so much value. These pathologists, and paticularly the latter, have called atten- tion to the fact that the choreic phenomena are symptomatic merely of the seat of the disease, and that the only essential condition of their production is an impairment of vigor and instability of the sensori-motor ganglia, a condition which may probably be induced in different ways. We are now prepared to consider the manner in which the various causes of chorea may be supposed to act. We have already seen that in a certain number of cases chorea is inde- 1 Keynolds's Syst. of Med., Art. Chorea, vol ii, p. 127, footnote ; and Med. Times and Gaz , March 6th, 1869. 2 British Med. Jour., 1869. NATURE OF CHOREA. 5lM pendent of any appreciable lesion of the nervous system. In some of tliose cases it is possible that the impaired nutrition of the motor centre may result from an altered and ana^nic state of the blood ; and, indeed, it ap- pears to us quite as reasonable to explain a certain class of case* of chorea in this manner, as to apply the same explanation to analogous cases of paralysis. It is probable, also, that in another group of cases, chorea may be reflex in character, and depend upon a different degree of that peculiar action upon the motor centres which produces reflex paralysis, whether by ex- hausting their excitability or by causing a reflex spasm of their vessels. This view is maintained by Broadbent {loc. cit.) as well as by Radcliffe,^ who states that irregular choreic movements may be produced not only by injury of certain parts of the nervous system, but by injury of certain nerves at a distance from the nervous centres, the portions of the cerebro- -piual axis which are concerned in the development of such movements, being afl^ected by reflex action. It is probable that if this mode of production be admitted, it will serve to explain a large number of cases of chorea, both where the source of irri- tation is at a distance (as in cases of pregnancy, or where there are worms in the intestinal canal, or, as in the case already quoted from Packard, where a splinter was lodged in the matrix under a finger-nail) and where it is seated in immediate connection with the nervous centres. As instances of the latter kind, may be suggested such conditions as thickening of the meninges of the brain or spinal cord, and the presence of bony spicuhc de- veloped in the meninges. Finally, we must admit as a cause of chorea, primary alterations of the tissue of the sensori-motor ganglia and adjacent parts ; the degree of dis- ease not being so great as to abolish entirely their function and produce paralysis, but only suflicient (as for instance would be secured by an early .^tage of softening) to weaken it and render it unstable. It will be seen from the foregoing remarks that we deem it impossible, at least in the present state of our knowledge upon the subject, to consider the cause and mode of production essentially the same in all cases of chorea, and that we are disposed to admit the existence of cases due to mere anajmia and impaired nutrition, or to an altered stute of the blood ; of cases due to reflex irritation, in both of which clavSses of cases, some minute and as yet inappreciable lesion may exist ; as well as of cases wliich are due to priraar}' material altemtions of the sensori-motor ganglia. We have already, in considering the causes and anatomical appearances of chorea, had occasion to dwell upon the connection which exist** between it and rheumatism, and before leaving the present subject it is desirable to refer to the various explanations wliioh have been ofll'red of tiiis circinn- stance. Among these, the most important and interesting is that of Kirkes,^ who, noticing the frequent presence of vegetations upon the valves of the ■ » > Reynolds's Sjrst. of Med., Art. Chorea, vol. {{, p. 126. » Med. Times and Gaz., 18C3, vol. i, pp. 636 and 662. 598 CHOREA. heart in fatal cases of chorea, was led to suggest that very small fragments of fibrin might be detached from the valves, and entering the circulation cause temporary obstruction of the minute capillaries of the nervous cen- tres, producing irritation and impaired nutrition. This theory, which at- tributes the production of chorea to embolism, has been accepted by J. Hughlings Jackson (Joe. cit.), by Savory,^ by Tuckwell (loc. cit), and, in part at least, by Broadbent (loc. cit). It is supported strongly by the facts that continued observation of cases of chorea has shown even more clearly the very frequent existence of cardiac murmurs during life, and of vegetations upon the valves after death ; that complete paralysis, usually in the form of hemiplegia, fre- quently follows the choreic movements ; that in many fatal cases there is found just such cerebral softening as follows embolism ; and, finally, that in a few cases, already referred to, the existence of embolism has been actually demonstrated. It is also to be borne in mind that recent researches have shown that endocarditis with the production of fine vegetations on the margins of the cardiac valves, is not a complication of rheumatism alone, but occurs in connection with scarlatina, diphtheria, and some other acute specific dis- eases. If then the theory is finally substantiated which would explain some cases of chorea as the result of minute embolisms, it is possible that it may be found that such is the mode of production of a part of the post-scar- latinal or post-diphtheritic choreas. There have, however, been numerous objections advanced against this theory, the most powerful of which are urged by Barnes (loc. cit) and Ogle {loc. cit.). Thus it has been objected that, on the supposition of nu- merous minute fragments of fibrin circulating in the blood and becoming impacted in the minute capillaries, it w^ould be difficult to explain the fact that chorea is so frequently unilateral, or even localized in a single group of muscles. It must be remembered, however, in answer to this, not only that in some cases of fatal chorea embolism of single large arterial branches has been found, but that the number of minute fragments of fibrin detached from the heart's valves may be very small, and that it is quite supposable that they should in some instances nearly all pass into the iunom.inate, or the left carotid artery, and thus be chiefly dis- tributed to one side of the brain. It may be mentioned also in this con- nection, that it is especially in these cases of unilateral chorea that the affection is succeeded by pamlysis, such as might readily follow in case of embolism. Again, it has been objected that if chorea be invariably dependent upon embolism, the results of this accident must be of a very transient and trifling character, since in so great a majority of cases the disease termi- nates in complete and permanent recovery. The weight of this objection must be admitted, and yet Tuckwell fairly remarks in answer to it, that the "mere fact of recovery is not enough to condemn the notion of embol- 1 St. Barth. Hosp. Rep., vol. i, 1865, p. 107. DIAGNOSIS — PROGNOSIS. 599 ism. Ou the other hand, the very frequent presence of a cardiac niiir- nuir, even in the milder attacks of chorea which recover, would rather dispose me to look for the same exciting cause in the mild as in the severe cases, viz., embolism." It is evident also that if the supposed embolus were minute, and therefore obstructed only a very small vessel, a collateral circulation might soon be established and restore the nutrition of the area aflected. Another objection advanced by Ogle [he. cit., p. 232) is, that in other cases of capillary embolism the symptoms produced are not those of chorea, but rather of pyi\?mia or of gangrene. It is quite evi«lent, how- ever, that these symptoms alluded to (which are met with for instance in ulcerative endocarditis) are due, as remarked by Savory and Tuckwell, not to the mere capillary embolism, but to the concomitant septic condi- tion of the blood. In this connection, reference may be made to the elaborate experiments of Panum as to the results of embolism ^Arrh. f. Path. Anat., xxv, 308, 433; Syd. Soc. Year-Book, 1863, p. 211), in which he demonstrates that embolism of the vessels of the brain and medulla oblongata is followed by tetanic symptoms. This extremely interesting question cannot be considered as definitely settled ; there is still needed a series of careful examinations in regard to the various points under discussion. It appears to us, however, conclu- sively shown that, in a certain number of cases, the peculiar irritation and impaired nutrition of the sensori-motor ganglia, which leads to the devel- opment of the choreic phenomena, are due to embolism of the vessels supplying these parts. We have, however, already expressed our opinion that, at present at least, there must be admitted two other classes of cases of chorea, due primarily to alterations in the blood and to reflex irrita- tion respectively. It is quite possible, therefore, that in some instances rheumatism induces chorea indirectly, either by causing amemia and im- paired nervous vigor, or by causing inflammatory lesions, as of the spinal meninges or sheaths of spinal nerves, which may serve as the foci of reflex irritation. Diagnosis. — The diagnosis of chorea cannot be attended with any diffi- culty, and we shall therefore make no remarks upon it. Pke continued for several weeks in gradually increasing doses, until some visible effect is produced, a,s nausea, headache, vertigo, or dis- ordered vision. The usual doses are from half a drachm to a drachm of the powder, from one to two ounces of the officinal decoction, and one or two drachms of a saturated tincture, given three times a day. For our own part we prefer the decoction, of which we give to children of eight or nine years old, from four ounces to half a pint a day, made in the propor- tion of half an ounce of the root to a pint of boiling water. Prepared in this way, it is not a disagreeable drink, and is usually taken without much objection. The bromide of potassium in full doses has in some cases in our expe- rience proved of marked benefit. "NVe have used it especially in those cases which were connected with rheumatism as a cause, and have then frequently administered it in combination with the iodide of potassium and the iodide of iron. Some French authors recommend chiefly valerian, oxide of zinc, and assafcetida. Of these the one which has the highest reputation is valerian, and from the evidence adduced in its favor there can be no doubt tliat it exerts a very beneficial effect upon the disease. It may be given in the form of powder, infusion, or fluid extract. The dose of the powder is from twelve to eighteen grains in the day, to commence with, to be rapidly in- creased to several drachms, as the stomach becomes accustomed to it. It may be given in honey or preserve-syrup. We should prefer the fluid extract, of which half a teaspoonful may be given to a child eight or ten years old, three times a day, and the quantity gradually increased. The oil of valerian is employed by some practitioners. Oxide of zinc is given in doses of a grain every three hours to children eight years old, and is much relied upon by some practitioners. Assaf«T?tida is recommended both by English and French writers. It is best given in pill, on account of the nauseous taste of the mixture. Two three-grain pills may be given to a child of four or six years of age, three times a day. Dr. Bardsley gave it by injection, in combination with laudanum, every evening, after using musk and camphor, through the day. Xarcotic^ have been recommended by .«»ome writers. Those whirh are most employed are opium, belladonna, stramonium, and cannabis Indica. Substances of this cla.«a are seldom, however, made the basis of treatment. Opium is useful in some cases in which the agitation is very great, so that the sleep of the child is much disturbed, but it is seldom necessary except as an adjuvant to other nif an- : anath u.«ed once a day, or every second day, would always be useful in promoting the general health, when the cold bath is not bonie well. Ether spray has been recommended by Lubelski ( (Jnz. Jlrhd.^ April 19th, 1867), as an application along the spine, and a number of cases in which iti* use was successful have V>een placed on record. Sulphurous baths have been recommended and employed with much 606 CHOREA. success, by M. Baudelocque of Paris. A rapid and definite cure was obtaiued in 68 out of 65 cases. Thirty drachms of sulphuret of potas- sium are added to each bath, which is employed for at least one hour daily, at a temperature of 91°. Generally amelioration occurs after the second or third bath, but sometimes not until after twelve or fifteen days, a mean of twenty-two days having served for the cure of fifty out of fifty- seven cases. Where the cure is retarded, it ordinarily depends upon the patient's powers being lowered by other remedies or insuflScient diet, upon irritation of the skin induced by the bath, or upon acute irritation of the internal serous membranes, — circumstances contraindicating the baths while they continue. The conjunction of other remedies retards rather than aids the cure. Deducting the cases in which the bath was improp- erly used under the above circumstances, there remain but nine true failures in eighty-one cases, these being almost all recent or rheumatic choreas. (S6e on Chorea, Banking's Abstract, No. 16, p. 51.) Counter-irritation to the spine, in all its shapes, from pustiilation with tartar emetic, issues, and blisters, down to frictions with coarse towels, has been proposed and employed in the treatment. The use of any but the milder remedies of this class is unnecessarily harsh and cruel, except when the disease is evidently dependent upon an afiection of the brain or spinal marrow. The great majority of cases will recover perfectly well without a resort to such violent means, and they ought therefore to be avoided. Electricity has been resorted to, and apparently with good effects in some instances, and it might therefore be tried when other and simpler means fail, or in conjunction with these means. In cases where the spas- modic movements are constant and persistent despite the use of internal remedies, the inhalation of anaesthetics has been tried, but with uncertain results. In violent cases, it is of course desirable to confine the patient to bed ; and it may be necessary to have padded sides made for it to prevent him from dashing himself out of bed in his uncontrollable and violent move- ments. In such cases it may even become necessary to employ padded splints, or to envelop the body with bandages carefully applied over layers of wadding, so as to secure the legs together, and to confine the arms by the sides. Gymnastic Exercises. — M. See (loc. cit.,- p. 481) says that this method is one of the best that has been employed. He states that it was recom- mended by Darwin, and then by Mason Good, and was first employed by Louvet Lamarre in one case, after which it fell into oblivion until some of the physicians of the Children's Hospital, at Paris, and amongst others, MM. Bouneau, Baudelocque, Guersant, and Blache, " struck, no doubt, like myself, with the good effects of gymnastics in scrofula and other ca- chectic diseases, and taught especially by the effects of musculation on the general health, conceived the idea of applying this treatment to nervous diseases, and particularly to chorea, which, besides the perturbation of the nervous system, is so often attended with disorders of nutrition and of the functions of organic life. To put a stop to this state of languor, to re- establish at the same time the equilibrium of the movements, which are TREATMENT. 607 rather irregular than convulsive, to endeavor, in fine, by regulating the contractions, to break up their vitiated habit, — this is the triple object sought to be attained by gymnastics. Be it theory or empiricism, success crowned these previsions, and proved the utility of the new treatment, of which we are about to study the methods and it:s consequences." M. See says, that to commence the treatment, we must prescribe first simple and cadenced movements, and exercise at the same time the larynx by means of singing. " To place the child in a vertical position, make it fiex and extend the knee^, touch the ground, stretch out and bend tlie arms, har- moniziuu at the same time these various movements bv rcixulated sin<;ing:, — such are the first means by which to replace the contractions under the power of the will. This end will be so much the more rapidly attained, as the attention of the patient is the less distracted, its intelligence tlie less changed, and its temper the less capricious ; so also is it often impos- sible to succeed unless we first obtain control over the patient by kindness and gentleness. "After reaching this point, we may attempt walking, regulated to a slow or quick step, running, jumping, hanging by the arms, or other more complicated movements, always graduating them to the degree of the dis- ease, watching them most carefully, and repeating them daily without pro- longing them beyond fifteen or twenty-five minutes, in order to avoid mus- cular fatigue and palpitation of the heart, which occur sometimes when the exercises are too long continued. *' With these precautions, and no matter how severe the symptoms, we may, after a few lessons, and sometimes after the first, and at latest after the fifth or sixth, perceive a manifest change in the abnormal mobility, which is usually so rapid that we are generally able to decide, after the first eight days, as to the eflicacy of the treatment. When, after this length of time, the patient can neither stand erect, walk in a straight line, nor hang by the arms, there is reason to fear that the method will fail ; it is at least certain that it will be tedious and difficult." In Hanking s Abstract (loc. cit.y p. 50; may be found the following statements in regard to the treatment by gymnastic exercises : They were first employed under the guidance of M. Laisn^*, gymnastic profes.>Mjr of the Polytechnic .School, their eff'ects being tried first on scrof- ulous children. " Commencing with simple movements of the legs and arms, accompanied by appropriate wjngs, the children's progress was so r;i;id that they were soon able to employ the orthojx'dic ladder, the jarallel bars, and other machinery, in succession. By the twentieth les- stjii they were exercised in wrestling, and afterwards in running, special exercises being devised for the lame. From the first lesson the children became fired with emulation, and movements which seeniecl imjK>sj«ible were so«jn executed with eaM- and pleasure. A marked ameli(»raMon was speedily o^>served, their countenances becoming animated, their fle.-h firm, their voices stronger, their appetite keener and more regular; glandular swellings, which had long resisted all treatment, were ra^olved, and fi.ntu- lous sores, that had been open for vf^n*, closed up. The le?«.*ons, one hour each, were given three times a week ; and in the intervals the children 608 CHOREA. amused themselves by repeating such of them as did not require ma- chinery." This treatment, at first applied to scrofulous children, was, as stated above, extended to those laboring under nervous affections, partial paralysis, rickets, and especially chorea. Since 1847, ninety-five children suffering from chorea, sometimes so obstinate as to have resisted the most various treatment, have been cured by this means alone, or in conjunc- tion with others, and no accident has resulted from the employment of the exercises. The movements are graduated according to the severity of the case, and they are repeated daily, but not for more than from fifteen to twenty-five minutes, so as not to induce fatigue or palpitation. " Im- provement is sometimes seen after the first lesson, and at latest after the fifth or sixth ; so that at the end of a week we can judge whether the means are likely to prove efiicacious, and if manifest improvement has not then taken place, it is doubtful whether the cure will be thus efiected, or if it is, it will be so only after a long time. The worst as well as the slightest cases have reaped equal benefit, the cure in the favorable ones only requiring a mean of twenty-nine days, and old or relapsed chorea being more amenable than recent. Dr. See has found that when other remedies are conjoined with the gymnastics, the proportion of cures is less, and the period of their attainment later; and he recommends no other adjunct to be employed than good diet." (Dr. See on Chorea, loc. cit, No. 16, p. 50.) Hygienic Tkeatment. — The management of the hygiene of the patient is quite as important as any other part of the treatment. The diet should be arranged to suit the particular condition of the individual, and with a view to procure and maintain the most healthful possible state of the di- gestive apparatus. It should always be light and easily digestible, in order that neither the stomach nor bowels may be oppressed and deranged by the products of an imperfect digestion. When the stomach is weak and dyspeptic, the food ought to consist for some days chiefly of preparations of milk and bread, whilst in the meantime, a tonic remedy is administered internally, in order to invigorate the power of that organ. As the diges- tive function becomes stronger, the child ought, as a general rule, to be put upon the kind of diet most likely to promote the general health and vigor of body. It ought to consist of bread, milk, plain wholesome meats, and simple vegetables. Coffee and tea, and all other nervous stimulants, had better be avoided. The meats ought to be mutton, beef, or poultry. There are few vegetables, besides rice, potatoes, and tomatoes, which are suitable under the circumstances. All candies, preserves, unripe, coarse, or dried fruit, hot bread and cakes, except the very simplest, ought to be withheld. Of dress we need merely say that it must be suited to the season. Ex- ercise, or at least, exposure to fresh air and insolation, are of the utmost consequence. When the disease is so violent as to prevent the child from walking, it ought to be taken to drive as often as possible. In cases which seem connected with a debilitated and anaemic condition of the constitu- tion, removal to the country, and particularly to the seaside, will often effect a cure w-ith great rapidity. Whenever, indeed, a patient inhabiting ATROPHIC INFANTILE PARALYSIS. G09 a large city or towu can be conveinently taken to the seaside in the sum- mer, it ought to be done, for the change is useful not only at the time, but it les;seus, also, by strengthening and invigorating the constitution for the future, the danger of a relapse. ARTICLE XI. ATROPHIC INFANTILE PARALYSIS. Paralysis occurs in the young child in almost, if not quite, all the forms observed in the adult. Many of these are however rare in childhood : whilst, on the other hand, there is one form which, although it is occa- sionally observed in the adult, occurs with such peculiar frequency in young children as to have received the name of infantile palsy. It is char- acterized by total or partial loss of power over one or several groups of muscles, usually without impairment of sensation, occurring suddenly as a rule, and often followed by atrophy of the pal:?ied muscles, and consequent deformities. History and Synonyms. — Occasional allusions to infantile paralysis may be met with in medical writings even as far back as the latter part of the last century, but of such a vague and indefinite nature that the full recognition and accurate description of this peculiar affection cannot be -aid to date further back than the writings of Kennedy and Heine, in 183() and 1840 respectively. Since the publication of Heine's classical memoir, however, a number of observers have studied the disease with much attention and success. We have subjoined a list of the principal writings upon this subject to which we have been able to obtain access.* * Bibliography. — Underwood, Treatise on Disensesof Children, London, 1789. Roj'tan, Rcch. sur le Kamoll. du Cerveau, 2eme ed., Paris, 1823, obs. L. Shaw, on Nature and Treatment of Distortions, London, 1823. Cazauvit'ilh, Arch. Gen. de M6d., t. xiv, 1827, pp. 6 and 347; Koch, sur I'Agen- i^ie et la Paral. Congenitalc. Badham, London Medical and Surgical Journal, 1835. Kennedy, Observations on Apoplexy and Paralysis of New-born Infants; Dublin .Jour. Med. .Scien., 1836; and Dublin 3Ied. Press, 1841 ; and Dublin Quart. Jour. ■f Med., 1850, and Nov. 1861. Marshall Hall. Lect. on Nervous System, London, 1836, p. 81. Heine, Beobach. 0. Lahmung^zu.'tiinde der untorn Extrr-mitaten und deren Be- handlung, Stuttgart, 1810; and Spinale Kinder Luhmung, Stuttgart, 1860, seo Can- stall * Jahr., vol. iii, p. 70, 18<»0; and Med". Times and G««., London, 1863. Grave«'» Clinical Med , 1843, p. 409. Colmer, London Med. Gaz , April 21, 1843. McCormac, Lancet, May* 27, 1843. R. Dt.herly, Dublin Med. Jour., vol. xxv, 1844, p. 82. West, Lect. on Dis. of Childhood, London, 1848. Richard (de Nancy), Bull, de Ther., Fevr. 1849, p. 120. 39 610 ATROPHIC INFANTILE PARALYSIS. It will be observed that the vague and discordant views which have been held in regard to its cause and nature, have led to the employment of Fliess, Jour. f. Kinderkr., July and August, 1849. Bellingham, Dublin Med. Press, 1850. Rilliet, Gaz. M^d. de Paris, Nov. 1851. W. Gull, on Paralysis during Dentition, in article on Value of Electricity as a Remedial Agent, Guy's Hosp. JHep., 2d ser., vol. viii, pt. i, 1852, p. 81. Little, on Deformities of Human Prame, London, 1853, p. 120. Rilliet and Barthez, Traite des Mai. des Enfants, ed. 2eme, 1854, t. ii, p. 545. Vogt, Essential Paralysis of Children, Berne, 1858, pp. 86 ; New York Journal of Med., Jan. 1859, p. 117. Eulenberg, on Essential Paralysis of Children, Yirch. Arch., 1859, 177 ; and Schmidt's Jahrb., vol. 107, p. 55. Bierbaum, Paralysis of Children, Jour. f. Kind., 1859, 1 and 2, p. 18. Copland, Diet, of Pract. Med., vol. iii, Amer. ed., 1859, p. 24. Valleix, Guide du Medecine Prat., ed. 4eme, 1860, t. i, p. 759. Brunniche, ii. d. sogennant. Essentiellen Lahmungen bei Kleinen Kindern., Jour. f. Kind., 1861. Echeverria, Atrophic Fatty Palsy in Infancy, Amer. Med. Times, July 18, 1861. Chassaignac, a Peculiar Porm of Infantile Paralysis, Med. Times and Gaz., Nov. 9,1861. Duchenne, De I'Electrisation Localisde, Paris, 1861, p. 275. Smith, Paraplegia occurring in Young Children, induced by Wet and Cold, Lancet, 1861. Bouchut, des Maladies des Nouveaux-nes, etc., ed. 4eme, Paris, 1862, p. 122. Cornil, Comp. Rend, de la Soc. de Biologie, 1863, p. 187. Laborde, De la Paralysie (dite Essentielle) de I'Enfance, These de Paris, 1864. Jaccoud, Des Paraplegics, etc., Paris, 1864, p. 448. W. A. Hammond, on Organic Infantile Paralysis, New York Med. Jour., Dec. 1865, p. 168 ; and Jour, of Psych. Med., vol. i, 1867, p. 49, and vol. ii, 1868, p. 581. Adams, on Club-Foot, London, 1866. Prevost, Comp. Rend, de la Soc. de Biologie, 1866, p. 215. C. Handfield Jones, Functional Nervous Dis. (Amer. ed.), Philada., 1867, p. 88. J. Russell Reynolds, Lancet, vol. ii, July 11, 1868, p. 85. C. B. Radcliflfe, Art. on Infantile Paralysis, Reynolds's Syst. of Med., vol. ii, 1868, p. 661. T. Hillier, Diseases of Children (Amer. ed.), Philada., 1868, p. 255. S. Wilks, Lect. on Nerv. Dis., Med. Times and Gaz., Dec. 19, 1868, p. 689. Z. Johnson and J. Lockhart Clarke, Med. Chir. Trans., vol. Ii, 1868. Moritz Meyer, Electricity in Practical Medicine (translated by W. A. Hammond, M.D.), New York, 1869, p. 218. Niemeyer, Practical Medicine (Amer. ed.). New York, 1869, vol. ii, p. 338. Vogel, Diseases of Children (Amer. ed.), New York, 1870, p. 391. Charcot and Joflroy, Cas de Paralysie infantile spinale avec lesions des cornes anterieures de la substance grise de la Moelle epiniere, Arch, de Phys. Nom. et Path., 1870, vol. iii, p. 134. Parrot and Joffroy {id. loc), p. 309. Vulpian [id. loc). p. 316. Allbutt, T. Clifford, London Lancet, November 10th, 1870, p. 481. Damaschino and Roger, Gaz. Med., 1871, p. 457, and in Syd. Soc. Biennial Ret- rospect, 1871-72, p. 96. Rinecker, Berlin Klin. Woch., 1871, p. 627. Rosenthal, Centralblatt, 1872, p. 176, from Oestr. Zeitschr. f. prakt. Heilkund., 1871, No. 52. Sinkler, Palsies of Children, Amer. Jour. Med. Sciences, April, 1875, p. 348. CAUSES. 611 many uames by which to designate it. Thus it has boon eallod by Iloine iutautile spinal paralysis, and Moyer follows him in the use of this term ; by Gull it was called paralysis during dentition ; by Rilliet and Barthez, Vogt, Eulenberg, Valleix, Brunniche, Laborde, and Niemeyer, essential paralysis of children; by Duchenne, who is followed by Echeverria, fatty atrophic paralysis of iutaucy ; by Reynolds, paralysis with wasting of the muscles; by Bouchut, myogenic paralysis; by Hammond, organic infan- tile paralysis ; and it has also been called idiopathic and congestive infan- tile paralysis. We have been led to select the name which heads this article, because those above enumerated appear to us to be either vague and inaccurate, as the terms essential and idiopathic; or to neglect one of the most striking features of the disease, the muscular atrophy, as the term infantile sj)inal paralysis does; or to convey a partial or even erroneous theory of the pathology of the disease, as the names congestive and myogenic respect- ively do. The terms organic and fatty atrophic paralysis also seem to us defective, since the first is equally applicable to cases of palsy due to or- ganic disease of the brain, while the second is based upon the fatty degen- eration of the aftected muscles, which, however, occurs only in a portion of the cases of infantile paralysis. It is evident, however, that a term might be introduced which would embody our present accurate knowledge of the seat and character of this form of paralysis, and which should supplant all those above mentioned. Causes. — The etiology of this affection is very obscure, doubtless partly owing to the tact that, as the paralysis occurs when the spinal system is extremely impressible, the causes which induce it are trivial and usually entirely overlooked. Age is the only influence which can be said to have a positive action in its production, since the great majority of cases occur between the ages of six months and two years, during the period of primary dentition. By several of the early observers especially, the dis- ease was on this account attributed solely to dental irritation, but more careful observation shows that in most cases no such ilircct connection can be traced ; and it is probable that early age and dentition only act indirectly by inducing a remarkably susceptible condition of the entire t»pinal system. Sex appears to have no influence whatever upon its production ; and the disea.>*e is almost as frequent among the children of the wealthy as among the ill-fed and ill-tende*l children of the poor. In some few ca.**?, where the loss of power is sudden, the exciting cause seems to be the direct ex- posure to the l(K-al action of cold, a< from sitting upon a stone step (West), or lying on the damp ground (Hammond;. Atrophic infantile paralysis is usually primary, and occurs in the midst of gofKi health ; but it has also been obt*er\'ed in a secondary form, apfK'ar- iDg during the convalescence from mea.*ile8, scarlatina, or typhoid fever, or during rheumatism and chorea. In one of the cases following chorea, which are recorded by Kennedy {loe. cit.), it is positively stated that there was a distinct cardiac murmur. 612 ATROPHIC INFANTILE PARALYSIS. due to organic valvular disease ; and it may be suggested that the essential cause of the parylysis was embolism of some of the spinal arteries, as ob- served by Pauum.^ Mode of Attack ; Initiatory Symptoms. — There is considerable va- riety in the mode in which this disease makes its appearance. In some cases the paralysis is the first symptom observed, and is found to have almost immediately attained its full extent, without any recognizable cause or premonitory symptom. Thus the child may have appeared per- fectly well when put to bed in the evening, and yet on the following morn- ing, there may be more or less complete loss of power over the lower extremities. But in the great majority of cases, especially the more severe ones, the attack is preceded by quite marked constitutional dis- turbance. This may consist merely of fever, appearing without evident cause and lasting from a few hours to a week or more, unattended by any gastro-intestinal disturbance. Or, during this period, the child may also complain of pain in the back, or there may be tenderness on pressure, espe- cially in the lumbar region ; there is frequently slight dulness of the mind, or finally, in comparatively rare cases, one or more convulsion may occur. It is the rule, however, for no marked symptoms of cerebral disturbance to be present at any period of the disease. There are rarely any symptoms connected with the parts about to become paralyzed, though in an interest- ing case recorded by Kennedy {loc. cit), there was spasm of the muscles subsequently affected. The disease usually makes its appearance during health, but it is proba- ble that many of the cases of paralysis occurring during convalescence from the various exanthemata properly belong to this variety. Whether preceded by initiatory symptoms or not, the development of the paralysis is generally sudden, and it is only in rare cases that it js par- tial at first and increases gradually. Indeed it usually happens that when first observed the paj-alysis is at its maximum, both as regards the number of muscles affected and the degree of the loss of power, and that there soon occurs a diminutian in its extent, so that only some of the parts first affected remain palsied. The form of the paralysis clearly indicates its spinal origin. Complete hemiplegia is scarcely ever observed, though in a few cases the arm and leg of the same side, or even all four extremities, have been palsied.^ 1 Ueber den Tod durch Embolie (Bibliothek fiir Lager, 185G), quoted by Jaccoud (op. cit., p. 297), iind Arch. f. Path. Anat., xxv, 308, 443, 1863, in Yearbook of N. Syd. Soe., 1863, p 210. 2 With reference to the parts affected, in 43 cases observed and analyzed by "West, in only 2 was the arm alone palsied, though in 19 instances the paralysis was limited to one or both legs. In 8 cases the right leg, and in 5 the left, was paralyzed ; and in one of the former instances paralysis of the right portio dura was also present. In 6 instances, the right arm and leg, and in 8 the left arm and leg, were affected, with which ptosis of the left eyelid was once associated, and once paralysis of the left portio dura. Paraplegia existed in 8 instances, combined in one case with paralysis of the right arm, and in another with loss of power over MUSCLES AFFECTED — SYMPTOxMS. 613 Most frequently the disease takes the form of incomplete paraplegia ; though occasionally the paralysis affects single groups of muscles or eveu iudividual muscles. According to Mr. Adams, the groups of muscles most frequently affected are : 1. The muscles of the anterior parts of the leg, forming the extensors of the toes and the flexors of the foot ; 2. The extensoi-s and supinators of the hand, these muscles being always affected together; and 3. The ex- tensors of the leg, and with them generally the muscles of the foot, as in the first group. Wheu single muscles are affected, the most likely to suffer ;ire these: 1. The extensor longus digitorum of the toes; 2. The tibialis anticus ; 3. The deltoid ; and 4. The sterno-mastoid. The bladder and rectum are very rarely involved. The degree of the paralysis varies as much as its extent ; usually com- plete at first, in some cases it soon becomes partial or even sliglit ; while in others the loss of power remains absolutely complete. The paralyzed muscles are perfectly relaxed, so that the affected parts cau have all their normal movements impressed upon them without difficulty, and fall in a lifeless manner if left unsupported. The special senses are unimpaired ; and general sensibility is usually only blunted for a time. Occasionally it is not affected at all, or, as stated by West, there may even be hyperies- thesia for a variable time. The paralyzed muscles are rarely the seat either of painful subjective -ensations or of tenderness on pressure ; though in some cases severe pain may be present in the affected parts. Reflex movements are, as a rule, abolished in those parts where there is complete loss of voluntary motion ; though Laborde (loc, cit.) has shown that they may occasionally be preserved even in the first stage of the paral}teis. During the early stage we are at present considering, the electro-mus- cular contractility usually remains intact, and the muscles respond both to the induced and direct current. The constitutional disturbances which we have described as preceding the paralysis may persist for a variable time after its development, or dis- :ir quickly, leaving no other symptoms present but those connected the paralyzed parts. The following case, seen by one of ourselves with Dr. James Tyson, may be quoted as an illustration of this form of paralysis. A male child, set. thirteen monthi*, was brought to Dr. Tyson for treatmont by it« molhfT, an intellieont woman, with govoral hoalthy children. The following Nislory of the case was obtained : The little boy had walked at the ai:«' of nine mr-nth?, and always* »eemed a viirorou.'i, intelligent child ; he had also cut eipht . without much irritation. Alnrnt Sept. lOlh, 1868, after no particular ex- f;, he became fretful and feverioh, with occaftional vomiting ; and after three days it was noticed that right-sided hemiplegia had developed itself. The paralysis lx>th delt^»id muscle.s, and over the flexor muscles of both thumbs. Six times none i»f the limbs were palsied, but the affection was confined once to the portio dura <»f the U*ft, and five times to the portio dura of the right side ; but in one of the»e instances, though there was no actual paralysis, the patient's gait was feeble and tottering. 614 ATROPHIC INFANTILE PARALYSIS. of the arm was never complete, while the leg had entirely lost all power of motion. This loss of power had not become complete suddenly, but, at first partial, had gradually increased. There was no tendency to coma and no evidence of any acute pain. The febrile symptoms soon disappeared ; the arm regained the power of motion in a few days, but the leg remained palsied. It also soon grew remark- ably cold, and when seen on October 1st, three weeks after the attack, the tem- perature was decidedly lower than that of its fellow. Sensation was impaired, but had never been aboli'shed. There had been no paralysis of either bladder or rectum. At the time of the examination the child seemed bright and lively, though rather pale. There was no tenderness along the spine, nor in the leg. 'No reflex move- ments were developed in the paralyzed leg by tickling the sole of the foot. jSTeither atrophy nor deformity had as yet occurred. The subsequent course af the disease varies greatly in different instances. In one set of cases, though the paralysis may be quite extensive and com- plete at first, the symptoms gradually subside, the paralysis disappears, and complete recovery ensues in from four to six weeks. These cases correspond exactly to the form of paralysis originally described by Ken- nedy (loc. cit) under the name of " Temporary Infantile Paralysis," and, as we shall see hereafter, in all probability depend upon mere congestion of the spinal cord. In the other set of cases, on the contrary, the loss of power persists, and after it has continued for a time, varying from one to several months, is followed by marked and more or less rapid atrophy of the affected mus- cles. The circulation in the paralyzed parts becomes feeble, the sub- cutaneous veins are smaller, and Heine, and Rilliet and Barthez each cite a case of paralysis of the arm in which it was almost impossible to detect the radial pulse. The temperature of the affected part becomes perceptibly lower, the fall amounting, according to Hammond, to from 5 to 8 or even 10 degrees,, as tested by a galvanometer. The muscles them- selves undergo marked atrophy, frequently accompanied by fatty degenera- tion ; and their reflex motility and electro-muscular contractility disappear. It is important to notice, however,, that long after muscular contractions fail to be produced by the induced current, they may frequently be excited by the use of a direct current of low tension, slowly interrupted. The mere wasting of the muscles is not, however,, the only cause of the great difference in size between the healthy and paralyzed members. The nutrition of the whole limb is affected, and the growth and development of all its tissues arrested, so that the paralyzed member becomes smaller in all its dimensions than its fellow. Rilliet and Barthez cite an example which they observed, to show to how remarkable a degree this conjoined atrophy and arrest of development may progress. The patient was a young girl who was seized with instantaneous paralysis of the right lower extremity ; and the following measurements show the degree of inequality which was produced by four years* continuance of the paralysis and arrest of development. Eight leg. Left leg. 1. From thegreat trochanter to the external malleolus, 49 cent. . 54 cent. 5 mill. 2. From the patella to the malleolus, . . . 29 " . 32 " 3. Length of foot from heel to great toe, . . 14 " 3 mill. 18 " DURATION. G15 Five months previously, the followinsr tliniinution in tliit'kness of the limbs was noticed : at throe fingeiV breadth above the pateHa, on left side, 20 centimetres, 16 on r'mtht; at the middle of the thigh, on left side, 29 centimetres, and 22 on right. The height of the child was 11(> eontim- etres. This wasting and palsy of the muscles is associated with relaxation of the ligaments, and the combination of these causes induces many of the deformities observed in childhood. "When the paralysis atlects one side of the body chiefly, it indirectly leads to various lateral curvatures in the spinal column, probably from a want of symmetrical action in the muscles of the two sides. In cases of paralysis of the arms, the relaxation of the ligaments about the shoulder-joint and the atrophy of the deltoid allow tlie head of the humerus to drop out of the glenoid cavity, so as to produce even complete dislocation, with apparent elongation of the paralyzed limb to the extent of three-fourths of an inch (West). As the muscles of the lower extremitie.s are far most frequently affected in this form of paralysis, we usually find the resulting deformities in- volving the feet and legs, where they constitute the greater proportion of all cases of club-foot. According to Adams (he. cif.), " these deformities occur in the following order of frequency: 1. Talipes equinus; 2, equino- varus; 3, equino- valgus ; 4, calcaneus, or calcaneo-valgus ; and 5, talipes varus. When both feet are affected, equino-varus of one foot is generally found with equino-valgus of the other." In addition to the influence which the actual wasting of the limb and the arrest of its development exert, Adams believes that the great cause of .such deformities is the " adapted atrophy" of Paget, the changes which ensue in consequence of the mechanical relations of the foot to the leg. Although, however, it is true that paralysis of a group of muscles does not excite active contraction in their opponents, it appears that in the efforts of the child to move the part, the non-paralyzed muscles must gain con- trol over the limb, and aid at lea.st in producing the various characteristic distortions. During the development of this atrophic stage, the general sensibility of the affected parts is usually normal, and the general health, intelligence, and nutrition of the patient unimpaired. DruATiox. — As will be inferred from our description of the course of this affection, the entire duration and that of its different stages varies greatly in different cases. In some, which have hence had the name "tenipf>rary" infantile paralysis bestowed upon them, the loss of power rapidly diminishes, and complete recovery folIf»WH in from a few days to a few weeks ; while, in other cases, the paralysis persists until atrophy ensues, and the limb may remain crippled and useless throughout life. The |)erifHl which elapses before atrophy commences, and the rapidity with which it advanres, also vary extremely, even in apparently similar cas^-s. Thus the palsied muscles may begin to atrophy within four or five weeks, though more frequently this change cannot be noticed for several months. Dif- ferent muscles also atrophy with very different rapidity, the deltoid and 616 ATROPHIC INFANTILE PARALYSIS. tibialis aiiticus appearing to waste more rapidly than any other muscles of the body; and, in different cases, the same groups of muscles show equal variety in this respect, a few weeks serving^ some instances for as much wasting to occur as would requii'e months to produce in other cases. Prognosis. — The great uncertainty of the progress and duration of atrophic infantile paralysis render it highly desirable to ascertain, if pos- sible, the conditions which determine its result. Of itself, it is never fatal ; but, unfortunately, our prognosis is limited, in the early stage of the disease, to this assertion, for the duration and course of the case are not influenced, in any constant and reliable way, either by the age of the patient, the extent of the paralysis or the parts aflTected, or the initiatory symptoms. It may perhaps be stated that, in general, cases which are ushered in by high fever, especially if associated with convulsions, and in which the paralysis is extensive, will prove severe and tedious. But there are too many exceptions to every particular of this statement for it to be regarded as a general rule of much positive value in prognosis. When paralysis has lasted three or four weeks, we are able to determine with much accuracy the approach of atrophy by the condition of the electro-muscular contractility; for it has been frequently observed that those muscles which lose their power of responding to the interrupted current, soon begin to waste. After the occurrence of atrophy, also, much valuable aid in prognosis is gained from the use of electricity. We may here mention the interesting and highly important observation, first made in connection with this disease by Hammond (loe. cit.) and J. Netten Radcliffe,^ that in many cases where the atrophied muscles have lost entirely their power of reacting to the most powerful induced electri- cal currents, they will still react vigorously to a direct (galvanic) current of low tension and slowly interrupted. The importance of this discovery, in the treatment of the disease, can scarcely be overrated ; and it has also enabled this point to be established in the prognosis, that whenever mus- cular contractions can be excited by either induced or direct currents, no matter how far advanced the atrophy of the muscles, the restoration of their power can certainly be accomplished; though it would appear from a case successfully treated by Hammond, that even when such contractions are not at first produced, the prognosis is not absolutely unfavorable. The still more curious, and as yet inexplicable observation has also been fre- quently made, that as the muscles regain their power of voluntary motion, their susceptibility to the direct galvanic current is apt to diminish, but, on the other hand, their normal reaction to the induced current returns. The prognosis will also be materially influenced, especially when the atrophic stage has begun, by the condition in which the tissue of the palsied muscles is found, as in cases where advanced fatty degeneration is present, it is far more unlikely that they will ever regain their power. In order to ascertain this point, Duchenne has devised a small trocar/ called by him 1 See footnote to page 665, vol. ii, Reynolds's System of Medicine. 2 These trocars are manufactured by Tiemann, of New York. Dr. Hammond has published (Jour, of Psych Med., July, 1867) a description of their form and mode of use, illustrated by a woodcut. MORBID ANATOMY AND PATHOLOGY. 617 " emporte-pi^ce," by which small j^iooes of muscle can be extracted, and subsequently submitted to microscopic examination. It is evident, finally, that the duration and result will depend, to a great extent, upon the period at which treatment is instituted. In those cases where the paralysis has been allowed to continue until marked atrophy has ensued, and the electro-muscular contractility is almost lost, althouu:lj the prognosis may still be favorable as regards the ultimate cure, it must be carefully guarded as to the duration, since the treatment will probably re- quire to be steadily pursued for many weeks, or even months. MoRP.iD Anatomy and PATnoLOGY. — It appears desirable to introduce the consideration of the anatomical appearances at this point, in order to facilitate the subsequent discussion of the pathology and diagnosis of the disease. In regard to the changes which take place in the atrophied muscles, the brief yet complete summary given by Hillier, may be (juoted {op. rit., page 268): " 1. The transverse striae become less apparent and separated l)y wider -paces, which are filled with opaque granules, which are not dissolved by ether, but are sensil)ly acted on by acetic acid. " 2. The transverse striaj disappear, and there is an abundant appear- ance of granular substance. "3. There remain but slight traces of longitudinal fibres, filled with granules, with a larger quantity of connective tissue between the bundles. "4. The granules have disappeared, and emply transparent tubes of myolemraa with a few scanty granules on their walls remain, with more connective tissue and some elastic fibres. "o. In some cases, fat-globules take the place of the granular matter in the muscular fibres, and in the cellular tissue between the bundles of mus- cular fibre. This change is not universally j)resent in cases even when atrophy has proceeded to an extreme degree." The last conclusion stated here, which has been confirmed by other ob- sers'ere, shows that perhaps the most frequent change which occurs, is a .simple atrophy of the muscles, with a granular but non-fatty degeneration, and conclusively shows the inaccuracy of the name proposed by Duchenne for the dis€a.*e ''namely, fatty atrophic paralysis of infants). In approaching the question of the lesions of the nervous centres in this affection, which have now been definitely determined, it is necessary to refer to the general question of the existence of so-called essential, purely neurotic paralyses. In one form of paralysis, the reflex, it is true that as yet no material lesion has been detected, and that the most plausible ex- planation of the loss of power in such ca«e8 is simply the exhaustion of the fiiiirtiunal activity of the spinal cord, owing to the prolonged irritation of r> •..](' of the peripheral nerves. And it muxt be borne in mind that the form of infantile paralysis under consideration was formerly by some re- garded as a reflex paralysis depending on dental irritation. Apart, how- ever, from the fact, that the symptoms much more closely resemble those due to spinal congestion than those seen in refl<-x fwiralysis, it is to he re- menjbered that the disease is by no meauji limited to the period of denti- 618 ATROPHIC INFANTILE PARALYSIS. tion, and that all local signs of dental irritation are frequently absent at the time of the appearance of the paralysis. With the exception, then, of reflex paralysis, it may be asserted with confidence that all other forms of spinal paralysis are associated with some material lesion of this nervous trunk. It is to be remembered that it is only a few years since the beauti- ful researches of J. Lockhart Clarke have shown that positive structural changes, in both nerve-cells and nerve-fibrils, may be detected by micro- scopic examination in spinal cords, which present no alteration apparent to the naked eye. In rejecting the evidence of all post-mortem examina- tions of the spinal cord, made before the introduction of Clarke's method, as incomplete and inconclusive, we find that in all those diseases formerly classed as pure neuroses (such as tetanus and chorea), which have been subjected to this latter mode of examination, positive demonstrable lesions have at least occasionally been detected. Among this class of diseases, so long considered as purely functional neuroses, atrophic infantile paralysis has always, until lately, occupied a prominent position, as is evinced by the large number of authors who have described it under the terms " essential," or " idiopathic." It is indeed difficult to secure opportunities of examining the state of the spinal cord in this affection, owing to the fact that the disease is scarcely ever, if at all, fatal of itself; so that the arguments in opposition to the view of its functional nature, will be in part drawn from the close analogy of its symptoms to those of certain spinal diseases, which are well known to be attended with positive lesions of the nervous tissue. Thus, in its mode of appearance, and in the character of the paralysis, there is so per- fect a resemblance to the onset and symptoms of congestion of the spinal cord, as to leave little room for doubt that this is the condition at first present in many cases of atrophic infantile paralysis. In both this affec- tion and spinal congestion, the paralysis may appear quite abruptly, or be preceded by pains in the back and fever ; in both, the paralysis is usually paraplegic, the loss of power only partial, and the affected muscles are relaxed ; in both, general sensibility is but slightly impaired, the bladder and rectum are not involved, and there are no disturbances of the cere- brum or special senses; in both, finally, recovery usually follows, if proper treatment be promptly instituted. In those cases where the paralysis disappears within a few days or weeks, it has been supposed by various authors that the nature of the disease is entirely different from that of atrophic infantile paralysis ; but it appears to us highly unnecessary to complicate the question by such a supposition, since the temporary character of the paralysis is readily accounted for by supposing that the spinal congestion which produced it was slight and transient. It is quite possible also that in other cases the loss of power caused by more severe spinal congestion should persist until atrophy of the affected muscles ensued, and rendered the case more protracted. Indeed, some of the authors who most forcibly support the view of the pathology of this affeetion which we have given above, as Dr. C. B. Rad- cliffe {loc. cit.)j hold that the lesion of the cord does not advance beyond MORBID ANATOMY AND PATHOLOGY. 019 this stage of congestion. The evidence in support of this opinion is prin- cipally found in the result of post-mortem examintitions, as tliose reported by Rilliet and Barthez, Fliess and Adams, Avhere no lesions of the cord were detected. But in none of these cases does it appear that the careful and skilful microscopic examination, which is now recognized as necessary to detect some lesions of the nervous tissue, was performed ; so that we may feel at liberty to doubt the complete accuracy of these autopsies. On the other hand, it certainly seems entirely consistent to suppose that in cer- tain cases, where the congestion is unusually marked and prolonged, or where it is repeated, that a process of subacute inflammation should be ex- cited, resulting in the permanent structural change. The usual change which takes place in the spinal cord, under such cir- cumstances, is that described under the name "sclerosis," in which there is marked proliferation of the connective-tissue elements of the cord, with swelling and consequent pressure upon the nerve-tubules. In the subse- quent development of the new-formed connective tissue, it undergoes con- traction, and induces atrophy of the compressed nerve-tubules. The por- tions of the spinal cord where this lesion exists, may either be atro}>hied or retain their normal size, shape, and external appearance, but on trans- verse section, though the tissue is firm, certain parts of the white substance are seen to present a grayish, translucent appearance, differing noticeably, in well-marked cases of the lesion, from the opaque whiteness of the sur- rounding healthy tissue. In other instances, however, the change in color cannot be detected, and it is only by microscopic examination that we can discover the increase in the connective tissue of the cord, and the atrophy of the nerve-tubules. This view of the nature of the lesions in atrophic infantile paralysis, was forcibly urged by Heine, in the last edition of his classical monograph on this subject (oj). cit.), who based it merely upon an analysis of the symp- toms, and it has since been adopted by Jaccoud (he. cit.). It does not rest, however, solely upon such reasoning, for there have been a limited but rapidly increasing number of autopsies made in which the above-de- f^ribed lesions of sclerosis have been actually observed. Heine quotes three post-mortem examinations in support of this theory. One of these, quoted from Longet, was of a girl of eight years, with club- foot on the right side, following an attack of paralysis, who died of variola ; and at the autopsy the muscles and nerves of the right leg were atroi)hied, and the anterior roots of the spinal nerves which make up the right sciatic nerve, were scarcely one-quarter the size of the corresponding roots on the left side. In the second case, quoted from Hutin, the subject was forty-five years old, had been paraplegic from the age of seven years, and had considerable deformity of the lower members; at the autopsy, after death from dysen- ter}-, there wa« atrophy of the lower part of the spinal cord. The third observation quoted by Heine, has been quottid more fully from the original source (Trans, de h Soc. Mfd. de Berlin^ Dec. 7th, 1862), by Jaccoud (op. cif., p. 450 t. It was the autopsy of a child with paralytic club-foot, reported by Berend and liemak, where the "spinal arachnoid 620 ATROPHIC INFANTILE PARALYSIS. was found thickened by inflammatory product, and exercising such pres- sure upon the cord, that when the false membranes were cut, the nervous tissue immediately protruded through the incision." Berend also reported (id. loc.) another observation upon a child four years old, who died paraplegic with contraction of the legs and feet. The autopsy was performed by Recklinghausen, who found tubercles in the cord. Hammond reports (Jour, of Psych. Med., vol. i, p. 51) a case where the paralysis affected the left leg, and had lasted four years, in which he found, upon post-mortem examination, a cicatrix, partly, filled with clot, in the lower part of the dorsal region, in the left anterior column. Recently, however, the opportunities for careful study of the lesions in atrophic in- fantile paralysis have multiplied, and have been seized by numerous able observers, especially in France, where the first demonstration of the true characteristic morbid changes in this disease was effected. The earliest cases placed upon record in which this lesion was accurately described were by Coruil (loc. cit.) in 1863 ; by Laborde (loc. cit.), in 1864 ; by Prevost (loc. cit), in 1866 ; J. Lockhart Clarke (loc. cit.), in 1868 ; Charcot and Joffroy (loc. cit.), in 1870 ; Parrot and Joff'roy,^ in 1870 ; Roger and Damas- chino,' in 1871 ; Dujardin-Beaumetz,^ in 1872 ; Petitfils,* in 1873 ; and numerous other observers have followed in confirmation, so that the morbid anatomy of atrophic infantile palsy may be regarded as clearly and fully determined. The lesions occupy the antero-lateral columns, and especially the an- terior horns of gray matter. There is atrophy of the nerve-fibres in the anterior and lateral columns, which varies in amount in different cases, and is associated with a varying degree of hypertrophy of the interstitial connective tissue (sclerotic). These parts are more translucent than nat- ural, and often present a very appreciable grayish rose tint to the naked eye. The consistence of the affected tracts is diminished, and upon micro- scopical examination there may be observed a marked proliferation of the elements of the connective tissue, the cells and nuclei being dispersed in the midst of a finely granular substance, in which there are fibrils of extreme tenuity. In the parts which are most affected the nervous tubules are either lost altogether, or they present a varicose appearance, while the other portions of the spinal column preserve a perfect integrity. But the most characteristic changes are found in the anterior horns of gray matter, where there is invariably atrophy of the ganglion nerve-cells and of their processes, so that in some instances the anterior group of cells has entirely disappeared from atrophy. In other cases the remains of the cells are found atrophied, misshapen, and with granular degeneration of their contents. The other elements of the gray tissue are usually changed also ; there is proliferation of the nuclei of the neuroglia, and occasionally 1 Arch, de Physiologie, torn, iii, 1870, p. 135. 2 Gaz. Med. de Paris, 1871. 3 De la myelite aigue, Paris, 1872. * Considerations sur I'atrophie des cellules motrices, Paris, 1873. DIAGNOSIS. 1)21 increase in the delicate fibrils of this connective tissue. In some cases the walls of the vessels in the aHected parts are found thickened, with proliferation ot^ their nuclei. These chauixes have been so prominent in some case^ as to have led ta the opinion (.Damaschino, Duchenne) that they constituted the primary and essential lesion. This, howtver, does not seem probable. It is thus seen that the progress of anatomical investigation ha:^ at last developed the true pathology of this atiection. It is possible that in some cases the lesion of the anterolateral columns may be the result of hajmor- rhage into the substance of the cord, or of pressure from thickening of the meninges ; but in the vast majority of cases the morbid proccs^s is one of slow subacute inflammatory, sclerotic change, with atrophy of the nerve- tubules in the antero-lateral columns and anterior horns of gray matter, and especially with atrophy and destruction of the anterior groups of gan- glion nerve-cells. Diagnosis. — There is but little danger of overlooking the nature of those cases where the paralysis appears quite suddenly in the midst of ap- parent good health, excepting in cases occurring in young children who have not yet learned to walk, and where the loss of power is limited to the lower extremities. In such instances the paralysis may be entirely overlooked by the parents or nurse for some time. So also in cases pre- ceded by constitutional disturbance, as there is nothing whatever charac- teristic in these premonitory symptoms, it is quite possible to fail to rec- ognize the presence of j)aralysis. It is well, therefore, whenever a child between six months and three years of age presents feverish symptoms for which no apparent cause exists, to ascertain carefully whether there is any loss of power of its extremities. The diseases with which atrophic infantile paralysis is most likely to be confounded, are other forms of paralysis of cerebral or spinal origin, and progressive muscular atrophy. In paralysis due to haemorrhage into the substance of the brain (see page 520 J, the case is more apt to be ushered in by delirium or convul- sions, followed by more or less marked coma, while in atrophic infantile j-nralysis there is either entire absence of cerebral symptoms, or at most a -;: _lc convulsion occurs. Cerebral paralysis is usually hemiplegic, while in the form of spinal paralysis we are considering, paraplegia is more common, or the loss of power may be limited to one leg or to a single group of muscles. In those comparatively rare cases where the paralysis is at first hemiplegic, the arm usually soon regains its power of motion, leaving the leg paralyzed ; while the reverse of this occurs in cerebral hemiplegia, where the leg usually improves much more rapidly than the arm. In cerebral paralysis, also, the affected raui*cles are frequently rigid instead of being relaxefl ; and there is not the tendency to atrophy and deformity, the loss of electro- muscular c*)ntra('tility, nor the hiwering of the teraj>erature of the affrct« d part, whirli arc ob-rrv.d in atrophic infantile paralysis. In cases of meningeal ap^^iph-xy wniir im- iiiiiii«iiiiiii;.'i- mi" <»< i iirr«d upon the surface of the brain, the symptoms are still more e(iius branch, the hearing becomes more acute; but in children the cause of the palsy is so often necrosis of the petrous portion of the tem- poral bone ass^ociated with disease of the internal ear, that there is fre- quently deafness with purulent otorrha^a. Finally, if the point of paraly- sis be near the stylo-mastoid foramen and below the chorda tympani, none of the above symptoms will be present, and there will only be the pal.^y of the external muscles already indicated. The possibility of mistaking simple facial paralysis for hemiplegia from cerebral disease must be borne in mind, though attention to tlie symptoms of the case will prevent any error in diagnosis. Thus in hemiplegia of cerebral origin, the paralysis is usually ushered in by convulsions and coma; the frontalis and orbicularis oculi muscles are not paralyzed; the sense of taste is not affected, but, on the other hand, the masseters, tempo- rals, and pterygoids, supplied by the fifth nerve, occasionally are para- lyzed, and the tongue is protruded towards the paralyzed side; and, finally, there is loss of power in the arm and leg on the same side. Webber ( Chicago Jour, oj JS'ervows and Menial Di^ea^'^e, July, 187<), }). 363) records several interesting cases where the facial palsy appeared after convulsions, and while the paralysis of the arm and leg was very transient so as to have passed away before the case came under observation, the loss of power of the muscles of the face was persistent, and was associated with impairment of electro-muscular contractility. In these unusual cases the author thinks the lesion was in the brain, affecting the centre of innerva- tion for the facial muscles, which the researches of Hitzig and Ferrier tend to locate in the lower part of the central ascending convolution. The prognosis of cases of facial palsy must evidently depend upon the cause. When the paralysis is due simply to exposure to cold, a cure may be expected, though the affection is often very tedious, the paralysis at times persisting for months. But when, on the other hand, it depends upon disease of the temporal bone, the prognosis is usually unfavorable. The treatment must also be modified according to the cau.se of fh<' at- tack. In simple acute ca-^es, the application of hot fomentations to the part, or of one or two leeches near the stylo-ma.stoid foramen, should always be di- rected, and is often productive of good results. Later in the afll»ction, if the paralysis persists, small blisters should be repeatedly applied near the point of exit of the nerve. Electricity is here also of very great .service, and the same curious observation, which was mentioned in atrophic infantile paralysis, as to the pr)wer of the direct current to excite muscular contractions when th'- muscles have cea«!ed entirely to respond to an induced current, has Ih.ii frei|uentlv made in this aff*ection ( Baierlacher, Neumann, Hadcliffe, Hillier;. In addition to these local remedied', the internal use of strychnia, iron, or iodide of potas.*«ium, is often followe. — The essential causes of progressive muscular sclerosis are un- known. There are, however, some influences which exert marked control over its occurrence. One of the most important of these is early age, since in a very large majority of cases the disease begins in childhood, and has even appeared in some cases to be congenital (Niemeyer). Although, however, it must be distinctly classed among the affections of childhood, it has been shown (Benedikt, Lutz, and Laycock) to occasionally occur in :t'! It life. Sejc also exert-s a powerful influence: of 4o case^ collected by \\-- razulas ijoc, cit.), in which this point was noted, it occurred only 7 times in females. The curious fact has also been observed, that several children in the -anie family are apt to be aflJ*ected, probably indicating some hereditary ucy. Eulenburg' is consequently inclined to regard the disease as ^, -ijdent upon some congenitally defective formation of the central nervous -ystera, probably in the cells of the gray substance of the spinal cord. In- fs are on record where four brothers were affected (Meryon); and in iier two brothers (Euleuburg) ; and in still another by the son of the latter author, in which the affection first showed itself in three nisters suc- cesgively in the eighth year of their age. SYMiTO>L*i. — The disease either begins in early infancy, and is first mani- fested at the time the child should Ix'gin to walk, or it makes its appear- ance some years after the power of walking has been acquired. The disease usually affects first the muscles of the legs, and advances upwards; in Xiemeyer's case, on the other hand, it began in the gluteal muscles, and subsequently affected all the muscles of the lower extremities. The early symptoms are, therefore, connected with walking, and it is ob- served either that the child does not begin to walk until very late, and then walks imperfectly, or that, having walked well for several years, he • _'ii3 to be readily tired by standing or walking, and soon presents pccu- i ities in his gait. In a few instances, pains in the limbs have been com- plained of ID the early stage. When the disease is fully established, though before it has advanced far, the rao Vircbow't Arcbiv, liii, S61. 630 PROGRESSIVE MUSCULAR SCLEROSIS. tioiis become more and more difficult and painful, and that they are sub- ject to frequent falls. In order to maintain their equilibrium while stand- ing or walking, the lower dorsal and lumbar spine is arched forwards, while the upper part of the spine, the shoulders and head are bent back- wards, frequently to so great an extent that their point of equilibrium falls behind the pelvis, thus producing the deformity known as "ensellure" or " saddle-back." The legs are widely separated, and in walking the body is inclined laterally towards the leg which rests on the ground, thus pro- ducing a characteristic balancing of the body during progression, while the arms are swung about, and the legs are advanced by jerks, describing a small arc. While this impairment of strength and power of progression is develop- ing, the affected muscles undergo remarkable changes. For a time they may be noticed merely to cease developing and increasing in size, or, more rarely, as in the case reported by one of ourselves {loc. cit.), and which is quoted below in full, they may present a well-marked stage of atrophy. After the stage of muscular weakness has lasted for a variable time, from a few months to two or even three years, whether or not there has been any noticeable atrophy of the affected muscles, a progressive enlargement of them makes its appearance. This usually affects the gastrocnemii first, then the glutei, the lumbar muscles of the spine, of the' trunk, and finally the muscles of the arms, and even of the face and tongue. In five of the recorded cases, the heart has been hypertrophied. In one of these, reported by Dr. B. W. Foster, quoted by Poore (loc. cit.), the heart was normal when first examined, but three years later, and without apparent cause, it was found to be enlarged. The above order is not invariably followed, and in by no means every case is the affection of the muscles so universal. The apparent hypertro- phy may occur in nearly all the muscles which have shown weakness, but in general, according to Duchenne, it does not, and may even be limited to a very small number of them. The same observer {loc. cit), thus de- scribes the appearance of the muscles after this consecutive enlargement has occurred. ..." The hypertrophied muscles are firm and elastic ; they become very hard while they contract, and show all the relief or projection which prop- erly belongs to their contracted state ; .they then appear to form a hernial protrusion through the integument, which is very thin ; moreover, their great size shows off the apparent smallness and delicacy of the joints at the knee, ankle, etc." When this pseudo-hypertrophy is marked, and afl^ects many muscles, it gives a most curious appearance to the children. Niemeyer speaks of his patient as looking "as if he had the body and head of a weak child on the hips and thighs of a strong man ; " and J. Lockhart Clarke, in de- scribing one of Duchenne's patients, says: " He looked like a little Her- cules. Every visible muscle of the body, except the pectorals, was enor- mously developed ; his head, even, appeared swollen, and the temporal muscles stood out like convex shells. Yet, when the poor boy attempted to walk, he labored to get along, presenting the most grotesque appear- SYMPTOMS. 631 ance ; and when laid on the ground, ho was wln^lly unahle to rise hy liis own nnaided effort;?." ' Dr. Mitchell (/oc. cit.) chills attention to the faet, however, which W(> have also observed, that the enlargement of the calves is lower down than would be the case in excessively developed, but well-formed limbs. The marked enlargement of the muscles of the calves is often attended with forced extension of the feet, producing double pes equinus or ecjuino- varns. In the ease reported by Estrazulas {loc. cif.), there is also marked enlargement and retraction of the posterior muscles of the thigh, with atrophy of the extensor group, so that there is forced flexion of the legs, rendering the boy unable to stand at all. Knoll ^ also describes such con- tracti(»ns in the enlarged muscles, but they are not usually present. Ac- cording to Berger,' fibrillar contractions are of constant occurrence in the aflTected muscles : this does not accord with our own observations, nor with many of the reported descriptions of the disease. In one of the cases re- ported by Gerhard (loc. cit.) there was constant tremor of the flexors of the legs and feet, and of some of the muscles of the forearms. The electrical condition of the afl^ected muscles is peculiar. Frecjuontly the results, when tested with faradaic currents, are different from those ob- tained with galvanism. The results also vary at difterent stages of the same case. Usually the muscular contractility, as tested by faradization, is impaired in all the affected muscles, those whicli are hypertrophied, how- ever, contracting more actively than those which are atrophied. The gal- vano-contraetility is also slightly impaired. The electro-muscular contrac- tility has been found unimpaired in the earlier stages of the disease; but later it diminishes, the muscles continuing, however, to respond actively to galvanism after they have partly lost their power of responding to fara- dization. Electro-muscular sensibility has been found normal or imjiaircd in dif- ferent cases : in one of our patients i^ was diminished to faradization, hut remained acute to galvanism. The skin over the aflx'cted parts often presents a marbled or mottled appearance. In one ca.se that we have seen Ulescribcd by Mitclicll, /or*, n't.), the mottling ** consists of spaces of pallid t?kin surrounded by quite regular circles of congestion, which aflTect an irregular polygonal shape." The skin is usually thin and delicate, and can be easily lifted from the muscles. Disorrlers of the cutaneous sensibility have not been usually found, but Berger (ioc. cit.) describes violent neuralgic pains and formication, followed at a later stage by aniesihesia. We have already alluded to the pains in the limbs occa.-'ionally complained of in the early stages of the disease. The temperature of the part'* is lowered. This can be distinguished hy the hand, and has been found, on careful tlirrrnoinetric study, by Miichcll,* » Trans, of London Pai.i. >.. .. vol. xix, in , , ,. ,. » Wif-n. Med. Jahrb., 1872; and in .Syd. S«»c. Bicnn. Rfltronpocl, 1871-72, p. 71. * Deut. Arch. f. Klin. .Med., .March, 1872, Bd. ii ; Hfl. 4. 5, p. 303. * Thi^ case wr» re-examined by Gerhard {loc. eii , p. 31) nt a later periftd of itA d<»veIopment with the followint; r(?^ult«i : rmhl delU'id, \)2? ; left deltoid, 92}° ; right thigh (inner side), 94^" ; left thigh (inner »ide), 94|«» ; right calf, 1K)« ; left calf, WV*. 632 PROGRESSIVE MUSCULAR SCLEROSIS. to be as follows: Left axilla, 97.5°; right axilla, 97°; perineum, 94.5°; right calf, 91.5° ; left calf, 91° ; and Estrazulas, in the case observed by him, reports the temperature in both axillse 98° ; on right calf, 91f ° ; and on left calf, 91°. The following case, which has already appeared in print {loc. eit), may be quoted as an illustration of many of the previous remarks : W. E., set. 20, was admittod to the Philadelphia Hospital, April 19, 1871. He was born in Virginia, and has resided there or in the District of Columbia until the present time. His parents are both dead, — his father from cholera, his mother from some unknown cause. He had two sisters and a brother, all of whom are dead, — two from unknown causes; but one sister had paralysis (apparcntl}' hemi- plegia) and was unable to walk for some time before her death. The patient him- self was a delicate and weakly child so far back as he can recollect. He never sutFrred either frcmi malaria or rheumatism. He was engaged in the country on a farm, and his strength was overta>ked by heavy lifting. He never, however, met with any injury. Six years ago he began to notice gradually increasing loss of strength in the legs, which progressed so slowly that for eighteen months he was still able to run about, though not so actively as other boys. He was not obliged to use a cane until two years ago, and since then only in walking considerable dis- tances. This gradually increasing debility was attended with no pain, formication, or subjective sense of change of temperature in the legs. There were also no con- tractions or cramps of the muscles. The progressive debility had not continued long before he noticed that it was necessary, when he was standing or walking, to throw iiis shoulders back and protrude his abdomen and lower part of the thorax, thus showing that the muscles of the back were affected at a very early date. Dur- ing this early period he could walk quite naturally, but in running he threw his shoulders far back and stretched his legs widely apart ; he assumed the same posi- tion also in going up an elevation. Two years later the muscles of the arms be- came affected in the same way as those of the legs and back. During the first three years he merely noticed that the legs did not grow as they should do, but afterwards atrophy began, first in the muscles of the calves, shortly after in those of the thighs and of the back, and soon afterwards in those of the shoulders and arms. About two years ago, after the atrophy of the muscles of the calves had become very marked, he noticed that they began to increase in size, and this growth has con- tinued until they have acquired a size much greater than they ever had previously. This process of renewed growth next appeared, about one year ago, in the muscles of the forearm, and has continued at a slow rate. During all this time his weak- ness has steadily increased; he has, however, never been kept in bed by it, but has been able to get about feebly by the aid of a cane. He has never had a sense of constriction about any part of the body. His appetite throughout has been good, his digestion fair, and bowels regular. His urine has always been passed with case, and has merely been noted to be occasionally yellow. About one year ago he was seized, without any apparent cause, with a severe epileptic convulsion, and since that time he has had similar attacks- at intervals of from fifteen to thirty days. He has usually been unable to tell when these fits were coming on, but occasionally he has had a strange feeling in the head, and has thought of foolish things, before the attacks. The fits have been attended with entire unconsciousness, sudden falling to the ground, and muscular convulsion. He has usually been half a day in en- tirely recovering from them. He has never had more than two convulsions on the same day. Present Condition. — His expression is natural, mind active, and special senses un- affected. The muscles of the face are not involved, and their action is perfect. His tongue is clean and moist, appetite fair, digestion easy, and bowels regular. There is no enlargement of the abdominal viscera. The urine is normal and secreted in I CASE. G33 norniHl quantity. Hi* respiration? nro easy, twelve in the minute, chiefly dinphrnu:- niMlic: the ve>iouhtr murmur is soft and healthy. The cardiac sounds are normal. The pulse is To, in the recumbent position. Muscular System. — The muscles of the neck (sterno-eleido-mastoids and i-xtensors of the head) are of fair size, and their movements are strong and free. The Irapezii are fi*eble, and he retracts the shoulders with difficulty and feebly. The pectoral muscles are moderately wasted and feeble. The scapular group of muscles are less wasted and the scapulje do not project markedly from the thorax, so that the serrati magni are probably not much wasted and enfeebled. The deltoids are extremely wasted and he is unable to raise either arm within thirty degrees of the horizontal plane; when the arm is raised, there is a marked depression below the acromion process. The biceps muscles are also extremely wasted, and he is able to flex the forearm only a little beyond a right angle. The triceps muscles are also very feebb', and the lung head of eaeh is greatly wasted, while the external and short heads appear as quite prominent fleshy masses. The forearms seem unduly large in comparison with the atrophied arms, and are in reality largt*r than they have ever previously been. They have, moreover, H |M?culiar blunt and swollen appearance, owing to the sudden enlargment of the muscles above the wrists. The atrophy of the forearms seems never to have reached the degree attained elsewhere, so that the degree of consecutive bypt^rtro- phy has not been so m.-irkcd as in the calves. The grasp of tho hands is decidedly weaker than would be expected from the size of the forearms, that of the rijjht being much weaker than that of the left hand. There has been no atrophy of the muscles of the hands. "When he sits up in bed, he is only able to hold the shoulders back with effort; there is increased bowing forward of the vertebral column, with absence of the lumbar d<'pression. There is decided wasting of the erector spinse muscles on eiihrr side. When lying in bed, the lumbar spine is raised, so that the obliquity of the pelvis and hypogastric region is increased. The muscles of the abdomen and thorax are not wasted, and preserve goi>d strength. "When he is lying down, the feet are strongly extended and adductod (equino- varus}, so that the toes point t<»wards each other, while the soles rest on the bed. There is great prominence of the tarsus. The muscles of the thighs are all much wa>t**d, a.< are those of the buttocks. It is with difficulty that, when lying down, he can draw up the l«'g> by the action of the flexor muscles. He has much m«)rc power of extending them by the quadriceps extensors. The rotators, abduct<»rs, and adductors of the thighs are much less affV-cted. He can move in bed only by a wrigg'iing motion. The calves a[)[»ear as large as those of a vigorous man, contrasting very strangely with the waited thighs. They feel quite firm, even when relaxed, and when he contracts the muscles they stand out well, and are hard and clastic. The heads of the tjastrocnemii especially become prominent, standing out lik<' firm subcutaneous tumors. He has considerable power of flexinir, adducting, and alMlucting the feet, but the extensors are very feeble The muscles of the right thigh and leg are de- cidedly stronger than the i-orre«ponding ones of the left i*ide. In rising from the recumbent position into a sitting one, he is obliged to mako a very strong cffi»rt. When about to stand up, he throws his body forward till it aU mr»*t rests on his thighs, and then, placing his hands on his knees and rising a little from his sext, he ^lowly raises his body by sliding his hands U[» his thighs; and when h*» has raised him.«flf as far as po'siblo in this way, he places one hand after thr- olhor on a chair-bnck or edge of a table, and b-anti forward. He then, by jorks of the alternate sides of the body, draws his legs forward, thus assuming more and more nearly an erect position. So soon a.* he approaches this, the legs are widely separatr-d, the shoulders thrown quickly back, and the abdomen protruded, and, «U»T tottering a few times, he secure* his r>quilibnum in this peculiar position. It U very tiresome for bim to stand without some support, and when bo does to b« 634 PROGRESSIVE MUSCULAR SCLEROSIS. bears with his whole weight on the right foot, the sole ^of which rests flat on the ground, while the left leg is thrown forward in advance, and the heel elevated from the ground. When a support is afforded him, he places both hands on it, and leans forward, rising on the balls of the feet, so that the heels are raised one- half inch from the ground. In this position he stands for half an hour or more at a time. The muscles of the calves are contracted and thrown into prominent relief. In walking, as in standing, the shoulders are thrown very far back, and the lum- bar depression is rendered very deep ; the arms hang down by the sides, coming decidedly behind the line of the buttocks. The legs are kept quite widely apart. He advances each one b}' resting his weight on the opposite foot, and then swing- ing forward the whole side, the foot describing a slight arc. At the moment of thus swinging forward either leg, he rises slightly on the opposite foot. While standing on the right foot, the whole sole rests on the ground, though the heel merely touches it lightly; but when his weight is thrown entirely on the left leg, the left heel still does not touch the ground. The effort of advancing each leg is evidently great ; the muscles of the thighs tremble and quiver, but those of the calves contract forcibly and are thrown into bold relief. Walking is very tire- some, and gives him pain and soreness in the back. No fibrillar contractions are seen in any of the muscles. Elective examination^ April 23d, 1871. — The muscles of the forearm (tested on the right side) contract well under a faradic current of rather unusual strength ; they also respond well to faradization of the brachial plexus. Electro-muscular sensi- bility is not acute, though this may be a mere individual peculiarity. The muscles of the arm, the pectoralis major, and the trapezius all contract on faradization, whether direct or applied to their motor points. It requires rather too powerful a current to produce these effects. A still more powerful current is required to induce contraction of the thigh muscles, but they all respond, though feebly : the sensibility to the current is impaired. The contractions of the flexors of the leg on the thigh are the most feeble, and are obtained only by very strong currents. The muscles of the leg respond more actively than the muscles of the thigh, whether the electrode is placed over the nerve in the thigh, or on the motor point of the muscle, or di- rectly over its body. When tested with a galvanic current, the muscles of the calves of the legs con- tract with each interruption and renewal of a current of rather unusual strength (twenty cells, Stohrer), and electro-muscular sensibility is acute. The muscles of the thighs also respond, but with more diflSculty, to the galvanic current. The following measurements were taken : Eight arm, greatest circumference, 7 inches. * " forearm, circumference one inch above wrist, 6 '' " " " at middle, 8^^ " " " " three inches below elbow, point of greatest thickness, . ?>% " " thigh, circumference hand's breadth above knee, 10|4 " " " " at middle, 113^ " " " " close to perineum, 12% " " calf, " at thickest part, 1*2 J^ " Left arm, corresponding point, 7 " " forearm, " " 6 " " " " " 83^ " " " " " 8% " " thigh, " " 103^ " " " " " 11% " " " " " 12^ " " calf, " " 1%^ " The general sensibility is everywhere normal, and there are no subjective dis- turbances of sensation. The circulation of the extremities is somewhat feeble, and CASE. 635 both hand? and feet rendily become bluish on exposure to c6ld. The color of the surfrtce is. however, everywhere norninl, without any ni(»ttling. April 30. — He hnd to-day an epileptic attack, with frothin*::^ at the mouth, iren- eral muscular spasms, and unconsciousness, lastinj; for eii;ht minutes. There was deep stupor and sleep for four hours subsequently, and he did not entirely recover until the followini; morning. The fit was preceded for about a minute by the fool- ish fancies he has fri-quently had before. OrderiKl s\ r. phosphat. comp., f*5ij, t. d Faradization of arms and lo^s on alter- nate days. A fraijment removed by Duchenne's " emporte-piece " from the left deltoid was of a slightly pale reddi'sh color. When exanjined microscopically, a large niiijor- ity of the fibrils showed distinct, though often fine and delicate, transverse striation. In a few instances, striation was entirely absent, the fibrils looking homogeneous and much like ground glass cylinders. In a very few fibrils, also, distinct longi- tudinal striation was visible, and in others there was multiplication of the nuclei in the .«arcolemma. In not a single fibril was there any trace of fatty degenera- tion. The fibrils varied in size from jl^^^ to ij^^g'', or even, in a few cases, yj^''. The striation wjv« particularly faint, or at times even absent, in the largest fibrils. There was a lari^e amount of interstitial white fibrous tissue, with abundant gran- ular matter containing many oval nuclei. In places there were small collections, of minute fat-globuleS or refracting granules. Fragments removed from the gastrocnemii presented closely analogous condi- tions. The muscular tissue was merely rather paler red than normal. The mus- cular fibrils varied greatly in apjioarance and in size. The transverse striation was in some fibrils perfectly healthy, but in a majority it was altered, though in various ways. Thus, in some it was very faint and difficult to distinguish ; in others, it was whidly absent, the fibrils presenting the appearance of fine ground-glass. In other fibrils there was a marked appearance of longitudinal striation, due to deli- cate fibres or verj' fine fusiform cells arranged in the long axis of the mu cular fibril. In many fibrils there was distinct excess of the nuclei of sarcolemma, which Hj»peared as large oval nuclei with a punctiform nucleus. A few fibrils presented streaks of minute fatty granules along their centres, and a very small nuuiber were decidedly fntty. The muscular fibrils varied greatly in size also. Many were about tss'' to 5J5" in diameter; but a number were ^^5" to jIj^^^, while others were as much as yjj", yiff'^i 205'' '" width. There was a large ex- cess of interstitial tissue, in places taking the form of long, narrow, wavy bands of pure white fibrous tissue; in others, appearing as abundant granular stroma, thi'.kly strewn with ovhI nuclei. There wa-s also some curly, elastic fibrous tissue. There was a considerable amount of interstitial, fat, existing as scattered globules, or arranged in patches of large, closely aggregated fat-globules. In places, iso- lated muscular fibril.* lay imb^'dded in this fibroid tissue so as to be scarcely visible ; but in other places a number of fibrils lay directly in contact with each other, forming a little bundle, around which the excessive growth of interstitial ti-^sue had occurred. The arterioles and capillaries appeared healthy. No nerve-fibrils were detected. The patient continued for several months upon the above treatment, and appeared to gain slightly in strength. The recurrence of his convulsions was checked by full dose* of bromide of potassium ; still it could not be said that any material improve- ment had occurred, when he left the hospital, and was lost sicht of. There i.*« u.sually an entire want of (li.«een walking in the street with the mother, on the day before the first dream occurred, and had been suddenly shocked and ter- rified by a large white dog brushing sharply against her, as it was careering along the street. There was no disturbance of the health at the time nor afterwards. As in the last case, the attack was evidently the result of the reproduction in a dream of the fright it had had in the street. The following case was still more curious. It is related very much in the language of the mother. The child, a girl two years and two months old, wa.< the daughter of a very bright and highly educated mother, and of a father of unusual intelligence and force of character. The child was herself very precocious and active-minded. The parents were both very healthy persons. On the night of Sept. 13th, 1873, the child awoke par- tially in a great fright, screaming, trembling, and covered with cold perspiration. Nothing calmed her for some time. She repeated over and over again, " Teeth bite you, teeth bite you." Finally, at the end of an hour, she was roused from the state of half sleep, the sobs and crying cea.«H?d and the attack ended, but at dawn of the same night there was another seizure which was not quite so violent. During the attack she l>egg<'d to have her head covered, evidently fancying that this protected her from some threatening object. During the following day she mani- fested great fear of the large slop jar in the nursery, and could not be in- duced to approach it. When her father took it into his hands to explain to her that it was "only ajar," she screamed most pitifully and seemed in abject terror. Being a child of peciHiarly vivid imagination, it was supposed that she had, by some freak of fancy, come to imagine the top or opening of the jar, to be an open mouth armed with teeth, ready to rend and tear her. She conceived, also, a great terror of the carved orna- ments on the head-lxjard of her crib, and, indeed, these fears became so marked and so great, that she was moved into another room, where the fin.:*'ire was plainer and unvarnished, so that the shadows and reflections _ not feed her disturbed fancy. In December she was seized with typhoid fever, from which f*he did not recover until February, 1874. In that month her mother had another child, a boy. When she was taken into the chamber to see her little brother, she had another nervous attack, in w},i. li she fancieii that an animal wa.'i biting her mother and that it rnii.'lit i>ite her al^). The nervous seizures at night continued to recur at intervals of about five weeks, generally after violent exercise or hearty f^*''ir..r, until May, 1875, when a severe attack of scarlet fever seemed to ite them in great measure. At the present time, she has a night terror only when her imagination has been, in some way, excited, or her i^ympathies overtaxed. With one more case, which shows the curious features of this sleep-in- 41 642 NIGHT TERRORS. toxication in a very marked manaer, we shall end the citation of cases, and pass on to a consideration of the pathology and treatment of the condition. A gentleman, whose eldest son was rather remarkable for his intellectual development, was roused from a sound sleep in th« early morning by a touch on the shoulder. On waking he saw this boy, then about twelve years old, standing by the bedside, dressed in his wrapper, his legs bare, and with his bare feet in slippers. The boy said : " Father, there are rob- bers in the house, they are downstairs now, but I do not think there is any danger, for I have been downstairs and have locked the doors, but I thought I had best tell you." The father thus waked suddenly from sleep, thought at first that the child was insane, but seeing some peculiar fixity in his look and manner, it flashed into his mind that the child was acting under the influence of a dream. He touched him sharply, and said loudly, " My son, you are sleeping ; wake up, wake up." The boy drew a long, deep breath, gaped, waked, and said, " Why, so I am," and walked off to bed again in the most natural manner. Pathology. — The best explanation of the conditions which exist in this curious disorder of sleep is, we think, to be found in the works of writers on forensic medicine. Thus, Dr. Johann L. Caspar {Forensic Medicine, Sycl. Soc. Ed., vol. iv, p. 273), remarks that " the dreaming state passes quite insensibly into that of somnolence, that middle state betwixt sleeping and waking, in which the connection with the outer world is neither that of sleep nor waking. The dreaming state is wholly sleep, somnolence is half sleep, half waking. In it the senses are neither quite awake nor quite roused, but are surrounded by a cloud of dream phantasms ; the somnolent man sees and hears self-made phantoms instead of real objects ; he hears a shot fired, and dreams of it, while it was only a stool that fell. He reasons logically, as is well known to be the case also in dreams, in regard to the impressions supposed to be felt, ahd may, since muscular action is not pre- vented by sleep, act in the most illegal manner." In the Treatise on Medical Jurisprudence (Philadelphia, 1855, p. 119), by Wharton and Moreton Stille, in the article on " Mental Unsoundness as connected with Sleep," it is stated that " under this general head may be grouped somnolentia or sleep drunkenness, somnambulism, and night- mare, the two last of which may be joined." Sleep is interrupted, they suppose, by whatever terminates the peculiar condition of the brain upon which sleep depends, by the natural exhaustion of the state of the brain, by vivid and sudden impressions on the senses, and by disagreeable sensa- tions. " Now, in a certain morbid condition of the brain this awakening is not complete, and does not restore the waking state with a full and cor- rect perception of surrounding things, but an intermediate state between sleeping and waking is produced, which resembles intoxication, and is called the intoxication of sleep (schlaftrunkenheit). This state admits of action, which is directed by the phantoms of the dream ; talking in sleep being very nearly allied to waking, and dreams themselves being midway between sleeping and waking, for in the depths of sleep we no longer be- come conscious of dreams." In this explanation they differ somewhat I CAUSES — TREATMENT. 643 from Caspar, who a?sert5 that dreams are "purely phantasmagoric concep- tions arising spontaneously in the brain, which continues to act during sleep and during the so-called dreamy waking, without any stimulation produced by the external world through the senses." Wharton and Stills say further: " It is important to dfj^tinguish somnolentia, or sleep-drunkenness, which is a state which in a greater or less extent is incidental to every individual, from somnambulism, which is an abnormal condition incident to very few." The experience of every-day life demonstrates how much the former enters into almost every relation. Children, particularly, sometimes struggle con- vulsively in the effi^'t to wake up, which often is continued for several min- utes. The very exclamations, " wake up," " come to," which are so common in addressing persons in the waking condition, are scarcely necessary in bringing to the mind many recollections of cases where the waking struggles were peculiarly protracted. Of course there are constitutions where this struggle is peculiarly distressing, just as there are constitutions in which the tendency to sleepless^ness is equally marked. If we recall to the reader the fact, that it is in the state of somnolentia or sleep-drunkenness, that acts of violence have been committed by persons, as stabbing a friend, shooting a passer-by who sought to wake a sleeping sentinel, and other acts of this kind, for which the unfortunate individual has been tried for his life, all of which unhappy events have been committed in the mental state induced by some dream, which has pursued the patient into the only partial awaken- ing, it will not be difficult to understand the phenomena we have described as occurring in some of the cases of night terrors above cited. Causes. — In some children it evidently needs but a vivid impression upon the mind in the waking state, to produce in the course of the fol- lowing night, and sometimes for many nights afterwards, the dream which is to cause all the phenomena of the severest night terror. The child may be in perfect health, and yet the mind shall, in sleep, so act as to re- pro-teriug it in combination with ipecacuanha, as in the form of Dover's powder, we derive the double ben- efit of a sedative and diaphoretic action. We have already given the formula by which we usually direct it in this di.sea.se. The inflamed and painful joint.s should be bathed with a sedative liniment, as of sweet oil, chloroform, and laudanum, and enveloped in bats of wool, and then cov- ered with oiled silk, so accurately applied as to exclude entirely the ex- ternal air. In addition to the other remedies, particular attention must be paid to the condition of the bowels, and if constipation exists, as is very frequent, mild saline laxatives or laxative enemata should be administered as frequently as required. Anything like purgation, however, should be avoided, on account of the excruciating suffering often produced by the movements necessary to have a stool. We desire, however, to call atten- 6o0 MATISM. tion to the fact that young children with this disease may persist in lying in one fixed position for even several days, dreading to be touched ; so that there is added to the inevitable pain of the disease, the distress occa- sioned by the long-continued contact of single points of the opposing artic- ulating surfaces. Under these circumstances it is wise, and greatly pro- motes the comfort of the patient, to gently change the angle of the limbs by arranging pillows so as to support them and alter their direction. In regard to the last indication — the prevention of complications — the most important means is the avoidance of all exposure of the patient to damp or to changes of temperature. In the fulfilment of this, the greatest care must be paid to the temperature of the sick-room, to the clothing of the patient, and to the mode of conducting all our examinations. Dr. Chambers, in his admirable lectures upon this subject {Clinical Lectures ^ American edition, pp. 156, 177, etc.), dwells with special force upon this point, and enjoins the exclusive use of blankets and flannels for the bed- ding and clothing of patients with rheumatism, and gives the following summary of his observations of the effects of this precaution alone in the treatment of nearly two hundred cases of rheumatism : "That bedding in blankets reduces from sixteen to four, or by three-fourths, the risk of in- flammation of the heart, diminishes the intensity of the inflammation when it does occur, and diminishes still further the danger of death by that or any other lesion." If, for any cause, local depletion should appear contraindicated, the immediate application of a blister is to be recommended. The importance of confinement to bed in this disease is difficult to over- estimate; the inflamed condition of the joints absolutely demands it, and the tendency to cardiac inflammation warns us to save the heart all un- necessary exertion, which strict attention, as above recommended, to the equable warmth of the surface, effects better than any other means. As to the diet in this affection, we must be guided by the acuteness of the symptoms and the condition of the patient. If the fever be marked, and the child vigorous, a diet chiefly consisting of milk and water is best suited to the early part of the attack, but so soon as the febrile stage has passed off, or when the patient is of feeble constitution, we may give soft- boiled eggs, and meat-broths, with advantage ; and frequently we will find concentrated nourishment and a moderate amount of stimulus required towards the close of the case. Complications. — In those cases where, despite our precautions, the membranes of the heart are threatened with inflammation, as evinced by sudden pain in the cardiac region, frequency of pulse, and oppression — even before the development of any murmurs — we should lose no time in employing local depletion by leeches or cups, abstracting as much blood as the urgency of the symptoms and the vigor of the constitution justify. After the removal of the cups or leeches, or blister, warm mush-poultices should be applied steadily over the whole prsecordial region. I DIPHTHERIA. 651 ZYMOTIC DISEASES. Under this title, as already stated, we include those acute general dis- eases whicli are dependent upon the action of some infectious morbid prin- ciple introduced into the system from without. They embrace a non-erup- tive group, of which we shall describe diphtheria, mumps and malaria, epidemic cerebro-spinal meningitis, and the group of eruptive fevers. ARTICLE II. DIPHTHERIA. Definition ; Synonyms ; History ; Frequency. — Diphtheria is an acute febrile, moderately contagious, and infectious asthenic blood disorder, occurring both endemically and epidemically ; without characteristic erup- tion, and distinguished by a disposition to the formation of false mem- branes upon inflamed mucous surfaces, especially in the fauces, or upon abrasions of the cutaneous surface. It is the disease called by the older writers, angina maligna or gangre- nosa ; cynanche maligna ; garotillo ; angina suffocativa, under which name it was described by Dr. Samuel Bard, of New York, in one of the best of the early essays upon this subject (Trans. Amer. Philos. Soc, vol. i). It is, indeed, thought probable, that the history of this affection can be traced back to a period beyond the time of Hippocrates ; but unquestion- ably the writings of Aretieus, who flourished in the second century of the Christian era, contain a distinct description of this malignant sore throat. He describes it under the names of ulcus Syriacum and malum ^Egypti- acura. From this period, there is quite frequent mention of the disease in the works of medical writers ; the earliest account of its appearance in modern times being given by Hecker, who describes an epidemic of it that prevailed in Holland, in 1337. About the middle of the last century, it prevailed in Paris, where it was describe*! by MM. Maloniu and Chomel ; and in some parts of P^ngland, where it was studied and described by Fothergill, though it is now doubted whether the disease to which he refers was not more nearly allied to scar- latinous angina. The first full description of this affection published in this country, was the paper, already referred to, by Dr. Bard, based upon an epidemic which ap|>eared in 1771 ; the views advanced in which have been universally recognizeil, even to the present day, as most clear and just. From that time, the complaint seems to have attracted but little atten- tion, until its occurrence at Tours, in 1818, and subsequent years, called forth the treatise of Bretonneau in 1826, in which he gave the first precise notion of the disease, and Ijcntowed the iiaiue difjhthcrite upon it. 652 DIPHTHERIA, ^ Siuce then it has occurred frequently epidemically in France ; in 1857 it appeared almost simultaneously in England, and in the extreme western part of our own country, and from that time has occurred in the form of epidemics of greater or less extent and severity, in the most varied climates and seasons, in almost all known parts of the globe. Diphtheria, the name by which this epidemic pseudo-membranous angina is commonly designated, is a synonym of the word diphtherite, originally used by Bretonneau in his treatise on this subject. At Med. Times and Gaz., July 23d, 1859. 654 DIPHTHERIA I 00 CO oo > M Oh O o o H t o Siiianp uit!>i ^ CO 00 b- S 05 CO 1>. CO 05 - rJ CM -^ t^ rH TjH t~- .S-o, (M (M '"^H (M CM CM CO CO ■^ CO CO 10 ■^ 05 CO CD 00 a. s 05 Oi (M CD ,—1 Oi rH 05 >*l CO j—i ,—^ »o k; CO CD CO -rJ^ rH I— 1 CO CO 10 10 TtH Ttl (N "* I— 00 CO lO c» CO "^ CM ■^ .r^o CO rfi — 1 rH CO CO CO CO CO CO CO CO Q-a -* CO 00 3 CD t~ CD Tt< 1— 1 t- (M CJi Oi tr- CO 2 CO T^i !M CO rH I— 1 3^ Tti CO cx> TJH T)H H CO ■M (M (M tH ■^ tH CM 05 to CO rt< CJ (M 3^ CM CM CM "■Ji CO CM CM 'M Q-S CO CO 00 1 5* Tt* -rt< 05 >o t^ t^ 00 l^ CO 00 CO l^ 00 rt^ tM CM rH r— ( CO CO >o (M ^ ^ ^ ^ ^ ^ ^ >> V O) 7 1 a c a 1 c ^ ^ (/I 3 b/) < 1 s CD 1 6 s > s a> H J NATURE. 655 Season. — As we have already remarked, the influence of season upon the prevalence of diphtheria is comparatively slight, and there are nu- merous records of epidemics occurring in the summer, as well as in the winter months. Notwithstanding, however, it will be seen that in our own city the mortality from diphtheria does not vary very much during the months from September to March inclusive, whilst during the other five months it falls off from thirty to fifty per cent., the minimum mor- tality usually occurring in June. We have before had occasion to allude to the diflTerence, in this respect, between diphtheria and croup, which latter disease shows in the clearest and most marked manner the direct influence of season upon its frequency. Thus croup is far most frequent during the three months of November, December, and January, and, with the exception of February, becomes less and less frequent as you leave these months in either direction, until during July, the hottest month of our year, it fiills to even less than one- fourth of its maximum frequency. During the same month, diphtheria, whose maximum mortality is one-third less than that of croup (both maxima occurring in December), causes more than half as many more deaths than croup does, the proportion being 16.3 to 10. Sex appears to have absolutely no influence upon the frequency of diphtheria, since of 1804 fatal cases occurring in this city during the above seven years, 901 were males, and 903 females. Age, on the other hand, unquestionably exerts a very strong predispos- ing influence, a large majority of all recorded cases occurring between the ages of one and eight years. Of the 1804 cases in our table, 190 occurred under the age of one year; 335 between one and two years ; 725 between two and five years, and 355 between five and ten years. Although the liability thus diminishes, in an uncertain ratio, with advancing years, no age is exempt from it. By reference to the influence of age upon the frequency of true primary croup, it will be seen that the maximum of its frequency is also attained between the ages of one and five years. We would also call attention to the much greater frecjuency with which diphtheria occurs in later life than croup ; since of 2136 deaths from croup, but 77 were over ten years of age; while of 1804 deaths from diphtheria, not less than 199 occurred after that periml. Of course it is evident that the above statistics not only prove that diphtheria is much more frequent during the first decade of life than at any subsequent period, but also that it is much more fatal then. Natirk. — In his earliest writings upon this subject, Brctonneau at- tached little importance to the constitutional symptoms attending diph- theria, and upheld the view that it was essentially a local affection ; and though he subsequently somewhat modified his views, he yet only admitted that the constitution becomes involved secondarily. It is indeed true that the epidemics which have occurred during the past twenty-five years seem to have been attended by far more grave constitu- tional symptoms than were present in the cases upon which Brctonneau's memoir were founded. And at present, it appears to us, that a careful study of the very numerous reports of epidemics occurring in all parts of 6oQ DIPHTHERIA. Europe, Great Britain, and the United States, especially during the past ten years, can leave no doubt upon the mind that diphtheria is a blood dis^ease, attended with marked constitutional disturbance, which is usually of a decidedly asthenic character. This view is at present almost universally adopted ; and in accordance with it, we find diphtheria removed from the place which it formerly held in systematic treatises, among the local affections of the pharynx, and dis- cussed as one of the general diseases. The chief arguments in favor of its being a constitutional disease, are its epidemic and contagious nature ; the continued febrile action, of asthenic type, which attends its course; the marked alteration of the blood mass in color and consistence ; the tendency to pseudo-membranous exuda- tion on mucous membranes, or abrasions of the skin ; the occurrence of albuminuria ; and, finally, the frequent development of paralytic sequelae, showing the presence of some morbid agent, acting especially upon the nervous system. Bouchut,^ to a certain extent, agrees with Bretonneau. He divides diphtheria into false, or non-infecting, which is mere pseudo-membranous angina ; and the true, or infecting, which involves the entire system, by means of the absorption of septic substances from the pharynx. In this respect it resembles pyemia, and produces swelling of the lymphatics, alteration of the blood, albuminuria, and even metastatic deposits. Pathological Anatomy. — False Membranes. — We have already dwelt upon the fact, that the pseudo-membranous exudation can no longer be regarded as the essential and most important element in diphtheria ; it is, however, one of the most constant and striking phenomena, and in certain cases, where it extends into the larynx, becomes the eifective cause of death. It has been most carefully studied in regard to its mode of development and extension, seat, and microscopic characters, by Empis, Bretonneau, Wade,^ Thompson, Darrach,'* Trousseau, Sanderson.* Mode of Development. — When fully developed, the pseudo-membranous deposit has the ordinary appearances of a fibro-plastic membrane ; but this stage is preceded, according to the researches of Empis and others, by the exudation of a sero-mucous, transparent, and viscid fluid, which varies in abundance in different cases, at times even forming, as noticed by Trous- seau and Empis, in the neighborhood of parts lately covered by deposit, a sort of submucous exudation, suflicient to raise the epithelium in the form of phlyctense. This sero-mucous liquid does not long remain transparent and diffluent, but soon becomes a little less transparent in points^ gains a yellowish tint, acquires greater density, and adheres more strongly to the subjacent mucous membrane. These points, at first isolated and circumscribed, soon coa- 1 Mai. des Enfants, 4feme ed., pp. 907-923. 2 London Lancet, February 5, 1859 [et cmie). 3 Trans. Coll. of Phys. of Phila., February 6, 1861 (Araer. Jour. Med. Sci.). * Brit, and For. Med.-Chir. Rev., Jan. 1860. PATHOLOGY AND ANATOMY. 657 lesce so as to form a «1elicate pellicle, but slightly cohering, and capable of being raised from the mucous membrane by slight traction ; although, owing to its friability, it is dithcult to raise a piece of any considerable size. TJiis pellicle is more dense and thick at its centre than towards the edges, and soon after its formation, the exudation continuing beneath it, and co- alescing with it, it gains in thickness by the apposition of an under layer; until, when the membrane is fully developed, it may consist of several layers, and appear imbricated. At this j)eriod its adhesions are so strong that, if it be detached from its connections, slight haemorrhage will follow, or numerous minute bloody points may be seen upon the subjacent mucous membrane. According to Empis, the appearance of the opaque spots in the clear sero-mucous Huid is due to a precipitation of fibrin independently of any agency of living tissue. Thus the tubular casts which form in the air-pas- sages are rarely adherent, and are usually much sn^aller than the cavity occupied; and in cases of tracheotomy he has noticed the canula to become lined within a few hours with a layer of whitish concretion, the thickness of which continually increased, and which was evidently only the result of coagulation of the liquid by which the sides of the canula were con- stantly covered. Color. — The color of the pseudo-membrane varies at different stages, and somewhat according to its seat. In the fauces, the deposit is often whitish at first, but soon acquires a yellow tint; though in some cases it is quite gray, and produces the appear- ance of extensive sloughs on the fauces and pharynx. In severe cases, there is usually a bloody sanious fluid effused, which imbues the pseudo- membrane, discolors it, and promotes its decomposition, so that it forms dark-colored shreddy patches, exhaling a fetid, gangrenous odor. It is essential to bear in mind that these appearances of the fauces in diphtheria are usually due to decomposition of the false mem))ranc alone; and that, if this be removed, the mucous membrane will generally l)c found merely raw, excoriated, and oozing blood. It is, however, true that in certain epidemics the rule has been for seri- ou.« lesions of the mucous membrane, involving even its entire thickness, to occur. In milder cases, where the disappearance of the false membrane can be studied, it is never seen to separate all at once, leaving in its place a cica- trized surface, but the pH-llicle gradually diminishes in thickness and extent. "When the })seudo-membrane extends into the larynx, it is more apt to re- ain whitish throughout its course there than in the fauces. Cojufi^ence. — The consistence of these deposits varies considerably. In ' u-es of ordinary severity, where the symptoms are not of a very adynamic type, the pseudo-membrane is often quite firm, tenacious, and elastic ; while in grave asthenic ca.«es, with .severe inflammation of the throat, the depo^it is apt to be much less firm, or even quite pultaceous. It has been attempted to base upon these conditions and corresponding microscopic appearances, a divi.«jion of diphtheritic pseudo-membranes into 42 658 DIPHTHERIA. two classes, answering to the well-known division of inflammatory lymph into the fibrinous and the corpuscular. Microscopic Anatomy. — There were formerly different views entertained with regard to" the minute anatomy of the pseudo-membranous deposits in diphtheria. -• Vogel originally associated with the disease the presence of the oidium albicans, the parasite which we have seen to be characteristic of muguet ; and, more recently, Laycock, of Edinburgh, has insisted upon the occur- rence of this cryptogam in the pseudo-membranes of diphtheria. Dr. Wade, of Birmingham, has noticed also in some cases, in or near the exudation, the spores of the leptothrix buccalis, a fungus very commonly met with in the secretions of the mouth and pharynx. Further investigations have shown, how^ever, that these parasites are occasionally present in numerous diseased conditions of the mouth and fauces, and that their occurrence in diphtheria is to be considered as a mere accident, and not as an essential part of the affection. The microscopic appearances which are constant, are the ordinary ele- ments of corpuscular lymph : exudation cells or even pus-corpuscles, gran- ule-cells and free fatty granules, and more or less abundant and closely interlacing fibrillse, mixed with epithelial cells of various shapes and sizes. In the majority of specimens, the corpuscular elements greatly predomi- nate, the fibres being few and small ; and indeed it is only in the firmer, more tenacious, pseudo-membranes that mucii true fibrillation is noticed. Chemical Characters. — The false membranes contract and shrivel when treated with alcohol ; mineral acids, such as sulphuric, muriatic, nitric, or chromic ; strong solutions of nitrate of silver ; or solutions of the per-salts of iron. On the other hand, they soften more or less quickly when treated with alkaline solutions, as of potassa, soda, lime, or ammonia ; or of chlorate of potash, chlorate of soda, bromide of potassium ; or with glycerin and various other agents. Recently, pepsin and lactic acid have also been announced as powerful solvents. These various chemical properties are ■constantly turned to account in the treatment of diphtheria, in guiding our selection of the most appropriate local applications. Condition of the subjacent Mucous Membrane. — Even before the appear- ance of the slightest exudation, the mucous membrane of the fauces is often seen to be red and somewhat swollen. After the pseudo-membrane is fully developed, it is of course impossible, without forcibly detaching it, to gain any idea of the condition of the mucous membrane beneath, and unquestionably very many of the descriptions given of extensive gan- grenous ulceration of the fauces and pharynx, have referred merely to the changes in the pseudo-membrane due to its decomposition and the im- bibition of sanious fluid. In the vast majority of cases, the subjacent mucous membrane is not truly ulcerated, but is merely much congested and swollen, with an exco- riated and roughened appearance from removal of its epithelium, and oc- casionally presents spots of ecchymosis. At times it is whitish, opaque, or unnaturally pale ; while in other cases SEAT OF TUE EXUDATION. 659 it is purplish or otherwise discolored. When the depos^it is raised up, es- pecially if it be of. the firmer variety, it is often seen to be attached to the surface beneath by numerous small filaments, as though processes of the deposit passed into the mucous follicles. Although these may be considered as the most usual conditions of the mucous membrane, it is undoubtedly true that in some cases extensive and deep ulceration, and even gangrene occur, exposing the muscular tissue of the pharynx, or even producing the destruction by sloughing of an entire tonsil gland. This accident occurs much more frequently in some epidemics than others, as may be readily seen by a comparison of the accounts given by different authors of the anatomical lesions noticed in the epidemics they have re- spectively studied. The submucous tissue is often edematous, infiltrated with bloody serum, or is the seat of an interstitial exudation of lymph. In some cases the cesophagus and the muscular tissue around the fauces and pharynx are congested and infiltrated. When croup ensues, the mucous membrane of the larynx and trachea is more or less swollen and congested, and, according to West, presents dis- tinct erosion of its surface, with small ulcers about the edges of the glottis, in a larger proportion of cases than ulceration is met with in the fauces. M. Isambert* suggested that this condition might serve to distinguish diph- theritic from idiopathic croup; but West has met with precisely similar ulceration of the mucous membrane of the larynx in cases of primary croup, and is disposed to regard its presence or absence as mainly depen- dent on the rate of progress of the disease towards a fatal termination.^ Seat of the Exudation. — The pseudo-membranous deposit is usually first seen upon the tonsils and soft palate, and in some cases is limited to these parts throughout the whole course of tlie case. Frequently, however, the exudation spreads and coats the i)haryux more or les3 extensively, or extends into the posterior nares, or downwards through the larynx into the trachea and bronchi, or more rarely into the CES^)phagus. It is rare for any exudation to occur on the mucous membrane lining the cheeks, or upon the gums, though according to some authors, as Hutch- inson,' Trousseau, and Bouchut, ulcerative stomatitis is in reality buccal diphtheria. The epiglottis is at times covered with a pseudo-membranous deposit, so as to become swollen, rigid, and almost immovable, and hence partially obstructing, without being able to protect, the entrance into the larynx. The tendency for the exudation to extend into the nasal passages varies much in different epidemics, and when present, almost always betokens the great gravity of the caae. * Arch. Gen. de M^d., March and April, 1857. « Dii-eascs of Children, 4th Am. fd., 18G0, p. ;i5G. » Med. Times and Gaz., 3Iarch 19lh, 1859. 660 DIPHTHERIA. AccordiDg to Bretonneau, the exudation occasionally begins in the nares and extends thence in so insidious a manner as readily to escape detection. We will discuss more fully the questions relating to the extension of the exudation into the larynx under the head of diphtheritic croup. The diphtheritic pseudo-membrane is not, however, limited to these mucous surfaces, but is occasionally seen, and especially in very severe cases, to form upon the mucous membrane of the vulva or of the anus. It is, moreover, a most significant fact in regard to this affection, that any portion of the external cutaneous surface which has been denuded of epidermis, may become the seat of this deposit, and that in some cases the pseudo-membranous formation is even limited to the skin, constituting the so-called external or cutaneous diphtheria. So far, however, from the at- tending constitutional symptoms being less severe in the external than in the ordinary form, the tendency to deposit upon the cutaneous surface usually presents itself in cases of a typhoid adynamic type. It appears, indeed, that this pseudo-membrane may occur at any point of the body to which the atmospheric air has access; but it has never been noticed on parts which are removed from its influence. Notwithstanding these apparently distinctive features of the diphtheritic deposit, it is impossible l)y mere ocular or microscopic examination to dis- tinguish it from the pseudo-membranous deposit in cases of ordinary scar- latinous angina. It is more, therefore, in the peculiar constitutional disturbance that we must look for the specific nature of diphtheria, than in the presence and characters of the false membranes. The Suhmaxillary Glands are almost always enlarged, though they rarely acquire the enormous size and peculiar brawny induration so often noticed in scarlatina. It is, moreover, very rare for this condition to ter- minate in suppuration of the gland. The Heart has been found, by Hillier,^ in a state of fatty degeneration in two cases; and by Bristowe {id. loc.) in one; all of which were rather chronic. We have observed marked granular degeneration of the cardiac fibre in several instances, however, where the disease had been of a violent and rapidly fatal form. In some instances where symptoms of endocar- ditis were present during life, the auriculo-ventricular valves have been found in an incipient stage of inflammation. (Bridger.^) We have also observed in several cases, in at least one of which a valvular murmur was heard during life, incipient inflammation of the mitral valve, with rows of minute, delicate, beadlike vegetations fringing the free -borders of the leaf- lets. In other cases, pericarditis has been developed during the course of diphtheria. We desire to call particular attention to these cardiac com- plications, on account of their great importance as influencing not only the prognosis of the attack itself, but possibly also the subsequent develop- ment of chronic cardiac disease. Heart-clots of large size and firm consistence, evidently of ante-mortem 1 Diseases of Children, Am. ed., 1868, p. 154. ^ Med. Times and Gn/.., Jan. 1864, p. 201 ; and Brit. Med. Jour., Oct. 22d, 1864. t SYMPTOMS. 661 formation, are also foiiml in a certain number of cases where death has been preceded by peculiar signs of circulatory embarrassment. The Lungs are not rarely found inflamed and consolidated to a greater or less extent. In other cases the exudation is found penetrating deeply into their structure, filling the smaller bronchial tubes, and the lung itself is in parts collapsed or carnified. Bouchut speaks of having seen small apoplectiform patches, similar to those which precede the so-called metastatic abscesses in pyaemia. The Kidneys are at times quite healthy ; in other cases, however, they have been found congested, and the renal epithelium granular and de- tached, so as to distend the tubules, which also contain fibrinous casts ( inclosing granules of hoematin, blood-corpuscles, or a few altered epithelial cells). (.Hillier (he. cif.), Greenhow,' etc.) The ga^tro-inte'Sfinal canal presents no lesions of importance ; in a few cases enlargement of the solitary glands of the lower })art of the ileum has been noted. Secondary Form. — When diphtheria appears in the secondary form, the raucous membrane is more violently inflamed. It is of a deep red color, rough, and very much thickened and softened. The tonsils are large and soft, uneven, and often infiltrated with pus. In addition, the mucous membrane is far more frequently and seriously ulcerated in this form than in the primary. False membranes are almost always present, generally on different portions of the fauces, and more rarely over their whole ex- tent. They are generally rather soft and thin, of a whitish, grayish, or yellow color, dispersed in fragments and easily torn. The inflamed parts are usually bathed in a purulent fluid. The sub- maxillary glands are large, red, and soft ; and, in addition, there may be found various lesions of other organs, due to the primary disease, in the course of which the diphtheritic angina has been developed. Symptoms. — Diphtheria occurs both in a sporadic and epidemic form ; it a\>o presents itself either as a primary or secondary aflectiou. The symptoms of this latter form are, however, so involved with the symptoms of the diseases in the course of .which it is developed, that it seems desira- ble to consider it in connection with them severally. It would a|)pear that, under the influence of widespread epidemic in- fluences, the symptoms of diphtheria have of late years presented a higher degree of .severity. Owing to the fact, however, that, until the descrip- tion of diphtheria by Bretonneau, it was confounded with anginose scarla- tina, with ulcerated sore throat, etc., it is extremely difficult to form a correct comparison between the disease as we are now familiar with it, and as it undoubtedly occurred in former years. In a strictly systematic discussion it might be well to divide dij)hth<'ria into a mild form, which would include most sporadic cases and many of the epidemic ones, and a severe form, under which head would he com- prised all cases distinguished by a high degree of constitutional disturb- ance. For practical purposes, however, it is suflScient to give a descrip- 1 On Diphtheria, New York, 1861, p. 160. 662 DIPHTHERIA. tion of the ordinary course of the disease, dwelling upon some of the most important symptoms, and alluding to the chief peculiarities which at times present themselves. Local Symptoms. — Examination of the TJiroat — The onset of diph- theria is often very insidious ; so that our attention may not be called to the throat by any complaint of the patient, even when a considerable amount of exudation is already present. If the throat be examined, however, on the first day of the disease, the exudation may often be found even at that time, though it is sometimes not found before the second day. The fauces generally present more or less swelling and redness prior to the appearance of the false membrane, which almost always shows itself first on one of the tonsils only, in the form of whitish or opaline spots, like coagulated mucus, which soon run together and extend over the whole gland, and then to the soft palate and pharynx, though it sometimes remains limited to the tonsils and soft palate. A little later in the attack the plastic deposit exists in the form of layers of greater or less extent; it has lost its transparency, become firmer in consistence, thicker, and changes from a white to a yellowish- white or lardaceous, and sometimes grayish color. The breath in this case is offensive, but not fetid ; and there is but little salivation. When, in favorable cases, the disease is left to pursue its natural course, the pseudo-membrane becomes thinner, assumes a grayish tint, and falls ofi" about the sixth or seventh day. When, on the contrary, topical remedies are applied to the throat, the membrane is often detached after one, two, or three days, but may be reproduced several times before the conclusion of the case. In some unfavorable cases, on the contrary, even though the exudation may disappear more or less completely from the pharynx, it extends down- wards into the larynx, and we have true croup developed, which but too often proves fatal in spite of all remedies. In more violent cases, the pseudo-membrane, about the time that it begins to be detached, assumes a grayish or blackish color, and hangs in shreds from the surfaces to which it was attached. The fauces, under these cir- cumstances, present a gangrenous aspect, the mucous membrane having an appearance as though it were falling off in sloughs ; the breath is extremely fetid, and there is more or less abundant salivation, or in some cases an expuition of sanguinolent fluid. There can be no doubt that it was from misconception of such cases as these, that the titles of gangrenous and putrid sore throat arose. As the exudation disappears from the pharynx, the swelling of the parts affected gradually subsides. The mucous membrane, from which the plastic matter has just fallen, is more or less injected and red ; the tonsils and soft palate are sometimes found to be reduced below their natural size. Even when the throat affection is very severe, there is not often so much difficulty in opening the jaws nor in deglutition as is met with in scarlatina. The submaxillary glands are almost always enlarged and slightly painful to the touch, about three or four days after the appearance of the pseudo- 1 SYMPTOMS OF DIPHTHERITIC CROUP. G63 membraue. The enlargemeut is usually irroatost on the side where the inflaniiiiation of the tauees is most intense. The surroundinii- eellular tissue shares in the intlanimation, so that the swelliui:: is often verv ij^reat, and impedes the movenients of the jaw ; it is rarely, however, save in very had eases, so hard and painful as the corresponding swelling in sca»'- latina. Piiin and Difficultij in Derjhitition. — Tliere is sometimes no complaint of pain in the throat, although, even at the outset, swallowing is usually somewhat difficult and painful, and pressure behind the angles of the jaw causes a moderate degree of suffering. In some cases, especially of the sporadic sthenic form, the earliest symptom may be excessive pain on swallowing. As the pseudo-membranous exudation increases, and the submaxillary glands become swollen and tender, deglutition becomes more difficult and painful, and, at times, attempts to swallow fluids are followed by cough and the return of the fluid through the nostrils. In cases where the false membranes decompose and acquire a gangrenous aspect, and typhoid symptoms are present, the pain and difficulty in swal- lowing, if they have existed, are apt to disappear. Varieties depending upon Extension of the Exudation. — 1. Croupal Variety. — It would be a matter of much interest to determine in what proportion of cases this complication may be anticipated, and whether there be any definite and constant relation between the amount or charac- ter of the exudation in the pharynx and its extension to the larynx. As yet, however, no general conclusions can be arrived at in regard to any of these points. The frequency of its occurrence varies much in different epidemics, the proportion varying from one or two per cent, to as high as fifty [>er cent, of all the cases. Indeed, as in an epidemic referred to by Trousseau, the disease may, in almost every instance, assume a primary laryngeal form. As might be expected from the considerations presented under the head of croup, this complication occurs more frequently and is much more fatal in children than in adults. It is a well -recognized fact that true diphtheritic croup is nearly always preceded or accompanied by p-eudo-membranous exudation in the fauces or pharynx, but the amount of depf)sit in these latter places may be extremely small and yet be followed by extensive exudation in the air-passages ; while, on the other hand, there is often copious deposit upon the pharynx in cases where the larynx doe?* not become invaded. No case, indeed, is free from the chance of this com[)lieation ; it con- stitutes the chief source of danger in the mild variety, and yet is occa- .^ionally met with as the immediate cause of death in the most malignant attacks. The pseudo-membrane is quite frequently found, in cases where the air- passages have become involved, to extend through the larynx and trachea, as far down as the tertiary bronchi, or in some instances, even to their finest divisions. In this respect diphtheritic croup does not differ from i)riiiiary rrouj), 664 DIPHTHERIA. imless it be, indeed, that it seems to be more frequent in the former for the exudation to extend to the smaller bronchial tubes. We have seen that there is no essential difference in the condition of the mucous membrane beneath the deposit in the two affections; and that they are equally liable to be associated with inflammatory conditions of the lungs. Unless, therefore, the more highly corpuscular character of the exudation in diphtheria constitutes a ground of distinction between these two forms of croup, it seems difficult to establish a diagnosis between them on merely anatomical grounds. When diphtheritic croup is secondary, appearing in the course of measles, scarlatina, or other general disorders, the conditions found after death in the larynx are much the same as in primary diphtheritic croup. The mucous membrane here, however, as in the fauces, is usually more intensely in- flamed, and is more frequently ulcerated. The possibility of the occurrence of croup should never be lost sight of, and every case should be treated as though it tended to invade the larynx. It is especially important to detect the very earliest signs of the approaching danger, since its onset is frequently extremely insidious. If violent cough is excited by attempts to swallow liquids, it usually in- dicates that the epiglottis is inflamed, and the seat of pseudo-membranous exudation, which impedes its movements and thus allows the fluid to pass into the larynx. The extension of the exudation to the larynx is indicated by the cough acquiring a rough croupy sound, though it often has not the loud clangor of ordinary croup ; the respiration becoming sibilant, and the voice weak and hoarse. When the false membrane in the larynx is fully developed, the voice is almost or quite extinct, and the cough, losing its croupy character, becomes stifled and less frequent. The respiration is now peculiar; there is con- stantly a certain degree of dyspnoea, as shown by the frequent labored breathing, but there are, in addition, paroxysms of suffocation, induced by spasm of the laryngeal muscles, during which the dyspnoea is frightful, and attended with tossing of the whole body and the most violent efforts at in- spiration. Death may occur during one of these paroxysms; but usually they sub- side and are followed by intervals of comparative ease, soon interrupted by the recurrence of the same alarming phenomena. The intervals become more and more brief, and finally the patient sinks into a comatose condition, and dies with all the symptoms of asphyxia. If, during the violent efforts at respiration which attend these paroxysms of dyspnoea, or owing to the action of remedies, portions of the exudation are dislodged and coughed up, the most urgent symptoms are often imme- diately relieved. It is, however, but a deceitful repose, for in most cases the pseudo-membrane reforms, and the recurrence of the croupy voice and sibilant respiration announce that the danger of suffocation is again imminent. In favorable cases, however, either when the membrane does not reform, or when it is dislodged as often as formed, recovery may occur ; the par- CUTANEOUS DIPHTHERIA. 665 oxysnis of dyspnc^a recur at lonirthoiiinir intervals, and tiiially disappear; the cough becomes ixradually more soft, and frairments of pseudo-mem- brane, mixed with muco-purulent fluid, are disciiarged ; the voice returns, and the capihiry circulation becomes re-established. In some cases, when the exudation has extended through the larynx and tnichea deeply into the minute bronchial tubes, there is an absence of marked croupal symptoms, and death occui's slowly, after extreme dysp- ncva and oppression of the chest, with all the sym})toms of deficient aera- tion of the blood. These cases occur more frequently in adults than in children on account of the larger size of the larynx in the former. The reader is referred for a 'more full account of this condition to the article on pseudo-membranous laryngitis. 2. Xiual Vnrietif. — We have already mentioned that Bretonneau states that the disease occasionally begins at the uares, and extends thence in a most insidious manner. ^lore frequently, however, the affection of the nares is consequent upon an extension of the exudation from the pharynx. This complication is second in gravity only to the occurrence of croup. It impedes still further the already obstructed respiration, is attended with a foul acrid discharge from the nostrils, and, in addition, experience has shown that it is usually a sign of great malignancy in the case. Accord- ing to Trousseau, the result is almost always fatal, the blood-poisoning being marked, as shown by the great alteration in the physical properties of the bloixl, the proneness to hiemorrhages, the waxy pallor of the skin, and the ultimate fatal termination by syncope. The detection of this complication in its incipient stage is therefore of the highest importance, and Bretonneau (5th memoir, Syd. Soe. Trans., pp. 196, 197) has laid down the most minute directions for its recognition at this stage. If the patient present any evidence of disease of these passages, as a slight snuffling or coryza, during the prevalence of diphtheria, the finger should be placed behind the angle of the lower jaw, below the lobe of the ear, and thence passed down the side of the neck, and if swelling of the cervical glands be noticed, it renders it probable that there is false meinhrane in the nares. If, further, the upper lip be found reddened exclusively under one nos- tril, and that on the >'n\e of the glandular swelling, or if the swelling ex- ist.*? on both sides, but unequally, and if the lip is correspondingly red- dened, the probability that there is nasal diphtheria is converted into a certainty, since ordinary coryza, acting equally on both nostrils, produces equal rednes« of both sides of the upper lip. 3. Cutaneous Diphtheria. — It is one of the characters of diphtheria which entitles it to be regarded as a blood disease, that different and distant parts are apt to become affected simultaneously or consecutively with the pecu- liar inflammation and exudation. We find, indeed, that in many cases of diphtheria there is a tendency to the formation of pseudo-membrane upon any portion of skin denuded of its epidermis. This tendency varies greatly in different epidemics; according to our ex- pf-rience it is of rare occurrence in this city. It was, however, noticed by Bard nearly a century ago, and has been made the subject of special study DIPHTHERIA. by Bretonneau and Trousseau.^ The pseudo-membrane forms upon any blistered surface ; upon leech-bites ; upon excoriations; in fissures, as behind the ears, or at the angles of the mouth ; or on the outlets of the vagina and rectum. The part that is to be the seat of pseudo-membranous deposit becomes surrounded by an erysipelatous redness ; it is painful, exudes an abundant fetid serous fluid, and soon becomes covered with a grayish false membrane. This deposit gains in thickness from beneath ; and, at the same time, ex- tends in every direction, by the development of vesicles in the neighbor- hood, the bases of which become the seat of diphtheritic deposit. The layers of membrane, bathed in the fetid serous fluid, soon change color, decompose, become horribly offensive, and impart the appearance of true gangrene. Trousseau has observed this cutaneous exudation in cases where no affection of the throat existed, and has clearly established the identity of these various forms of diphtheria by facts collected in an epidemic in the neighborhood of Orleans, where the disease in some persons presented its ordinary features, while in others the exudation occurred on the vulva, on blistered surfaces, on the hairy scalp affected with favus, or upon ulcers. The constitutional symptoms which accompany cutaneous diphtheria are usually extremely grave and adynamic. General Symptoms. — In the mild form of this disease the invasion is often highly insidious ; there is usually fever, but the strength and appetite are not much disturbed at first. There is at the same time, in some, but not all cases, pain in the throat, which may or may not be accompanied by difficulty of deglutition. Both these symptoms are, however, often very slight, or they may be entirely wanting, a fact with which the prac- titioner should be well acquainted, as this, absence of local symptoms by which to explain the cause of the sickness, gives to the disease, in some in- stances, a remarkably insidious character which may well mislead. In one fatal case, at three years of age, that came under our notice, there were neither complaints of pain, nor difficulty of swallowing, so that the parents had not the least suspicion of the throat being the seat of disease, though we found it violently inflamed, and covered with deposits of thick false membrane in points. On another occasion, we were sent for to see two children who had been sick for four days with slight fever, languor, and loss of appetite, but who were not thought to be seriously ill. We found them laboring under extensive pseudo-membranous angina, with the early symptoms of croup. They both died a few days later of croup. The symptoms, prior to the development of the croup, had been so mild in both cases as to cause no alarm, and yet the anginose disease had evidently been progressing insidiously for several days. We attended, a few years since, for three days in succession, a boy who was attacked suddenly with vomiting and slight fever, loss of appetite and languor, and whom we sup- posed to be suffering from mere gastric irritation. His only local symp- tom was pain in the chin, and this was not reported to us until afterwards. 1 On Cutaneous Diphtheria, Arch. Gen. de Med., 1830 (et loc. ante cit.). GENERAL SYMPTOMS. 667 The mother chanced to look into his throat, and, finding there some whitish spots, sent us word. AVe found him with very considerable mem- branous exudation, which was fortunately prevented from extending into the larynx by proper treatment. Quite frequently have we been sent for to see children attacked with croup, and on finding the fauces thickly covered with exudation, have been told that the patient has been ailing for near a week before with languor, slight peevishness, loss of appetite, and some little pain in the throat. To this point, the strangely insidious char- acter of the anginose symptoms in the early stage of many cases, we can- not too strongly invite the attention of the reader. It is one of the very greatest importance, since at that time, above all others, ought the case to be placed under proper treatment. It is to this class of cases that, owing to the trifling character of the constitutional symptoms, the name of diphtheroid sore throat is sometimes applied, although inaccurately, since it is calculated to create doubt as to their essentially diphtheritic nature. It has been, on the other hand, stated, that, during epidemics of diph- theria, cases occur which present the usual general symptoms, with some difiicultv of swallowintr and swellinor of the cervical glands, but in which no pseudo-membrane is formed, the fauces being merely of a dark-red color, with swelling and elongation of the uvula, and sometimes tumefac- tion of the tonsils. Such cases are rarely fatal, and, as a rule, yield readily to the ordinary treatment for diphtheria. In addition to these mild cases, in which the chief danger is from the extension of the exudation into the larynx, the disease in many instances, and especially under the influence of epidemic causes, assumes a grave form, in which the danger depends not upon an accidental extension of in- flammation, but upon the essential alteration of the blood, and the condi- tion of the entire system. In these cases also the onset may be insidious, though it is often pre- ceded for a short time by general malaise, indisposition to play on the part of children, and to exertion on that of adulti?, and slight swelling of the cervical glands, and pain on deglutition. Whether these prmlromes have been present or not, a more or less marked chill ushers in the febrile action, which is often quite intense for a few days; so that, when the throat aflTection is decided, a doubt may exist for a short time whether the approaching attack is one of scarlatina or diphtheria. The fever, however, soon subsides almost completely, some- times indeed leaving the surface pale and cooler than natural. The pulse may remain frequent, but is weak and compressible; and the general symptoms are all characteristic of deficient vital force. There is not usually any marked mental disturbance after the second day, the child being intelligent, though dull and indisposed to pay atten- tion to anything. There are but few symptoms of digestive disorder; the appetite, which is often retained for the first day or two, soon diminishes, and the child often becomes unwilling to take anv food, partly from the pain caused by 668 , DIPHTHERIA. the efforts to swallow, partly from complete anorexia. There is rarely any vomiting, unless provoked by remedies ; and the bowels, though usually torpid, occasionally incline to be loose. The urine is rather scanty, quite frequently albuminous, and upon microscopic examination is found to con- tain renal epithelium and casts from the renal tubules. This symptom will be again and more fully alluded to among the complications. At the same time, the submaxillary glands enlarge, and the fauces as- sume the appearances we have already described. There is a great in- crease in the secretion of saliva, which often dribbles quite profusely from the mouth, and is apt to be offensive, though rarely fetid. In many cases there is in addition a discharge from the nostril, which becomes acrid and offensive when there are false membranes in the nasal passages. The voice is commonly obscured and nasal, or somewhat hoarse, even when the larynx is not involved. Cough sometimes exists, and may have a slightly ringing spasmodic character, due to mere irritation of the larynx, though it usually resembles in sound that produced by the action of hawking, rather than a common cough. In a very small proportion of the cases, an eruption, resembling that of scarlatina, appears at irregular periods in the course of the disease. It appears, however, that this eruption lacks the punctated appearance of the scarlatinous rash ; does not appear at any fixed day of the disease ; is irregular in its progress, and is not followed by desquamation. The reports of it are, however, scarcely numerous or accurate enough to enable us to say positively that intermingled cases of scarlatina have not been mistaken for diphtheria, or that the two poisons may not have been acting jointly. The further course of these cases varies widely. If the result is to be unfavorable, the depression and loss of strength increase rapidly ; the sur- face grows pale or sallow, and is below the natural temperature; the pulse becomes exceedingly frequent and feeble ; the fauces assume a gangrenous appearance from decomposition of the false membranes ; the swelling of the cervical glands increases, and the patient often refuses to make the effort to swallow, though deglutition is still generally possible ; there is a constant fetid discharge from the mouth and nostrils ; the breath is horri- bly offensive ; and death ensues amid the most profound prostration. Or, at a much earlier period of the disease, the fatal event may be precipitated by the extension of the exudation to the larynx. We must also allude to the occasional occurrence of sudden death, even in cases not of the gravest type. This dreadful accident appears to result from paralytic failure of the heart's action, or, less frequently, from the sudden formation of heart clot ; and the fact that it may occur, should call for the most careful attention to the avoidance of all exertion on the part of the patient. If, on the other hand, the case tends toward recovery, the false mem- branes become detached and thrown off, the strength improves, the pulse becomes fuller and stronger, and the appetite returns. Even in advanced PROGNOSIS. 669 convalescence, however, there is serious danger, as will be seen more fully hereafter, of the occurrence of troublesome or even fatal sequeliw In a still more severe group of cases than those above sketched, the symptoms are of the most asthenic or malignant type. In these cases the anginose affection, though it may be severe, rarely attracts much attention. The pseudo-membranes in the fauces are soft and pulpy, and, when examined microscopically, highly corpuscular and gran- ular ; they soon decompose, and become discolored by the blood which ex- udes from the mucous membrane. There is, moreover, a strong disposition for the exudation to extend to the posterior nares, or to appear on various portions of the external cutaneous surface. The breath and the discharge from the mouth and nostrils are indescribably fetid. In some cases true ulceration, and even gangrene, of the fauces occurs. There is, however, less i»ain ccmiplained of, and less indisposition to swallow than in many lighter cases, owing probably to the depression of the nervous centres from the poisoned state of the blood. There may be high fever during the first few days, but this soon disappears, and is replaced by a deadly pallor of surfiice; extremely feeble, running pulse; and at times low muttering de- lirium. Passive haemorrhages from the nostrils, mouth, rectum, or other mucous passages, are of frequent occurrence. The result in these cases of profound diphtheritic infection is almost in- variably fatal ; death resulting quietly from pure exhaustion, without the development of any complications. The duration of diphtheria varies considerably. Ordinary cases recover in about seven, eight, or nine days, whilst more severe attacks are often protracted until the end of the second week. It is impossible, however, to say that the disease has actually run its course in this time, since there are sequehe \Niiich may appear during ad- vanced convalescence, and retard the recovery even for many weeks. On the other hand, in fatal cases, death may occur from croup, as early as the end of the second day ; though usually the larynx does not become implicated under five or six days, and this accident may occur so late as the twelfth or fourteenth day of the attack. In extremely malignant cases, death may also occur during the first few days. On the whole, however, it may be said that the majority of deaths from all causes occur in the period between the sixth and twelfth days. When death results from one of the sequela?, either disease of the kidneys or paralysis, it may be deferred for weeks, or even for several months. Phognomh. — In cases of ordinary severity, when the patient is seen early, and the disease remains limited to the pharynx, the result is usually favorable; though no case, not even the mildest, is free from danger, either of extension into the larynx or bronchial tubes, of exhaustion, or of the supervention of some complication, such as endocarditis, or the formation of h^art-clots. If, on the contrary, the exudation extends to the nasal passages, the prognosis is more unfavorable ; and when the larynx becomes implicated, the prognosis b exceedingly grave ; if the disposition to the 670 DIPHTHERIA. production of false membrane spread to the skin, rectum, or vulva, the prognosis is also very grave, and death generally occurs in a state of pro- found adynamia. If any other signs of unusual malignancy are present, such as abnormal slowness, or great frequency and smallness of pulse ; marked prostration, with pallor and coolness of the surface; great tumefaction of the cervical glands; abundant pseudo-membranes, pultaceous and rapidly decomposing; hi-emorrhages from various mucous surfaces ; acrid, fetid discharges from the mouth or nostrils ; intense and persisting albuminuria, with diminution of the amount of urea excreted ; the prognosis is, of course, much more unfavorable. It must be remembered, however, that no one of these symptoms, nor even any combination of them, is necessarily of fatal import ; that cases are often rescued apparently from inevitably impending death ; and that, however threatening the symptoms may be, it is our duty, in this disease even more than in many others, to persevere to the very latest moment in the judicious application of suitable remedies. It is as yet impossible to arrive at any plausible estimate of the average mortality of diphtheria, so widely does the proportion vary in different epidemics. Neither sex nor temperament appear to have any influence upon the result ; but extreme youth undoubtedly renders the prognosis much more grave. The prognosis in the secondary form of diphtheria is also more unfavor- able than in the primary. Diagnosis. — We have already sufficiently dwelt upon the general symp- toms and local signs which enable us to detect diphtheria, in every instance, after the disease has fully developed itself In examining the fauces in the early stage of the affection, it is well to remember that in simple 'angina, the crypts of the tonsil-glands occa- sionally become so distended by their secretion as to present the appear- ance of small, round, and slightly elevated whitish patches, which might readily impose upon a hasty observer for pseudo-membranous deposits. In regard to the value of the peculiarities upon which a differential diagnosis between diphtheritic croup and idiopathic primary membranous croup is so frequently based, we have fully expressed our opinion in the article on the latter disease, to which we would refer the reader. Diagnosis from Scarlatina. — The great resemblance which at times exists between the anginose symptoms of scarlatina and diphtheria has led some authors to suggest that they are identical diseases, and the following fur- ther points of resemblance have been adduced : the two affections prevail frequently simultaneously in the same region, and even in the same family; in certain cases of diphtheria, a rash, very similar to that of scarlatina, is said to appear; and the urine, in diphtheria, is frequently albuminous. That this similarity is, however, more apparent than real, is evident from the following considerations. 1. Although in some epidemics of diphtheria a rash is said to have been occasionally noticed, its occurrence is at most the rare exception, instead COMPLICATIONS AND SEQUEL.E. 671 of the almost invariable rule, as in scarlatina ; it differs, too, from that of scarlatina, in appearing at irregular period:?, in being partial, appearing suddenly in patches, not deepening gradually in intensity, and in being of a uniform erythematous redness, without the punctated appearance pecu- liar to the scarlatinous eruption. L\ The albuminuria of diphtheria presents these distinctive features as compared with that of scarlatina, that there is not always any diminution in the amount, nor any constant change in the character of the urine when it is present ; that it occurs in the early part of the attack, and in- creases as the disease approaches its height, or may disappear suddenly, even in the early part of its course; that although usually noticed in severe cases (and probably a very unfavorable symptom), there seems to be no necessary connection between the urine becoming non-albuminous and the disease assuming a milder type. 3. There is a wide difference in the sequela? which succeed the two affec- tions ; dropsy scarcely ever following diphtheria, while various paralytic phenomena, which are rarely noticed after scarlatina, are of frequent oc- currence. It is very much more common, also, to have suppuration of the glands of the neck after scarlatina. 4. In the same way, endocarditis, though it has recently been noticed in a few cases of diphtheria, is much more frequent in scarlatina. One of the most positive proofs of the essential difference of these two affections is the fact, attested by universal experience, that they exercise no protective power whatever against each other, and that individuals whose systems are protected against a second attack of scarlatina, are fully as likely to contract diphtheria as those who have never suffered with either of these diseases. It may also be added that second attacks of scarlatina are very rare, while they seem to be much more common in diphtheria. It geems evident to us, therefore, that in the present state of our informa- tion uj>on this subject, scarlatina and diphtheria must be regarded as en- tirely distinct affections, although presenting quite numerous points of singular resemblance. Complications and SKCiVELJE. — A/bvminuna. — AVe have already briefly alluded to the peculiarities of the albuminuria of diphtheria, but the importance of the symptom merits a more full discussion. The occasional presence of albumen in the urine in cases of diphtheria was first noticed by Mr. Wade in 1857, who also found associated with the albumen, tube-casts and renal epithelium. It was shortly afterwards recognized by MM. Bouchut and Empis' in thirteen out of fifteen cases; and since then has been found, in a varying proportion of the cases, by many ob.servers in different epidemics. The character of the urine when it contains albumen is not constant, but usually it is quite pellucid, of acid reaction, and a[)parently free from any dejxisit ; although, on standing, both tube-casts and epithelium may settle to the bottom. The quantity also varies considerably, Hillier hav- > De rAlbum. dans lea Mai. Cuuenneuses, Cumpt. Rcndus, 1859. 672 DIPHTHERIA. iug found it much diminished, while, according to West and Wade, it fre- quently remains normal. The amount of urea excreted is usually increased in diphtheria, and, according to Sanderson, the presence of albumen and tube-casts in the urine is not necessarily associated with any interference in its elimination, but this does not agree with the examinations of others, who have found a diminution of the solid excreta when albumen was present. The quantity of albumen varies much, being at times a mere trace, and again being present in large amount. The kinds of tube-casts noticed by Wade, and which are the ones usually found, were small, waxy casts ; casts of a similar size, but granular, probably from commencing disinte- gration, and ordinary epithelial casts, and fibrinous flakes. Albuminuria in diphtheria occurs at various stages of the disorder, in some cases even during the first few days. It not rarely comes on insidiously, and may manifest its presence by no peculiar constitutional symptoms. There can be, however, little doubt of the grave import of its appearance, though as yet its exact significance has not been accurately defined. It is indeed true, that it has been found in large quantities in cases which have preserved a mild character throughout (Sanderson) ; but on the other hand, Bouchut and Em pis regard it as a highly unfavorable sign, coinciding w^ith very great gravity of the disease ; and Wade be- lieves that the quantity of albumen is usually in direct proportion to the retention of effete material, and that indications of impairment of the renal function are almost constantly precursors of an unfavorable termi- nation. Hillier {op. cit.) examined 38 very severe cases in regard to this point, and found albumen present in 33, 32 of which proved fatal, while of the 5 free from albuminuria, all recovered. The albumen appeared in 1 case on the fourth day, in 3 on the fifth day, in 2 on the seventh day, in 5 on the ninth, and in 1 each on the thirteenth and nineteenth days. Usually the albumen disappears from the urine as the severity of the symptoms diminishes, but Bouchut has known it to persist after convalescence, and finally produce, as in Bright's disease, anasarca and hydrothorax. Heart-clot. — The formation of coagula in the cavities of the heart during life has been noticed in many conditions of the system ; and this terrible, because almost necessarily fatal accident, is now always dreaded in the course of several diseases, of which diphtheria is eminently one. There have even been epidemics of an unknown nature, but where the only discoverable lesion have been enormous fibrinous concretions in the heart. Such epidemics have been recorded by Huxham, Chisholm, and recently by Armand.^ The symptoms mentioned by these authors as significant of this acci- dent are, pain at the pit of the stomach ; difficulty in respiration ; extreme anxiety and restlessness ; anxious expression and depression of spirits ; ' Des Concretions Fibrineuses et Polypiformes du Coeur, 1857. HEART-CLOT. 673 slight, dry, and rather spasmodic cough ; the face beiug at times livid, and the surface dry and inclining to be cool, with coldness ot' the extremities. The pulse was small and irregular, and, in some of Armand's cases, an abnormal murmur was detected in the heart; there was usually consider- able duluess over the cardiac region ; the resj)iratory murmur remained pure and quite full, and the chest normally resonant. According to Robinson, the first observation of sudden death in diph- theria from the formation of heart-clot was made by Dr. Werner, of Linz, in Austria, in 1842; and the second by Winkler, in 1852. In England, Dr. Richardson^ appears to have been the first to call attention to the diflerence between these symptoms ef embarrassed circu- lation and those of obstructed respiratiou, as met with in diphtheritic croup. His account of the symptoms of the former condition agrees closely with that given above as to the coolness and almost marbly pallor of the surface; the moderate lividity of the face; the constant restlessness and intense anxiety; the feeble, quick, and irregular action of the heart, with a muffled character of the sounds, and in some cases an abnormal mur- mur. He also calls attention to a peculiar prominence of the anterior part of the thorax in very young children, which he believes to be strictly diagnostic of fibrinous obstruction. In obstruction of respiration, on the other hand, the surface becomes livid, the veins turgid, and the muscles are often convulsed ; the heart- sounds are clear, though feeble, and the breathing is the first to stop at death, instead of the circulation, as in the other case. In three cases occurring in the practice of one of ourselves,^ in which we were able to diagnosticate the condition, death took place on the twenty- first, twenty-fifth, and twenty-eighth days respectively. In each case the local symptoms had given way and almost disappeared, and the children seemed to have entered upon convalescence, when slight but steadily increasing signs of circulatory embarrassment became perceptible, and after a few days' battling against the constantly increasing obstruction, the little patients each died as though worn out by the unequal struggle. In no ca.se was there any evidence of any other organ l)eing implicated; one of the cases was, however, complicated with all)uminuria. The pulse was not noted to be over one hundred ; the cardiac sounds were unattended with murmur, but confused, indistinct, and seeming as though reduplicated. There was no marked paralysis, but in one case partial paralysis, and in another marked mu.scular debility. At the autopsy, in each ca.se, the right side of the heart was full of clots, which were either dark-colored, with whitish six)ts, or yellowish-white throughout, quite firm, and adherent to the endocardium, and ai)peared to have been forming for several days. In one case, a clot in the left ven- 1 Med. Times and Gaz., March 8, 1856 j British Med. Jour., Feb. 16, and April 7, 1860. « Dr. J. F. Meigs, Am. Jour. Med. Science, April, 1864, vol xlvii, p. ?A)o. 43 674 DIPHTHERIA. tricle presented at its lower extremity a broken, irregular, uneven, and frayed or granulated appearance, as though the disintegrating process by which thrombi are broken up, had commenced in it. In none of the cases were there any evidences of endocarditis. The same accident has been observed during the past ten years by Dr. Barry,^ Mr. H. Smith/ and Mr. C. R. Thompson,^ and many others, and in a valuable thesis published recently* by Dr Beverley Robinson (now of New York), ten cases are fully described, in at least five of which the ante-mortem formation of clots occurred. The symptoms which he deduces, from a careful analysis of his own and the other recorded cases, as indicative of this condition are : coolness of the extremities, pallor of the face, prostration, anxiety, agitation, and peculiar intense dyspnoea ; associated with a feeble pulse, dull, weak, and veiled heart-sounds, and frequently with the signs of emphysema of the lungs. Most of the cases have occurred in young subjects, and the clot has formed late in the course of the disease, or even after convalescence has begun. The cause of this deposition of fibrin is not very apparent; in our article on this subject, already referred to, it was suggested that the coagulation might depend upon some peculiar change in the tissue of the endocardium, analogous to that which gives rise to the diphtheritic exuda- tion on mucous surfaces. No such alteration has, however, as yet been detected, and Dr. Rich- ardson, to whom the profession is so much indebted for his investigations upon the coagulation of the blood, attributes it, in this case, to a deficiency of the volatile agent which retains the fibrin in solution, together with an actual increase in the amount of the fibrin of the blood, this combi- nation producing the most favorable condition possible for fibrinous depo- sition. Endocarditis. — Although in the above cases no lesion of the endocar- dium has been found, inflammation of this membrane has, as already stated (page 660), been quite frequently noticed in diphtheria. It has usually appeared late in the course of the disease, and has been attended with pain in the prsecordia, frequent pulse, hurried respiration, an anxious countenance, with in some cases a systolic murmur. In fatal cases, there was found a roughened, reddened, thickened appearance of the valves, as if due to interstitial deposit. In some cases, also, a granular or fatty de- generation of the muscular fibres of the heart has been observed, as by Bristowe, Hillier, Robinson, ourselves, and others. Paralysis. — One of the most frequent and important, and certainly the most peculiar of the sequelse of diphtheria, is the occurrence of paralysis. It originally attracted the attention of MM. Trousseau, Lasegue, and Faure, under the form of difiiculty of deglutition, and a nasal character 1 British Med. Jour., 1858. 2 Med. Times and Gaz., Dec. 17, 1859. 3 Med. Times and Gaz., Jan. 7, 1860. * De la Thrombose Cardiaque dans la Diphtherie. Paris, 1872. PARALYSIS. 675 of the voice ; but since then has been observed in the most varied forms and degrees, affecting both general and special sensation and the power of motion. In most cases, every trace of the primary disease has disappeared before any paralysis is noticed ; the patient sleeps, eats, and dige^t^ well, yet many cases emaciate, and there is often marked pallor of the surface. In many instances, also, especially in children, there is great irascibility or irritability of tem{^)er. Most frequently a nasal character of voice and regurgitation of liquids through the nose are the first symptoms to call attention to the disease, though these may be preceded by some slight difficulty in articulation, or by alteration of the sense of taste at the back of the tongue. On examining the fauces the soft palate is found hanging relaxed, and, if it be pricked, there is no contraction of it, nor does it give the patient pain. At times but' one side is paralyzed, and the uvula is drawn towards the sound side. The affection may extend no further than the fauces, and soon disappear; or it may advance, the eye usually becoming next affected, fol- lowing the throat affection, and preceding any paralysis of the limbs. The impairment of vision is rarely of long duration, lasting from a few days to two months, and is of every grade, from mere inability to read fine print to perfect blindness. Dr. Greenhow has noticed that the pupils become dilated, and act slug- gishly under the influence of light, for a day or two before the sight becomes sensibly impaired, and may remain so for a time after sight has been re- gained. He has also observed that patients who were unable to read with unassisted sight could do so with the aid of convex glasses, so that he at- tributes the impairment of sight to paralysis of the ciliary muscle and temporary loss of the adjusting power. In addition to this want of accommodation, however, depending on paralysis of the ciliary muscle, Bouchut believes thj^t there is in many cases, and e.sjx^cially in those who have had albuminuria, a serous infiltra- tion of the fundus of the eye, due to the amemic condition of the blood, and which may impair the nutrition of the optic nerve, and even lead to it* atrophy. The following case, which came under our observation recently, at the clinic at the University of Pennsylvania, affords an interesting illustration of the peculiarities of this form of paralysis. The ophthalmic examina- tion was made by Dr. S. D. Risley, who has kindly placed the results at our disposal. Case — Emma W., »t. 7 years, suflored with an attack of sore throat, tho nature of which «a* not recognized by the physician in altondance. It was quite H-vere, WH<» accompanied by marked ^welliiij? of th*- glnnds at the anglers of the jaws, and cttnifK-llpd her to be confined to bed fur a week or ten days. Soon after convalescence began, it was noticed that her voice became altered, and that fehe occa-sirmally r«'gur- gilated fluids that i^hc attempted to swallow. Her general health improved, how- ever, and in a few days she roturn*»d to school, which she was soon obliged to quit in cons«^-quence of rapidly increasing inability to read, on account of the print seem- ing blurred and " the letters running together." 676 DIPHTHEHIA. Two weeks later, or about five weeks from the time of the first attack, examina- tion of the eyes showed the fundus of both eyes entirely healthy. 0. D., V =: Acuteness of vision, as determined by Snellen's types, normal, and she can 20 14 at2^^ 0. S., V: and she reads Jr. No. 16 at 2^ 0. D. 20_ XX road Jr. No emmetropic; 0. S. hypermetropic = ^V- With glassses -f- ^V (convex glasses with 12'^ focus) 0. D. reads Jr. No. 1 at 12^^, O. *S'. at 14^^. The pupils react promptly to iii;ht. She was directed to wear -f- J^ gh^sses for near work, and strychnise sulph., gr. ■ji^, was ordered four times daily. This was in a few days increased to five times a da}', and its use was followed by prompt improvement, so that in less than two weeks the power of accommodation was entirely restored. Deafness may follow this amaurosis ; then the lower limbs become affected, the patient becoming paraplegic, and next the upper extremities ; then the muscles of the alimentary canal and bladder, causing impaction of the rectum with fseces and retention of urine, or tlie sphincters of these organs alone may be involved, and lead to involuntary discharges. Finally, the muscles of the trunk, including those of respiration, may be- come paralyzed, and in some very rare cases even the muscles of the heart are involved. It is stated that the paralysis of the extremities is never strictly unilateral. The paralysis is rarely confined to loss of motion, but, in a majority of cases, sensation is either much modified or lost ; and in- deed in some instances there has been no loss of motion, the sentient nerves alone being affected. In other cases the sensibility has beqn found exalted, or there has been in the same case hypersesthesia in the upper, with anaes- thesia in the lower extremities. The paralysis, whether it be of motion or sensation, is progressive and gradual, even in the same set of muscles, and usually involves one limb before it extends to other parts. The mind, though often feeble and dull, acts correctly in most cases. During the continuance of these phenomena, the appetite may remain good and digestion easy ; but there are often marked evidences of the con- tinuance of some morbid action in the economy. The surface is of an earthy, sallow hue, calorification is often imperfect, and the circulation is much depressed, the pulse being small, weak, and much reduced in fre- quency. In some cases, indeed, the affection runs on to a fatal issue, usually con- sequent upon a failure of one of the vital functions of circulation or res- piration. M. Faure has given a vivid picture of these sequelae in their worst form, when the patient, paralyzed, indescribably prostrated, with imperfect speech and power of deglutition, impaired vision, imbecility of mind, oedema, and even gangrene of the extremities, finally dies in some fainting fit, or passes away almost imperceptibly. The result of diphtheritic paralysis is, however, favorable in a large majority of cases ; thus of 77 cases collected by Dr. Keynolds, but 9 were fatal. We have ourselves never met with a fatal result in a single in- stance, although a large number of cases, some of them of very severe character, have come under our observation. The duration is, however, more uncertain, varying from one or two weeks to several months, the mean duration being about a month. 1 PARALYSIS. 677 It is as yet impossible to advance any satisfactory explanation of the cause of these grave paralytic sequelie. They occur probably in one-fourth of all cases, in greater or less degree, and are noticed with at least equal frequency after mild as after severe attacks. At tii*st, indeed, the fi\ucial paralysis was attributed to some such local cause as indamniation of the sheath of the nerves supplying these parts, and Greenhow still contends that the nerve affections bear some proportion to the local severity of the attack, the paralysis and auiesthesia being more complete on that side of the fauces which has been most severely affected by the primary disease; but we have been able to satisfy our- selves that this does not occur with any uniformity. Charcot and Vul})ian have, however, demonstrated in a case of paralysis of the palate, lesions both of the palatine nerves and muscles. It is difficult to determine whether such lesions are of constant occurrence in the ordinary cases which rapidly recover. It seems improbable, also, that in cases where widespread paralytic symptoms are present, which subsequently entirely disappear, any serious lesion of the nerve-trunks or of the muscles could have existed. Nor is the occurrence of albuminuria necessary for the development of paralysis, since the urine is often quite normal throughout the entire course of cases, which are nevertheless followed by marked palsy. The most plausible view we can entertain of the nature of these nerve affections, is that they are the direct effect of the diphtheritic poison, which while modifying the blood crasis, and so acting on the system at large, has an especial tendency to the nervous system ; while at the same time, some of the local forms of the paralysis may be associated with lesions of the nerves and muscles of the part affected. Ataxic Form. — In some cases, which are comparatively rare, the nerve affection does not constitute actual paralysis, but takes the form of loco- motor ataxia. In such cases, the muscular force in the affected parts, usually the lower extremities, is not materially diminished, so that the patient can move them forcibly when he is lying down ; but there is such a degree of incorirdination in the motions communicated to them, that combined movements, even in the supine position, may become impossible. It is, however, especially in walking, that this loss of coordinating power manifests itself; the gait becomes irregular, the patient falls if the eyes are closed, and the ca.se presents all the characteristics peculiar to well- marked locomotor ataxia. The first instance of this diphtheritic ataxia appears to have been observed by Jaccoud' in 1861 ; it was soon after noticed by Eisenmann ;' and more recently a well-marked case has been reported by Dr. Gray,' in a boy of nine years old, following an apparently mild case of diphtheria. It is evident, also, as pointed out by Jaccoud, that a certain number of the cases which have been reported under the name of diphtheritic j)aral- Tsis, have in reality been examples of locomotor ataxia, the paralysis hav- * he* Parapl^ics et I'AUixip du Mouvement, p. 681, Paris, 1864. ■ Die Bewei:unc^^ Atnxie, Winn, 1863. » London Med. Times and Gazette, February 6tb, 1809, p. 141. 678 DIPHTHERIA. iug been only apparent. We have met with two well-marked examples ourselves, in both of which entire recovery followed. This diptheritic ataxia is in all probability due to the same unknown morbid condition or dyscrasia, which causes the actual paralytic symptoms which are more frequently observed as sequelae of diphtheria. It usually yields to the treatment recommended for the latter conditions, though in Gray's case, death occurred, apparently from rapid loss of nervous power, seven weeks after the appearance of the nervous symptoms. Treatment. — The treatment may be usefully considered under the two heads of local and general. Of late yeai*s, the importance of the latter has been more and more recognized as supreme, and, indeed, the utility of all local treatment has even been questioned on the ground that the throat affection is merely a local evidence of the constitutional disease, and that the disease rarely kills save by involving organs beyond the influence of such agents. We have, however, no doubt as to the very great importance of proper local treatment; although, on the other hand, we are not pre- pared to say, with some eminent authorities, as Trousseau, that topical applications are the most successful and important remedies in diphtheria. The great objects to be held in view in the local treatment, are to favor the separation of the pseudo-membranes, and to prevent their extension from the fauces into the larynx and nasal passages. Local Treatment. — The most important of the local remedies are in- cluded in the lists of astringents and caustics. Of these, nitrate of silver has properly been used more than any other substance for many years past, and is highly recommended by MM. Bretonneau, Yalleix, Grisolle, Rilliet and Barthez, Trousseau, West, and many others. It is employed both in solution and substance. The latter form is, however, open to the objections, that if the extent of the false membranes be at all considerable, the solid caustic can seldom be applied to more than a small portion of it, and that it is attended with the risk of slipping from the porte-caustic into the pharynx, and thence passing into the stom- ach.^ The solution is therefore generally preferred. M. Bretonneau ad- vises its employment in the proportion of half an ounce of the salt to an ounce and a half of water ; and West employs a solution of the strength of a drachm to an ounce. We have usually made use ourselves of a solution of ten or twenty grains to the ounce, and have found it abundantly strong. It may be applied either by means of a piece of sponge fastened upon a proper handle, which is the best method, or a camel's-hair pencil, nearly as large as the end of the little finger. The application should be made once, twice, or even three times in the course of the twenty-four hours. Hydrochloric acid is also frequently employed, either pure or diluted ^ Dr. Geddings recommends, when it is desirable to use the solid nitrate, to re- duce it to powder, and to roll the sponge probang, previously moistened with mu- cilage of gum arabic and squeezed, in the powder until a suflficient quantity adheres, and to apply it thus prepared to the diseased parts. LOCAL TREATMENT. 679 with from oue to ten parts of honey; the more dilute forms being used in the case of children. It possesses the great advantage over the other mineral acids, that its caustic action does not extend much from the point of application, but is open to the objection of causing a white plastic exudation on any part of the raucous surface, not covered with false membrane, with which it may come in contact, which may lead the physician into error. When the limits of the pseudo-membrane can be seen in the pharynx, following M. Bretonneau's advice, the acid may be used more concen- trated, and the sponge, after being dipped into the acid and squeezed so as to be merely moistened, should be carried rapidly into the pharynx, and withdrawn after lightly cauterizing the surfiice. When on the contrary, the limits of the membrane cannot be seen, the acid should be more diluted, and leaving more of it upon the sponge, this should be passed down over the epiglottis and then pressed against the base of the tongue, by raising strongly the handle to which it is tied, in order to express a few drops upon the mucous membrane of the larynx. The cauterization is to be i)erformed once or twice a day, according to the necessity of the case. For children under ten years of age, the sponge ought to be about half as large as a pigeon's egg. It is to be fastened to a piece of flexible whalebone, by making a crucial incision into it, intro- ducing into this the end of the whalebone, and securing it with good seal- ing-wax, which is not acted upon by the acid as any ligature would be. When about to be used, the whalebone is warmed and curved into such a shape as will allow it to pass into the pharynx without touching the roof of the mouth. M. Valleix proposes that the sponge should be fastened to the whalebone with waxed thread, and that this should be covered with sealing-wax, to preserve it from the action of the acid. This would cer- tainly be safer than the mere wax alone. Applications of powdered alum, tannic acid, and chlorinated lime, are recommended by writers of high authority. In slight cases, in which the disea-cal condition as secondary to that of the alteration of the blfx>d. The operation must further cause the greatest alarm and most powerful resistance on the part of young children, and it seems highly improbable that a large proportion of cases should be attended with the same for- tunat<* exemption from a recurrence of pseudo-membranous formation, as occurred in Boucbut't 682 DIPHTHERIA. Some years ago, before opportunities had been presented for studying diphtheria in its epidemic form, as it has since occurred, it was customary to employ moderate depletion early in the attack, if the patient was vigor- ous and strong, and to follow this by the use of mercury and antiphlo- gistics, with a view of subduing the febrile excitement, and causing the dissolution and absorption of the pseudo-membrane. With the increase of knowledge, however, of the true pathology and natural history of the disease, which has been gained of late years, all depleting and antiphlogistic plans of treatment have been, by common consent, abandoned as indefensible either in theory or practice, and all efforts are directed to promoting the nutrition of the patient and sup- porting the strength of the system, as indicated by the marked tendency to prostration, the feeble pulse, and the manifest deterioration of the blood. It is probable that those cases in which bloodletting and the administra- tion of mercurials were adopted with such apparent benefit, were either erroneously considered diphtheritic, or that the disease, when occurring sporadically, as it formerly did, was of a far more sthenic type than it has presented of late years. It must be added, however, that in the sporadic cases still frequently met with, when no grave epidemic influence is prevailing, the use of alkalies, as soda, combined with small doses of calomel, has been found very successful. Kegarding diphtheria as a constitutional aflfection, depending upon a peculiar alteration of the blood, we must admit that we are in possession of no remedy which in any respect merits the name of a specific in its treatment. Among the best internal remedies, however, are the various preparations of chlorine, iron, and bark, which may be given singly, or, preferably, in combination. Thus there are no remedies of more uniform and marked advantage than sulphate of quinia and tincture of the chloride of iron, given in full doses at short intervals. Hydrochloric acid or chloric ether may be added to these tonics, and this combination is strongly recommended by West and other high authorities. The Sanitary Commission, in London, reported very strongly in favor of a mixture containing tincture of the chloride of iron, with chlorate of potash, chloric ether, and hydrochloric acid, sweetened with syrup ; full doses being employed according to the age of the patient, and frequently repeated. This combination has been, by Gibb, rendered still more stimu- lating by the addition of muriate of ammonia. Oil of turpentine has been recommended (Dr. Perrey, Med. Times and Gaz., March 5th, 1859) in large doses, both for its stimulating effect, and from its tendency to promote the absorption of lymph in adynamic states of the system, where mercury cannot be given. Chlorate of potash, given in Huxham's tincture of bark, has been vaunted as almost specific in the treatment of diphtheria ; but, as re- 1 GENERAL TREATMENT. 683 marked by West, it unquestionably fails to produce here those excellent effects which are obtained from its use in ulcerative stomatitis. Permanganate of potash, which has been so extensively used of late years in zymotic diseases, has been used both locally and internally in this affection, but apparently without any very positive advantaire. Emetic,^; Purrjafive-^. — Emetics are useful when the exudation shows a disposition to extend to the larynx, or when there is much difficulty of breathing from tumefaction of the fauces, or from accumulation of the pseudo-membranous deposits. We would recommend under these cir- cumstances the use of alum or ipecacuanha, as recommended in the article on pseudo-membranous laryngitis ; the emetic being repeated in six or twelve hours, if the same indication should continue or recur. A purgative dose is useful at the commencement of the disease, merely as an evacuant. After that period only such laxatives need to be em- ployed as may suffice to keep the bowels soluble. Stimulants. — In the milder forms of diphtheria, where no complications exist, the cases usually terminate favorably without the use of any stimu- lants ; but there are many cases, on the other hand, characterized by pallor of surface, marked weakness of the circulation and tendency to prostration, great enlargement of the cervical glands, and extensive disease of the throat, where the pseudo-membranes rapidly decompose and assume a gangrenous appearance, and the urine is frequently albuminous, in which stimulants, freely administered, are positively required. In cases where such adynamic symptoms are present, we should begin early in the attack with the administration of the weaker stimuli, and em- ploy the stronger forms as the disease advances and the strength of the system succumbs more and more. Food. — In no disease should more sedulous care be paid to securing to the patient a proper amount of suitable nourishment; and, indeed, in the absouce of any remedy which can be looked upon as essential or specific, we mu<«t assign, perhaps, the most important part in the treatment of diphtheria to food and stimulants. It is at least certain that where these cannot be administered in proper quantity, all other treatment is un- availing, and hence it is our duty, upon finding that the pain and fatigue experienced by the child when forced to take frequent doses of medicine make it utterly unwilling to take food, to abandon all strictly medicinal treatment, and trust to sustaining the powers of the system by the free use of stimulants and concentrated food. In cases where mer-hanical obstruction exists, or where all efforts at voluntary' deglutition are obstinately resisted from fear of the great pain caused by the act, nutritious and stimulating enemata must be immedi- ately resorted to. These may consist of beef tea, eggs beaten up in milk, brandy in the form of milk-punch, and, further, may be medicated by the addition of quinia. They should be given every three «)r four hours, in rather small quantity, and not so concentrated a« to irritate the bowel. When thus administered it is quite possible to sustain life for several days, until fofKl can again be introduced into the stomach. In addition to the local and general treatment above recommended, the 684 DIPHTHERIA. patient should be rigorously confined to bed during the whole treatment, and for at least ten days after the disappearance of the exudation. This caution is given, not only on account of the danger of that most fatal ac- cident, the formation of a heart-clot, but because we have twice known the exudation to reappear when the patient had been allowed to leave the bed at too early a period ; and in one of these the exudation extended into the larynx on the occasion of the second attack, in spite of all that could be done, and life was saved only by the operation of tracheotomy. The most scrupulous cleanliness of the person and surroundings of the patient should be preserved ; free and uninterrupted ventilation secured ; and on account of the positive, though perhaps slight, contagiousness of diphtheria, it is wise to practice separation of the well children in the family from the sick. The treatment required in those cases where the pseudo-membrane ex- tends into the larynx, and especially the discussion of the indications for the operation of tracheotomy, will be found in detail in the article on pseudo-membranous laryngitis. Treatment of Paralyds. — We have already stated that the prognosis in diphtheritic paralysis is usually favorable, the symptoms often disappear- ing in the course of time without treatment. The cure may, however, be much hastened by a persistence in the administration of iron and quinia, to which strychnia should be added in full doses. Nitrate of silver has also been employed in full doses with apparent benefit. The paralyzed jnuscles should be faradized daily; and, when accessible, sea-bathing or sulphur baths may be employed with advantage. In those cases where the muscles of deglutition are especially affected, and the nutrition of the patient is suffering from his inability to swallow sufficient food, it is desirable to resort to the use of nutritious enemata. Treatment of Heart-clots. — Under the supposition that the blood is hyperinotic in the latter stage of diphtheria, the various salines, especially the vegetable ones, such as the citrates and acetates, and ammonia, given either as the carbonate or in the liquid form, have been recommended by Richardson. When, however, the symptoms indicate that deposition of fibrin has absolutely occurred, it is probable that nothing can be done in the way of curative treatment. Alkalies may be given internally, the vapor of ammo- nia inhaled, alkaline solutions injected into the veins, but there is little reason to hope that any effect upon the clot can be produced. In one of the cases reported by us (Joe. cit.), the clot presented at one extremity a granular, partially disintegrated condition, as though its re- moval had begun by interstitial action, and the mechanical effects of the blood current ; and it is possible that by supporting the powers of nature the removal of the clot might be effected in this way. Indeed, there are cases on record (quoted by Robinson, loc. cit.) in which the symptoms have most clearly demonstrated the existence of a clot in the cavities of the heart, where still recovery has occurred. MUMPS. 685 ARTICLE III. MUMPS. Definition; SynonYxMs; Frequency. — Mumps is an acute febrile spe- cific disease, contagious and epidemic ; occurring but once in an individual ; attended by an intlammation of the parotid and sometimes of the sub- maxiUary glands, with a tendency to metastasis to the testicles in males and to the mamma?, vulva or ovaries in females ; and almost invariably resulting in recovery. Some authors, as Niemeyer, object to classifying mumps with constitu- tional diseases; but the fact that it undoubtedly possesses the features enumerated in the above definition, and which, in the present state of our knowledge, must be regarded as specifically characteristic of that class of affections, seems to us to fully entitle it to be included with the other gen- eral diseases. Mumps is known under a variety of names in every language. The terms usually employed to designate it by English and American authors are cynanche parotidea, parotitis, parotiditis, and inflammation of the parotid. It will be impossible to obtain any definite idea as to the frequency of this affection, until the system has been introduced of registering not merely deaths but all cases of disease, since mumps is scarcely ever fatal. Its frequency is, however, known to vary very widely in different years, owing to epidemic influences ; so that while in certain years we do not meet with a single case, in others we are called to a considerable number. Causes. — Nothing is known in regard to the essential nature of the cause of mumps. The disease is, however, unquestionably contagious, and it quite rarely happens that one member of a family sickens with mumps, without some of the other children being attacked. Mumps rarely occurs iis a sporadic affection, but appears, as already stated, in epidemics of varying extent and severity, at times being limited to a single locality or even a single institution, and at others affecting large cities or districts. Ses. Thus the disease is far most common between the ages of seven and fifteen years; whilst it is almost unknown before the end of the first year, comparatively rare between the ages of one and five years, and, on the other hand, quite rare in adult«. Although it appears certain, however, that the susceptibility to the con- tagion of mumps diminishes with each succeeding year after the age of fifteen, we must in great part explain the rarity of the disease in adult 686 MUMPS. life, by the fact that a large proportion of people have had it in childhood, and are thus protected against a second attack. Second attacks of mumps are indeed of extreme rarity. Anatomical Appearances. — Opportunities very rarely occur for the .examination of the parotid glands in mumps, since this disease is scarcely ever fatal. Virchow,^ who has shown that, in cases of symptomatic sec- ondary parotitis, the affection starts in the gland-ducts, maintains that the idiopathic form occupies the same seat. Bamberger,^ on the other hand, states that the whole gland appears enlarged and reddened, with its tissues swollen and flaccid, owing to an interstitial exudation of lymph. The softness and indolent character of the swelling, however, the fact that it usually extends beyond the borders of the gland, and its usually rapid and complete subsidence, all induce us to believe rather that there is slight catarrh of the ducts, with mere oedema of the interstitial and surrounding connective tissue. It is only in rare and very severe cases that there is sufficient lymph effused to undergo organization and lead to persistent increase in the size of the gland, or to so compress the ducts as to induce atrophy of the true gland-tissue. In even more rare cases, it is said that suppuration may occur. In the secondary form, on the other hand, such as is seen in con- nection with the various specific fevers, the occurrence of suppuration is frequent. Symptoms. — In some cases the attack of mumps is preceded for a day or two by slight prodromes, consisting of restlessness, feverishness, loss of appetite or vomiting; in excitable children, symptoms of nervous disturb- ance may occur. More frequently, however, the local symptoms appear simultaneously with the fever, and we have generally found positive swell- ing of the parotid gland upon our first visit to the child. The earliest local symptom is often pain, complained of under the ear, and increased by pressure and by all movements of the jaw, as in masti- cation. There is also stiffiiess felt in opening the mouth. The swelling appears first immediately beneath the ear ; the depression between the mastoid process and the ramus of the jaw quickly becomes filled, and the swelling rapidly extends on to the cheek and neck. At first the swelling is flat, indurated, and presents the outlines of the parotid gland; but it soon becomes prominent, the most marked projection usually being ob- served immediately anterior to the lobe of the ear, and extends beyond the limits of the affected gland. The central part of the swelling cor- responding to the parotid, remains firm, indurated, and more or less elastic, while at the periphery it is softer and often pits on pressure. The degree of enlargement varies much in different cases, being at times mod- erate and confined to the parotid region, while in other cases, it extends over a large part of the neck and face, and may be so great as, especially when both glands are affected simultaneously, to give to the head and neck a pyramidal shape. ' Quoted by Niemeyer (op. cit., vol. i, p. 436). 2 Quoted by Vogel (op. cit., p. 113). GENERAL SYMPTOMS. 687 Quite frequently the submaxillary glauds are involved, and the swelling con-ecjuently extends along the baae of the jaw ; in more rare oases, the enlargement is most marked in this region, or, indeed, the submaxillary glands may be almost exclusively the seat of the aftection. The skin over the seat of enlargement is at times scarcely altered in color, or may present more or less marked redness. There is usually only very moderate tenderness on pressure. The pain sutiered during the at- tack varies greatly ; in some cases it is merely a marked sense of tension and pressure, while in other instances, it has been complained of as constant and severe, and extending even to the chest and shoulders. The movements of the head are impaired, and those of the jaw are impeded to such an extent that the mouth can only be slightly opened, and mastication is per- formed imperfectly and with great difficulty. Usually the swelling increases for from three to five days, remains at its acme for a day or two, and then rapidly subsides, so that in about ten days the face has regained its natural appearance. Mumps usually involves both parotids, though they rarely become af- fected simultaneously; the left gland is said to be most frequently the first inflamed, and subsequently, in twenty-four or forty-eight hours, or even when the swelling has disappeared from the side first affected, the opposite gland becomes enlarged. Occasionally the enlargement does not undergo complete resolution, and a circumscribed, painless, hard swelling remains for a variable time in the parotid region. In very rare cases, sup- puration is said to have occurred. The salivary secretion is variously aflTected, and may be either diminished or excessive, or remain unaltered. Occasionally the external swelling is associated with enlargement of the tonsils and (edema of the submucous tisssue of the pharynx. In such cases the difficulty of deglutition is much increased, and there may even be marked obstruction to respiration. General Symptols. — Usually the constitutional disturbance in mumps is but slight and subsides even before the swelling of the parotid gland. Until the disease reaches its height, however, there is fever, with heat and dryness of the skin ; the pulse and respiration are accelerated, the api^etite impairefl or lost, and the thirst usually extreme. There may also be, espe- cially in nervous children, marked restlessness, sleeplessness from the pain and discomfort caused by the great swelling of the neck and face, and even mild delirium at night. As already mentioned, however, these febrile symptoms usually disapf>ear alx)Ut the fifth or sixth day. One of the most curious features in parotitis is the tendency which oc- casionally exhibits itself to metastasis. The parts which are liable to be thas secondarily inflamed are the testicles and scrotum in males, and the mammse, the vulva, and the ovaries in females. The most frequent of these metastatic inflammations in mumps is the afltction of the testicle, which is much more common in men than in boys, is usually seated upon the same side with the enlarged parotid, and is attended with enlargement of the body of the testicle, serous effusion into the tunica vaginalis, and oedematous swelling of the scrotum. The swelling of the parotid ordi- narily subsides when any of these metastatic aflTections appear, but occa- MUMPS. sionally the two inflammations continue together, a circumstance which shows, as Nieraeyer points out, that they are in reality due to a common cause, and that no true transference of inflammation takes place from one point to the other. In some instances, the swelling of the parotid subsides a variable time before the development of the metastatic affection, and, during the interval, alarming symptoms of depression and cerebral dis- turbance have been noticed, and at times referred to a metastasis to the membranes of the brain. There is, however, no actual meningitis pres- ent, and upon the redevelopment of the external swelling, these nervous symptoms disappear. Prognosis ; Duration ; Course ; Termination. — Idiopathic parotitis or mumps almost invariably terminates favorably. The duration of the case varies from four or five days in very mild cases, to ten or twelve in severe ones. As already stated, the inflammation usually terminates in complete and rapid resolution. In some cases, however, a large amount of lymph is formed in the interstitial tissue of the gland, undergoes par- tial organization, and causes a hard, painless swelling, which persists for some time. In some epidemics, suppurative degeneration of the gland has been noticed, and the abscess which formed has either opened out- wardly or into the external auditory meatus. We have known persistent hydrocele to follow the inflammation of the testicle occurring during an attack of mumps. Diagnosis. — The acute febrile character of the affection, and the pecu- liar seat and shape of the swelling, always serve to render the disease readily recognizable. Treatment. — As mumps almost invariably runs a favorable course, the treatment should be of a mild and expectant character. The child should be strictly confined to bed ; the diet should be fluid, partly on account of the great difficulty in mastication, light and diges- tible, consisting chiefly of preparations of milk and light animal broths. The only internal remedies required are febrifuges, such as spirit of nitrous ether and solution of acetate of ammonia, with a free supply of water and acidulated drinks; occasional laxatives; and, if there is sleeplessness, small doses of Dover's powder or some other anodyne. Local applications appear to have little or no influence upon the course of the swelling. The only ones to be recommended are warm, light poul- tices, or light water-dressings, covered with oiled silk, which do not annoy the child, and tend to favor resolution. If the induration be marked and extensive, so as to threaten suppuration, it has been advised to apply a few leeches behind the angle of the jaw. If it should become evident that suppuration has occurred, the abscess should be opened immediately, and the discharge favored by the application of poultices, in order to prevent further destruction of the gland or perforation of the external auditory meatus. In cases where induration and enlargement of the gland persist, absorbent applications, such as inunctions of iodine or mercury, should be made over the tumor. In cases where alarming symptoms of depression and cerebral disturb- ance make their appearance after the sudden subsidence of the parotid r MALARIAL FEVER. 689 s\Yelliijg, the eff« rt may be made in order to redevelop the external inflani- matiou by stimulating applications to the surface, and by the internal administration of nervous and ditlusible stimulants, such as ammonia, musk, or brandy. After the acute symptoms of the attack have subsided, and the chikl has fully entered upon convalescence, we would caution against allowing it to leave bed too soon, since we have occasionally observed such prema- ture exposure to be followed by marked febrile secjuehie. Thus in one case, occurring in au adult, there was marked fever lasting for a week ; in another case, in a child, there was high fever for ten days; and in a third case, also in a child, there was most obstinate and violent vomiting for four days; so violent, indeed, that we feared lest some renal complication might have been developed ; on examination, however, the urine was fouud to be entirely normal. ARTICLE IV. MALARIAL FEVER. The propriety of introducing a chapter upon malarial fever in the present work, is shown not only by the fact that malarial disease is ex- tremely frequent in children, but also because it presents, as it occurs iu them, so many peculiarities as to frequently lead to the true nature of such attacks being overlooked. Causes; Frequency. — There are cases upon record in which malarial disease appears to have been contracted in utero, and where immediately after the birth of the infant it has presented unmistakable evidences of the disease. We have ourselves met with several such cases, where the symptoms, and the prompt effect of quinine, left no doubt as to the diag- nosis. At all periods of childhood, even from the age of a few weeks up- wards, there can be no doubt that children readily contract malarial disease on exposure to its cause. Indeed we have met with cases which have shown that the susceptibility of children to malarial poison may be even greater than that of their parents or other adults exposed to the same influences. In children over five or six years old the symptoms of malarial fevers are apt to be almost the same as in adults: the following remarks must therefore be understood to apply especially to those diseases as they present themselves in younger subjects. Sympto3LS. — Malaria presents itself in children both in acute and chronic forms. The former occurs both as intermittent and remittent fever. In our article upon typhoid fever we have carefully pointed out the fact, that in children the febrile movement in this latter disease often presents such marked remissions as to have led many authors to confound it with malarial disea.se, under the name of ** Infantile Remittent Fever." But apart ^rom this, true malarial remittent fever occurs in children, and 44 690 MALARIAL FEVER. indeed it is a peculiarity of all forms of malarial disease in early life to present a less marked development both of the paroxysms and of the in- termissions. Intermittent fever in children may occur in any of the forms met with in adults, still the quotidian is by far the most frequent, the tertian less common, and the quartan decidedly rare. Whichever form may be present, is apt to present several peculiarities. In the first place, the features of the paroxysms are apt to be imperfectly developed This is particularly true of the cold stage. It is very rarely present as a well- developed chill ; in some cases, it seems to be entirely absent, but usually can be detected by careful observation. The child may merely become pale, seem weaker and more languid, or with this there may be distinct coolness of the hands and feet, and blueness of the nails : less frequently is there any discernible rigor, and as before stated a fully developed chill is very rare. The cold stage is of short duration, lasting from a few min- utes to a quarter of an hour. It is followed by the hot stage, or in some cases the beginning of the attack is marked by the appearance of fever. The degree of this is rarely very high. Sometimes the child, who has been merely drooping during the earlier part of the day, is noticed to grow more dull, to wish to be constantly in bed, or on the lap, and its head and hands grow warm, with perhaps some flushing of the cheeks. Indeed, in some cases, the fever is so slight as to pass unnoticed, unless the attention of the nurse is directed to it by the physician. In other cases the accession of fever is more marked ; the skin becomes very hot, and the cheeks brightly flushed ; the child is dull and yet restless ; there is rapid breathing, and marked acceleration of pulse. In some children, the fever is attended with delirium, and it is not a very rare thing to have it ushered in by a convulsion. This fact of the occasional occurrence of a convulsion, as a substitute for the chill as the initial symptom of the malarial paroxysm, must be borne in mind as of positive diagnostic importance. The fever lasts a very variable time, and rarely terminates abruptly, as in the case of adults by a sudden defervescence with profuse sweating. Indeed, in many cases, the child seems somewhat feverish during the entire twenty- four hours, but on careful observation is found to present increase of heat at some period of the day, and this is often preceded or followed by a short period during which the child is pale and languid, with cool moist brow and hands. Added to this irregularity in the symptoms and duration of the paroxysms, is the further source of difficulty, that the accession of fever occurs at very irregular hours. In children of even five years of age, it may occur at the ordinary time towards noon, but in younger children it may appear much later in the day, or even, as we have several times seen, late in the night. There are a few other symptoms to be mentioned in connection with the paroxysms. We have already alluded to the occurrence of convulsions ushering in the hot stage. Frequently the child will vomit whatever food was in the stomach at the time of the attack. The urine that is passed during the paroxysm is scanty and high-colored, while not long after the subsidence of the fever, there is apt to be a quite free discharge of limpid urine. Between the paroxysms, if no complication exists, the child may I DIAGNOSIS — PROGNOSIS. 691 appear merely listless, with scanty appetite. Quite frequently, however, the disease is attended with some more marked disturbance, either of res- piration or digestion. The complications which we have ourselves most frequently observed have been bronchitis and pneumonia. In cases where the latter has been present, the seat of the inflammation has occasionally been the apex of the lung. The chronic fonn of mahiria reveals itself in children in tlie same way as in adults. No well-marked paroxysms may occur, but the patient has a sallow, cachectic, or anremic appearance, which of itself is quite charac- teristic. There is more or less emaciation from interference with nutrition, as the appetite is poor or capricious, and the action of the liver and bowels sluggish and insufficient. Enlargement of the spleen frequently follows, and we have met with well-marked examples of ague-cake in very young children. The blood becomes very poor and watery, and this, added to the obstruction to the circulation through the liver and spleen, in advanced cases may lead to ascites or cedema. We are not aware that the marked development of pigment-granules in the blood, which has been so often observed in the adult, has vet been detected in children suffering: with chronic malaria. In some very severe and protracted cases, granular de- generation of the kidneys with albuminuria, and finally urannia, has seemed to follow in quite young children. Some of the manifestations of malaria which are quite common in the adult, are very rare in children. This applies especially to the various forms of neuralgia, which, as met with in the adult, are so frequently of malarial origin, while we do not remember to have met with a single case of this character occurring in children. Diagnosis. — It is our belief that malarial disease in children is often not recognized, and that this is due, not so much to its real difficulty of detection, as to the fact that the frequent occurrence of the different forms of malaria in young children, is not sufficiently borne in mind. Undoubt- edly also there are difficulties in its diagnosis, which do not usually exist in adults. These arise, as before said, from the irregularity and imperfect development of the paroxysms. Our own experience has taught us in all cases of irregular febrile action, especially when occurring during the spring or fall, without any discoverable lesion to account for it, to suspect the malarial character of the attack. Bo, too, in cases where some slight lesion or disturbance of function exists, and yet the child seems too seriously and too obstinately ill for the apparent cause, and presents irregular fever with considerable fluctuations, the idea of the malarial nature of the attack should always be entertained. In some such cases, where it is impossible to reach a definite decision from a study of the symptoms, the diagnosis may be made by the therapeutic test of administering full doses of quinia for several days in succession. pRr>oNOSi8. — The result of malarial fever is usually quite as favorable in children as in adults, when uncomplicated with any serious local inflam- mation. All of its forms usually yield readily to specific treatment. The chief source of danger lies in the tendency to severe bronchitis or pneu- monia. In protracted chronic malaria, the autemic and cachectic symp- 692 MALARIAL FEVER. toms have seemed to us to yield to treatment even more rapidly than in the case of adults. Treatment. — Children, even at a very early age, bear full doses of quinia very well. The amount which we have usually found necessary to arrest an attack of intermittent fever is three grains daily for children of one year of age or under, and one grain additional for each succeeding year, though we have given as much as five grains by the mouth in the course of the day to children of ten months, and without the slightest ill effect. It may be administered in the form of powders containing one- half grain, mixed with an equal amount of sugar and powdered extract of liquorice, repeated as necessary, and given at such times as to bring the system thoroughly under the influence of the drug before the hour at which the accession of fever has been noticed. Some children, however, will not take the powders without difficulty or nausea, and the quinia may then be given merely suspended in syrup of red orange, or in the following com- bination : R. — Quinise Sulph., gr. xxiv. Acid. Sulph. Diluti, gtt. xxx. Syr. Zingiberis, Syr. Simplicis, Aqua3, aa . . f^j. Ft. sol. — Dose, a teaspoonful three or four times a day, according to age. If, however, the stomach rejects it in all of these forms, as we have known it to do, we have found the administration by enema of two grains of quinia in a tablespoonful of starch-water, three times a day, equally successful. We may also resort to the use of suppositories, which when neatly made with butter of cacao and of small size are perfectly well tol- erated, as a rule, even by very young infants. In ordinary acute cases no other treatment is really required. It may be well to give a few doses of some saline febrifuge during each day, until the fever is entirely subdued, and of course any speeial disturbance of function must be relieved by appropriate remedies. The treatment of pul- monary complications must be subordinate to that of the general disease. All depleting or perturbing treatment must be avoided, and it will gener- ally be found that with the aid of mild counter-irritation, the local symp- toms will begin to improve, after the malarial fever has been subdued by quinia. It is necessary to keep up the action of quinia for some time after the paroxysms are broken, because the tendency of the disease to recur is fully as great in children as in adults. We are in the habit of thus con- tinuing it for three or four weeks in diminished doses, giving, however, on each septennary period, dating from the arrest of the paroxysms, the full antiperiodic dose, suited to the age of the patient. At the same time the child should take suitable doses of iron and arsenic, which may be conve- niently given in the following form : R. — Liq. Potassse Arsenitis, . . . • f^j* Vini Ferri Amari, ..... f^iij. — M. Dose. — From a half to a whole teaspoonful thrice daily in water after meals. In chronic malaria we must persist in the use of quinia, iron, and arsenic, EPIDEMIC CEREBRO-SPINAL MENINGITIS. 693 for a considerable period. At the same time careful attention must be paid to securing the best possible hygienic influences for the child. Wlien practicable, a change of climate should be secured by a journey to the mountains or to the sea-shore. The patient should be warmly dressed, and carefully guarded against all exposure to damp or cold. Tht^ diet should be carefully selected, and every error of digestion promptly corrected. Even after the child is apparently restored to health, it should not be allowed to return to the locality where it contracted the disease, and for several successive springs and autumns should take a short course of quinia and arsenic. In the treatment of the enlargement of the spleen, which frequently occurs in chronic malaria, we have obtained excellent results from the use of hyjx)dermic injections of ergotin into the subcutaneous tissue of the abdominal wall. ERUPTIVE FEVERS. "NVe shall describe in this eruptive group of General Diseases, scarlet fever, measles, small-pox and vaccine disease, varicella, and typhoid fever. ARTICLE V. EPIDEMIC CEREBKO-SPINAL MENINGITIS. Definition ; SYNONYM^^ ; History ; Frequency. — Among the large Dumber of names which have been applied to this disease, the only ad- ditional ones which call for mention are cerebro-spinal fever and spotted fever. The latter ha.s been much used in this country, but as it is based upon a symptom of occasional occurrence only, is evidently inadmissible. The name we have adopted is the one now almost universally accej)ted. Epidemic cerebro-spinal meningitis is an acute specific febrile affection, occurring in epidemics of widespread or local character, but not propa- gated by contagion ; characterized by alterations of the blood and by in- flammatory changes in the membnines of the brain and spinal cord, and running a most irregular course both as regards symptoms and duration. Although it is highly probable that epidemics of varying extent oc- curred previous to the present century, it appears that their true nature was not recognizofl, and the first distinct account of epidemic meningitis waa published in 1805 by Vieusseux. Since that time, however, it has appeared more or less frequently in almost every country of the globe. It began its course in the United States in 1806, and numerous epidemics of it occurred between that time and the year 1816; again between 1823 694 EPIDEMIC CEREBRO-SPINAL MENINGITIS. and 1830; again between 1842 and 1850, and again between 1856 and the present time. The last epidemic began in Philadelphia in 1863, and re- turned annually for some years, reaching its height in 1866-67. Since then, however, as will be seen from the table below, it has continued to furnish annually a considerable number of deaths. It was made the subject of several valuable memoirs, among which may be mentioned those of Gerhard,^ Githens,^ Levick,^ and particularly the admirable treatise of Stille.* Owing to the employment of various names for this disease in the mor- tality reports, it is difficult to estimate the actual mortality occasioned in this city by it, but a good idea may be obtained from an inspection of the subjoined table, which presents the annual mortality for fifteen years from epidemic cerebro-spinal meningitis, typhus and typhoid fevers, and diph- theria. Epidemic Cerebro- spinal Meuingitis. Tj'phus Fever. Typhoid Fever. Diphtheria. 1860 14 68 214 1861 17 148 502 1862 37 654 325 1863 49 131 486 434 1864 384 335 648 357 1865 192 334 773 460 1866 92 96 381 192 1867 102 138 367 119 1868 54 108 395 119 1869 36 49 373 182 1870 36 69 409 172 1871 44 37 313 145 1872 128 35 369 150 1873 246 31 382 110 1874 80 461 179 Causes. — The disease we are considering has occurred " in all portions of the temperate zone inhabited by European races and their descendants ; in all sorts of localities, among all ranks and conditions of society, at all ages, and in both sexes ; and it is therefore in the strongest sense of the word a pandemic disease." (Stille, op. cit, p. 94.) While its epidemic character is so strongly marked, there is no reliable evidence as to its being contagious. A few authors, however, even of such recent date as Bristowe, assert their belief in its contagiousness. • Amer. Jour. Med. Sci., July, 1863, p. 105. 2 Ibid., July, 1867, p. 17. 3 Trans, of Amer. Med. Assoc, xvii, p. 311. 4 Epidemic Meningitis, Phila., 1867, pp. 178. ANATOMICAL LESIONS. 695 Although occurring iu both sexes and at all ages, it is more frequent in females, and a large majority of the cases are among minors. The dis- ease has undoubtedly been more frequent and virulent among overcrowded and filthy populations, but there is no reason to think that these conditions exert any more than a general depressing influence. Anatomical Lesions. — The chief lesions in this disease are found in connection with the blood and the nervous centres. Blood drawn from a vein during life usually presents its normal char- acters or else those indicative of inflammatory action, excepting in cases of the most malignant and rapidly fatal type. On the other hand, in post-mortem examinations, the blood is most frequently found to be dark, and either altogether fluid, or with only small dark and soft clots, in the cavities of the heart and the larger bloodvessels. These alterations are evidently what should be expected in a disease presenting the double con- dition of a specific blood poison and a distinct and serious local inflam- mation, which two elements vary greatly in their relative preponderance in diflferent epidemics, and even in difl^erent cases of the same epidemic; no definite chemical changes have been ascertained. In cases where the crasis of the blood is greatly impaired, microscopic examination has fre- quently shown an absence of the ordinary mode of arrangement of the red corpuscles in rouleaux, and a crenated appearance of the corpuscles themselves. The lesions of the nervous centres are chiefly seen in the meninges of the brain and spinal cord. In the early stage, there is extreme engorge- ment of the vessels of the meninges, with a loss of the normal translu- cency of the pia mater and arachnoid. Later, an exudation occurs which at first may be serous, but soon becomes sero-puruleut or entirely composed of thick creamy pus, with a varying proportion of lymph. The amount of this exudation varies greatly in diflferent cases; at times being quite scanty, while in other instances, several ounces of pus are present. The exudation usually occtipies the subarachnoid space, and is at times a.«5sociated with effusion into the ventricles of the braim The convexity and the base of the brain are both involved, though the exudation is as a rule more abundant over the latter, and especially about the optic chiasm, the fissures of Sylvius, and the base of the cerebellum and under surface of the pons. One or more of the cranial nerves are completely imbedded io the exudation. The spinal meninges present the same general changes, the vessels being congested, the pia mater infiltrated with sero-pumient fluid, and the sub- arachnoid space occupied by a more or less extensive exudation. These lesions are usually most marked about the medulla and again at the lower part of the cord. It is probable that the tendency of the exudation to accumulate at the latter pf)int is partly, at least, due to gravity. The substance of the brain is usually vascular and more or less softened; and the spinal cord presents the same changes, though less constantly and usually to a less degree. In some cases, however, the softening of the cord is extreme, and Hirsch has recorded a case in which the central canal of the cord was distended with pus. 696 EPIDEMIC CEREBRO-SPINAL MENINGITIS. In some cases where death occurs very rapidly, within twenty-four or forty-eight hours, the cerebro-spinal lesions have been found wanting, not having yet been developed to an appreciable extent. There are no characteristic lesions of any other organ. Symptoms; Course. — In some cases the attack is preceded by the usual prodromes of acute specific fever ; but in many instances it occurs with- out warning in the midst of perfect health. Usually the actual outbreak is marked by a distinct rigor, followed by fever, prostration, vomiting, in- tense headache, and pains in the back and limbs. It is soon evident that the patient is seriously ill. He grows restless and tosses about, at times with slightly spasmodic twitchings of the muscles. The intellect often remains clear ; but delirium or a disposition to heaviness and dozing may be present. The temperature is rarely very high at first, and the pulse ranges from 90 to 120, according to the age of the child. As early as the second day we may observe that the head is retracted, and thus increases in its degree and soon becomes associated with a tendency to opisthotonos. The other nervous symptoms increase in severity ; h.eadache persists, and is even so severe as to elicit screams of pain ; the pupils are contracted ; there is delirium, with excessive restlessness or even convulsions. Extreme cuta- neous and muscular hypersesthesia are very common symptoms. Vomit- ing is apt to continue ; the bowels are constipated, the abdomen retracted, and the urine is usually retained. The pulse grows more frequent and small, the respiration greatly accelerated, and the temperature increases to perhaps 103° or 104° F. Herpetic eruptions about the mouth are com- mon ; and in a varying proportion of cases a purpuric eruption appears from the second to the fourth day. In some instances the course of the symptoms presents marked fluctuations, which may assume the form of distinct quotidian or tertian remissions. In unfavorable cases, stupor supervenes, interrupted by more or less marked spasmodic movements ; respiration and circulation become more and more impaired, and the patient dies in profound coma. In favorable cases, on the other hand, the nervous jactitation and delirium diminish, the tetanic muscular spasms relax, the urine is passed voluntarily, the pulse and respiration gradually uniform, and the patient enters upon convalescence. Death may occur even in a few hours from general paralysis, from the overwhelming effect of a violent and universal meningitis. It may occur in the course of one or two days, in malignant cases with extremely marked blood lesion. In cases of the regular form, death may occur from the fourth to the eighth day, from the eflfects of the cerebro-spinal lesion ; but after convalescence has commenced, the supervention of some complica- tion or sequel may prove fatal, even after the lapse of weeks or months. Before proceeding to discuss a few of the principal symptoms more in detail, the following case of severe type, which occurred in our practice, may be cited in illustration of the general sketch above given-: Case — David R., aet. 12 years, in good health, was attacked on June 8th, with- out apparent cause, with violent headache, languor, and occasional vomiting. Cerebro-spinal meningitis was prevalent as an epidemic at the time (1864). On June 9th (second day), at noon, headache continued intense, the fever in- CASE. 697 creased in severity, and he vomited twice a greenish liquid. The bowels were con- stipated, and urine scanty. He lay in a drowsy condition ; the eyes slightly in- jected, but pupils of normal size ; the nose was pinched, the mouth closed. There was no rigidity of the muscles of the neck or of other parts. There was marked jactitation, with mild delirium. The skin was dry and slightly pungent; respira- tion 48, quick and sighing ; pulse 105. Over the whole body, but especially on the extremities, there are small petechiie, of livid color. Abdon)cn meteoric. Ordered brandy f3ss. every half hour, a saline laxative, and the following: R. — Morphia^ Sulph., gr. ^r^j Acid. Sulph. Aromat., .... tijjv. Elix. Cinchonae, f^ss. Ft. sol. — To be taken every two hours. In the evening, his mind was more clear ; but rigidity and soreness of muscles of back of neck had ajipeared, with tendency to opisthotonos. Pulse 120, irritable and quick. Vomiting continued. The bark mixture was changed for one contain- ing quinia, morphia, and dilute sulphuric acid. Iced champagne and beef tea were given in small quantities. Counter-irritation by capsicum and whisky. In the night, at two o'clock, vomiting continued frequent and uncontrollable. Pulse was very feeble, almost threadlike, and very irregular, varying from 100 to 120 within a few minutes' time. Temperature equally variable, surface being al- ternately burning hot and chilly. Quite conscious, and complains of intense head- ache ; extreme restlessness continues. Frequent thin, dark stools. June 10th. — In morning, pulse 90, varying from minute to minute ; respiration less hurried. Surface warm. He passes urine and faeces. Ordered suppositories of gr. ss. opium and grs. ij quinia every five or six hours ; a blister behind each ear; f^ss. brandy every hour, and concentrated nourishment. About five hours later, stupor supervened and continued until night, interrupted by fits of violent delirium. Slight convergent strabismus. Petechia? continue, and there is a herpetic eruption about the mouth. Temperature reduced in ex- tremities. Ordered nutritious enemata ; blister 4 x 4 to back of neck ; small doses of opium by rectum to maintain its influence. June 11th. — More quiet ; no more active delirium. Bowels open more freely. Urine free, acid reaction, sp. gr. 10 32, with a very heavy deposit of whitish urates. Nourishment and medicines retained by stomach. Pulse 85 to 105, with more volume. Consciousness partially regained ; complains of frontal headache and mui^ular sorene.«8. No opisthotonos. Eyes slightly injected. Continue opium and quinia; beef tea ; iced champagne ; milk with lime-water. June rjlh. — Condition about the same. Some quiet sloep. Skin of ploasant temperature. Herpes abundant around mouth. Urine quite free, and light col- ored. Pulse about 100; respirations more full. Troatmont continued. June 13. — Pul«e 72 to 100. Con-M^iousness perfect, but complains of intense fron- tal pain. Temperature almost normal. Petechia; disappearing ; herpetic eruptions on face still marked. Passes urine freely; sp. gr. 10 11 ; no albumen ; bowels cos- tive; quinia discontinued on account i>f headache. Ordered blue mass, gr. i, every two hours for four doses, followed by a laxative enema, which acted freely, and gave much relief. June 14th. — Restless, and complaining of his head. Still some retraction of the hr-ad, and muscular soreness. Respirations 35; pulse 100 to 110. Stomach reten- tive. Tongue cleaning, but dry and cracked. Passes urine copiously, very light- colored and watery. Suppositories of quinia and opium resumed ; stimulus and nourishment as before. June 15th. — Doing well. Has emaciated very rapidly. Pulse 110; fnllint; dur- ing the day to 96; respirations less sighing and labored. Decubitus more natural, 698 EPIDEMIC CEREBRO-SPINAL MENINGITIS. and movements more easy and free. Opiate suspended. Takes Quinia sulph , gr. i ; Acid, muriatis, dil. gtt. x, q. q. h. Stimulus and food as before. June 16th. — Doing well. Petechiae disappeared; herpes around the mouth bet- ter. Tongue moist, but very sore, with ulcerated cracks covered with pultaceous crusts. Pulse 100, of good volume. Expression natural. No signs of spinal irri- tation. June 19th. — Ninth day of disease. Convalescent. June 20th. — Kapidly regaining strength. Sleeps well, and eats with great ap- petite. No headache; expression bright and natural. Tongue has healed, and herpes around mouth nearly gone. Bowels regular ; urine free and normal. Con- tinues quinia and mineral acids. The subsequent course of the case was that of rapid restoration to health without any sequelse. In entering upon a study of the special symptoms, it will first be observed that the mode of onset of the disease is peculiar, and is characterized by its suddenness and by the early appearance of grave nervous symptoms without a high grade of fever. The symptoms furnished by the nervous system merit the closest study. So important are they that many authors have been* led to regard the whole affection as due to the meningeal inflammation, losing sight of the coexistent lesion of the blood. The most marked of them is headache, which, as already stated, appears early, is usually sharp and lancinating in character, and violent in the extreme. It is accompanied with pain along the spine, especially in the cervical region, which is much increased by pressure or by motion. Neuralgic pains are also very common, and at times are extremely severe ; they chiefly affect the extremities and the abdomen. From an early period of the case, there is apt to be marked and painful hypersesthesia of the skin, and also of the muscles ; so that handling the patient causes complaints or even cries of pain. Later this may be followed by more or less marked anaesthesia. There are frequently also various forms of muscular spasm. At times a high group of muscles will be affected with spasm, either tonic or clonic. The most frequent instances of this are the retraction of the head from rigid spasm of the cervical muscles, and the tendency to opisthotonos ; both of these condi- tions are very constant, and may be present in a high degree. Trismus is not very infrequent ; while in other cases, the muscles of the extremities are affected with spasm ; or again, the tetanoid vsymptoms may assume the form of general epileptiform convulsions, which are much more frequent in children than in adults. Paralysis in various forms, hemiplegia, paraplegia, but much more fre- quently as affecting a single cranial nerve (facial, abducens, or oculo-motor) has been observed, but as a rule is not met with until the later stages of the disease. In some cases, marked subsultus is present. In addition to these symptoms, there is rapid and marked debility, frequently associated with vertigo on rising into the sitting posture. Disturbances of the intel- lect are also more frequent in children than in adults. At first there are great restlessness, jactitation, and wandering delirium, which may persist or be replaced by more or less profound stupor ; perhaps occasionally in- terrupted by active delirium. In fatal cases, this stupor deepens into coma as the end approaches. SYMPTOMS. 699 There is frequently loss of control over the bladder aud rectum, attended with retention or with involuntary discharges. The organs o{ special sen^e furnish Important symptoms. There is often u uniform, ditiused redness of the conjunctiva?. The pupils are usually contracted at fii^st, but later may be dilated or unequal. Not rarely blind- ness follows; due either to keratitis, to exudative inflammation of the retina or choroid, or to purulent exudation in the chambers of the eye. Squinting frequently results from paralysis of one of the motor nerves of the eye as already stated. In like manner, deafness often results from suppurative inflammation of the internal ear, or from inflammation of the auditory nerve. The exprejision of the patient varies much at different periods of the disease. In the early stage, the face is often pale, with pinched nose and sunken features. This peculiar f'acies, which was noted in the case above narrated, is regarded by Hii-sch and others as very characteristic. The puke and temperature are less uniformly affected than in any other of the acute specific febrile diseases. At first the pulse may not be much accelerated, but later it may be very rapid, or again, may present remarka- ble variations at short intervals. The course of the fever is very irregular ; in most cases the temperature does not rise above 103° or 104°, and not infrequently is much lower throughout the whole course of the attack. The disturbance of respiration is marked but Very irregular. In the early stages it corresponds with the condition of the pulse ; but later it presents irregularities due to the pressure of exudation on the pneumogas- tric nerves, and may then assume the peculiar form known as ascending and dejicending breathing, which is so frequently seen in the exudative stages of tubercular meningitis. The digeMive system presents few constant symptoms. Vomiting, how- ever, is nearly always present in the early stage, and may be frequent and uncontrollable. It is oflen unattended by any nausea, and there evidently depends an irritation at the base of the brain. We have already referred to the severe aMominal neuralgic pain sometimes complained of. The bowels are usually constipated, and the abdomen retracted. In the later stage, it is not rare for involuntary discharges to occur. The urine presents the ordinary febrile characters, and in addition is at times albuminous or even bloody. There is frequently retention, requir- ing the use of the catheter, though we think this less frequent in children than in adults. We have already alluded to the occurrence of eruptions on the skin. They are not constant, and in some epidemics have been rarely noticed. Still they constitute very important symptoms in the majority of cases ; and indeed the occurrence of a petechial orufjtion has been so marked a feature in most American epidemics as to render the objectionable name, "spotted fever," the popular title for this affection. Among these eruptions, groups of herpes are frequently seen on the face, especially about the mouth, while, in more rare instances, erythema and urticaria has been observed. But by far the most frequent and important is the petechial eruption, which appears early in the case, usually in the 700 EPIDEMIC CEREBRO-SPINAL MENINGITIS. form of small spots. The proportion of cases iu which such an eruption is present varies greatly iu different epidemics. Stille concludes {op. cit., p. 64) that, taking the whole of the cases of epidemic raeuingitis in Europe and America, it did not occur in more than 10 per cent. On the other hand, of 96 cases recorded by Dr. Githens {loc. cit), 36 had marked petechial eruptions ; and of the cases we have ourselves observed, the proportion has been even greater. The duration of this disease is extremely variable. We have seen it prove fatal in the adult within forty-eight hours from collapse, with all the evidences of profound blood alterations, and before the characteristic lesions of the meninges had passed beyond the first stage. Death has been known to follow even in a few hours, with symptoms of general paralysis. In cases of ordinary severity which terminate favorably, the duration of the acute attack may be stated as from five to fourteen days, but complete convalescence may be postponed for weeks or months on account of the occurrence of some of the sequelse so frequent after this affection. On the other hand, death may occur at any period from the first day, as above stated, to as late as months after the original attack. Hirsch states that its duration is between a few hours and several mouths. Convalescence may be prompt, satisfactory, and complete ; or it may be irregular and protracted, in consequence of the persistence of some symp- toms or the development of some of the sequelae. Among them may be mentioned blindness and deafness due to causes already stated. Some neuralgic pains, dependent upon irritation of the posterior roots of spinal nerves, tonic or clonic spasm of certain muscles, and more rarely paralysis of a single muscle or of one or more members. It will be observed that these sequela are, for the most part, the results of the inflammation of the cerebro-spinal meninges. The mortality varies greatly iu different epidemics. According to Hirsch it has varied from 20 to 75 per cent. As we have met with it in this city, the mortality was about 33 per cent. The prognosis should always be guarded in epidemic cerebro-spinal men- ingitis. Even when the threatening symptoms of the acute attack begin to subside, it is impossible to predict that there will not be left behind some sequel which may protract convalescence indefinitely or induce a lingering and painful death. The diagnosis of this disease is not difficult. It could scarcely be con- founded with typhoid fever ; but in case of the coexistence of an epidemic of typhus fever, it is important to note the differential marks by which this latter may be distinguished from epidemic meningitis. Thus the headache of typhus fever is less violent and sharp, and the delirium less active and marked. In typhus, also, the face presents a dusky flush, and the con- junctiva is injected ; while in meningitis the face may be pale at first, and the conjunctivae are of a uniform pinkish color. The rapidity of pulse and elevation of temperature are much more marked in typhus, and follow a much more regular course. The eruption of typhus appears on the third or fourth day ; while in meningitis the occurrence of petechise is not at all constant, and when present they may appear as early as the first or second I TREATMENT. 701 day. On the other hand, the herpetic eruptions so frequent in meningitis are wanting in typhus. Vomiting is much more frequent in meningitis than in typhus. Retraction of the head, opisthotonos, muscuhvr spasms, neu- ralgic pains, cutaneous hyperiesthesia, irreguLarity of the pulse and respi- rations also, which are such marked symptoms of meningitis, are not characteristic of typhus. We may add that although typhus occurs in childhood, it is comparatively rare; while, as we have already seen, epi- demic meningitis occurs more frequently among children than at any other age. We would call attention also to the possibility of confounding mild cases;, without eruption, for rheumatism of the cervical and dorsal mus- cles. We knew this error to be committed in one case, with fatal results. Treatmext. — In the treatment of this affection it is necessary to bear in mind its real nature. There can be no doubt, however, that, in the ma- jority of cases at all amenable to treatment, the meningeal lesions must be the chief object of our medication. The use of cathartics is to be adopted with great caution. A mild saline laxative may be administered, and it^ action aided by an enema, if marked constipation exists at the onset. But it is to be remembered that but little food can usually be retained, and also that the constipation is the result of the cerebral irritation. Opium administered freely, so as to quiet the intense pain and nervous restlessness, is to be recommended. Its use will also at times control the cerebral vomiting. It is best given by suppository or enema, or in the form of morphia by hypodermic injection. Bromide of potaj<.-erience agrees with that of most American physicians, in p^ard to the beneficial effects of quinine, given in large doses, either by the mouth, or, if vomiting be persistent, in the form of suppository. Local depletion by leeches or cut cups to the back of the neck and along the spine should be employed, unless the evidences of blood dyscrasia for- bid it. After its employment, or instead of it, in case it be deemed in- admissible, the repeated application of dry cups along the spine is to be recommended. Food should be very carefully administered in small quantities, and if necessary nutritious enemata should be resorted to. In ca.se of extreme debility, of depression of the circulation, or of tendency to collapse, alcoholic stimulus should be freely employed, and the same is true, when, later in the course of the case, the typhoid state is markeflly develof)ed. It may also be necessary to apply external wjirmtli to maintain the temperature of the body. For the relief of the sequehe which result from the imperfect al>--<>rpti(;n of the exudation, and the consequent irritation or pressure upon the roots 702 SCARLET FEVER OR SCARLATINA. of the cranial or spinal nerves, evincing itself by neuralgic pains, mus- cular spasms, contractions or paralysis, the necessary treatment com- prises continued counter-irritation to the spine ; the internal use of iodide of potassium, nitrate of silver, or bichloride of mercury ; the use of one or the other form of electricity. ARTICLE VI. SCARLET FEVER OR SCARLATINA. Definition ; Frequency ; Forms. — Scarlet fever is an epidemic and contagious eruptive fever, characterized by a scarlet rash, which appears on the first or second day of the disease, and ends usually about the sixth or seventh, or in rare cases as late as the tenth ; by simultaneous inflam- mation of the tonsils, and of the mucous membrane of the mouth and pharynx ; and which is followed by desquamation. The frequency of the disease is exceedingly variable in different years, owing to its epidemic nature. This may be readily seen by a glance at the following table, which gives the annual mortality for the past sixty years in this city, from scarlatina and measles : Scarlatina Measles. Scarlatina Measles. Scarlatina. Measles 1809 3 1829 9 53 1849 242 27 1810 2 1 1830 40 7 1850 440 72 1811 3 2 1831 200 23 1851 391 17 1812 1 20 1832 307 118 1852 434 90 1813 1 1833 61 1 1853 388 14 1814 9 1834 83 7 1854 162 62 1815 7 1835 305 248 1855 163 24 1816 2 1836 240 4 1856 992 141 1817 1837 205 49 1857 704 66 1818 1 1888 134 123 1858 241 28 1819 2 108 1839 225 136 1859 232 51 1820 31 47 1840 244 2 1860 591 15 1821 13 1841 83 119 1861 1190 74 1822 9 1842 220 24 1862 461 109 1823 11 156 1843 395 1 1863 275 82 1824 9 102 1844 269 3 1864 349 90 1825 9 38 1845 199 90 1865 624 54 1826 4 101 1846 221 6 1866 491 221 1827 1 9 1847 344 77 1867 367 83 1828 58 1848 172 99 1868 224 108 It will be noticed that for five successive years, 1813-17 inclusive, not a single death from scarlatina is reported ; and that during twenty years, 1809-28 inclusive, only 99 deaths occurred from this cause ; while in the single years 1856 and 1861, 992 and 1190 deaths respectively are reported. FORMS. 703 Durins: the entire series of sixty yeai*s, there have been 13,016 deaths from scarlatina returned. Hillier states, that during the eighteen years from 1848 to 18G6, the deaths from scarhitiua in London amounted to 52,401. It is impossible to estimate the actual relative frequency cf scarlatina and measles, owing to the absence of any returns of non-fatal cases. It is evident, however, from the above table that, although the mortality from measles is also very variable, and thus may for a short time exceed that from scarlatina, in a long series of years the latter disease is far the more fatal. Thus the number of deaths from measles in this city, during the past sixty years, amounts to but 2279. MM. Guersant and Blache {Did. dc Med., t. 28, p. 173) state that it is less frequent than measles or variola. They added together the cases of the eruptive fevei*s collected in 1838 and 1839, by MM. Roger, Rilliet and Barthez, and Barrier, in the Children's Hospital at Paris, and found that there had only been 157 of scarlet fever ; whilst there were 2G7 of measles, and 213 of variola and varioloid. The/o?-m.5 of the disease generally enumerated are the simple, amjinose^ and maliffuant. Authors differ widely in their descriptions of these three forms. Many of the English authors include in the simple form only the cases in which there is no affection of the fauces, while the auginose form includes all in which there is any throat affection whatever. M. Rayer, on the contrary, describes under the head of the simple form the cases in which the throat affection is mild, while he considers the anginose form to l)e that in which a pseudo-membranous angina occurs. Again, the de- scriptions of the malignant form are vague and uncertain, some including under this terra only the rapidly fatal cases in which cerebral symptoms are present, while others include those also which are rendered malignant by the occurrence of pseudo-menlbranous angina. We believe this division of scarlet fever into distinct forms and varie- ties to be, for several reasons, a faulty arrangement. It is not, it appears to as, in the first place, consonant with the nature of the disease. Scarlet fever h, in fact, with all its degrees of severity, and apparent differences, a single and di.stinct fever, produced by one cause, determining similar effect*, howsoever much they may vary in degree, and requiring no more than does typhoid fever to be divided into the variety of different forms, which it has been customary to ascribe to it. Again, the above mode of division is not, we are sure, a good one for practical purposes. It is im- possible, indeed, as we have often found it, to refer many cases we meet with in practice, clearly and satisfactorily to any one of the forms of the disease described in books. The simple form of some of the English writers, or that in which there is no anginose affection, has no existence whatever, so far as we have been able to discover. We believe that in- flammation of the mucous membrane of the fauces constitutes an essential element of the disea.se, for we have never yet seen a case of scarlatina in which it was not present to a greater or less extent. It is often very slight, so slight, indeed, as to be unaccompanied by any evidence of pain in the part, but in all that we have examined, it has been decided and 704 SCARLET FEVER. obvious. This supposed form of the disease does not, therefore, in our opinion, exist. The two other forms usually described, the anginose and malignant, are also of little value practically, since we have found that in all severe or grave cases, in which the patient did not die with violent nervous symp- toms under the first shock of the scarlatinous poison, there has been de- veloped a severe and dangerous anginose inflammation about the third or fourth day ; so that it is fair to say that we cannot imagine any malig- nant case, lasting over the third or fourth day, which is not anginose, nor any severe anginose case, which might not also be styled, from its danger- ous character, malignant. We have found it impossible, in our experi- ence, to draw the distinction clearly and indubitably between the anginose and malignant varieties, because all severe cases partake more or less of the features of both. Feeling this difiiculty of describing the disease according to the mode that had before that time been generally followed, and believing it also to be insufficient for practical purposes, we were led to attempt, in the first edition of this work, a different arrangement. We made, accordingly, two forms or degrees of the disease, which we designated by the terms regular and grave. In the first form or degree we included all the cases in which the angina was simple and the eruption regular in all respects ; in which there was no predominance of one set of symptoms over another, but in which all held a due relation to each other. In this form was embraced all the cases of scarlatina simplex of writers, and many of those of scarlatina anginosa of the English authors. In the second form we included the cases which departed from the regular course of the disease, and which were rendered dangerous by the occurrence of severe symptoms not belonging in the same degree to the simple affection. This form we subdivided into two varieties, the grave anginose, which con- tained all the cases accompanied by pseudo-membranous, ulcerative, or gangrenous angina ; and the grave cerebral, which comprised all those marked by the early occurrence of dangerous cerebral symptoms. The grave form comprehended, therefore, some of the cases of scarlatina angi- nosa, and all those of scarlatina maligna of writers, dividing, however, those in which a pseudo-membranous, ulcerative, or gangrenous angina determined the type of the attack, from those in which the cerebral or nervous symptoms gave to the case its stamp. More extended observation and more patient reflection have taught us that this division also is incorrect, — that it does not afford a good classi- fication for the purposes of description, and that it is defective as a guide in practice. We adopted, therefore, in the third edition, and shall follow in the present one, a different method of considering the disease, one which we believe to be more consistent with its nature, more suitable for the pur- pose of description, and much more likely to prove useful in practice. We shall follow the same arrangement in regard to scarlet fever as that now generally employed for typhoid fever. We shall consider it as a single and distinct disease, and not as made up of a number of uncertain 1 CAUSES. 705 and imperfectly separated forms or varieties, since these so run into each other, as to make it absolutely impossible to draw the line clearly and palpably between them. The only division we shall make will be into mild and ffrave cases, since the only real difference between the cases is a difference in the degree of severity they exhibit. Causes. — It has been abundantly proved by long and reiterated ob- servation that scarlatina is propagated by two causes, contagion, and epi- demic influence. Of these two modes of propagation, we have not the least doubt ourselves that the latter is by far the most active. It is only neces- sary to look over the results afforded by the tables of mortality for this city, as quoted in the early part of this article, and to observe that in some years the disease caused a heavy mortality, in others a very small one, and that in others again not a single death from it is reported, to be con- vinced that it is of a highly epidemic nature. The coniaf/ious character of scarlatina has been doubted by some few persons, but seems to us clearly proved by the evidence adduced by various writers. Our own experience also convinces us that it is a con- tagious disease, though much less so, we are sure, than either small-pox, measles, hooping-cough, or chicken-pox. We have quite frequently, in- deed, known children exposed directly and for a considerable length of time to the infection to escape entirely, while it is extremely rare for us to meet with children, unprotected by previous attacks, who can resist the contagion of measles, hooping-cough, or varicella. But, though we believe it to be much less highly contagious than has been generally supposed, and than the other contagious diseases just named, we are also well convinced, a.s was stated above, that it is propagated to a considerable extent by a direct contagion. We have, in a number of instances, known one child in a family to contract the disease from direct exposure to it, or from the epidemic constitution of the atmosphere, and a second, third, and even a fourth, to take the disease from the first, in five, seven, or nine days after the latter had fallen sick. In other instances, on the contrary, it would eeem that cither several children in one family contract the disease nearly gimultaDeously from the epidemic influence, or else that the period of in- cubation is sometimes very short. For example, during the winter season, a child five months old, who had never been out of the house, was seized with it. On the second day after the eruption appeared on this child, her sister, between four and five years old, fell sick, and on the third day another sister, the only remaining child, between two and three years of age. In the first of these cases it must have been contracted through the epidemic influence which was at that time prevalent in the city, since the child had in no way been directly exposed to it. In the other two, we niU't either suppose the cause to have been the same, or else that the period (){ iiK iiliation was only two and three days in the respective cases. The period of incubation is shorter than in other contagious eruptive diseases. It may be stated to vary between twenty-four hours and two or three weeks. MM. Guersant and Blache are of opinion that in the ma- jority of cases, it is from three to seven days. MM. Rilliet and B^rthcz 46 i06 SCARLET FEVER. found that of 38 cases in which the time was recorded, it was between and 7 days in 16, between 8 and 13 in 15, and 15 and 40 in 8 cases. Our own observation would fix it at from 9 to 15 days in the majority of cases. Occasionally, however, it is very short ; thus Trousseau mentions a case in which the evidence is almost conclusive that the period of incubation was less than twenty-four hours. Murchison also states that this latent period varies from a few minutes to five days, rarely, if ever, exceeding six days. It is impossible to state with any certainty the length of time during which the power of imparting the contagion continues in the patient. M. Cazenave {Ahrege Prat, des Mai. de la Feaii, p. 54), states that it lasts throughout the period of desquamation, and that it would even seem to be most active at that time. Whatever may be the duration of this period, it is certain that the virus may attach itself to clothing, bedding, or furniture, and that the disease may thus be transmitted by one who is not himself attacked. We also learn from some remarkable instances, as for example, from a case related by Richardson in " The Asclepiad,'' that when the virus is thus attached to fomites, it may retain its activity for many months. In regard to the essential nature of the poison, it appears probable, in the first place, that it is contained in the secretions of the skin and fauces. The distance to which it may be carried by the air does not appear to exceed a few feet, and in those cases where prompt isolation does not pre- vent the communication of the disease, the virus has either been previously imbibed or is carried by fomites. It is probably of material nature, and is admitted to the system either through the skin, the respiratory, or, per- haps, the gastric mucous membrane. As we have seen, it retains its activity for a long time; but is rendered inert by a temperature somewhat below 212° F. Scarlatina is stated to be also inoculable, by the blood, the secretion from the fauces, and the fluid from the miliary vesicles which occasionally form on the skin. The resulting disease appears in some instances to have been favorably modified, but the operation has been comparatively rarely practiced. The epidemics of scarlet fever vary exceedingly in their extent and violence. During the years 1842 and 1843, the disease prevailed very extensively in this city, and assumed a malignant type, so that in a con- siderable number of families, two, three, and even four children, died within a very short period. During the winter of 1856-7, and throughout the spring of 1857, we had one of the most prevalent epidemics that ever visited this city, and yet the proportion of deaths to the whole number of cases in our own practice and that of our friends, was such as to seem to show that the type of the epi- demic was mild. The disease prevails at all seasons, but is most frequent in the spring and summer, and next in the autumn. It rarely occurs more than, once in the same individual, but that it does so sometimes, is proved by facts brought forward by difi'erent authors. It has been asserted that second INFLUENCE OP AGE. 707 attacks of scarlet fever occur in the same person not more than once in a thousand cases. Of the truth of this assertion we are, however, very doubt- ful, since it has occurred to us to see no less than three examples of second attacks in our own experience. We attended in this city one child with perfectly well-marked scarlet fever, attested by subsequent anasarca, who had had the disease two years previously under the care of the late Prof. C. D. Meigs. In the winter of 1852, we attended two children in one family with the disease, one of whom died, and both of whom had had the disease four years and a half before. They were attended in the first attack by one of oui*selves, and as it chanced, owing to our absence from town during one day, they were seen also by one of our friends, who made no exception whatever to the diagnosis of scarlet fever. The only doubt as to these cases having been veritable examples of double attacks of the disease, must rest of course upon the diagnosis. In the first example, the diagnosis was made by Prof ^Nleigs in the first attack, and by one of our- selves in the second. In the two latter it was made by one of ourselves in both, accidentally confirmed in the first attack, in both children, by the opinion of a competent professional friend. The first attacks in the latter cases were both mild, but well marked ; the second were both severe, and one proved fatal on the sixth day. We have not the least doubt ourselves that all of the three were cases of true scarlet fever. If they were not, the two latter must have been cases of roseola, so closely resembling scar- latina as to oblige us to confess ourselves incompetent to distinguish be- tween the two diseases. What adds to the certainty that the two which came under our own observation were examples of scarlet fever, is the fact that they occurred simultaneously with a third case in the same family. Now, roseola is not apt, so far as we know, to occur epidemically in a household. Most of the cases of that disease that we have seen, have been solitary ones. Again, in the spring of 1857, one of us saw a well-marked attack of the disease in a boy nearly four years old, who had had it one year l)efore, under the charge of a perfectly competent practitioner. Dr. Richardson (/oc. cit.) asserts that he has known the disease to occur twice in the same patient, and also states that he himself has suffered from it three times. Ag*. — MM. Rilliet and Barthez state that it is most common from six to ten years of age. Of 251 cases that we have seen, in which the age was noted, 64 occurred under 3 years of age, 78 between 3 and 5 years, 51 between 5 and 7, 47 between 7 and 10, and 11 between 10 and 15. From thi"* it would appear to be more common in the first five years than be- tween the ages of five and ten, since of the 251 cases, 142 occurred in the former, and only 98 in the latter period. By uniting the statistical tables of Dr. Emerson with those of Dr. Condie (DU. of Child, 2d ed., note, p. 86), we obtain the deaths from scarlatina in this city at different ages for a jK'riod of thirty years. These tables show clearly that the disease is mont common between the ages of one and five years. The total mortality from scarlatina under ten years, during the time stated, was 2171, of which 132 were under one year of age, 411 between 1 and 2, 1130 between 2 and 5. and 510 between 5 and 10. 708 SCARLET FEVER. Of 148,829 cases collected by Dr. Murchison from the death returns of Great Britain, 9999, or about 7 per cent., were under 1 year; 30,974, or 20 per cent., under 2 years ; 95,070, or 64 per cent., under 5 years ; 38,- 591, or 26 per cent., between 5 and 10; and but 13,168, or about 9 per cent., at all ages above 10. This agrees quite closely with the averages calculated from the exten- sive statistics collected by Dr. Richardson, which show the following per- centage at different ages : Under 5 years, . . . ... . . 67.63 From 5 to 10, 24,33 " 10 to 20, 5.52 " 20 to 40, . 1.73 " 40 upwards, 0.66 Out of 12,962 deaths under 5 years, 1289, or 9.9 per cent., were under 1 year ; 2874, or 22 per cent., between 1 and 2 ; so that 4163, or 31.4 per cent., were under 2 years. The earliest age at which w^e have seen it perfectly well marked, was twenty-one days. We saw it once also in a child five months of age, and twice at the age of six months. It is not nearly so common in the first year of life as it is afterwards. The largest number of cases occur, accord- ing to our experience, in the third, fourth, and fifth years of life. The influence of sex seems not to have been determined with certainty. Dr. Tweedie {Cyclop, of Prac. Med., art. Scarlatina), says it is most com- mon in girls. MM. Rilliet and Barthez, on the contrary, state it to be more common in boys. Of 262 cases under 15 years of age that we have seen, in which the sex was noted, 133 occurred in males, and 129 in females. The truth is, probably, that under puberty it attacks the two sexes with about equal frequency, while after that age it is most common in females. It occasionally happens, that patients, both adults and children, who have undergone surgical operations, are attacked with a scarlatinous rash, with mild constitutional symptoms (Hillier, Gee). The disease, accord- ing to these authorities, is true scarlatina ; and its occurrence at that time probably depends upon the system being in an unusually favorable condi- tion for the reception of the virus. Symptoms ; Course ; Duration. — As has already been stated, we in- tend, in our description of the symptoms of scarlet fever, to depart from the ordinary mode of arrangement of the subject. We shall discard the old division of the disease into three forms or degrees, scarlatina simplex, anginosa, and maligna, and substitute, for reasons already given, the sim- ple division into mild and grave cases. We shall class as mild cases those which pursue an even and regular course, without being accompanied by dangerous or malignant symptoms, in which there occur neither violent nervous, nor threatening anginose symptoms ; while among the grave cases we shall place those in which there occur severe nervous symptoms, in the form of violent delirium, coma, or convulsions, dangerous symptoms in the form of diphtheritic, ulcerative, or gangrenous inflammation of the mucous SYMPTOMS OF MILD CASKS. 709 membrane of the fauces, and finally, those iu which the general symptoms assuFiie a low and typhoid character. When it seems convenient, we shall follow the usual division of the course of the disease into the three stages of invasion, eruption, and desquamation. Mild Cases. — Stage of Invasion. — The following description of the symp- toms of scarlet fever in its mild form is drawn partly from books, but much more from our own observation of several hundred mild cases of the disease, of 213 of which we have kept a faithful record, and, when there wa.s anything peculiar or important, full notes. The onset of mild cases of scarlet fever is generally sudden. A child is well, or so slightly ailing on one day, as that the change from its usual condition is not noticed at the time, though it may be recollected afterwards, and on the following day, or often within twelve hours or even less, the symptoms of the disease become marked and characteristic. In a large majority of the cases that we have seen, the eruption was already visible at our first visit. Frequently the patient has been put to bed well in the evening, and, becoming restless and feverish in the night, is found on the following morning with fever, sore throat, and very considerable eru})tion ; or, as happened in one of our cases, a child gets up in the morning appar- ently well, breakfasts as usual, goes to church, and falling sick while there, comes home and, a few hours later, shows the eruption over the neck and upper part of the trunk, and has fever and sore throat. In another case, a boy between seven and eight years old was perfectly well in the morn- ing. At 2 P.M., his mother, a most sensible and accurate person, observed him playing in the garden, and remarked upon his healthy looks. Fifteen minutes after this he felt sick at his stomach ; he came into the house and went up to the nursery, looking pale and pinched, with a cold skin, and nearly fainted in the nurse's arras. He had then in the course of an hour three copious and watery stools, each one accompanied with vomiting. We saw him one hour after this, dozing, very pale, with pinched features, sunken and half-clased eyes, cool surface, and with the pulse at 128, and rather feeble. There was no eruption. At 6 p.m., we found him with a hot and dry skin, with the tongue heavily coated, the fauces swollen and ghowing flecks of exudation upon the tonsils, a pulse at 128, and with a well-marked scarlatinous eruption coming out abundantly. The case pursued a verj' regular course, without dangerous or malignant symptoms of any kind. But the invasion, though sudden in nearly all cases, is not always so precipitate as we have just described. When we come to analyze the early symptoms, we find that the first one observed in most of the cases is fever, marked by considerable acceleration of the pulse and heat of skin. In soMu- few ca.«es the fever is preceded by the ordinary prodromes of febrile di-(:i-*s, languor, la-ssitude, pains in the back and lind)s, and slight rigors. Simultaneously with the fever there is in nearly all cases more or less sore- ness of the throat. In all that we have examined, even those in which no pain waa complained of, there has been redness, or redness with swelling of the fauc-es. In a majority of the cases vomiting occurs, or if not vomit- ing, some degree of nausea. There is complete anorexia; the thirst is 710 SCARLET FEVER. acute ; the bowels are usually in their natural condition, or slightly con- stipated. The child is quiet and dull, or else restless and irritable, and sometimes there is delirium; the face is generally flushed, and the eyes often slightly injected. The duration of these symptoms is irregular. They are said to last generally about a day, but they may continue either a shorter or longer period. We are very sure, from our own observation, as we have already stated, that these preparatory symptoms rarely precede the eruption more than twelve hours, and very often the time is even less, so that the eruption may even be the first symptom noticed. Stage of Eruption. — The eruption generally appears first on the face and neck, whence it extends rapidly over the whole surface. It continues to increase in extent and intensity, so as to reach its maximum about the third or fourth day. It appears first in minute dark-red points dotted upon a rose-colored surface, forming patches of irregular shape, of consid- erable size, level with the skin, disappearing under pressure, divided at first by portions of healthy skin, but running rapidly together, and giving to large portions of the surface a uniform scarlet color. The eruption is not generally equally difiused over the whole body, but is more marked upon one portion than another. It is often most intense on the back, and is there of a deeper color than elsewhere, not unfrequently assuming a purple hue. It is generally very well marked on the abdomen and thighs, and about the articulations, and assumes in those regions a particularly bright tint. It does not always cover the whole surface, but in some very mild cases, and, as we shall find when treating of the grave cases, in these latter, also, it may occur only in patches of moderate extent upon different portions of the body, leaving us at times in some doubt as to the real nature of the rash. The surface of the eruption is smooth and even to the touch, unless, as not unfrequently happens, it is accompanied by the development of miliary vesicles, or crops of minute pimples or pustules. A certain degree of rough- ness is sometimes occasioned also by enlargement of the papillae of the skin in various parts of the body, particularly on the extensor surface of the limbs ; but these are evidently independent of the characteristic eruption. The skin upon some parts of the body, especially the face, hands, and feet, often presents a swollen appearance, rendering the movements somewhat stiff. There is in most cases a feeling of burning, irritation, and itching in the skin, the latter of which symptoms increases as the malady pro- gresses. If the nail be drawn firmly over the skin where the eruption exists, a white line is produced, which lasts for a short time and then passes away; if the pressure be more firm, a central red line with a white streak on either side is developed. This was originally pointed out by Bouchut as pathog- nomonic of scarlatina, the peculiarity, according to him, consisting in the great duration of the white line so caused. It does not appear, however, to have any positive value in distinguishing this affection from many forms of erythema. The eruption generally reaches its height about the fourth day, and SYMPTOMS OF MILD CASES. 711 then remains stationary for one, or less frequently two days, after whieh it begins to decline. Its decline is marked by a diminution in the in- tensity of the color, which, from scarlet, becomes red, then rose-colored, and growing paler and paler, finally disappears entirely about the sixth, seventh, or eighth day. In some very mild cases, however^ the whole duration of the eruption is not over two or three days, and in such the color it imparts to the skin is never very bright nor very deep, nor is it accompanied by intense heat, or by much irritation or itching. The symptoms which preceded the eruption do not subside on its ap- pearance, but persist or are augmented. The febrile movement continues unabated ; the pulse is full, strong, and frequent, running up very soon after the onset to 120, 140, 150, and often to 160. This frequency of the pulse is, in fact, one of the most marked symptoms of the disease. We have rarely, even in very mild cases, found it less than 140, and in not a few it has beeu in the first few days, and in children of four or six years old, even as high as 168 or 170. Occasionally, however, it has been lower, and in a case that occurred to one of us, in a boy five years old, it was 96 on the second day, and only 88 on the third, though there was still a good deal of rash upon the skin. The skin is burning hot and dry, as a gen- eral rule, and loses its usual softness and suppleness. The expression of the face is usually natural. The eye is often animated, and slightly in- jected. The respiration is generally easy and natural, though sometimes, when the fever is violent, it becomes quickened. The auscultation and percussion signs are natural, unless some complication exists. There is often a rather frequent cough, which is dry, and evidently depends on the guttural inflammation, and not on any bronchial or pulmonary aflTection ; it exists during the early period of the eruption, and declines with the in- flammation of the fauces. The voice is seldom altered beyond having a nasal sound, so long as the disease continues simple and regular. If the voice becomes hoarse or whispering, it indicates an extension of the in- flammation from the pharynx to the larynx. The anorexia continues until the eruption begins to decline, and the thirst is acute up to the same period, when it moderates. At first the dorsum of the tongue is covered with ar whitish or yellowish-white fur of variable thickness, while its tip and edges are of a deep red color. After two or three days, and during the course of the eruption, the coating just described disappears from the toDgue, and its whole surface assumes a deep red tint and a shining ap- pearance, which makes it look like raw flesh. At the same time it is often much diminished in size from contraction of its tissues, and its papilhc be- come enlarged and projecting; this condition generally lasts from six to ten days, after which it returns to its natural state; it is commonly moist throughout the attack. Vomiting is rarely troublesome in mild cases, though it often occurs; the bowels continue nearly in their natural con- dition; in some few ca.ses slight diarrhffa occurs, but more frequently there is very moderate constipation. The abdomen is natural in most of the cartes; sometimes, however, there is slight distension and pain for a few days, which coincide generally with enlargement of the liver, or more rarely of the spleen. 712 SCARLET FEVER. The uriue during this stage usually presents the ordinary febrile char- acters ; it is diminished in quantity, often of high color, though the pig- ment is not necessarily increased. The urea is not increased, which Einger regards as indicating that the kidneys are affected from the beginning of the attack. The chlorides are always more or less diminished. The phos- phoric acid, according to Dr. Gee, is about normal for the first three or four days ; it then diminishes, and remains for a few days at a half or a third of its normal amount. Uric acid appears to be retained during the pyrexia, and excreted in excess so soon as it begins to subside. Accord- ing to Holder's examination of 17 cases, there is bile pigment present during the first six days. Early in the second, or even in the first stage, the fauces present the signs of inflammatory action ; the pharynx is reddened, and in some in- stances swelled ; the tonsils enlarge and become red ; the submaxillary and lymphatic glands are somewhat tumefied and tender to the touch, and when the case is at all severe, deglutition is generally painful, and in some instances extremely so. The absence of complaints of sore throat in a child, or the fact of its swallowing without hesitation or apparent diffi- culty, is no proof that angina does not exist, since we have always found upon examination in a good light much greater redness than natural, and in many instances redness and swelling combined. As the eruption pro- gresses, and the tongue loses its coat and becomes red, the inflammation of the pharynx usually augments ; the redness becomes deeper, and the tonsils are more swelled and painful, and, in a good many, but not by any means all the cases, are dotted over with small white spots, or with thin, whitish, and soft false membranes. The throat-affection, however, is rarely severe enough to constitute a serious danger in mild scarlatina, while in many of the malignant cases it is a frequent cause of a fatal termination. During the eruption, the nostrils are either dry and incrusted, or there is some coryza. The strength of the child is reduced for the time, but there are no signs of prostration, and the decubitus is indifferent. There is almost always more or less disorder of the nervous system, sometimes amounting only to headache and restlessness, while in other instances there is great irritability, wakefulness, and occasional delirium, especially at night. Stage of Decline and Desquamation. — The eruption reaches its height, as already stated, about the third or fourth day, then remains stationary for one or two days, and afterwards declines gradually, so that no traces are left on the sixth, usually, or at most, in rare cases, on the ninth or tenth day. In some very mild attacks, the whole duration of the eruption is not over two or three days. By the third day it has disappeared entirely. Such cases are not, however, very common. The other symptoms, both general and local, decline with the eruption : the pulse loses its frequency, and falls to the natural standard ; the heat of the surface first subsides and then disappears, but the skin remains somewhat harsh ; the redness and swelling of the tonsils and pharynx diminish ; the spots of false membrane, if these be present, are thrown off"; the deglutition becomes easy if it have been difficult, and soon all signs of throat-affection vanish ; the tongue SYMPTOMS OF MILD CASES. 713 cleans off, becomes reddish aud glossy, and after a time returns to its natural state. At the time that the subsidence of all the symptoms takes place, dei^qua- matioH begins. It dates, therefore, in most cases from about the sixth day, though it may be either earlier or later. According to Hiller, the date of commencement varies from the sixth to the twenty-fifth day. It com- mences in most of the cases on the face aud neck, though in a few instances it appears first on the abdomen. It then extends gradually over the body and becomes general. About the thorax and abdomen it occurs in the form of minute points, like those which result from the desiccation of sudamina; on the face it is in the form of thin light scales or squama^ while ou the extremities large flakes of the epidermis become separated from the derm, and are removed by the child, or rubbed oflT by his movements in bed. The whole process usually occupies some ten or twelve days, but may be prolonged into the third week, or even until the middle of the second month. It is generally accompanied by roughness aud dryness, and some itching and irritation of the skin. Not unfrequently, the surface beneath the exfoliation is left tender and irritable for some time afterwards. During this period, dating from the sixth or eighth day, the urine be- comes abundant, pale, of neutral or faintly acid reaction, and, according to Gee, deficient in phosphoric acid. Albuminuria is also frequently observed during desquamation, very much more so than during the eruptive stage. It is usually transient, but may continue until dropsy occurs. Sometimes the albumen totally disappears, and reappears when dropsy comes on a fortnight or three weeks later. The proportion of cases in which this form of albuminuria is present varies in different epidemics, from twenty-five or thirty to ninety j>er cent. Temperature. — The fiery redness of the surface and the pungent char- acter of the heat, have led to much exaggeration in the description of the pyrexia in this disease. The range of temperature is indeed from 100° to lOo", and only in rare cases does it reach 106°. In 30 cases reported by Ringer (Med. Times and Gaz., Feb. 15th, 1862), the temperature remained at the same point throughout the day in the more severe attacks ; in slighter ones, it fell in the morning and rose during the day, l>eing most frequently at its highest point between 2 and 8 r.M. AVhen the morning remission was marked, it indicated the approach of a favorable termination. The first decided fall of temperature, coinciding with a diminution in the eruption, occurred in the majority of cases on the fifth day, or if not on this day, it usually was deferred until the tenth or fifteenth. In these latter cases, however, a fall of varying extent had oc- curred on the preceding fifth days. After the marked fall on the fifth, tenth, or fifteenth day, the temperature remains from 99° to 101° for a variable time, coinciding when persistent with continuance of the angina, or some of the other lesions of the disease. If at any time after the com- plete fall of the temperature, there is any considerable elevation again, it indicates the development of some sequel, either an afl^ection of the kidneys, 714 SCARLET FEVER. throat, or oue of the serous membranes. It is thus seen that the tempera- ture in scarlatina tends to form ares or cycles, usually of five days' duration. Before quitting this part of our subject, we must remark that, though the above is a correct description of the usual symptoms of mild cases of this disease, the reader would be greatly deceived should he expect always, and invariably, to find this exact train of morbid phenomena. On the contrary, the mild and the grave cases both vary so much, that it is impossible to describe them accurately by one or two portraits. Taking the above sketch as a standard of the mild cases, the observer will find that many fall short of it in all their features, while others deepen gradually in their shades, so to speak, until they pass into the grave type. Those that are milder in their type than the above sketch, may be so in such a degree as to make it very difficult, and in some cases impossible, to determine positively whether the child has had the disease or not. Indeed, we doubt not our- selves that children sometimes have the disease so slightly, that it is not discovered by either the physician or parents, and, being protected by the attack, are in after-life classed amongst those insusceptible to the disease. Our grounds for asserting this are the facts that some cases we have seen have been so very mild that, but for the existence of the disease amongst other members of the family, they might have passed unobserved ; and that in one instance we were sent for to see a patient, who had had the eruption for three days, and yet who was so slightly sick that he was sent for from school, to which he had gone, for us to see. It was a well-marked case, and the child had no troublesome symptoms afterwards, notwith- standing the exposure he had undergone. A. still more remarkable case occurred to one of us two years since, which shows clearly how a child may take scarlet fever without its being recognized by the family. Cask. — The mother of one of the families we attend consulted us about one of her sons, a sturdy boy of seventeen years of age. She stated that hn had not been well for two days ; that he had a severe sore throat, was restless and feverish at night, could eat nothing, and complained of debility, but, as he was then going through his examination at the High School of this city, he refused obstinately to remain at home. It was agreed that he should call at our oflBce the next morning, on his way to the school. When he arrived, which he did on foot, as usual, we found him covered with a copious, dark-red, perfectly characteristic scarlatinous eruption; his throat was very red, swollen, and quite painful ; the pulse was over 120, active and full, and the skin hot. He was, of course, ordered home, there to remain until perfectly well. He recovered and had no drawback. The distance from this boy's home to his school was not less than a mile and a half, and he had walked this distance twice a day. Grave cases. — The following description of the symptoms of grave cases of scarlet fever is, like that which has just been given of the mild cases, drawn partly from books, and partly from our own observation of the disease. We have had the opportunity of carefully observing a very large number of grave cases of scarlatina, but we find that we have pre- served a more or less complete record of but 61 such cases. We shall include under this division of the subject, as already stated, most of the SYMPTOMS OF GRAVE CASES. 715 cases usually classed by writers under the title of scarlatina angiuosa, and all tliose generally described under the title of scarlatina maligna. The symptoms which mark the invasion of grave cases of scarlet fever, though sufficiently alike in all to show the unity of the disease, diifer very materially as to their degree of severity in different cases. In one set (rather less than a third, or 18 in 61, of our cases) they are most violent and dangerous, or, indeed, appalling in their character. From the first, they declare the imminent danger of the attack. In the second set (rather more than two-thirds, or 43 in 61, of our cases), they may be either evi- dently severe and dangerous, though not appalling, as in the first, or they may be much milder, more like those which mark the invasion of mild cases; but even under these circumstances they soon put on their grave and dangerous character. The first set of cases, or those in which the symptoms are the most severe of all, and which include most of the malignant cases ordinarily styled ataxic, usually begin with nervous symptoms. The onset is in some in- stantaneous. In one, the little patient, a girl two years old, whose brother and sister had been sick for some days with scarlatina, was put to bed in the evening in her usual health, which was strong and vigorous. She slept quietly through the night, but was found by the mother the next morning in a state of drowsiness, violent fever, and covered with a deep- red scarlatinous rash. She soon became comatose, and died on the third day. In another case, a boy eleven months old was a little fretful in the afternoon, but was put to bed in the evening as usual and went to sleep. About ten o'clock the nurse heard a rustling in the bed, and on going to it found him in a violent general convulsion. The next morning he was covered with a scarlet rash, which became deeper and deeper as the disease went on. On the second day he was nearly insensible, and had frequent attacks of convulsions ; on the third day he had retraction of the neck, with spasmodic twitching>, and at the end of that day died in a state of cuma. In a third case, a boy six years old, whose sister had been sick for a week with a mild attack, went to bed well. At three o'clock in the morning, he was seized with vomiting and purging, paleness and coolness of the skin, and great exhaustion. At nine o'olock he was drowsy and dull, the .-kin was pale and cool, and the pulse extremely rapid ; the vomit- ing and purging had ceased ; at 12 m. he was comatose and had a convul- sion. From this time he continued comatose until he died at 6 r.M. of the .«ame day, after an illnes.s of fifteen hours. In a fourth instance, the invasion was that of croup; after a few hours came on coma and convul- sions; patches of eruption then appeared on the trunk, and death occurred in twenty-four hours from the beginning. The subject of this case, a boy five years old, was thought to be so well in the afternoon of the day he was taken sick, that he had been sent out to visit a relation, and while there fell sick. In the fifth case the onset was sudden, with violent fever, drowsiness, deep suffusion of the skin, and in a few hours insensibility, general convulsions, and death in thirty-six hours. In a sixth, in a boy four yean* old, the attack came on with vomiting, palenes«, drowsiness, and then a scarlet rash ; after a few days, coryza and otorrhtt«a occurred ; 716 SCARLET FEVER. the tongue and lips became cracked and dry; in the second week the child was comatose, with occasional attacks of extreme jactitation, and the most violent hydrocephalic cries, which condition lasted ten days. After this there was diarrhoea, extreme emaciation, loss of speech, and entire deafness. Gradually, however, the fever disappeared, the tongue cleaned off, and intelligence very slowly returned ; in the sixth week con- valescence was firmly established, and the child recovered perfectly with the exception of his hearing, which remained very dull in consequence of the perforation of both membranse tympanorum. In a seventh, a girl eight years old, whose brother was then sick in the house with the disease, was in the morning well. At breakfast, she said she felt sick and soon went to bed. At 5 p.m. of that day she was attacked with a general con- vulsion, which lasted about fifteen minutes. The pulse, immediately after the convulsion, was 150. At 11 p.m. she had another convulsion. Through that night she was very restless and wandering. On the morning of the second day there was a third convulsion, which, however, was very short. The pulse was now 160, small, and feeble. The patient was very heavy and dull, answering questions slowly and with great diflSculty, and during part of the day she was comatose. On the third day she was better, the pulse having fallen to 152, and she was less dull, though she still con- tinued very heavy and inattentive unless aroused by persevering efforts. The limbs were cool, while the head and trunk were hot. The eruption was thick on the trunk and upper part of the extremities ; elsewhere it was scanty. Wherever it existed, it was of a deep red or purplish color, and the capillary circulation was sluggish and imperfect. On the fourth day her intellectual condition continued better, but the extremities were still cold, and the lymphatic glands and subcutaneous tissues about the lower jaw and neck had begun to swell. On the fifth day, the swelling had become very great ; the stupor had returned; a profuse and disgusting coryza and otorrhoea had set in ; and the edges of the eyelids were in- flamed and sore. On the sixth day the discharges from the mucous mem- branes of the head were very copious, and consisted of a thick, offensive, purulent fluid intermixed with dull whitish grumous particles. The patient was now comatose or very restless ; she swallowed with great diffi- culty; the swelling under the lower jaw and about the throat was enor- mous ; the pulse was rapid and small ; the eruption was very dark in tint; the cutaneous circulation was slow; the extremities were cold, and death occurred about the middle of this day. In another case, the subject of which was a girl between three and four years old, the attack began with severe inflammation of the throat, causing great difficulty in swal- lowing. The rash on the first day was very extensive and of a deep-red color. The child was drowsy and heavy, or else delirious. On the second day she was comatose, and had strabismus and automatic movements of the limbs. On the third day the coma continued, and there were auto- matic movements of the extensor muscles, with retraction of the head. The eruption continued vivid, but was of a dark-red color. Death occurred in the middle of the fourth day, in a state of coma, without convulsions. In still another case, a boy, between eight and nine years old, was at- SYMPTOMS OF GRAVE CASES. 717 tacked suddenly, while in g(Xid health, with vomiting, sore throat, and high fever. Twelve hours after the onset, he had a severe convulsion, which lasted fifteen minutes. He soon recovered from this, however, and remained perfectly intelligent. On the second day the rash was moderate ; there was violent fever, and the child was heavy, but, wheu roused, still intelligent. Early in this day a severe fit occurred. This was most vio- lent, as severe as the worst epileptic convulsion. It lasted one hour and three-quarters. The pulse, after this, was 145. On the third and fourth days, the symptoms improved very much, the pulse having fallen to 125 and 132, but he continued drowsy and heavy. The eruption came out most abundantly. The fauces were very much inflamed, and somewhat ulcerated, and the external lymphatic glands were enlarged, but still the swallowing was not difficult. On the fifth he was not so well, being more restless and heavy alternately. There had now come on much difficulty in breathing, and some croupal sound. The latter symptom increased through the day, until the dyspnoea became very great. Deglutition now became excessively difficult ; the external swelling increased ; attacks of suflTocation attended with the most painful and distressing jactitation came on, and were renewed more and more frequently ; and death occurred by asphyxia about the middle of the sixth day. In a tenth case, in a girl five months old, convulsions occurred on the second day. These were followed by coma lasting several days, and by enormous swelling of the lymphatic glands and subcutaneous tissues on the left side of the neck, and by a less degree of swelling on the right side of the neck. The glands of both side^ suppurated and were opened, and the child finally recovered perfectly. In an eleventh case, in a boy seven years old, an attack of general convulsions took place on the third day, after which there were delirium and coma alternately for several days, with coryza, angina, and offensive otorrhoea, lasting in all six weeks. The child re- covered, but remained deaf. In this form of the disease, therefore, the symptoms are of the most vinilent character. The onset is sudden. The child passes within a few hours from a state of apparent health, into one of the extreraest danger. Mo>t of the cases begin with violent fever, and great depression of the strength. The pulse »oon becomes very rapid (140, 150, 180), or so fre- quent that it cannot be counted, and it is at the same time small and often irregular. The skin is dry and burning hot in some parts, in others cool or even cold. There is generally nausea or vomiting, and these may be violent and constant. These are accompanied in some cases, but in our experience, only in the severest of all, by colli(pjative diarHuea and me- leorism. Delirium often exists from the first, or else there is drowsiness and dulness of intelligence, verging gradually in coma. In the most vio- lent cases, the 8tupf)r or coma alternate with convulsions, which may cause a fatal termination in eighteen, twenty-four, or thirty-six hours. When a case of this kind lasts over three, or even two days, the vio- lence of the nervous symptoms almost always subsides ; the convulsions cease to recur; the delirium is less violent; the coma gives way to drow- sineas, or the patient becomes again quite intelligent and observant ; the 718 SCARLET FEVER. pulse often falls in frequency, and the heat of skin may diminish, and the eruption assume a more favorable appearance. All the symptoms seem, indeed, to be more promising, and very often both the physician and friends are greatly elated by the improvement in the patient's condition. Nor are these hopes always illusory, since children do recover occasionally even in cases that have exhibited the most threatening and malignant ap- pearance at the moment of invasion. It happens, unfortunately, however, in a majority of such attacks, that the improvement which takes place on the third or fourth day is only momentary. The nervous symptoms sub- side, but new phenomena make their appearance in the shape of severe inflammation, membranous deposit, and perhaps ulceration of the fauces, and extensive swelling and induration of the lymphatic glands and subcu- taneous tissues about the angles of the inferior jaw, and under the chin and throat. In connection with the throat-atfection which develops itself in this way, it is very common to have abundant purulent or membranous coryza, and often also otorrhoea. The symptoms assume, in fact, the fea- tures of the cases usually described under the title of scarlatina anginosa. As we shall, however, describe them directly in our account of the second set of grave cases, it is unnecessary to pursue the description at the present moment. We will state, however, before proceeding further, that the an- ginose and general symptoms which occur in cases beginning with violent nervous phenomena, and especially with convulsions, are nearly always of the most dangerous and malignant character, and usually end fatally in two, three, or four days after their appearance. The eruption in this class of cases varies according to the violence of the attack. In the severest one that we saw, that which proved fatal in fifteen hours, no eruption whatever was perceived, and we only knew it to be scarlatina by the character of the other symptoms, and by the fact that the sister of the boy had been sick in the same house with the disease fOr a week. In the case which terminated in twenty-four hours, the eruption showed itself in the form of scarlet patches about the face and upper parts of the body, twelve hours after the onset. In a third case the eruption was moderate, but perfectly well marked and general. In the other thir- teen cases, which lasted, with one exception, not less than three days, the eruption was perfectly well marked. It covered the whole surface, was at first scarlet in color, soon ran into a deep red, and then became violet or purplish. The exceptional case was one which lasted thirty-six hours, and proved fatal in that time. In this also, the eruption was well marked and extensive. M. Gueretin {Arch, de Med., t. i, p. 292, 1842), in his account of the acute malignant form which he witnessed, states that the eruption was nearly constant. In all our cases it occurred within twenty-four hours from the invasion, while in those of M. Gueretin, it appeared within twenty- four or forty-eight hours, or, as more frequently happened, not uutil the fourth or fifth day. If no favorable change takes place in these severe cases, and when they do not prove fatal at once, the patient grows weaker and weaker ; the de- lirium continues, or is replaced by coma; subsultus tendinum, rigidity of the limbs, spasmodic twitchings or general convulsions, make their appear- SYMPTOMS OF GRAVE CASES. 719 ance ; the eruption becomes more and more livid ; the pulse grows smaller, more frequent, and irregular; the respiration is excessively embarrassed; deglutition becomes impossible ; and the patient dies in from three to seven or nine days. In some few instances, the child struggles on for several weeks, and dies in a state of utter exhaustion, or having a con- stitution of great powers of endurance, at last surmounts the disease and recovei*s. The invasion of grave cases is not always, as we have stated above, so violent as in those which have just been described. In rather more than two-thirds (4.'>) of the Gl grave case of which we have preserved notes, the onset was less threatening than in the other third, though the symptoms were severe and dangerous in most of these also, and when not so at the very start, very soon assumed the serious characters which make it neces- sary to class the cases in which they occurred as grave. The chief differ- ence between the symptoms that mark the onset of grave cases of this kind, and of those in which the symptoms are still more violent, which latter we have thus far been describing, lies in the character of the nervous phe- nomena — in the latter most severe, threatening, and dangerous, consisting of stupor, coma, or convulsions, and in the former, merely excessive agi- tation, restlessness, heaviness, or stupor. In one well-marked case of the kind now under consideration, the patient, a boy between seven and eight years old, was attacked in the evening with headache, fever, and vomiting. On the following morning a faint rash was perceptible, which, by the after- noon of that day, was distinct, though not very full. The case now rapidly assumed unpleasant features. The pulse rose to 150. There was much drowsiness and delirium, and on the fourth day constant picking at the l>ed-clothes and at the fingers. In another case, in a boy between four and five years old, the first sign of sickness was slight languor after dinner, which was followed by fever in the evening, and the development in the course of the night of a scarlatinous rash. On the following day, there was K)mc pain in the throat, with redness ; the pulse was 140, and the skin hot and dry ; there were no nervous symptoms, except slight drowsiness. On the third day the pulse was 136, the rash was well out, and there were no un|)]easant symptoms whatever. From this time, however, the symp- toms gnidually grew worse ; the throat-affection increasing, the cervical lymphatic glands becoming very much swelled, and the child growing more unea-y and restless, though retaining perfectly its intelligence. By the sixth day, the grave character of the case was fully developed, the eruption being intense, and of a deep brick-red, verging towards a purple color. There was at the same time very great drowsiness, al)undant dis- charges from the nasal pas-sages of thick sero-mucous and purulent fluiils, membranous exudation in the fauces, with gurgling and great difl[iculty in swallowing, and an utter lo.s8 of appetite. In a third case, a boy between one and two years old wa** a little fretful in the morning, and was seized in the evening with vomiting and fever, and very considerable restlessness. On the next day he was covered with a scarlet rash from head to foot, and the skin was fierj' hot. The pulse was IGO, regular, not large. The child was very drowsy, dozing nearly all the time, but quite intelligent when 720 ;rlet fe" aroused. The fauces were intensely red and rough, and the tonsils much swelled ; there was very little external swelling. On the third day he was still very drowsy, and, when roused, less observant than before, though he still recognized persons. The pulse was 168, small, difficult to count, very hard and corded. The skin, especially that of the limbs, was scarlet, very hot, and dry ; the cutaneous capillary circulation was good. After this the symptoms grew rapidly worse ; the pulse continued at from 148 to 168 on the fourth and fifth days, and on the sixth rose to 172, at which it stood a few hours before death. On the fourth and fifth days, he was still very heavy and drowsy, and so much so on the former as to take no notice whatever except when moved. On the fifth day, an abundant sero- mucous discharge took place from the nostrils; the cervical lymphatic glands, which had begun to swell before, now increased in size ; there was some loud faucial gurgling, and the swallowing became difficult. On the morning of the sixth day, some of the symptoms improved so much as to flatter very greatly some of his attendants, who were unacquainted with the treacherous character of the disease. He roused up from his state of stupor, and noticed several things that were shown him, even taking them into his hand ; but the breathing continued bad, the lymphatic glands were swelling rapidly, and had already become very large, so that they formed great projections on either side of the neck. The pulse was 155, and small. In the middle of the day the breathing became difficult, from the internal and external swelling, and from the collection in the fauces of thick and viscid phlegm. The surface had now become pale. The tumefaction about the neck was immense. Down the front of the neck and along its sides to the clavicles, a kind of oedematous swelling of great size had come on, and was rapidly increasing. The pulse was 160, small and feeble. The legs and arms were of a dark, congested tint. Deglutition was excessively dif- ficult. In the evening the pulse was 172, and death took place just before midnight with slight convulsive movements. The mode of invasion is diflferent, therefore, in diflferent examples of the kind of grave cases now under consideration. In some it is even milder than in any of those that have just been detailed ; and it is not until the third, fourth, or fifth day, or even later, that the severity of the attack shows itself fully and unmistakably. After the disease is once established, it will be found upon examination that the fauces are of a deeper red color, and that they are more swelled, than in mild cases. At the same time there is more difficulty and pain in deglutition ; these are complained of by older children, and are shown in those who are younger by their refusal to swallow, by their crying upon making the attempt, and in some instances, especially at a later period of the sickness, by a positive inability to perform the movement. In nearly all of these cases, false membrane is formed upon the mucous membrane of the throat. This is never, or very rarely, present on the first day of the attack. In most cases it is not found until the second or third, and often not before the fifth or sixth day. MM. Rilliet and Barthez state that they have known it not to appear until the tenth and eleventh days. It appears first in small, thin, whitish, yellowish, or ash-colored points or SYMPTOMS OF GRAVE CASES. 721 patches, on one or both tousils, or on the soft palate only, where it remains limited, or from whence it extends to the pharynx, which it may cover in whole or in part. The patches' are of variable thickness and consistence, and adhere sometimes very slightly, and sometimes with considerable tenacity to the mucous membrane beneath. They may remain for a day, and then be thrown off not to be again produced ; or they may form in several successive crops, until the case is terminated ; or, as most frequently happens, they last three or four days or more, and are then detached. The mucous membrane upon which they are seated is found in various condi- tions. It may present the redness and swelling indicative of severe in- flammation, or it may be softened, ulcerated, and, according to MM. Guer- sant and Blache, gangrenous, though as a general rule, what have been supposed to be sloughs are in fact portions of altered false membrane. There is more or less fetor of the breath, sometimes amounting to a gan- grenous odor, after the appearance of the pseudo-membrane. The severity of the symptoms is in proportion to the extent and thickness of the false membrane. "We have already seen that it is not uncommon to find ulcerations beneath the false membranes. In other cases of this kind the throat affec- tion assumes very great violence without the presence of any exudation whatever. In some the mucous membrane is of a deep red or even pur- plish hue, its consistence is softened, and it is swelled and covered with a layer of grayish or sanious pus. The tonsils are enlarged, infiltrated with pus, softened, and break down easily under the finger. In other cases, in addition to the redness and softening, ulcerations are present. These may be superficial, amounting only to erosions, or they may extend through the mucous, and even submucous tissue to the muscles beneath. They are seated generally in the pharynx, but may exist also on the tonsils, and in some rare cases they extend into the larynx. In still more malignant attacks of the disease, we find evidences of gangrene of the pharynx. It is important to distinguish between those in which the pseudo-membrane becomes so changed as to assume the appearance of sloughs, and those in which the tissues of the pharynx are really gangrenous. The former con- stitute by far the greater number of the cases which have been generally regarded as iihstances of gangrene of the throat. That gangrene of these ti-ssucj* docs actually occur in some few cases, is proved, however, by the evidence of Dr. Tweedie, who says {loc. cit., p. G50), that in malignant scarfatina "the membrane of the pharnyx is sometimes of a dark, livid color, and occasionally in a sloughing state," and by that of MM. Guer- sant and Blache, who state that they met with several instances of gan- grene of the phar)'ux in the p.seudo-membranou8 angina which prevailed in 1841. An almost constant accompaniment of cases of this kind is inflamma- tion and swelling of the submaxillar}' lymphatic glands and surrounding cellular ti.-sue. The tumefaction is generally confined at first to the glands beneath the jaw, which become painful to the touch. After a short time it extends to the parts behind the angle of the jaw, and beneath that bone, until at last the sides of the neck and the throat are largely dis- 46 722 SCARLET FEVER. tended, so as to interfere with, or even prevent in great measure, the open- ing of the mouth, and by the pressure exerted on the internal parts of the throat, to add to the difficulty of deglutition which already exists. In some cases the pressure is so considerable as to embarrass the respiration of the child. This swelling has been generally supposed to depend on in- flammation of the parotid glands ; but MM. Breton neau, Guersant and Blache, and Rilliet and Barthez, all state that parotitis is of exceedingly rare occurrence, and that the swelling in question depends nearly always on the causes just described. The last-named writers state, moreover, that the tumefaction of the cellular tissue is often of the nature of active oedema. The swelling of the cervical lymphatic glands, and of the cellu- lar tissue of the sides of the neck, and that under the throat and chin, seldom takes place to any considerable extent, according to our experience, prior to the third or fourth day. During the first two or three days, the chief symptoms are the fever, the eruption, and the nervous phenomena, which latter consists, in this class of cases, of either excessive agitation and restlessness, or of drowsiness or stupor. Very often, after a child has seemed to be very ill for two, three, or four days, from the violence of the febrile reaction and the severity of the nervous symptoms, it will appear to improve very decidedly on the third or fourth day, and elevate greatly the hopes of those interested in it. It is just at this time, however, that the throat affection is apt to set in severely ; and, moreover, it rarely fails to come in children who have presented violent symptoms during the first three days. The enlargement generally disappears, in favorable cases, in from three to twelve days, by resolution, while in others it terminates by suppuration of the glands and surrounding parts. In the form of the disease we are now considering, it is common to observe violent coryza, which may be either purulent or pseudo-membra- nous. It may appear from the very first, or not for several days after the eruption has commenced. The discharge is yellowish, granular, thin at first, and afterwards thick ; it contains often flakes and shreds of ex- udation, and becomes sometimes very offensive, and highly acrid, so as to excoriate very much the upper lip. It often flows in surprising quanti- ties, and generally continues up to the moment of death, or until all the symptoms have moderated. Otorrhoea is another symptom of this form. It generally occurs simul- taneously with coryza. The discharge is at first thin and watery, like that from the nostrils, but becomes gradually thicker as the case advances. The quantity is extremely variable. In some cases we have known it to fill the meatus and concha of each ear, and then to flow out and make large stains upon the pillow, or to collect very rapidly after being wiped away. It is, like the coryza, an unfavorable symptom, as it is a mark of the grave form of the disease, and because, if the child recovers, it is very apt to result in deafness, which is but too often permanent. These symptoms, coryza and otorrhoea, sometimes exist also in mild cases, but they do not then assume the peculiar characters which they present in grave cases. The discharges are much less abundant, and the mucus or pus is healthy, and scarcely oflensive to the smell ; they last but SYMPTOMS OF GRAVE CASES. 723 a short time, and arc very rarely accompanied at the time or followed by more than a slight degree of deafness. The eruption is generally stated to appear later than in mild cases, and often to be less vivid and less extensive. It is also said to occupy only portions and not the whole of the body, to occur in irregular patches, or to appear and disappear alternately. This has not been the case in the instances which we have seen. In all but two of the forty-one, the erup- tion occurred early, generally within twenty-four hours from the onset. It was of a deep brick-red or livid color, and covered the whole surface. In one of the exceptional cases it did not take place until the seventh day, when it appeared in patches on the wrists and knees. On the eighth day, it extended to the rest of the extremities and abdomen, and on the ninth was general and of a rather dark hue. In the second exceptional case the eruption did not appear until the second day. It then came out over the whole trunk, and to a moderate extent upon the limbs also. In this, as in the previous one, it was dark in its tint. In three other cases it was quite moderate in amount, but general and well-marked. The general sipiipfoms are more severe in grave than in mild cases. It sometimes happens that for one or two days, or even longer, the case promises to be mild, but then suddenly assumes the threatening features of the form under consideration. The fever is usually intense, the pulse being full and strong, and rising very soon after the onset to 140, 150, or 170; the skin is very hot and dry; there is more restlessness and irrita- bility than in the mild form, and after one, two, or three days, appears a strong disposition to delirium and stupor, not unfrequently merging into coma. The respiration is accelerated, and in many instances, owing to the throat-affection, labored and difficult. In most of the cases, a loud gurgling, which is very characteristic, is heard in the throat, particularly when the child is asleep or dozing. This depends in part upon the col- lection of viscid and tenacious secretions in the fauces, — which sometimes embarrass the respiration so much as to make it necessary to remove them with a mop, — and in part upon the existence of the coryza of which we have spokeD. The coryza is a symptom of very serious consequence at all ages, but especially in young children. There is generally some cough, which may be frequent and troublesome, though not usually so unless there be a disposition to laryngeal complication. The voice is hoarse, guttural, and sometimes whispering. When the cough is very frequent, and still more, when it becomes hoarse and croupal, in connection with ] f- • or whi.«pering voice, or aphonia, there is great reason to fear the . \' -ion of the exudation into the larynx, which constitutes an almost ii» '^' -arily fatal accident. The face is deeply flu.shed at first, and the ex- pre?v»ion anxiou.s. If no improvement take place, the case as.«ume8 in four or 6ve days, or even less, a .«till more threatening aspect. The pulse be- comes ver}' rapid and small; the restles.sness and delirium pass into drowsiness or coma ; the tongue becomes brown and dry; the teeth are covered with sordcs; the lips are dry, cracked, and bleeding; diarrhnea is apt to occur; and the patient dies in from three to ten days, in a well- marked typhous condition. In other instances, on the contrary, the case 724 SCARLET FEVER. runs on from week to week, and at last, after an illness of four, five, or six weeks, the child either dies or recovers after all chances for life seem to have been lost. In order to show, in their natural connection, the different symptoms that have just been described, we will cite the following abstract of three of our cases. The first occurred in a boy between seven and eight years old. On the fourth day of the attack the pulse was at 150, and the fauces presented flakes of false membrane. The fauces were very much swelled, and deglutition became difficult; faucial gurgling came on, and the throat was filled with viscid and tenacious secretions. The nasal passages now became occluded by constant discharges, at first mucous and then muco- purulent, with admixture of membranous particles. From the fifth to the ninth day there was an excessive fetor from the nose and mouth. The lymphatic ganglions just beneath the ear swelled very greatly, so as to ex- tend much beyond the line of the inferior maxilla. The tongue and lips became dry and cracked, the teeth were covered with sordes, and the angles of the eyelids inflamed and then ulcerated. On the sixth, seventh, eighth, and ninth days, there were taken away from the mouth and throat of the child, with a mop, hard and most offensive masses of dried-up mucus and incrusted epithelium, enveloped in thick, gluey, dark-colored mucus. These masses stuck to the fauces, tongue, and lips, so tenaciously, that they could be removed only by means of a mop, the boy himself being quite unable to detach them. On the seventh, eighth, and ninth days, though the cervical lymphatic glands were very much swelled, the patient was better. The pulse came down gradually from 152 to 132, 128, and 112, and the swallowing improved so much that the child could take liquids with less convulsive effort, and could drink continuously. The drowsiness diminished, and the delirium ceased. On the eighth day a slight erythematous redness appeared on the bridge of the nose, and ex- tended towards the malar bones. The skin of the face and eyelids be- came somewhat swollen and puffed by an oederaatous effusion. On the ninth day the pulse was down to 104, and the skin was nearly natural as to temperature. The swelling was very great on both sides of the neck, and the glands on the right side were red on the surface, very hard, and quite painful. The swallowing was much easier for drinks, but as yet no solid, not even of the softest kind, could be taken. On the fourteenth day from the onset we opened a very large abscess on the left side of the neck, which discharged abundantly a healthy and laudable pus. On the fifteenth day we opened a still larger abscess on the right side, and, after this, perfect recovery took place. In another example, which has been alluded to already, occurring in a boy between four and five years old, the gravity of the case did not show itself clearly until the sixth day. On the evening of that day the pulse was 128, the skin very hot and dry, and there was an intense eruption of a brick-red color. There was, at the same time, great drowsiness, and utter loss of appetite. Deglutition was difficult, and there was a loud faucial gurgling during sleep. There was now also a considerable amount of membranous exudation in the fauces. During the seventh and eighth SYMPTOMS OF GRAVE CASES. 725 days, the boy continued very sick. He was drowsy, almost comatose ; the eyes were half open and the conjunctiva? minutely injected ; there was an abundant coryza, the discharges being composed of offensive mucous and sero-mucous fluid, with an admixture of pus and of flocculent or grumous particles, the latter consisting evidently of broken-down membranous exudation. There was no otorrha?a. The pulse rose from 120 to 128. During the night of the seventh day the anginose affection was so severe that the child could swallow nothing from 10 p.m. to 3 a.m. ; fluids poured into the mouth ran out again in part, and were in part returned through the nostrils. On the tenth day there was still no decided improvement, except that the pulse had fallen to 112. The coryza continued as before ; the fauces were covered thickly with whitish exudation ; the deglutition was a little easier. The drowsiness continued, as the child dozed nearly all the time, merely rousing from time to time to take drinks, and then, in spite of all solicitation, sinking into sleep again. The abdomen was tympanitic. The urine was rather free, more so than it had been before, and it was also clearer and of a lighter color. By the twelfth day there was a decided improvement ; the pulse had fallen to 106, and the child was not quite so heavy. The act of swallowing was easier, and the fauces showed less of the plastic exudation, but they were still very much coated with tenacious mucus. On the thirteenth and fourteenth days the patient continued to mend. The pulse fell to 98 and 92 ; the fauces had become clear of the exudation, and presented instead an excoriated and ulcerated appearance. The secretions into the fauces were less viscid and less copious. The coryza had diminished, and the discharges had become first muco- purulent and then mucous. The drowsiness had diminished, so that he wakee8 present liir i.'hout their whole course, symptoms so dangerous as those which marked the two examples that have just been detailed. In some, on the contrary, the symptoms, though of such a character as to deserve and re- quire the title of grave, are of a much milder kind. In order to make this part of our description of the disease as clear as may be, we will relate the following as an example of a grave case in which the symptoms, though severe, were neither malignant, nor at any one time very dangerous to life. A girl between seven and eight years old waa well at breakfast. In the coarse of the morning she complained of sore throat, and of not feeling 726 FEVER. well, and at 4 p.m., when we saw her, was quite feverish, with a frequent pulse and hot skin, and showed already a well-marked but rather faint scarlet rash upon the trunk of the body, and about the elbows. On the following day the trunk and upper parts of the limbs were covered thickly with an intense eruption, of a bright scarlet color. The fauces were very red, somewhat roughened and a good deal swelled. The only nervous symp- tom present was severe frontal headache. There was no unusual agitation, no drowsiness, and nothing like convulsive movement. On the evening of this day, the pulse had run up to 168, and was rather full, but not hard. The skin was exceedingly hot and burning ; during the night there was great restlessness, and the child was wakeful and occasionally delirious. On the third day the symptoms continued much the same, except that the pulse was down in the morning to 152, that the rash had extended to the hands and feet, and that some small spots of whitish exudation were now visible on each tonsil. On the night of this day the fever again increased very much, and the child was again delirious. On the fourth day the pulse was 148 ; the exudation had increased so much as to cover a good portion of both tonsils, and it had extended also in a slight degree to the posterior wall of the pharynx. There was now a considerable enlarge- ment of the lymphatic glands situated at the angle of the jaw on the left side, and a smaller one on the right side. Deglutition was somewhat painful, and a little difficult, but not seriously so. The case continued in much the same way until the seventh day, when the pulse had fallen to 132, and the eruption had faded very much on the trunk of the body, and, to a considerable extent, upon the limbs also. The fauces now exhibited the false membrane over the whole of both tonsils, over the half-arches, the sides of the uvula, and upon the upper portion of the posterior wall of the pharynx. Instead of being whitish and clean-looking as at first, how- ever, the false membranes now looked exactly like sloughing portions of the mucous membrane. They were of a dirty brown color, softened, and seemed to be detaching themselves like sloughs from the tissues beneath. On the ninth day the patient was much better, the pulse having fallen to 116; the eruption had almost wholly disappeared; the heat of skin was very much reduced ; the dark-colored portions of false membrane had dis- appeared from the fauces, leaving the mucous membrane beneath red, excoriated, and in parts ulcerated. On the thirteenth day, the child was convalescent, the pulse having fallen to 96, the heat of skin having disap- peared, and the throat being nearly well. The appetite had returned, the temper was serene and cheerful, and the patient was, in fact, well, with the exception of weakness, and some remaining soreness of the throat. Laryngitis has been supposed by some persons to be of frequent occur- rence in the course of the disease", while others assert that it rarely, if ever, occurs. M. Bretonneau has never met with it. M. Rayer says he does not know that the exudation has ever been found in the larynx or trachea. Tweedie {Cyclop. Pract Med., Art. Scarlatina, p. 640) states that in the dissections he has made he has not seen an instance of the membranous exudation extending into the larynx. That it does sometimes occur, is proved nevertheless, beyond a doubt, by the evidence of MM. Guersant SYMPTOMS OF GRAVE CASES. 727 and Blache, Rilliet aud Barthez, and others, and by our own observation. MM. Rilliet and Barthez report three eases in whieh it was found in the larynx atier deatli. These gentlemen state, however, that they have never observed the peeuliar symptoms of croup. This does not accord with our own experience ; for in several cases that we have seen, all the peculiar symptoms of that malady were present during life. The subject of one of these cases was a boy two years of age. A few days after the invasion of the disease, a severe and extensive pseudo-membranous angina was devel- oped. This was soon followed by all the symptoms of croup — hoarse cough, stridulous respiration, weak, feeble cry, dyspna*a, and wliispering voice, which lasted about five days, when the angina and croupal symp- toms both diminished very much, and the child seemed in a fair way to recover : suddenly, however, extensive tumefaction of one side of the neck took place, and he died in twenty-four hours. Unfortunately no examina- tion couKl be made. In another case, in a child between six and seven years old, who had a most violent attack of the disease, severe croupal symptoms set in on the eighth day. They consisted of harsh, croupal cough, stridulous respiration, and great difficulty in swallowing, and the act of swallowing occasioned much harsh cough and strangling. The symptoms continued on the ninth day, after which they moderated, and the child finally recovered entirely. In a third case, also a violent one, in a boy between eight and nine years old, and in which general convul- sions occurred on the first and second days, the symptoms had improved a good deal on the third or fourth day. On the fifth day he was not so well, being more restless and heavy, and having much difficulty in breathing, with some croupiness of sound. These symptoms increased rapidly until they gave rise to most violent fits of suffocation, and caused a fatal termi- nation on the sixth day. In a fourth case, in a child nine months old, death occurred on the thirteenth day from laryngitis, occurring in connec- tion with membranous angina. The fatal termination was preceded by hard, dr}-, and croupal cough, stridulous respiration, and great diffirulty of deglutition. In a fifth, in a child under a year old, croupal symptoms made their appearance on the sixth day, the fauces being at that time covered with membranous exudation, and they caused or assisted to cause a fatal termination on the eighth day. In yet another case, the subject of which wa** between one and two years old, a grave attack of scarlet fever was entirely recovered from. At the end of the second week the child wa.« seized, owing to improper exposure in a cold house, against which the parent>< had been properly warned, with anasarca. This also was recovered from, and again the parents were warned against improper exposure. On the vent* day after our last visit, however, the child was taken down stairs into a nyftm with the windows open, and this on a mild day in the month of February. The child was seized now with di[»htheritic angina, and died, after a few days, of croup. This was in the fourth week from the on.«€t of the scarlet fewer. In a seventh case, severe from the beginning, the patient recovered so as to be apparently out of danger, but, owing to the rr>om being very cold from the fact that it was large, with wide rat- tling windows down to the 6oor, aud from the fire being too small, the child 728 SCARLET FEVER. took cold, and, at the end of the third week, was seized with severe croup, which had many of the features of membranous croup, but which was, in all probability, spasmodic croup, dependent on ulcerative laryngitis. The case -continued seven days, during which time the patient was violently ill, but finally, after a most dangerous struggle, it ended favorably. The symptoms which indicate a disposition to implication of the larynx are frequent, hoarse, and croupal cough, hoarse and whispering voice or cry, aphonia, and dyspnoea with stridulous respiration. The duration of grave cases of scarlet fever is very uncertain. In some the disease runs its course with frightful rapidity, destroying life within a few hours or days. In others, though the symptoms of the early stage may seem to be as violent as in those where death occurs in a very short space of time, the patient either lingers for several days or two or three weeks, and then dies, worn out by the violence or malignancy of the attack, or else, after a most dangerous and apparently desperate illness, he finally struggles through and recovers. In the most violent of the grave cases, those which we described first as forming a separate group, 18 in number, of which 13 proved fatal, the du- ration in the fatal cases was between eighteen hours and six days. Of the 13, 2 proved fatal in eighteen hours, 1 in twenty-four hours, 2 in thirty-six hours, 4 in three days, 1 in four days, 1 in five days, and 2 in six days. Of the 5 favorable cases, 1 lasted three weeks, 1 four weeks, 2 six weeks, and 1 two months. Of the less violent of the grave cases, 43 in number, 15 died, and 28 recovered. Of the 15 fatal cases, 1 died in four days, 2 in five days, 2 in seven days, 3 in eight days, 2 in thirteen days, 1 in fourteen days, 1 in fif- teen days, 2 in four weeks, and 1 in five weeks. Of the 28 favorable cases, the duration of the shortest was seven days. The remainder lasted from twelve days to six weeks, the most common period being between three and four weeks. Complications and Sequelae. — Dropsy. — This is one of the most fre- quent and important sequelae of the disease. We have already remarked that in a considerable proportion of cases, the exact number apparently varying somewhat in different epidemics, the urine becomes albuminous during the stage of desquamation. This, however, is usually transitory, and probably depends partly on the condition of the blood itself, and partly on renal congestion. But in some cases, owing to one of the causes to be mentioned hereafter, the albuminuria persists, or if it has not been present or has disappeared, again makes its appearance ; and the symptoms of acute nephritis develop themselves. Among these the most striking one is dropsy, and, indeed, so prominent is it, as to have alone attracted atten- tion for a long time, and only to have comparatively lately been associated with a lesion of the kidneys. Certainly, in the vast majority of cases, when dropsy appears as a sequel to scarlatina, the urine will be found to present all the characters present in acute Bright's disease ; and yet there are some high authorities (Simon, Becquerel, Philippe, Eayer) who assert that marked dropsy may occur without the slightest albuminuria. It is possible that some of these cases 1 SEQUELS — DROPSY. 729 raay be explicable by the fact that the urine has only been occasionally examined, and that albumen may have been temporarily present but have been overlooked ; but it at present seems undeniable, that, in some instances also, dropsy may appear without any abnormal condition of the urine what- ever. It is probable that, in these cases, the dropsy depends upon an anirmic state of the blood, developed during the course of the disease. The frequency with which dropsy is developed, varies greatly in differ- ent epidemics and in different forms of scarlatina. It occurred in a fifth of the cases of MM. Rilliet and Barthez, and in 31 of the 274, or in about 8 ninth, of those observed by ourselves of which we have kept notes. It occurs generally in the course of the second or third week of the* disease, and during the process of desquamation. It is thought to follow cases of moderate severity much more frequently than those of a grave character. Dr. Tweedie states that it has never been observed to succeed a malignant attack. This does not, however, accord with our own experience, since of the 31 examples that we have seen, 8 occurred in grave cases of the disease. Still it may be said on the whole, that the susceptibility to renal disease bears an inverse proportion to the activity and complete development of the symptoms of scarlatina. The efiusion may attack any one of the cavi- ties or the cellular tissue of the body, or all at once. The most common form in which it appears is anasarca, afler which the most frequent are, in the order in which they are mentioned, wdema of the lung, hydrothorax, ascites, and hydropericardium. The exciting cause of the dropsy is generally believed to be cold, con- tracted usually by exposure to air and moisture at too early a period. We have rarely known it to occur when the patient has been confined to the chamber or house until after the twenty-first day ; while, on the other hand, we have seen it to follow immediately upon a ride in cool weather on the fourteenth day, the child having apparently been convalescent for seve- ral days before. We have known it to occu^/'also when the child has been allowed to run through the house exposed \/) draughts from open doors and Windows. We have been able, in a number of instances, to trace it directly and obviously to cold. Thus, in one very marked example, a boy between six and geven years old had had a mild attack of the disease, and was so en- tirely recovered that we ceased our visits on the tenth day, leaving strict injanctions with the mother as to the necessity of confining the child to the house for at least ten days longer. On the fourteenth day, he was al- lowed to sit for fiflecn minutes, late in the afternoon of a cool April day, on the marble front-door step. He was seized that night with fever and vomiting, had anasarca next day, and, during an illness of two weeks, had dropsy of the pericardium, effusion into the right pleural sac, ascites, and gome figns of uraemia. In another case, a boy eleven years old had recov- ered entirely of a mild attafk. He slept in a room heated by a stove. On the nineteenth day, the weather being cold, he got up early in the morning to light the fire, which had gone out accidentally. He was attacked that day with bronchitw, and was, on the following day, anasarcous. In another instance, anasarca was produced at the end of the third week, the child 730 SCARLET FEVER. being quite well previously, by his being taken into a cold room to sleep. "VVe could cite other instances of the same kind, but these are enough. It is sufficient to say that in a large majority of the cases that we have seen, it has manifestly and obviously followed improper exposure during the second or third week. In a few cases, however, it has come on without any imprudence whatever, and we have been entirely unable to ascertain the cause. Nor can it yet be asserted positively that the action of cold will fre- quently cause dropsy unless the urine have been previously albuminous : although it is undoubted that when albuminuria is present, any imprudent exposure will insure the occurrence of dropsy. We are in the habit now of always directing the mother or nurse to keep the patient confined to the chamber for four weeks from the onset of the disease, or, if it be allowed to run through the house, to take care to have it well clothed, and to keep the windows and doors carefully closed should the weather be cold or cloudy. This direction is one of the most important to be given in the course of the disease. It ought to be insisted upon in all and every case, occurring in the cool season of the year. The question was formerly much discussed, whether the condition of the kidney which accompanies scarlatinal dropsy was one of the forms of renal disease known as Bright's disease. Dr. Johnson suggested that it was a peculiar affection of these organs, characterized by a desquamation of the epithelium of the tubules, for which he proposed the name of des- quamative nephritis. Recent observations have, however, shown that there is in reality nothing specific in the lesion, but that it is identical with other cases of renal catarrh or tubal nephritis, to use the excellent name bestowed by Dickinson, occurring from whatsoever cause. Indeed, it may be said that in almost 75 per cent, of all cases of chronic renal disease in children, the cause of the affection has been scarlatina, and the form of the lesion is that which we have above mentioned. Various causes have been assigned for the frequent development of tubal nephritis in the course of scarlatina. Thus it has been supposed that the affection of the kidneys resulted from inaction of the skin, owing to the intense congestion which attends the eruption ; but clinical experience shows that it is precisely in the cases where the affection of the skin is most intense that the kidneys are least disposed to disease. It would rather appear that when the action of the virus is not fully determined to the surface, there is violent congestion of the kidneys established, which, especially when the patient is exposed to the action of cold, may result in the development of tubal nephritis. Morbid Anatomy of the Kidneys. — When death occurs in the acute stage of the renal disease, the kidneys are found enlarged and very heavy. The surface is smooth and injected ; on section, the organ drips with blood ; the Malpighian bodies are congested, and appear as red dots; and the vessels of the cortex and cones are gorged with blood. The tubules are distended with granular epithelium, granular matter, or fibrinous plugs. The cortex appears coarse-grained, and presents intermingled dots or SEQUELS — DROPSY. 731 Streaks of red and buff color. In the more chronic form of the disease, the kidney is also much enlarged and very heavy; its surface smooth, and pale, or dotted with congested stellate vessels. The capsule is not thickened, and is readily removed. On section, very little blood escapes; the cones retain their pinkish or red color ; while the cortex is coarse- grained, thickened, and of a peculiar opaque white color. The Malpighian bodies may be distended, owing to obstruction to the escape of the blood. The principal lesion, however, is still found within the tubules, which are stuffed with epithelial cells, or with granular matter resulting from their disintegration ; occasionally, clear fibrinous plugs are also seen occupying their calibre. It frequently happens that the epithelium undergoes fatty degeneration, and when this is marked, the cortex acquires a yellowish tint. According to Dickinson, there is less tendency to this change in cases of tubal nephritis following scarlatina than after other causes ; a circumstance which he thinks may possibly account for the comparatively curable nature of scarlatinal dropsy. The drop.?ical sifmptoms usually show themselves in the third or fourth week of the disease, and are generally preceded for a few days by albu- minuria. In most of the cases that we have seen they occurred in the third week, but they sometimes appear at the end of the second, and sometimes not until the fourth week. In one case they showed themselves first on the thirtieth day, after the child had been exposed to too cool a temperature in an insufficiently warmed room. They occur, therefore, as a general rule, during the stage of desquamation. The attack is some- times very sudden, but in most instances it is slow and gradual. The effusion is not commonly the first symptom observed. On the contrary, the dropsy is almost always preceded for one or two days by the signs of a more or less considerable constitutional disturbance. The patient has usually passed safely through the eruptive stage of the fever, and has been considered for several days as convalescent, for, as we have already re- marked, the dropsical affection is much more rare after grave than after mild cases. The child has perhaps been running about the house, or it has even been out, the parents supposing, unless warned by the physician, from the disappearance of the fever and other symptoms of illness, and from the return of appetite and gayety, that complete recovery has taken place. But, either after some exposure, or sometimes without any appre- ciable cause, the child becomes drooping, languid, and irritable, or uneasy, peevish, and restless. Simultaneously with or very soon after these symp- toms, fever sets in ; the skin becomes dry and heated, and there is usually aD elevation of the temperature to the extent of 4° or 5°; the pulse is fre0, in young children, within the first twelve or twenty-four hours, and to 120, 130, 140, or higher, in those who are older. Nevertheless, this, like all other symptoms, is some- times wanting. We have lately seen a boy, between five and six years old, with a marked but very safe attack of the disease, whose pulse ranged between 80 and 90 throughout the sickness. This was, however, the only case we have ever met with, in which the pulse remained so little dis- turbed. It is sometimes ver}' difficult to determine with precision between roseola and sf-arlet fever. By the eruption alone, we believe it to be often im- possible. We have seen quite a number of cases in which the eruption of roseola resembled so closely that of scarlet fever, that we should have been obligerl to confess our inability to make the distinction had it not been for the other symptoms, and particularly the frequency of the circu- lation, the heat of the skin, and the throat symptoms. The most impor- tant difTerential symptoms are the tint of the eruption, which in roseola is mse-colored, in scarlet fever bright-red or scarlet ; the characters of the patches of eruption, which are more regular in shape, but of much smaller -ize in roseola than in scarlet fever; the absence or very slight degree of anginose inflammation in roseola; and, what is decidedly the most impor- tant of all, the very much slighter degree of febrile reaction in roseola, in which the pulse, instead of being doubled in frequency as it is in scarlet 740 SCARLET FEVER. fever, is scarcely above its natural rate, and in which the heat of skin is but little above the standard of health. Moreover, roseola is generally of shorter duration, and is a milder affection, and therefore accompanied by far less fever and general disturbance of the constitution. Diphtheria occasionally resembles scarlatina to so great an extent, as to have even led some observers to consider them identical. Thus, there is in diphtheria a pseudo-membranous angina, with swelling of the cervi- cal glands, and at times albuminuria, and even an erythematous rash. We have elsewhere (see article on diphtheria) given at length the differ- ential diagnosis between these affections, and will here merely call atten- tion to the fact that the rash is a rare exception in diphtheria, and is a mere uniform erythematous redness ; that even when albuminuria is pres- ent, the urine does not present the other characters noted in scarlatina ; and that the condition of the fauces in the two diseases is somewhat dif- ferent. There is, further, a wide difference in the sequelae of the disease ; and, finally, they do not exercise any protective power whatever against each other. There is a form of disease known as rubeola notha, epidemic roseola, rosalia (Richardson), rotheln, in which there are some of the symptoms of both measles and scarlatina ; the eruption appearing on the second or third day, at first resembling that of measles, but becoming soon more like that of scarlatina. Coryza and angina may both be present, and there is subsequent desquamation. Some authorities regard this as a union of the poisons of measles and scarlatina, while others consider it a separate disease, because epidemics of it occur when neither measles nor scarlatina are prevailing. Previous attacks of these latter do not protect against it. In an extensive epidemic in the lower part of this city, which appeared to be of this nature, not a single case, of the numbers which came under our observation, was followed by any of the sequelae of either measles or scarlatina. Prognosis. — It is impossible to obtain a useful average mortality of scarlet fever, since the disease varies so greatly in different epidemics, and under different hygienic conditions, that the results obtained during one period are inapplicable to cases observed at another. This is proved by the experience of almost every physician, and by the evidence of many writers. It is proved, also, by the following facts : M. Gueretin {loc. cit., p. 283) states that the mortality in the epidemic observed by him was about 1 in 12 ; of 99 cases, 8 died. MM. Pilliet and Barthez lost a little more than half their cases ; of 87, the total, 46 were fatal. These cases, let it be remarked, however, occurred in the Hospital for Children in Paris, which will account for the heavy fatality. The degree, however, to which the mortality may vary in the same place and under the same plan of treatment, is shown by the fact, mentioned by Hillier, that in the course of eleven years the annual mortality from scarlet fever in the Lon- don Fever Hospital, varied from 2.5 per cent, to 16.5 per cent.; and in the Hospital for Sick Children in London, from 9 to 31 per cent. Of the 274 cases that we have observed, 31, or rather more than one-ninth, were fatal. Of the 274 cases, 104 occurred between 1849 and 1853, and in PROGNOSIS. 741 those the mortality was much smaller than in those which occurred prior to that year. Of 104, 11 were fatal, or about one in nine and a half Seventy-eight cases occurred between 1853 and the spring of 1857. Of these 78, only 4, or 1 in 12, were fatal. Of 81 cases observed previous to 1849, 13, or about 1 in 6, proved fatal. Of 11 cases occurring in 1872-3, 3 proved fatal. The mortality met with by ourselves in private practice has greatly varied, therefore, in different series of years. In one series it was 1 in 6, in another 1 in 9], and in a third 1 in 12. Lastly, to show the influence of the epidemic type upon the mortality still more clearly, we may state that of the last series of cases observed, 78 in number, 43 oc- curred during the epidemic which lasted from the summer of 1856 to the spring of 1857, and of these only 3, or 1 in 14, died. The prognosis must be based, therefore, in part on the character of the epidemic prevailing at the time. It must depend, also, on the nature of the case. Mild and regular cases are rarely fatal. Of 206 mild cases that have been under our care, only three proved fatal. One of these would probably not have so terminated had it not been for the imprudence of the nurse. This was, in fact, the case of a young child who had recov- ered from the eruptive stage of the disease, but whom the nurse carried out of the room in the second week, notwithstanding express directions given her to the contrary. The child took cold and was seized with catarrh and slight anasarca; on the fifteenth day urajmic symptoms set in, and he died on the seventeenth day, comatose, and with convulsive movements of different parts of ihe body. The second case was that of the boy thirteen years old, already lescribed, who died with sudden hydrocephaloid symp- toms, at the end of the second week. The third fatal case occurred in a girl between eight and nine years old, who died suddenly at the end of six weeks. The patient had convalesced sufficiently to have been out several times, but remained very hydrjemic and weak. After being much fatigued one afternoon by playing with some little friends, she was seized next day with vomiting, and soon after with great difficulty of breathing and extremely rapid and feeble action of the heart. These symptoms increased on the following day. The dyspntea was most severe, and was attended with cyanotic color of the hands and face, and with cold colliquative sweats. The lungs were free, there wa.s no cough, and auscultation revealed no pericardial lesion. Death occurred suddenly at the end of a day and a half No post-mortem was made, owing to cirrumstanres that could not be controlknl. Our own opinion was, and is, that tho doath was caused by a coagulum in the heart. Oravp ca«e8 of scarlet fever are always, on the runitary, exceedingly danirf'f'tus : thus of 61 caees of this kind that we have had under charge, 28, or nearly a half, were fatal. In ordcT to render the description of the symptoms of this d&Ni of cases more clear, we divided them into two groups ; one, in which the onset of the disease is instantaneous and most violent, being characterized by excessive disturbance of the nervous sys- tem, taking the form usually of convulsions, but sometimes only of pro- found coma ; and a second, in which the symptoms of the onset, though severe enough usually from the first to mark the character of the case as 742 SCARLET FEVER. grave, are less violent than in the first group, and especially not marked by the occurrence of convulsive phenomena. Of 18 cases belonging to the first group, 13 died ; while of 43 belonging to the second, 15 died. Violent nervous symptoms occurring early in scarlet fever augur, therefore, great danger to the patient, since of 18 cases in which they were present, 13 died, ■whilst of 43 in which they were more moderate, though still marked and severe, only 15 died. The character of the nervous symptoms is, therefore, all-important in the determination of the prognosis, as the probable termination of the case is to be foretold more certainly by a just appreciation of these particular phenomena of the disease, than by any other means. Excessive jactitation or irritability, delirium, coma, and the hydrocephalic cries, are all unfavor- able symptoms, but not in the same degree as are those connected with the locomotor apparatus. MM. Killiet and Barthez state that they have seen recoveries take place in cases in which the intelligence of the patient had been very much disordered, while of those who " during the first fifteen days of scarlatina, were taken with convulsions, convulsive movements, contractions, in a word, any symptoms affecting the locomotor apparatus, all, without exception, died." This does not accord exactly with our own experience, though nearly enough so to show how exceedingly dangerous are the symptoms just enumerated when they occur early in the disease. General convulsions occurred on the first day of the disease in 9 of the 61 grave cases observed by ourselves, and of these not one terminated fortu- nately ; in four they occurred on the second day, and of these three recov- ered and one died ; in one they occurred on the ninth day, and this patient also recovered ; in another case there were no general convulsions, but on the first day there were automatic motions, with involuntary extensor mo- tions of the arms and fingers, and on the second day strabismus, with a continuation of the automatic motions. This case proved fatal. Of the 15 cases, therefore, in which marked disturbances of the muscular system occurred, only 4 ended favorably. Of 10 subjects in which the convulsive phenomena occurred on the first day of the disease not one escaped. Of 5 subjects in whom these symptoms appeared on or after the second day, 4 escaped. One of the favorable cases occurred in a boy seven years old, who had a general convulsion, lasting several minutes, pn the second day of the attack ; this was followed by delirium and coma alternately, but no return of the convulsions. The case was a most violent one, and lasted six weeks, leaving the child at the termination very deaf, but otherwise in good health. The second case occurred in a child five months old. The convul- sive symptoms appeared on the ninth day, and consisted of strabismus, spasmodic retraction of the head, and occasional slight spasms of the limbs. They alternated with coma, and disappeared on the tenth day, until the seventeenth and eighteenth, when the strabismus reappeared. The child recovered perfectly. The third was that of a very healthy and vigorous boy between eight and nine years old, who, on the second day of an attack which had begun like a severe cholera morbus, had, twice, fits of insensi- bility, with stiffening pf the extensor muscles of the fingers, rigid contrac- tions of the flexors of the arms, and spasms of the eyeballs. This case PROGNOSIS. 743 proved afterwards very violent, so that the patient nearly died on the fifth day, with asphyctic symptoms caused by very great swelling of the tonsils and fauces, and enormous enlariremeut of the external cervical lymphatic glands, complicated moreover with extensive acute oedema about the chin and front of the neck. These symptoms were followed again by diph- theritic deposit covering the whole of the pharynx. He finally, however, recovered, perfectly. The fourth case was that of a boy between five and six years old, who, on the second day, had an attack of general convul- sions, which were repeated frequently on the third day. This patient con- tinued ver>* ill for several days, and when, at last, he began to improve somewhat in the middle of the second week, it was found that he had lost entirely the power of speech, and all control over nearly the whole of the locomotor apparatus of the body. He could neither lift his head nor turn it ; the legs were immovable ; the hands were perfectly helpless. The only motion that remained was a jerking, apparently almost automatic, move- ment of the arms upon the shoulders, and the forearms upon the arms. But even these were most irregular, and badly co-ordinated. He was very much in the condition of a new-born child. It was very difficult to as- certain what the condition of his senses was; but after a short time we were able to satisfy ourselves that he saw and heard, and only after many weeks was he able to hold a very light object in his fingers, then to move his head from side to side, and at a still later period to hold it up. At the end of about two months, he could sit in a chair when once placed in it, but could not sit on the floor unsupported. At the end of three niduths he was learning to walk by being held up by the arms. He had never spoken a word. The only approach to anything like articulation was his ability to hum a low gentle musical note; his intellectual faculties, as ex- hibited by signs, had regained their natural condition at this time. At the end of ten months, he could speak intelligibly some three or four words. The fifth case was that of a male infant, nine months old, who, on the second day, had severe general convulsions, followed by very deep drowsiness. The eruption became intense, and, on the third day, the con- vulsive symptoms recurreea ranee of the eruption ; a livid or purple tint of the eruption ; slow and im[K'rfect capil- lar}- circulation, as ascertained by presj»ure; the appearance of petechia, ecchymoses, or hemorrhages; violent vomiting and colliquative diarrhcea ; 744 SCARLET FEVER. great violence of the throat affection, whether from tumefaction, great abundance of pseudo-membranous exudation, or disposition to ulceration and sloughing ; and lastly, severe coryza or otorrhoea. A disposition to a typhoid state, indicated by dulness of the intelligence, dusky hue of the skin, frequent and feeble pulse, dry, brown tongue, sordes on the teeth, meteorism, and disposition to diarrhoea, is always dangerous. When, on the contrary, the fever is moderate, the cerebral symptoms absent or very slight, and the eruption regular, and of a bright tint ; when - there is no disposition to typhoid symptoms; when the throat affection is mild, and the disease pursues a regular, uniform course, we have every reason to expect a favorable termination in a large majority of the cases. In addition to these remarks it may be said that neither age, sex, nor social position influence the prognosis. A delicate constitution does not seem to predispose to a violent attack of scarlatina, and indeed, many of the most malignant cases occur in very robust children ; but, on the other hand, it has been noticed that in certain families there exists a strong ten- dency for the disease to assume a grave and fatal form. Treatment. — Hygienic treatment. — -In all cases of the disease, whether of the mild or grave kind, the strictest attention should be paid to the hygienic condition of the patient. The room in which the child is placed ought to be, if possible, large, and at all events well ventilated. The tem- perature in winter should be carefully attended to. We usually direct it to be kept at from 68° to 70° F., during the early stages of the disease, unless the fever is violent and the child complains of heat, in which case it may be allowed to fall to 66°, or even 62°. The clothing ought to be moderate, not enough to increase the heat of the skin, nor yet so little as to endanger chilliness. During the latter stages of the disease, when the fever has subsided, and particularly when the heat of the skin has fallen, the temperature of the chamber ought to be kept, as a general rule, at from 68° to 70°, and, when the child is pale, weak, and chilly, it may be maintained w^ith great propriety at 72°. One of the most important points in the treatment of scarlet fever is, undoubtedly, the management of the patient during the convalescence, and especially during the desquamative period. It is during this period that the child is liable, as we have already shown in our account of the different complications and sequelae of the disease, to dropsy, which is the most frequent, and at the same time the most dangerous accident to which the patient is exposed. There can be no doubt, we think, from the opin- ions expressed by various writers, and also from our own experience, that the most common cause of this accident is exposure to cold. Chilling of the body, no matter how produced, is . exceedingly apt, when it occurs within three, or, more rarely, four weeks from the invasion of scarlet fever, to be followed by a more or less marked attack of some form of dropsy. It is true, we are well aware, that dropsical effusions sometimes take place in subjects who have been guarded in the most careful possible manner, and in whom there has been no evident exposure to cold ; but it is also true, that a much larger number of those who have been thus guarded, escape, than of those who are not thus taken care of. We have, therefore, 1 TREATMENT OP MILD CASES. 745 no doubt whatever, that it is most wise and prudent to confine the patient to well-warmed rooms, or at least to the house, for twenty-one or twenty- eight days from the outset of the disease. The fact that the attack has been a slight one only makes it the more necessary to carry out this regu- lation, as it has been found by experience that dropsy occurs more fre- quently after mild than after severe attacks. 'M. Legcndre {Bccherchc,-^ Anat.-PathoL, p. 311) is of opinion that the patient ought not to be allowed to leave the house until the skin, completely deprived of the old epider- mis, shall have regained its suppleue^, its smooth and polished appear- ance, and all its functions. When, therefore, after a mild case, the des- quamation is completely terminated in three weeks, the patient, he thinks, may be allowed to go out. But, on the contrary, this period would be too short by one-half, if the eruption had been very intense, as the des- quamation is, in such cases, scarcely finished on the hands and feet at that time. Our own opinion, as already stated, is, that in the cool seasons of the year, the patient ought to be restricted to the house during full four weeks. Treatment of ^Iild Cases. — Mild cases of this disease, those in which the eruption is moderate in degree, the temperature but little above the normal point, even though the pulse be very frequent, in which neither delirium, stupor, nor unnatural jactitation betray threatening conditions of the ners'e-centres, need but the simplest treatment. The child must be confined to a comfortable, well-ventilated room, and cooling drinks, as cold water, lemonade, or orangeade, should be allowed, and indeed they ought to be recommended, and the nurse should be made to understand that she is not to wait until a young child calls out for drink, but that she is to offer it frequently. Young children, or at least some, seem not to know when they are thirsty or hot or cold ; they have not yet learned to express their sensations in words, and a wise nurse or physician will act for them. In all ca.end upon the case. When the eruption is intense, the skin very hot, and the febrile symptoms marked, they should be made every two or four hours, or even oftener. In milder 748 SCARLET FEVER. cases they Deed to be repeated only three or four times in the twenty-four hours. Treatment of Grave Cases. — The most dangerous cases of this dis- ease are those of the type described at page 720, in which the attack is sudden, and in which disorders of the nervous system in the form of con- vulsions, tremors or rigidity, retraction of the head, delirium, stupor, or coma appear within a few hours of the onset. When this type of the disease attacks very young children, they, so far as we have seen, nearly always die in sixteen, twenty-four, or forty-eight hours. Older children have more chance of escape, but, even in them, the danger is extreme. We have seen everything tried in these cases, from depletion by bleed- ing and leeching, many years since, to expectancy, and must confess that we have little faith in the power of human agency to contend against this particular array of symptoms. Depletion is no longer, we believe, thought of by any, and there is often no time for the action of drugs. It is in such cases that the' use of water at different temperatures, and applied in the form of baths, affusions, packings, ablutions, and ice has been recommended, and has seemed in some cases to do good. We shall give a rapid sketch of the opinions of those who have used these means, and then state our own views. Dr. J. Currie, of Edinburgh, was the one who first and most promi- nently brought before the profession the use of cold water in this disease. It must be observed, however, that Dr. Currie limits its use to cases to w^hich he applies the term anginose, many of which, we doubt not from his description, ought to be classed as mild cases. He mentions another class of cases which he thinks ought rather to be called " purpurata," charac- terized by " extreme feebleness and rapidity of the pulse, and great fetor of the breath The heat does not rise much above the standard of health. Great debility, oppression, headache, pain in the back, vomiting, and sometimes purging, accompany its rapid progress ; the patient sinks into the low delirium, and expires on the second, third, or fourth day. .... The cold affusion is scarcely applicable to it, and the tepid affusion makes little impression upon it. In my experience, indeed, all remedies have been equally unsuccessful. It outstrips in rapidity, and it equals in fatality, the purple confluent small-pox, to which it may be compared." {Curriers Med. Reports^ Philada. ed., p. 277.) It is clear, therefore, that Dr. Currie, when he speaks of nearly invariable success in upwards of one hundred and fifty cases (p. 286), had to do, not with the malignant, or, at least, not with the most malignant forms, for which we are seeking a remedy, but with cases of a mild form, or at most with those of the severe anginose type. Indeed, at page 294, we find the following remarks : ** It has come to my knowledge, that in two cases of scarlatina, of the most malignant nature, the patients have been taken out of bed, under the low delirium, with the skin cool and moist, and the pulse scarcely per- ceptible. In this state, supported by the attendants, several gallons of perfectly cold water were madly poured over them, on the supposed au- thority of this work ! I need scarcely add that the effects were almost immediately fatal." We have been induced to enter thus much into detail, TREATMENT OF GRAVE CASES. 740 in regard to the use of cold aftusious, because of the iutriusic importance of the subject, and because of the remarks upon it in the >York of MM. Rilliet and Barthez, who bring forward Currie's success a^ a strong argu- ment in favor of their employment of them in that form of the disease in which cerebral symptoms predominate. Currie does not recommend them, however, except in case^ in which the reaction is full and strong, as indi- cated by very great heat of skin, scarlet eruption, and rapid, but not feeble pulse. In the famous cases of his own two children, it is evident that the attacks were not malignant, for the skin was very hot (108° and 109° F.), and no mention is made either of stupor or delirium, much less of convul- sive phenomena. Dr. George Gregory, of London, whose opinions upon ail matters connected with the eruptive fevers are of course worthy of great weight, says {Led. on the Eruptive Fevers, edited by Dr. Bulkley, New York, p. 190), in relation to the use of cold affusions: "Sanctioned by my uncle, the late Dr. Gregory, of Edinburgh, this plan has been amply tried in all parts of the world, but it has not realized the expecta- tions of its proposer. " The truih is that the cold affusion is applicable only to a small num- ber of cases. It is adapted for young people with high anginose inflam- mation and a burning hot skin, without plethora, without depression of nervous energy ; but it is inapplicable to the scarlatina of adults, accom- panied with coma, phrenitis, or marked debility. It is wholly unfit for causes of cynanche maligna. It answers its purpose very well for the first day or two, but it is often impossible to continue its use. Lastly, it seems to increase the disposition to dropsy." Dr. Currie's method of using water was by effusion. The child is un- dressed and placed erect or sitting in a tub, while four or five gallons of water, at from 60° to 70° F., are poured over the head and body. The good effects of the remedy are said to be an immediate reduction of the heat, a diminution in the rapidity of the pulse, which, in one of Dr. Greg- ory's children, fell in half an hour after the cold affusion from 160 to 120, a disposition to sleep and quiet, and, according to Dr. Gregory, a seeming arrest of the throat affection. These good effects of the affusions are tran- sient, however, as the heat of skin and rapidity of the circulation return in the course of one or two hours. For this reason it is necessary to re|>eat thera frequently, once in two or three hours at least, in order to render the effects permanent. Currie used fourteen affusions for one of his own chil- dren, and twelve for another, in thirty-two hours. These were not, how- ever, all cold. Gregory u.«*ed for his child five "good sousings," to use his own words, in twenty-four htjurs. MM. Rilliet and Barthez give, in the following words, the conclusions of Henke in regard to the use of cold affusions: 1. Cold affusions are not adapted for a general meth(xl of treatment. 2. The slight, or simply in- flammatory forms, do not all demand so energetic a treatment. 3. Their employment must be reserved for ca."ie8 in which the disease is epidemic, and accompanied by intense heat and dryness of the skin, with smallness and acceleration of the pulse, anfl for those in which the cerebral symp- toms are very violent and characterized by great restlessness, alternating 750 SCARLET FEVER. with drowsiness, commencing from an early period of the disease, Scarlet fever under these circumstances is so dangerous, they say, and so often mortal, that recourse ought to be had to all curative means, and in chil- dren the cold affusions are much more strongly indicated than bleeding (op. cit, vol. ii, p. 653). Dr. Hiram Corson, of Montgomery County, in this State, has, so far as we know, used cold externally more boldly than any one in this country. He began this treatment in 1844, and, in a report made by him to the Pennsylvania State Medical Society, " On the External Application of Ice to the Throat as a Remedy in Scarlet Fever and Diphtheria" (see Transact, of the Med. Soc. of the State of Pennsylvania, for the year 1864), declares his unabated faith in the excellence and safety of the treatment. He advises, in cases attended with convulsions, the pouring of cold water from a height of a few feet on the head for several minutes at a time, — this to be re- peated every fifteen or twenty minutes until relief is obtained. At page 467, he says : " Hundreds of times have I had patients brought to the side of the bed and cold water poured freely over the head, until the stu- pid, almost comatose child, was yelling, and kicking, and striking to get rid of the falling water ; and this I have repeated whenever the symptoms called for its repetition." He prefers in these cases the cold afifusion to ice. He also applied pieces of ice wrapped in cloths, to the neck, when the anginose symptoms were severe, and, when the temperature was very high, washed the whole body with iced water, until the heat was reduced. Dr. Corson, in this article, speaks with the greatest possible confidence of his treatment, and when others evince some dubitation as to the invari- able success of the cold treatment, avers that they had used it imperfectly or with timidity. It is really unfortunate that his paper deals altogether in general assertions. At page 458, he says : " And now, after twenty years of experience in the use of it, and after treating scores and scores of cases, I am most happy to say that I have never seen the least injury produced by it, but, on the contrary, regard it as the means, above all others, of comfort and safety to the patient." He does not refer to a single fatal case during the twenty years he has been using this system. At page 453, however, he speaks of having " during the whole winter, in about one hundred cases, continued the treatment in degrees apportioned to their mildness or severity, and without the loss of a single patient thus treated." Nevertheless his experience is valuable, for it shows that, in some cases, at least, the use of means which reduce rapidly the heightened tempera- ture of the body in scarlet fever, acts as favorably as it has been found to do in the hyperpyrexia of sunstroke, rheumatic fever, and in continued fevers. Hillier (Dis. of Children, p. 326) states that he has employed cold affu- sions with good effects in a few malignant cases. He used water from 70° to 75° F., wrapping the child immediately after the aflTusion in dry blankets. He adds that " in cases of collapse with cold extremities, it would not be prudent to resort to the operation." Trousseau {Clin. Med., Syd. Soc. ed., vol. ii), recommends cool or cold affusions when dangerous ataxic nervous symptoms make their appearance. ^1 let ^ I TREATMENT OF GRAVE CASES. 751 At page 198, he says : " I declare to you that I liave never resorted to the eraploynieiu of eoUl aftusions without obtaining beneficial results. I am ftir from pretending that all my patients recovered : like my colleagues, I have lost the greater number, but even those who died experienced a temporary relief frotn suftering, and the affusion, so far from proving injurious to them, always moderated the symptoms, and also seemed always to retard the fatal termination." At page 20(), he states that he does not use them in- discriminately in all cases, but only ** to subdue serious nervous complica- tions — formidable ataxic symptoms." Dr. Gee (Reynolds's Si/4. of Med, vol. i) speaks of the cold affusion as being sometimes useful in the malignant form of the disease, attended with delirium, diarrhcea, vomiting, full pulse, and great heat of skin. He adds, however (p. 355), that in the " primary adynamic form, all treat- ment will be baffled. The cold affusiou is the only means which has seemed to me to be of even momentary benefit." We shall now refer to our own experience in the employment of exter- nal cold. We never use it to its full extent except in really dangerous cases. So long as the case is mild or moderate, or even severe, if there be no cerebral, and especially no locomotor disturbances, we deem it un- necessary, and rest content with more simple means ; or we use simply ab- lutions with tepid or cool water, with cold applications to the head, so long as they are agreeable, and until the temperature is reduced. But, when the temperature rises very high (105°), or, as Currie states in one case 112^, and Dr. Woodman (Wunderlich on Medical Thermometry, ^yd. Soc. ed., p. 204, footnote), 115° F., with nervous symptoms, the danger is ex- treme, and we have used, and shall use heareafter, means to reduce the heat. In one case we made repeated affusions upon the head with water at 70°, pouring at one time seven bucketfuls upon the part. This was a case attended with coraa, strabismus, and spasmodic retraction of the head. In addition to the affusions, cloths dipped into iced water, were kept applied the greater part of the time. These means, especially the affusions, were evidently advantageous, and the child recovered. We have made use of lotions with cool water (70° to 72°) in three grave cases. In two they were evidently useful ; in one they did no good, and were perhaps injurious, as we believe now that the case might have been better treated with prolonged warm baths at a temperature of 92° to 95°, cold to the head, and internal stimulation. The latter case was one in which the patient had two convulsions on the first day, and one on the second. The pulse rose at once to between 160 and 170; the head and trunk were very hot, whilst the extremities were coolish ; the child was either excessively dull or comatose. Cloths wet with iced water were kept constantly upon the head and the body, and occasionally the limbs were sponged with cold water. The internal remedies consisted of carbonate of ammonia and milk punch. The patient improved decidedly on the third day, so that the pulse came down to 152, the intelligence returned, though the child was still very drowsy and heavy, and the case looked quite prom- ising. On the fourth and fifth days, the throat afffction came on ; the neck and throat swelletl enormously, the cervical lymphatic glands became very 752 SCARLET FEVER. large, the nasal passages discharged streams of offensive grumous pus, the ears ran copiously, the fauces became pseudo-membranous, the deglutition grew worse and worse, until at last it was impossible, and the child died on the middle of the sixth day, a mass of the most disgusting and offen- sive disease. One of the grave cases in which the cool applications proved useful, occurred in a hearty, vigorous girl, twelve years of age. On the third day of the attack, the symptoms were as follows : the pulse was be- tween 160 and 170, small and quick; skin intensely hot ; eruption very copious and of a dark red color tending to violet ; capillary circulation slow and languid ; tongue black, and covered with a hard, dry crust ; teeth and lips dry, and covered with dark incrustations. There was very great agitation and restlessness, with constant moaning and complaining, and total insomnia. Under these circumstances, we directed the nurse to sponge the head and extremities of the patient with water of the tempera- ture of the room (68° to 70°). As the water became heated by contact with the skin, small pieces of ice w^ere put into the basin so as to keep the temperature at the point mentioned. At the end of four hours, the wash- ing having been continued all the time, we found the patient decidedly more comfortable. The pulse had fallen to 140, and increased in volume; the heat of skin was much reduced ; the color of the eruption had im- proved, having become much more scarlet in tint ; the capillary circula- tion was more active; the agitation and restlessness had very much mod- erated, and the child had slept somewhat at short intervals. This treat- ment, in conjunction with the internal administration of the solution of chlorinated soda, and small doses of spirit of turpentine, was continued for several days, the sponging being used whenever the heat and restlessness were great, and the pulse very rapid. The child convalesced about the end of the third week, but was unfortunately seized with uraemic symptoms on the twenty-fifth day, and died in twenty-three hours, after the most frightful convulsions we ever saw. Since the publication of the last edition of this work we have seen but little grave scarlet fever, and our experience as to the exact value of cold has not been much increased. It was used by our advice in the follow- ing case, of the most violent type, to which we were called in consultation. Case. — The patient was a girl, two years old, who, seized in the morning of one day with vomiting, fever, and restlessness, had, during the following night, hot fever, violent jactitation, and moaning. She rofujed all food. Next day, at 9 a.m., when we saw her, she was imminently ill. She knew no one, paid no attention to father or mother, tossed incessantly about the bed or in their arms, so that it was almost impossible to hold her; and at times had rigid contractions of the muscles, like those in tetanus. The features were drawn and rigid; the pulse running up- wards of 180, very feeble and small ; the skin very hot, but there was no eruption. The latter fact might throw some doubt on the diagnosis; but the character of the symptoms, the rapid fatality, and the fact that a few days afterwards two children were seized with distinct scarlet fever in the house opposite, leaves no doubt in our own mind. The prognosis was as bad as it could be, and so we announced, but added that external cold ought to be tried. The body temperature was very high, and we directed basins of water with ice in it, as used by Dr. Corson, to be prepared. Towels wrung out of this water were kept on the head, and the body and limbs sponged TREATMENT OF GRAVE CASES. 753 ■wilh tho cftmo until the heat fell, when the washings were suspended tempornrily, to be renewed when the hent rose agiiin. The treatment was carried out very cor- rectly, as there was a medical man present all the time, but it was of no use what- ever. The child died at V2 m. of that day, in a little over twenty-four hours from the onset. This case was not a fair test of the value of the treatmeut. The cold was applied too late to show clearly what may be il^ power. But we con- fess that its total fiiilure, though used withiu tweuty-four hours of the inception of the disease, is a melancholy proof of the extreme danger of such cases. A second case, which occurred about the same time, also shows the vio- lence of this form of the disease. Case. — A very healthy girl, within a few days of two years old, whose sister and two of whose cousins had been ill with scarlatina in the same house for some ten days, was seized at six in the morning with vomiting. She then slept for a time and vomited again. At 9 a.m. she had a convulsion, which lasted, with short lulls, during which she was comatose, until 6 p.m., when one of us saw her in con- sultation. She was then very hot, covered with a copious, dark, dingj' eruption, and insensible. Despairing of any other treatment, we advised cold externally, and arranged for its use by a physician, with the thermometer as a guide. Before the treatment could be commenced, the child became again convulsed and died. After thus stating the conditions under which we think external cold may be properly used, we must protest against its indiscriminate use in all cases of dangerous scarlet fever. If the reader will glance back at page 748, he will see what Currie thought of the rash use of his cold affusions, and what Dr. Gregory also states of the effects of cold. When the body, instead of being hot, is cool — when a dingy and stagnant capillary circulation shows a feeble and struggling heart, it would be most dangerous to use cold. Here the warm or tepid bath or affusion should be used, or warm mustard foot-baths may be resorted to every two or three hours. If, even wiiilst the body and limbs are cool, the head is hot, it would be proper to apply cold by cloths or affusion to that part, whilst the body is immersed in warm water or wrapped in proper coverings. The true guide as to the propriety or impropriety of using cold is, none can doubt now, to be found in the thermometer. The method followed by Drs. Wilson Fox and H. Weber in the ca.ses of hyperpyrexia occurring in the course of rheumatic fever is the one which we propose to use ourselves and to recommend to others. It is the only scientific one, and therefore the one which can be accurately described and followed. If errors occur, they can be definitely stated and afterwards avoided. If successful, the ex- act means which led to success can be ascertained and communicated in pre- ci.«e language. Dr. Fox published his cases first in the London Lancet, and then presented them in a separate form as an e.«say, " On the Treatment of Hyperpyrexia, as Illustrated in Acute Articular Rheumatism, by Means of the External Application of Cold;" Macmillan & Co., London, 1871. Dr. H. Weber's case is to be found in the Traiisadious of the Clinical Society of London^ vol. v, p. 136, under the title of "A Case of Hy|K'rpyrexia 48 754 ■ SCARLET FEVER. (Heatstroke) in Rheumatic Fever Successfully Treated by Cool Baths and Affusions." The first point to be determined is the degree of temperature which be- comes dangerous to life, and to prevent or reduce which we may and ought to resort to the application of cold externally. Of course there is but one certain guide to the temperature of the human body, — the thermometer. A practiced hand may be relied on when no thermometer is to be had ; but no hand, however experienced, can give the certainty of the thermometer. Inasmuch, too, as the state of hyperpyrexia is always attended by con- comitant phenomena of a peculiar kind, these, to the experienced phy- sician, will assist in guiding him in his treatment. These phenomena con- stitute the group called ataxic or adynamic nervous symptoms. The patient is usually delirious and restless or comatose, and not unfrequently has local or general convulsive movements; the pulse is frequent and feeble, and sometimes so small as to be felt with difficulty, and the capil- lary circulation is sluggish and congested ; the respiration is usually hurried and embarrassed, so that the patient is readily judged to be in extreme danger. According to Dr. Fox, a temperature in rheumatic fever which rises suddenly from 103° or 104° to 107°, 108°, or 109°, has usually proved fatal within a very short time after the latter temperature (109°) has been reached. He, however, saved one patient, by external cold, in whom it reached 110° in the rectum. Dr. H. Weber thinks that until the cold treatment was used, a temperature of 108° had been nearly always fatal. Dr. Fox asks the question. After what degree of temperature attained by the human body in febrile states is recovery naturally possible without medical interference ? He states that the highest recorded temperature he knows of after which recovery has taken place (with the exception of relapsing fever), was in a case of tubercular pneumonia, in which it rose suddenly from 105° to 108°, and then suddenly fell to 104°. He refers, of course, to cases not treated by cold, since, as stated above, he himself saved a case in which the temperature had reached 110° in the rectum. It must not be forgotten that the axillary temperature is less than that of the mouth, under the tongue, and that this is less than that of the vagina or unloaded rectum. Wunderlich gives the averages in the adult as fol- lows : For the axilla, 98.6° F. ; for the mouth, 98.78° to 98.96° ; and that of the vagina or unloaded rectum, 99.14° to 99.5° F. In children the tem- perature is more variable, but does not differ very greatly from that of the adult. M. Roger gives 98.97° as the average axillary temperature be- tween 4 months and 6 years, and 99.15° between 6 and 14 years. Dr. Finlayson, in 21 children under 6 years, found the morning temperature in the rectum to be 99.41° F. Such being the normal temperatures, we will now give those which have been observed in scarlet fever. Wunderlich (Med. Thermometry ^ Syd. Soc. ed., p. 348) says that the height reached by the temperature in scarlet fever is almost always above 104° F., very commonly over 104.9°, while in cases which terminate favorably it seldom exceeds 105.8° F. The translator of Wunderlich (Dr. Woodman, footnote, p. 221) gives the noon temperature TREATMENT OF GRAVE CASES. 755 of typical nou-malignant scarlatina in a good many cases as 105°, 104°, 103°, and 102", on the first, second, third, and fourth days. In a note at page 204, he states that he has put on record {Med. Mirror for February, 1865) some fatal cases of scarlet fever in which the temperature reached 115^. ** The observations were made with one of Negretti and Tambra's thermometers, divided into fifths, which had been recently compared with a standard." From these fact^ we may assume that a temperature of 105° F. in scarlet fever is not necessarily very dangerous to life, but that from the moment it tends to rise above this point, the patient enters into a very dangerous period. If, with a temperature of 105°, there appear any of the nervous phe- nomena so often alluded to, delirium, drowsiness, coma, vomiting or purg- ing, and especially any locomotor disturbances, the time has come for the use of external cold ; and should the temperature continue to rise after it has reached 105°, the cold treatment ought to be resorted to, even though these nervous phenomena have not shown themselves, since they will be almost certain to appear should the temperature go on rising. And next as to the best mode of applying cold. It does not matter much how this is done, if only it be so managed as to reduce with cer- tainty the heat of the body towards the normal point. Dr. Fox used baths at different temperatures, and in one case applied ice to the chest and along the spine in an ice-bag, whilst he reduced the temperature of the bath rapidly from 96° to 6G^. At other moments in the same case he used the ice-bag applied to the spine for several hours at a time, and on -till other occasions employed the cold pack, wrapping his patient in a rheet wrung out of ordinary cold water (probably 60°). Dr. H. Weber placed his patient (a boy of 16) in a bath at 71° F., keeping him there the first time thirty minutes, when the temperature under the tongue had lallen from 108.2° to lUl.8°. Some hours afterwards, when the tempera- ture had risen to 105.8", the patient was again put into a bath at 72^, and water poured over the back of the head and neck. In twenty-five minutes the temperature fell to 101. Dr. Fox says, at page o4 : "I believe, however, that the bath may be altogether dispensed with, and that for the future it will be sufficient to place a Mackintosh sheet under the patients, so arranged that the water may escape into a receptacle, and to pour cold water over them from time to time." Dr. Corson uses affusions of cold water over the head of the child, which IS held over a tub, as the most powerful means in cases of coma or con- vulsions, and, when the temperature is very high, washes the whole body with iced water, or even rubs it with ice. The most convenient mwle, it appears to us, in children, will be either the one proposed by Dr. Fox, the Mackintosh sheet on the bed, and affu- sioDS of cold water; or a bath-tub or common large wash-tub, containing WAter at a temperature proportionerl to the heat of the body, 80^ to 70 , with affusions of cold water upon the head, or the application of towels wrung out of cold or iced water to the head >" ^oon as the thermometer, 756 SCARLET FEVER. held in the rectum or under the tongue, shows that the temperature has fallen to 101° or 102°, it will be best to remove the patient to bed between two blankets. Not unfrequently, a» the temperature falls, the patient be- comes partially conscious, grows paler, and shivers, and these are signs which show that it is time to cease, at least temporarily, the use of the cold. The physician, when he first uses this mode of treatment, should know that the temperature is apt to continue to fall, even after the use of the cold has been suspended. Thus, in one of Dr. Fox's patients it fell from 103° to 99.4° after the removal from the bath. The danger to be appre- hended from these continued falls in the temperature is not so great as might be supposed. Thus, Dr. Fox says that it may be doubted whether, in future cases, any external warmth may be necessary to prevent too great a fall of temperature. " Even severe collapse produced by cold has been shown by F. Weber's, Bartel's, and Ziemssen's observations on the pneumonia of children to be less dangerous than it at first appears." And Dr. H. Weber says, "Although the duration of the bath will be in- fluenced in some degree by the temperature of the water, we must be en- tirely guided by the condition of the patient while in the bath ; the heat of the blood ought to be reduced, if possible, to almost its normal degree, and the nerve-centres ought to be reduced to a more healthy condition." After the heat has been once reduced by the cold to near its normal state, the patient must be carefully watched by means of the thermometer, and if the heat rises again, the cold should be reapplied. This may have to be done several times a day at first, and less frequently afterwards, if the treatment prove successful. It is not always necessary to resort to the bath in every rise of the heat. Cold to the head, afi'usions upon the head alone, the application of an ice-bag to the spine, or the use of the cold bath, may suffice to keep the temperature within the safe limits. While the cold is being used to reduce the temperature, we may employ certain internal remedies with advantage. If the patient is not very much exhausted, we may make use of the antiseptic salts of Polli, to which reference will presently be made. But if the exhaustion be very great, if the circulation is rapid, feeble, and uncertain, with a dusky and congested skin, we should use brandy with milk, beef or chicken tea, and wine-whey. Dr. Fox used in the two cases which recovered (adults) very large quan- tities of brandy, from twelve to eighteen, and even thirty-three, ounces in twenty-four hours. He gave also large amounts of beef tea, two to three pints, and as much milk as three and four pints. In such cases quinia and carbonate of ammonia would also be proper means until the vitality is restored. In a former edition of this work it was stated that we had used the hyposulphite of soda or magnesia in 11 cases, of which 2 were malignant in type, 3 grave, and 6 moderate. All these recovered. It was then said that so small an experience was of little weight in determining their value. Since that time we have used the same salts in most of the cases that we have seen. Only 4 of these could be called grave. They were not of the convulsive form, but exhibited high fever, severe anginose symptoms. TREATMENT OF GRAVE CASES. 757 tedious duration, and copious desquamation. They were severe, but not malignant cases; and they all did well. In two cases of the malignant form, with profound adynamic nervous symptoms from the very onset, they were also freely used, but without effect. On the whole, we think these salts deserve a further trial. The soda or magnesia salt ought to be selected according to the state of the bowels. When these are constipated, the magnesia is to be used. In the contrary case, or when the bowels are in a relaxed state, we use the soda salt. The dose of either is five or ten grains, every two hours, according to the age. They are best given in solution in water, with a little ginger syrup. There are a class of cases which, though they do not exhibit the ex- treme severity of those we have just considered, well deserve the name of grave. The temperature is high, the pulse rapid, the nervous system shows disturbance by extreme agitation or by drowsiness ; there may be muscular starting, or tremors, or a single slight convulsion ; the eruption is very abundant, and vivid or dark in tint, and the anginose symptoms are marked and severe. Such cases are dangerous ; seldom last less than two or three weeks, anti require all the care of the practitioner and nurse. In this second grade of the grave form the temperature ought to be reduced, using the thermometer as a guide, at the beginning by the care- ful use of the cool or tepid bath, or by cool or tepid ablutions, and by the use of cold water or ice to the head. Internally, the hyposulphite salts or an alkaline febrifuge ought to be administered for the first few days. In addition to this, we may employ with advantage full doses of quinia or ealicylic acid ; both of which, and especially the latter, possess the prop- erty of greatly reducing the degree of febrile heat. The patient often, indeed generally, in this class of cases, sinks after a few days into a low ataxic condition. Here the best remedies, we think, are chlorate of potash with muriated tincture of iron, quinia with niuri- ated tincture of iron, or muriated tincture of iron with solution of acetate of amraonia and dilute acetic acid. Hillier thinks that in such cases the beet medicine is carbonate of ammonia, and Trousseau also advises it stroogiy. These medicines may be given in the following modes: B.— Pot*fs. Chloral., • .^• Tr. Ferri Chlorid., • f^j- Syrup. Zingiber; • r^vij. Aquae, . f5ij.-M. Do«e, A tewpoonful every two hours at five years of age, and under that age, half a teaspoonful. E— Quinia? Sulphat., . pr. xij. Tr. Ferri Chlorid., • f^j. Syrup. Zingib., • f.^v. Srrup. Simp., • f.^ij- Aqu», . f5'J-M. Dh them, even in the earliest stage. In measles also the general symptoms persist, or even become aggravated after the appearance of the eruption, instead of abruptly subsiding as they do in variola. A little later, the appearance of vesicles pn some of the papules about the face in variola, will show the difl^erence still more strongly. The distinction between measles and scarlatina has already been drawn in the description of the latter disease. It rests chiefly on the much shorter du- ration of the prodromic stage, the greater violence of the anginose symp- toms, the absence of the peculiar catarrhal symptoms, and the more rapid evolution of the eruption in .scarlet fever; and lastly, on the dif- ferences in the two eruptions, observable especially at their first appear- ance. The eruption of typhus fever appears nearly at the same time as that of measles, and in their earliest stage the two eruptions often resemble each other closely. In typhus, however, there is an entire absence of the char- acteristic catarrhal symptoms. The spots are less elevated; are isolated and round, instead of coalescing to form cre.«centic patches ; do not ap|)ear first on the face, but on the trunk or wrists (Ringer; ; more frequently be- come petechial, and la.st a much longer time. When measles are conjoined with some other eruption, the diagnosis is to be made out by a careful study of the initial .symptoms, and of the eruption on diflTereot parts of the body, for we can generally find well- 780 MEASLES. marked patches of the rash peculiar to each on some portions of the sur- face. In one of the cases of measles and scarlatina that we saw, the latter disease was developed first. The eruption made its appearance in the usual form ; on the second day of the eruption, the child was seized with hard, hoarse, laryngeal cough, and with redness of the eyes and lachrymation. These symptoms continued three days, at the end of which time the scar- latinous rash had disappeared from the face, but remained visible upon the trunk and extremities. Characteristic measly papules now made th^ir appearance on the face, and pursued their regular course, while on the trunk and extremities the measly eruption was never well defined, being mixed with and disguised, as it were, by that of the scarlatina. In the other case, the measles appeared first and went on regularly until the eruption was declining and the general symptoms moderating, when suddenly the fever, heat of skin, restlessness, and irritability returned, and the child was very soon covered with the punctated scarlet rash of scarlatina. Prognosis. — The prognosis of simple, uncomplicated measles is very favorable ; the cases almost always recover without difiSculty. This is shown to be true by the following facts : Rilliet and Barthez report 36 cases of simple measles, of which all but one recovered. Of 257 cases that we have seen, all terminated favorably. When, on the contrary, complications occui', the disease always becomes more or less dangerous, the degree of danger depending on the nature of the intercurrent afiection, and on the hygienic conditions in which the patient is placed. Thus of 131 cases observed by the above authors, in which some form of complica- tion occurred, 89 or about two-thirds proved fatal, while of the 53 com- plicated cases that we have seen, only 6 were fatal. It must be recollected that the cases of the French observers all occurred under the unfavorable hygienic conditions of a large hospital, in children of bad constitution from congenital or acqired causes, whilst ours were observed in private practice, where the hygienic conditions are favorable in the same degree as they are unfavorable in hospitals. The six fatal cases that came under our observation, proved so from the circumstances we are about to mention. The first occurred in a child Jiine months old, who was laboring under pertussis when attacked with measles. Bronchitis supervened upon the measles, and proved fatal by convulsions, which came on during a paroxysm of hooping-cough, two weeks after the disappearance of the rubeola. The second case was that of a boy, eighteen months old, who was prescribed for by an apothecary from behind his coun- ter, until we saw him. The eruption made its appearance imperfectly, we were told, and with a convulsion. After this he was very restless, and had rapid and difficult respiration and much cough. On the morning of the fourth day of the eruption, this had almost entirely disappeared, and the child was again attacked with convulsions. We saw him shortly after this for the first time, and found him comatose, with convulsive move- ments of the limbs, extreme dyspnoea, and all the symptoms of extensive bronchitis of both lungs. He died thirty-six hours from this, as was to be expected. The third was a case of pneumonia in a child between, one and TREATMENT. 781 two years of age, iu which the inflammation came on as the eruption was fading, and proved fatal, in spite of all that could be done, on the eleventh day. The fourth occurred in a boy between four and five years old, who appeared to recover perfectly from the measles, but was attacked in ten days with meningitis, and died. The fifth was the case of congestion of the brain, already detailed in the remarks upon complications, as proving fatal shortly after the decline of the rash. The sixth was that of sudden dropsical etiusion into the internal cavities, also described in the remarks upon complications. To conclude, we may state that the prognosis is always highly favorable under the folh)wing circumstances: when the disease is primary; when the initial stage is of the proper duration ; when the eruption begins upon the face and extends gradually to the rest of the bod}"^ ; when the febrile movement is moderate ; when the eruption, after increasing for one, two, or three days, gradually decreases; when the cough and other concomitant symptoms diminish with the fever; when the cutaneous surface, after the fading of the rash, assumes a natural color, and is neither flushed nor pale ; when the appetite returns, the disposition to be amused and take notice continues, and lastly when the sleep is natural. On the contrary, the prognosis becomes unfavorable under the following circumstances : when the initial stage lasts longer than usual, and when it is accompanied by violent symptoms of any kind, as extreme jactita- tion, irritability, dyspna\i, much stupor, coma, or convulsions; when the eruption is irregular in its appearance or course; when the fever does not disappear with the eruption, whether it remains violent or assume the form of hectic; when, after the eruption, the face continues deej)ly flushed or becomes very pale ; when the cough, dyspntiea, or diarrlura persist; and, lastly, when the child remains weak, languid, dispirited, or irritable. It may be stated, iu conclusion, that the prognosis of measles is always favorable in proportion to the health of the child at the time of the inva- sion, and the regularity with which the disease passes through its different phases; while it becomes unfavorable, though far less so in private prac- tice amongst people in easy circumstances, than in hospitals or amongst the poor and wretched, whenever it attacks a child already laboring under some disease, and when it becomes complicated with any other malady, either local or general. Treatment of the Regular, Simple Form. — This form requires, in a large majority of the ca»es, little other treatment than strict attention to the hygienic condition of the patient, the use of simple diaphoretics, of mild cathartics occasionally, and the palliation of any of the sym]H()m8 that may chance to become somewhat more troublesome than usual. The child ought to be confined as much as possible to bed in a large, well-ventilated chamber, the light in which should be somewhat softened. Every precaution should be observed to prevent chilling of the body, while at the same time it is nearly, if not quite as important, to avoid overheating the patient, either by excessive clothing, or by keeping the temf)erature of the rfK)ra too high. In winter, it is well to direct the temperature to be maintained at between 68'^ and 70^ F., night and day. 782 MEASLES. If this be done, the child is not apt to take cold, even though it be un- covered at times, and yet the warmth is not oppressive. We have often remarked that this temperature is just what it ought to be when the room is well ventilated, either by means of an open fireplace, or by communi- cation with adjoining rooms; but when, on the contrary, the room is heated by a furnace-flue, and not ventilated at all, or very imperfectly, the same temperature, as indicated by the thermometer, becomes ex- tremely close and oppressive. Under such circumstances, a door into an adjoining room, or if this cannot be, one into the entry, ought to be kept more or less open, with a screen of some kind between it and the child, in order to secure a good ventilation, which is assuredly of the very highest importance, and yet to prevent by the screen a current of cool air from chilling the patient. Miss Florence Nightingale remarks that doors are made to be shut and windows to open.- There is much in this saying, and when the nurse is intelligent and observant, we much prefer to shut the door and open a window. In our winter temperatures in this city this must be done very carefully. One of the sashes raised an inch, or one or two inches, will make a large difference in the temperature and vitality of the air of the sick-room. The diet during the febrile period ought to be very light. It may con- sist of milk and water, of arrowroot, sago, or tapioca, prepared with milk or water; or of crackers soaked in water, with salt, or some similar food. When the eruption and fever have in great measure disappeared, some light broth, either vegetable or animal, with dry toast or bread, plain boiled rice, a roasted potato, or ice cream, may be added ; and after all the symptoms have ceased, the usual diet can be gradually resumed. The drinks may consist of simple water, of lemonade, orangeade, gum-water, or flaxseed tea, with the addition of a little sweet nitre ; or of weak infu- sions of balm, sweet marjoram, or saffron, or cascarilla with a few drops of hydrochloric or nitric acids. They may be given in any reasonable quantity, at the temperature of the room. Some persons have a great dread of cold water in this disease. We have never seen small quantities (a wineglassful or two at a time) of cold water do any harm, and believe it to be most useful and necessary when the fever is violent, and the heat very great. We once, however, saw a boy, nine years old, attacked with violent colic and partial retrocession of the eruption, after swallowing suddenly a tumblerful of iced water. The unpleasant symptoms passed off in a few hours, and he had no difficulty afterwards. The patient should not be permitted to leave the room until a few days after the entire disappearance of the disease. This precaution is necessary for all, but particularly for the delicate, and in the cold weather of these latitudes. He should be kept in the house until he has regained in some degree his usual health, and then sent out with due precautions. Medical Treatment. — Many cases of measles — the mild, the moderate, the uncomplicated — need no other treatment than that just laid down in the paragraph on the hygiene of the disease. So long as the case goes on regularly, so long as the symptoms are moderate and such as to cause but little suffering, there is no necessity for drugs, or, at the most, a simple TREATMENT. 783 diaphoretic, as sweet spirit of nitre or the solution of acetate of ammonia, with a little paregoric or laudanum once or twice in the evening, will be all that ought to be done. The child doe^s not require, and therefore ought not be made to take as a mere routine, cathartics. If the bowels are known to be costive, and not to have been moved ft.r two or three days, a teaspoonful or dessert^^poonful of castor oil, or, better still, a dessertspoonful to a tablespoonful of simple syrup of rhubarb, or a simple enema, will answer every purpose. We are sure that active purging is unnecessary, and apt to be hurtful. When the case is a very decided one, and the eruption extensive and deep in color, the fever runs high, and the patient often sutlers greatly from the fever-pains, and from the violence and frequency of the cough. Here medical treatment is necessary, since it lessens sutleriug, diminishes the violence of some of the symptoms, and so promotes the safety of the patient. In infants, under these conditions, we order five drops of sweet spirit of nitre, two or three of syrup of ipecacuanha, and two of paregoric, in a teaspoonful of sweetened water every two hours, at the age of six months. At one and two years, we double the proportions of the active ingredients. Should even these small doses of ipecacuanha cause any sickness of stomach, we lay that drug aside. One of the best combina- tions is the following : E.— Potass. Citrat , ^}. Spts. Ether. Nit., f^ij. Tr. Opii Deodorat., . . . . . . "X^'j ^^1 xriv. Syrup. Simp., f.o^j- Aquae, . . , ... . . f5ij. — M. D'1'0. — A tablcjpoonful every two or three hours, at five years of age. In younger children, from two to five years, the same formula may be used, except that the laudanum should be reduced to six minims. When the cough is very dry, scraping, and, as it sometimes is, incc-'sant, there should be added to the above mixture syrup of ipecacuanha, in the pro- portion of five to ten drops to every teaspoonful, according to the age of the child ; and there may and ought to be given from time to time, if the patient be not too drow.^y from the effects of the fever or the mixture, an extra dose of opium. We prefer nearly alway.s the deodorized laudanum. Of this from two to four drops in a teaspoonful of water may be given two or three times a day, or, better still, once or twice in the evening, to chil- dren over five years of age. From one to five years of age, one or two drops are enough. In some few children paregoric may an.«wer better, but this rarely happens. When it is given, ten to twenty drops at five years, five or ten at one year, and from half a teaspoonful to a teaspoonful over five years, may be u.sed instead of the laudanum. Depletion, except that which comes of the above treatment, if< unnec- essary. We did, in past years, use depletion in 2 ca,ses out of 2.">7 regular cases of which we kept notes. In one, a venesection to four ounces was used in a boy seven years old, on account of the great violence of the febrile movement ; and in the second, leeches were applied to the temples 784 MEASLES. for an intense headache in a girl nine years old. For many years past we have used no general bleeding, but might be tempted to use leeches in a case of the same kind as that just mentioned, in which the pain in the head was something quite out of the usual way. Instead of venesection we should make use of a warm bath continued for fifteen to twenty min- utes. If the temperature of the body be very high, it may be reduced by careful sponging with tepid or cool water. Sometimes, when the cough is very troublesome, a mustard foot-bath used every three or four hours, and a mild liniment, as one composed of sweet oil and spirit of hartshorn, or of chloroform, camphor, and soap liniment, rubbed gently upon the front of the neck and over the upper part of the sternum, will assist materially in palliating this symptom. When the conjunctival inflammation is acute and painful, it may be re- lieved by lotions with simple warm water, milk and water, or sassafras- pith mucilage, alone or mixed with rose-water. If the headache be very violent it can generally be relieved by the use of a laxative, by the occa- sional use of a mustard foot-bath, or of a sinapism to the nucha, and by the application of cold to the head. If, at any time during the course of the case, symptoms of exhaustion appear, the most nourishing and concentrated food, with alcoholic stimu- lants in graduated doses, should be promptly resorted to. The malignant form of the disease must be treated chiefly with stimu- lants and tonics. The most useful are wine and brandy, quinia, ammonia, capsicum, etc. Camphor and opium would be proper, were the case at- tended with severe nervous symptoms. The diet ought to be nutritious and digestible, and may consist of milk and bread, light broths, and beef tea or essence of beef. When local inflammations occur, they may be treated by a few dry cups, or by means of counter-irritants, of which the most suitable are mustard, spirit of turpentine, or ammonia. Blisters ought to be avoided, as they are very apt to occasion dangerous and even fatal sloughing. Treatment of the Complications. — Bronchitis, Pneumonia. — The mode of treatment of these complications must depend upon the stage at which they are developed, and upon the age and constitution of the sub- ject. When they occur during the first stage, one of the most important points in the treatment is to endeavor to favor the appearance of the erup- tion, and when in the second stage, and the eruption has retroceded wholly or in part, the same indication applies with equal force. When they ap- pear during the third stage, they are to be treated without any regard to the eruption, but always with reference to the fact that the patient has just passed through an acute febrile disease, which must have weakened in some degree the vital powers. It may be stated in general terms, that the treatment proper for these local inflammations when they occur as i)rimary affections, is proper also, with some reservations, under the circumstances we are now considering. Thus even local depletion should be employed only with the greatest care, and, indeed, we should recommend in preference the application of dry cups, or of sinapisms. TREATMENT. 785 Purgatives should also be used with caution, on account of tlio dispo- sition to gastro-intestinal irritation which is always })resent in this dis- ease. Our own practice is to oniplov moderate counter-irritation, in con- junction with minute doses of sulphuretted antimony a»id Dover's powder, or a mixture containing citrate of potash and syrup of ipecacuanha. When in these cases the skin is at all coolish, or bathed with too consid- erable a perspiration, we have found the liquor ammonia^ acetatis a very useful remedy. It is universally acknowledged that it is exceedingly important to assist nature in throwing out the rash, whenever these complications either pre- vent its formation, or cause its; retrocession. The true mode of doing this is to cure or alleviate the internal inflammation, which is the cause of the difficulty. To attain this end the above plan of treatment ought to be in- stituted at once. At the same time, we may greatly assist the appearance of the eruption by a persevering employment of counter-irritants. The best of these is, we believe, mustard, and in some cases a warm bath. The mustard may be used in the form of plasters, poultices, or baths. Our own plan in moderately severe cases, is to apply a mustard poultice to the interscapular space, and to make use of a mustard foot-bath, two or three times a day, while in severe and urgent attacks we direct the cataj^lasm and bath to be renewed every two or three hours, taking care, however, to apply the former alternately to the front and back of the chest, in order to avoid all possibility of too violent an action upon the skin ; the feet and lindis also ought to be carefully watched, to avoid the same danger. We have had occasion to observe the great efficacy of this unremitting employment of revulsives, in several severe cases of bronchitis in young children. In some we have depended solely upon this treatment, and the use of small doses of ipecacuanha and spiritus Mindereri. In one partic- ularly, which occurred in a child eight months old, the attack came on in the first stage. On the fourth, fifth, and sixth days, the dyspnoea was ex- cessive, the respiration running up to 70 and 80 ; the pulse was frecpient and small ; the skin pale and rather cool; and the irritability and rest- lessness very great. For a period of twenty-four hours, we used the poul- tices and foot-baths every two hours regularly, and gave internally the spiritus Mindereri at the same intervals. Nothing else was done. On the sixth day, when one of the poultices was removed from the inter- scapular space, the integument beneath was observed to be covered with the measly stigmata, whilst there were none as yet on any other part of the surface. From this time the eruption came out freely, and the child recovered rapidly. The warm bath may be used under the same circumstances. It should be given with great care, the child being wrapped in a warm blanket the moment it is removefl from the water, to prevent the least sensation of chilliness. It may either lie for a short time in the blanket, or be wiiK'd dry beneath it, and then dressed. In 84»me of the cases of bronchitis, there has been profuse secretion at- tended with extensive subcrepitant and mucous rales. In such instances 60 786 MEASLES. we have found tlve internal use of the syrup or infusion of polygala seneka, "with an occasional revulsive, very effectual. The diarrhoea which occurs so frequently seldom requires any treatment. Indeed, unless it indicates evident entero-colitis, or is accompanied by fre- quent mucous or bloody stools, and by pain and tenesmus, it is better not to interfere with it, beyond paying strict attention to the diet. When at- tended, however, with the symptoms just mentioned, it must be treated by astringents, by opium and ipecacuanha, and by the application of poul- tices to the abdomen. The seven cases that occurred to ourselves recov- ered under the use of laudanum enemata, given twice or three times a day, the strictest diet, and small doses of Dover's powder. Laryngitis, as it occurs in most of the cases, needs but little treatment beyond careful avoidance of cold, the use of some mild nauseant, and re- vulsives to the neck. It is very seldom of a dangerous character. When, however, it assumes the character of pseudo-membranous croup, it must be treated with all activity, in the manner described in the article on that disease. In only two of the eight cases we have seen, did it appear at all threatening, and both of these recovered under the use of emetics and moderate leeching of the throat. The cerebral symptoms which sometimes occur, must be treated differ- ently in different periods of the disease. In the early stage, when they last but a short time and do not recur, they require nothing more than a warm bath and the use of revulsives. If they continue to recur, or are followed by stupor or other cerebral symptoms, more energetic treatment becomes necessary. If the child is strong and hearty we ftiay apply dry cups to the back of the neck or temples, and resort to purgatives, revul- sives, and cold applications to the head. When the symptoms are violent, and when the heat is intense, it has been proposed to use cold lotions in the manner recommended in scarlatina. The evidence upon this point is not very conclusive, and as we have never used them, nor seen them used, nor indeed seen any necessity for a resort to them, we can offer no opinion in regard to their value. We have met with five cases of convulsions in the first stage. One oc- curred in a boy five years old ; the convulsions were slight, lasted not more than ten or fifteen minutes, and were followed by no bad symptoms. The intelligence of the child returned very soon afterwards. The only remedy used was a warm bath. The other cases have already been described. When convulsions occur in the second or third stages, it is very impor- tant to ascertain whether they are not the result of some local disease. Two of the three cases that came under our notice accompanied violent attacks of bronchitis. The third was caused by congestion of the brain. Here the treatment must be directed against the local disease, if that can be detected. When, on the contrary, the convulsions seem to depend on nervous irritation, they may be treated with baths, revulsives, purgatives, and the careful administration of opium, as recommended by Sydenham, Copland, Rilliet and Barthez, and other authors, or of bromide of potas- sium, camphor, assafoetida, musk, or hyoscyamus. If accompanied by SMALL-POX. 787 intense heat and great dryness of the skin, without local complications, cold or tepid lotions may also be tried. The treatment suitable when any of the complications or sequela^ become chronic, will be found in the articles devoted to the respective diseases. Bearing in mind the tendency to the development of scrofula or tubercu- losis after this disease, the most careful attention should be paid to all hy- gienic measures; and alteratives and tonics, as syr. ferri iodid., cod-liver oil, and quinia, should be administered. ARTICLE VIII. VARIOLA, OR SMALL-POX. Defixition; Frequency; Forms. — Variola is an epidemi^c and con- tagious disease, characterized by an initial fever, lasting from three to four days, and followed by an eruption at first papular, then vesicular, and afterwards pustular ; the eruption attains maiturity in from six to nine days, after which the pustules are converted by desiccation into scabs, which fall off between the fifteenth and twenty-fifth days. The freqmucy of the disease varies greatly in diffv^rent years, because of its epidemic nature. It is far less common in childhood amongst the mid- dle and upper classes of the community, than either measles or scarlatina, in consequence, no doubt, of the attention paid to vaccination. During the early months of L'^Go, one of us had the opportunity of studying a severe epidemic which occurred in portions of this city, and we have pub- lished elsewhere' an analysis of thirty cases in children under fifteen years of age, observed at that time. Apart from these cases, however, we had met with but two cases of the disease under fifteen years of age, during the fifteen years preceding 1871-72, whilst during the same i>eriod we had met with 263 of scarlatina, and upwards of 314 of measles. In the last- mentiouefl years, a severe epidemic occurred in this city, when we again saw numerous cases at all ages. It prevails to a greater extent amongst the p Amer. Jour, of Med. 8ci., October. 18G9, p. 322. 788 SMALL-POX. MORTALITY FROM VARIOLA. 1848, 1849, 1850, 1851, 1852, 1853, 1854, 1855, 1856, 1857, 1858, 1859, 1860, 1861, 1862, 1863, 1864, 1865, 1866, 1867, 1868, 1869, 1870, 1871, 1872, Tot Under Between 1 Between 2 Total of all 1 year. and 2 years. and 5 years. ages. 21 13 17 100 25 20 34 152 13 8 4 40 40 30 54 216 89 54 100 427 22 9 9 57 12 4 6 49 57 39 85 275 86 44 88 390 19 17 11 65 1 2 1 7 0, 1 2 14 10 16 57 159 105 200 758 52 44 66 264 33 24 28 171 57 31 61 260 104 50 112 5J4 32 17 27 144 16 4 11 48 1 1 3 6 3 3 9 203 112 292 1879 347 188 446 2585 1406 828 1672 8486 An inspection of this undoubtedly establishes the fact that whenever the contagious principle of variola, favored by some peculiar epidemic influ- ence, is introduced into this community, it finds a large number of unpro- tected subjects who fall ready victims to its attack. We shall, in our description of variola, refer to several forms which it may assume. These are merely degrees of severity of the same disease — types given to each case by several causes. Chief amongst these is the presence or absence in the person attacked, of the protective power of the vaccine disease, next is the type of the epidemic prevailing at the time, and last we must place the inexplicable and utterly uncertain influence of individual constitution. According to the degree of reaction of the vari- olous poison in the system of the patient, shall we have distinct or discrete, confluent or hmmorrhagic small-pox ; or that form modified by vaccination, inoculation, or previous natural small-pox, called varioloid. We shall also describe the complications of the disease. Causes. — The principal causes of variola are contagion and epidemic influence. It is not clearly ascertained at what period of its course the disease first acquires the property of infectiousness. Some assert that it is not until after suppuration is established. This is, however, to say the least, doubt- ful, and it is best, therefore, to take any precaution that may be necessary SYMPTOMS — COURSE — DURATION. 789 to prevent the extension of the disease, from tho inoinont that its roal nature beeomes apparent. There can be no doubt that the body niay still impart the disease after death, and that clothes worn bv the patient retain the contagious principle, unless freely exposed to the air, for days, months, and, it is said, even for veal's. It is also capable of infecting furniture or letters, and may thus propagate the disease at any distance, and for an indefinite periinl, l)y fomites. One attack protects the constitution, in the great majority of cases, against subsequent contagion. When persons who have once had the dis- ease contract it again, it almost always assumes a much milder and less dangerous form. In the report of the Municipal Hospital of Philadelphia, made to the Board of Health of Philadelphia, for the year 1872, Dr. Wm. M. Welch, the physician in charge, states that out of the whole number of cases (2377) of variola admitted during the violent epidemic of 1871-2, 15 were said to have had a previous attack of the disease. Of these 15 cases, those which could not show a single scar as the result, he should classify as of doubtful authenticity ; those which exhibited only a few scars, as of prob- able authenticity; and those which exhibited well-marked pitting as au- thentic. To the first class belonged 7 cases, of which 3 died ; to the second class belonged 3 cases, all of which recovered ; to the third class belonged 5 cases, all of which recovered, and in all of which the eruption was very light, so much so in one as to be characterized as doubtful. The period of incubation, or the time elapsing between the reception of the poison and the onset of the malady, varies generally between nine and twelve days. It may, however, be seven or fifteen days. Symptoms; Course; Duration. — We shall describe three stages of the disease: 1. That of the initial or eruptive fever; 2. That of the prog- ress and maturation of the eruption ; and, 3. That of decline or desiccation. In addition to these, some writers make another stage, that of incubation, which includes the period between the introduction of the poison into the system, and the appearance of the first symptoms. This stage is seldom marked by symptoms sufficiently characteristic to enable us to detect the approaching disease, and in many instances is probably entirely unnoticed by the patient. TUe first dage, or that of initial fever, commences generally in children with pains in the bones and loins, and sometimes with rigors or chilliness, accompanied with headache, and soon followed by fever. Nausea and vomiting often exist from the first, or come on soon after the appearance of fever and headache. At the same time there is loss of appetite, thirst, and more or less obstinate constipation. The tongue is red at the point and edges. One of the characteristic sy«nptoms of this stage is pain in the loins, which generally dates from the first or secon«l day, and which, though varying much in degree, is usually severe. Tho patients often com- plain also of abdominal pains, which seem to be colicky, and are referred either to the epigastric or umbilical region. Fever and headache are the most con?*tant f)f all the initial symptoms. The chilliness and rigors which frequently exist in adults are not easily 790 SMALL-POX. ascertained in the cases of children, and are therefore much less important. The fever varies greatly as to degree ; the heat of skin is generally con- siderable, the temperature rising to 104° or 105°, and may be accompanied either with dryness or moisture. The pulse is commonly full and frequent, rising to 120, 140, or 160 beats, according to the severity of the case and the age of the child. The headache is usually frontal and often very severe. In some cases there are strongly marked cerebral symptoms, con- sisting of excessive restlessness and irritability, insomnia or somnolence, delirium, and even convulsions. The various symptoms just enumerated continue up to the moment when the eruption begins to make its appearance, which happens generally in the course of the third day, though it may occur as early as the second, or as late as the fifth, sixth, or even seventh. In severe and confluent attacks, t'.ie eruption, as a general rule, begins earlier than in mild and discrete cases. Second Stage, or that of Eruption. — In the great majority of cases, the specific eruption makes its appearance in the course of the third day from the beginning of the fever. This is the law of the disease. Before, how- ever, describing it, we must state that not rarely a more or less extensive roseolous rash precedes the specific eruption. So well known is this that it has been called roseola variolosa. It looks so like measles as to make a correct diagnosis difficult, since nothing could reveal its true character unless it were known that the subject had been exposed to variolous infec- tion, in which event the unusual severity of the constitutional phenomena, compared with those generally attendant upon roseola, might well lead the practitioner to defer his opinion. This roseola occurs in all forms of small- pox. Dr. Welch thinks he has seen it most frequently and in greatest quantity in cases of mild varioloid. The specific eruption appears, then, on the third day, in the form of small, isolated, and rounded red specks, which soon become projecting and solid, or in other words are converted into papules. The papules are from a third to two-thirds of a line in diameter, of a more or less vivid red color, which disappears under pressure, to return immediately when the pressure is removed. They are also hard, and feel almost like shot im- bedded in the derm. The eruption shows itself first on the face, and gen- erally about the chin and mouth, and then extends to the rest of the face, to the neck, trunk, limbs, feet, and hands. It sometimes happens, par- ticularly in very young children, that the eruption appears first about the genital organs, whilst in other cases it is first observed on the lower part of the loins, or upon the thighs. The papules increase gradually in size and prominence for one, two, or three days, and, as a general rule, some time in the course of the second day of the eruption, begin to change into vesicles. This change takes place by the formation on the top of each papule of a little transparent elevation of the cuticle, beneath which is deposited a drop of serosity. The conversion of the papules into vesicles occurs first on the face, and then on the neck, trunk, and extremities. The vesicles are at first smaller than the papules, and acuminated in shape, but as they grow larger, become gradually flattened and depressed in the SYMPTOMS. 791 ceutre : after a time thov cover the Avhole papule, and before long exceed it iu size. As tliese changes take place, the fiuid they contain loses its trausjiarency, becomes opaline, and by degrees the vesicles are transformed into pustules, and thus the third stage of the eruption or that of suppura- tion begins. • The pocks are more or less numerous, according to the extent and severity of the eruption. When scattered over the surface so as not to touch at their edges, the disease is said to be distinct or discrete; when, on the contrary, so numerous as to come into contact and run together, it is called conHurnf. Of these two varieties, the latter is necessarily more severe and dangerous than the former, in consequence of the greater extent of tegu- mentary surface inflamed. During the various changes the vesicles un- dergo, they are surrounded by small, inflamed areolie, which differ in appearance according to the number of the vesicles. In cases of the discrete form, in which the eruption is sparse, so that the pocks are widely separated, the areoke fade gradually into the natural color of the skin, at the distance of a third or two-thirds of a line or more from the base of the vesicles, whilst in those in which the eruption is more abundant, they run together, so that the spaces between the pocks are of a more or less bright- red c«tlor. In confluent attacks again, the areolae are more or less imper- fect, according to the manner in which the vesicles are grouped together. The change of the vesicles into pustules take^ place generally from the fourth to the sixth day of the eruption. During this process the fluid of the pocks becomes more and more opaque, whitish, and at length assumes a yellowish color, being in fact converted from serum into pus. At the same time the pocks become larger, begin to distend, and, as they approach complete maturation, gradually lose their umbilicated shape and become convex on the surface. The formation of the pustules follows the same course as did the vesicles, beginning on the face and extending thence to the neck, trunk, and extremities. The areolie that have just been described as existing during the vesicular stage of the disease, con- tinue during the early part of the stage of pustulation, but decline to- wards its termination, assuming as they disappear a purple tint. The number of pustules is in proportion, of course, to that of the vesicles, but from the increase in size of the pocks during the changes from papules into vesicles and pustules, the eruption, when at its height, seems to be greatly more extensive than would have seemed probable at the beginning of the first stage. As a general rule the pocks are most numerous on the face, and after that part on the neck and limbs. On the trunk the erup- tion is alway?* much leiegins with more or less vivid redness of the membrane, which is followed by the production of little elevations, the real nature of which, whether 792 SMALL-POX. papular or vesicular, seems not to be clearly determined. About the second or third day these red elevations assume the appearance of small, ■sUiitish, rounded, and umbilicated pseudo-membranous points, which last generally about five days, and are then detached, leaving usually a little ulceration or erosion, which heals without leaving a cicatrix. A short time after the appearance of the pustules in the mouth and throat, a true inflammation of the mucous membrane of those parts takes place. When the gums are inflamed they become swelled, red, and spongy, and are dotted over with white pseudo-membranous points of a rounded shape. Sometimes the velum pendulum, and more rarely the tongue, present the same white points, with redness and injection of the membrane between. In most of the cases there is also partial or general inflammation of the pharynx, which occurs subsequently to the formation of the variolous pustules. The existence of this inflammation is denoted by more or less severe sore throat, attended with difficulty of swallowing, and with swelling and tenderness of the submaxillary glands. When the mucous eruption extends to the larynx, as often happens, there is pain in that part ; the voice becomes hoarse or whispering, and there is a hoarse, laryngeal, smothered cough. The pharyngo-laryngitis just described occurs generally between the third and sixth days of the eruption, and ceases about the eighth or thirteenth. In some instances it does not exist at all or only to a slight extent. During the eruption there is more or less inflammation and swelling of the subcutaneous cellular tissue, the degree of which depends on the extent of the eruption. The skin becomes tense, red, shining, and elastic under the finger, and more or less hot and painful. The swelling is greatest upon the face, where it commences about the fourth or fifth day of the eruption, and goes on increasing for five or six days, occasioning much pain, stiff*- ness, and inconvenience to the child. The swelling diminishes when desic- cation begins, and ceases entirely as the latter is accomplished. It is important to study carefully the general symptoms of the second stage. The fever which existed during the initial stage sometimes con- tinues during the first day or two of the eruption. When, however, the papules are fully thrown out, the fever subsides or disappears entirely, so that the pulse falls from 100, 120, or 140 beats, to 100, 80, 76, or 74, and the heat of skin diminishes at the same time. The child remains without fever usually throughout the vesicular period of the eruption, that is to say, until the fourth, fifth, or sixth day; during which time the appetite sometimes returns, slepp is tranquil and quiet, and the patient is in most respects well and comfortable. About the fifth or sixth day of the eruption, at which time the matura- tion of the pustules is nearly completed on the face, and that process is commencing on the extremities, a new fever, to which the technical terra secondary fever is applied, makes its appearance. The pulse rises again to 88, 100, 120, and 140, and becomes strong, hard, and full, whilst the skin is hot and dry. After continuing for some days the secondary fever dimin- ishes after the suppuration is fully established, and disappears about the time that desiccation is nearly completed on the face, and has commenced SYMPTOMS. 793 upon the limbs. It ceases generally, therefore, about the nintli or eKvonth day, having lasted between four and six days. This attack of fever is evi- dently the consequence of the suppurative stage of the disease, or of the conversion of the vesicles into pustules. Towards the termination of the second stage, at the very height of the disease, when the pustules begin to break and discharge their contents, the patient exhales a peculiar, disagreeable, and fetid odor, which is character- istic of the disease. The third or declininc/ stage is that of the desiccation or drying of the pustules, and their desquamation. The desiccatii>n commences generally between the sixth and ninth days, and terminates between the tenth and •fourteenth. The formation of the crusts begins upon the face and extends thence to the neck and limbs. It does not reach the limbs usually until about two or four days after it has commenced on the face. The mode in which the drying of the pustules takes place is not the same in all. In some a dark point is formed in the centre which gradually extends and converts the whole pustule into a hard crust ; in others the whole surface dries at the same time: while in others again, the epidermis gives way and allows the contained fluid to escape, which then hardens into yellowish, irregular crusts, which become brown before they fall off. Some of the pustules, particularly those upon the arms and legs, do not form scabs at all, but shrink away from the absorption of their fluid, leaving behind nothing but pellicles of cuticle, which fall oflT by des(juamation. The desquanuition or falling of the crusts begins from the eleventh to the sixteenth, and ends somewhere between the nineteenth, twenty-fifth, and even fortieth days of the eruption. When the scabs fall oflT, the ap- pearances presented by the skin beneath vary in diflcrent cases. In some a true ulceration and loss of substance of the derm has taken place, which gives all the characters of a suppurating ulcer when desquamation has be- gun early in the disease; when that process occurs at a later period, the ulcer is found to be dry and cicatrized. In both these forms of desquama- tion, the cicatrices form little pits or depressions, which remain during life. In other instances, the fall of the scabs leaves red and excoriated surfaces which are on a level with the surrounding skin, but which soon dry, leaving blotches of a reddish-brown color, that do not disapj^car en- tirely for months. No cicatrices remain when desfjuamation tak<'s place in this manner. In a third series of cases the crusts do not fall until the surface beneath has completely cicatrized, and the only traces left behind are more or less deeply tinted reddish spot«, with occasional slight furfu- raeeous exfoliation of the cuticle, all of which disappear entirely afti. , I'dii-, 1^1 1. 796 SMALL-POX. which, though the eruption is really confluent, it runs through the stages of maturation, desiccation, and desquamation so rapidly that the con- stitution is not greatly tried, and the patient recovers without difliculty. Even in the severe form, the patient may, if his constitution be good, pass safely through the disease. The liwinorrhagic, malignant, ov petechial form is happily rare. We had rarely seen it until the epidemic of 1871-72 showed it to us in all its ter- rible power. Our forefathers knew all about it. We, of the generation which has risen since the introduction of vaccination, had read of it, but took little heed of what the variolous poison might do when it exerted its malignant forces. In this form the patient is weak and feeble from the beginning. The surface assumes a singular reddish hue as the eruption comes out. The vesicles when they form upon the papules, instead of filling with lymph, and then pus, contain only a thin, sanguinolent liquid ; they mature very imperfectly, or rather not at all, not acuminating but remaining flattish, or irregular in shape, and flabby. While the eruption is struggling along in this irregular mode, the vessels of the cutaneous tissues become gorged and partially stagnant, so as to give to the surface dark red, brown, blue or purplish, and livid tints. Extravasations take place amongst and beneath the eruptive points, the cuticle forming the bloody pocks breaks, blood exudes, and forms dark scabs, and the patient is so changed from his natural aspect that we may comprehend how in the olden time, people who had not the consolation which vaccination gives, may have been driven from the bed and even from the house of the sufferer in hopeless terror. Such cases look no longer human. The swollen face, purple or black, the dark or crimson-red eyeball, with the whitish cornea sunken into a pit formed by the projection of the blood-colored and cedematous conjunctival membrane, the eyelids thick and stiff' and im- perfectly closing, the gross body, changed from all its natural bright to blackish tints, the cuticle dissected from the skin by bloody exudations, which weep and stain the clothing and bed-linen. Such is the variola nigra or black small-pox of the old writers, and well does it deserve its name. Varioloid, or Modified Small-pox. — This is a term now usually applied to the modified form of the disease, as it occurs in individuals who have been vaccinated, or who have already had the natural or inoculated disease. Dr. Welch's rule is a very good one, — " to- classify as variola all un- vaccinated cases, no matter how mild, all malignant cases, and all the vaccinated cases in which the eruption does not reach maturity until after the sixth or seventh day from its first appearance." The true point of distinction here, when any uncertainty as to vaccination exists (and this is not rare amongst the poor), is the time of maturation of the eruption. This, in varioloid, ought to be matured and in the decline by the sixth or seventh day. The initial symptoms of varioloid are of the same general kind as those of natural small-pox, differing merely in degree. But the physician ought to know that, in a few cases of even very mild varioloid, while the erup- VARIOLOID, OR MODIFIED SMALL-POX. 797 tiou is destined to be sparse, to consist of but few pocks, ami to run throui;h its stages in five or six days, the initial fever may be very hiii:h, and the at- tendant phenomena of pain, nervous disturbances, loss of strength, etc., very marked. We once saw a girl nine years old, who was ill for three days with very high temperature, delirium, stupor, prostration of strength, violent headache, and rapid pulse, so that her case looked very threaten- ing, and left the diagnosis in great doubt. On the third day a moderately abundant variolous eruption came out, when all the unpleasant symptoms rapidly abated and disappeared. The eruption ran through its stages in six days, and the patient recovered without a pit. 8he had been well and carefully vaccinated in infancy. These severe initial symptoms are rare, however, in children as com- pared with adults. Usually the attack begins with slight fever, head- ache, languor, and sometimes constipation, which are followed in two or three days, by the eruption. The vomiting, lumbar pains, and different nervous symptoms which exist in regular variola, are not often present, or, if so, iu a very slight degree. The eruption consists of papules like those of true small-pox, but usually they are few in number, and entirely dis- crete in their arrangement. The initial fever and other symptoms subside completely upon the appearance of the eruption, and the child often seems perfectly well. The progress and character of the eruption are very similar to those of the regular form of the disease, with the exception that the changes are more rapidly effected, and, as a consequence, the duration of the attack is rendered by so much the shorter. The papules are converted into vesicles at a much earlier period — as early as the first or second day. The vesicles soon assume a whitish, opaline appearance, become umbilicated, and in the course of the second or third day begin to change into pustules. The sup- purative stage of the eruption, or maturation, is seldom accompanied by any marked .secondary fever, as in the regular disease. When the fever does occur, it is generally very moderate, consisting merely in slight accelera- tion of the pulse and a little increa.sed heat of skin, and in one or two days it disappears entirely. The pustules do not fill usually so well as in regular variola, and not unfrequently their contents are rather sero-puru- lent, than purulent, in the proper sense of the term. The tliird stage occurs earlier and goes through its periods more raj)idly than in true small- pox ; de-iiccation soon takes place, is speedily finished, and the falling of the scabs, which begins as early as the eighth day of the eruption, is usu- ally completefl about the twelfth or fourteenth. After de-cjuamation is completed, the only traces of the disease left are reddish spoU^ or blotches, which disappear after a time without leaving cicatrices. The whole dura- tion of the attack is generally from ten to twenty days. Varioloid may be so mild that the patient never goes to bed. Some ma- laise, a little loss of appetite, the appearance on the skin of half a dozen papules, which soon become umbilicated vesicles, and then rapidly form scabs, con.«titute the whole history of some cases. Here it is that a correct diagnosis is invaluable to the family. To the patient it is of no consequence. 798 SMALL-POX. He is safe, but he may inoculate any or all of those who have not been properly protected. Complications. — The most frequent and important complications of variola in children, are inflammations of the mucous membrane of the lower half of the intestinal tube, ophthalmia, otitis, and different hsemor- rhages. In a smaller number of cases, attacks of bronchitis, pneumonia, anasarca, articular inflammations, subcutaneous abscesses, simple and pseudo-membranous coryza, angina, and laryngitis, and other eruptive diseases, occur at different periods of the malady. It is impossible for us, for want of space, to attempt a description of the various symptoms of the diflTerent complications just enumerated. Having mentioned the possibility and probability of their occurrence, we must leave the reader with the advice always to suspect the existence or approach of some one of them, when the symptoms, in any case, differ much from those which have been described as characteristic of the regu- lar form. Anatomical Lesions. — The characteristic lesions of small-pox are a certain deteriorated state of the blood, congestion of the internal organs, and the inflammation of the skin and mucous membranes constituting the eruption. The blood is found to be entirely liquid and uncoagulable, and of a dark color; or if coagula exist, they are small, soft, and very dark in color. The exceptions to this rule are those in which some acute and severe inflammation exists, under which circumstances the dissolved state of the blood is less marked, and fully formed coagula are more abundant. The congestion referred to aflTects almost the whole system. The muscles are firm and of a deep red color; the membranes of the brain are strongly injected, the sinuses are filled with blood, and the cerebral substance presents numerous red points or dots. The vessels of the lungs contain a large quantity of blood, and the liver, spleen, and kidneys, are all deeply congested. The condition of the mucous membranes is important. The pharynx, larynx, and trachea, present an eruption, or simple inflammation without eruption. The eruption exists under the aspect of small, circular, thin, and whitish pseudo-membranous points, scattered over the mucous tissue, and slightly adherent to it, beneath which that tissue is often observed to be red and inflamed. At a more advanced degree, and in severer cases, the false membranes have disappeared, and in their places we find circu- lar ulcerations, which are either superficial, or they penetrate the tissue of the mucous coat and rest upon the muscular, or even pierce that and reach to the cartilaginous tissue beneath. In addition to these lesions are found inflammation of the mucous tissue with its consequences, redness, soften- ing, thickening, and extensive deposits of false membrane, quite distinct from the appearances above described as characteristic of the eruption upon these tissues. It has been a contested point whether a true vesicular or pustular erup- tion ever exists upon the mucous lining of the stomach and intestines. The general opiuiou appears now to be, however, that the changes ob- served in these organs cannot be ascribed to the formation either of ves- DIAGNOSIS. 799 icles or pustules. The appearances that have loil some observers to con- sider them as the result of a proper eruption, are the tuUowinp The follicles at the commencement and termination of the small intestines, and in rarer cases, of the large intestine also, present an abnormal degree of development, appearing in the form of small hemispherical or pointed, and sometimes llaitened projections, on which there often exists a dark, and sometimes depressed central point. At the same time Peyer's glands are often enlarged, more projecting than usual, softened, and red. According to the valuable researches of Desuos and Huchard {loc. cif.), the heart and pericardium present marked lesions in a considerable i)ro- portion of cases of confluent variola. These changes were rare in cases of the discrete form, and were not delected in any case of varioloid. The lesions may consist solely of endocarditis, or pericarditis, or these may be associated. These inflammations present the ordinary morbid products, and are not attended with the development of pustules. In other cases, the muscular walls of the heart are aftected with an acute myocarditis, which is marked at first by a granular state of the muscular fibres, which soon passes into fatty degeneration. The anatomy of the variolous pock is important and interesting. When a vesicle is opened soon after its formation, it is found to contain nothing but a little serosity, which is perfectly limpid and alkaline, while the skin beneath is red, softened, and moist. The umbilicated character depends on a filiform adhesion between the centre of the pock and the surface of the skin beneath. This adhesion is broken, when, at a later period, the pustule becomes globose in shape. The vesicle is also subdivided into several chambers by delicate radiating partitions, so thata single puncture will not discharge the entire contents. About the period of the conversion of the vesicles into pustules, or very soon after the formation of the latter, the cavity of the pock will be found to contain a false membrane, which is of an opaque white color, soft and friable in it-s texture, and seated upon the derm in small isolated points. After a time these points enlarge, and meeting, unite, and form a soft pseudo-membranous disk, uneven upon its surface, and which either fills the pock completely, or is covered at first with serosity and afterwards with pus. This false membrane is secreted originally by the true skin. At a somewhat later period it forms an adhesion to the inner surface of the cuticle, while still later in the progress of the pock, it becomes detached from the cuticle, and re- mains loose and free in the cavity of the pustule, siirrounded by the fluid contents of the latter. Diac;no**is. — The diagnosis of this di.sease in all its forms ought to be made as early as possible, in order that the persons in contact with the patient, whether from necessity or by accident, may be vaccinated or re- vaccinated. It is well known that expfwure to the mildest varif)loid may prf>duce in the unprotected any form of small-fK)X, from discrete to malig- nant, according to the constitution of the subject and the type of epi- demic prevailing. Therefore the only safety after expf)8ure is in the vaccine di.sea.se, and, therefore, the lives of the exposed hang upon the knowledge and action of the physician in charge, a resiKjuuibility from 800 SMALL-POX. which he cannot escape either in the estimate of the public or in his own consciousness. Dr. Welch concludes from his observations that " vaccination performed at a period less than seven days previous to the appearance of the eruption (small-pox) will not modify the disease," but that when performed "seven days previous, (it) will almost always modify the disease to the extent of rendering it harmless." Dr. Masson (article on Small-pox, in Reynolds's System of MecUcme, vol. i, p. 477) says that to be effective vaccination should have gone on to the stage of areola before there is any illness from small-pox. " It has before been stated that when small-pox has been taken into the system there is twelve days' freedom from illness, generally, forty-eight hours' illness, and then the disease begins to appear on the skin. The areola of vaccination is not fully formed until the ninth or tenth day of the progress of the vaccine vesicles on those who have never been vaccinated before, so that unless there has been time for the areola to be formed after the vaccination, before the illness produced by small-pox begins, the vaccina- tion will not be of the least benefit." He gives an example : " Suppose an unvaccinated person to inhale the germ of a variola on a Monday ; if he be vaccinated as late as the following Wednesday, the vaccination will be in time to prevent the small-pox being developed ; if it be put off until Thursday, the small-pox will appear, but will be modified; if the vac- cination be delayed until Friday, it will be of no use, it will not have had time to reach the stage of areola, the index of safety, before the illness of small-pox begins. This we have seen over and over again, and know it to be the exact state of the question. Revaccination will have effect two days later than vaccination will have that is performed for the first time, because revaccinated cases reach the stage of areola two or three days sooner than in those persons vaccinated for the first time." It is plain, therefore, that the diagnosis ought to be made as early as possible. Can it be made in the initial stage? Not, we think, with any certainty. Except in a time of general epidemic prevalence, cases of small-pox are almost unknown, and varioloid is very rare amongst chil- dren, and the medical man thinks of anything but varioloid or small-pox to explain a fever attended with vomiting, anorexia, restlessness, or drow- siness in the infant, and the same symptoms with headache and general soreness in the older child. The initial fever has no characteristic phe- nomena. When the disease is epidemic, the initial fever, as it has been described, may arouse suspicion, and the attendant physician may dare to announce the probable approach of the dreaded disease, and examine all the exposed persons as to their being fully protected. But this course is justified only by the presence of the epidemic. Not until the eruption begins to appear can the diagnosis be made with certainty ; and however easy it may be for old and experienced physicians to make it then, we desire to caution the youuger and more inexperienced as to the possibility of mistake. The important points to bear in mind are the following : 1. The pro- dromic stage, whether of mere ailing and lassitude, such as may not send I DIAGNOSIS. 801 the patient to bed, or violent fever with nervous symptoms and the differ- ent signs which declare a severe disease, which lasts two days, and on the third of which, as the law, the eruption makes its appearance. 2. The eruption appears first on the face and about the upper part of the neck, and consists of hard, distinct, shotty papules, seated, in mild cases, on a nodosal skin. 3. As the eruption appears, the fever diminishes. These three points kept steadily in view will usually prevent any mistake. The eruption of meerienced person might very well fail to detect the true nature of the disorder. But even here careful inquiry will generally show that the health has been dis- turbed for two days, at lem^i by altered temjK'r, lassitude, lessened ap|)e- tite, and one or two restless nights. These pro' up on the fourth, fifth, or sixth, can be nothing but variolous in their nature. Again, in severe cases of small-pox iL**elf, embarrassments sometimes occur. We once saw an infant, five weeks old, who had never been out of the mother's rfxjm, seized in the midst of perfect health, with violent fever, vomiting, loathing of the breast, and heavy stupor. On the second day of 61 802 SMALL-POX. the illness the whole cutaneous surface began to redden ; soon the tint be- came bright-red, not unlike some scarlet fevers, but of a more crimson- red; the skin was swelled, tight, hard, and, so to speak, shining. On the third day innumerable hard and distinct papules formed upon this evi- dently acutely inflamed skin, and on the following day the child died co- matose. The child had not been vaccinated, and there were at the time a few cases of varioloid and small-pox in the city. Even in such cases, how- ever, where a deep roseolous or erythematous efflorescence precedes and masks the variolous eruption, the violence of the prodromic symptoms, so unlike the mild phenomena which precede ordinary roseola or erythema, and particularly the intensity of the coloration and the hard and swollen condition of the skin, indicating active inflammatory states of its deeper layers, will go far to prepare an experienced eye for what is coming. Prognosis. — The fatality of small-pox varies greatly in different epi- demics. The result is also markedly influenced by age. It is particularly fatal in infants under one year of age. Of the whole number of cases, 2377, admitted into the Municipal Hospital of this city in 1871-2, there were 35 children under one year of age. Of these 26, or 74.28 per cent., died. Between the ages of 1 and 15 years there were 291 cases, of which 95, or 32.64 per. cent., died. The mortality was therefore nearly three- fourths of the whole number under one year, and very nearly a third of those between 1 and 15 years of age. Of a series of 23 cases that we have met with, 5 were fatal. All of these were under 5, and 3 under 1 year of age. The amount of the eruption governs the prognosis to a great degree. As the number of pocks is abundant or otherwise, — as the case is a dis- crete, moderately full, semi-confluent, or confluent one, — so is the danger. Cases of full confluence are almost as fatal as malignant scarlatina. Few children escape in the confluent form. A moderately full eruption, and of course a discrete one, is favorable. The hsemorrhagic form is, almost without exception, fatal. Varioloid rarely kills. Under 15 years of age we have never seen a fatal case of it. In one case only have we known it to be dangerous. The favorable symptoms in any case of variola are the occurrence of the disease in children previously in good health and over one year of age; the absence of any violent nervous symptoms during the initial stage ; a proper duration of the first stage ; and the subsidence of the fever after the appearance of the eruption. When, in addition to these circumstances, the secondary fever is not too violent, and no complication arises, there is but little doubt that the patient will recover. The unfavorable symptoms are the occurrence of the disease at a very early age; the existence of severe nervous symptoms during the first stage ; the occurrence of a thick and abundant eruption upon the face indicating a probably confluent case; continuation of the fever after the appearance of the eruption, or a merely slight subsidence of it ; delirium and other nervous symptoms during the secondary fever; and any irregularity in the appearance of the eruption, as paleness instead of the usual red color, a livid or purplish color of the pustules, imperfect development of the i TREATMENT. 803 pocks, or their sudden shrinking without diminution of the general symp- toms. The occurrence of the signs which mark the hiemorrhagic form, as petechia? and local htvmorrhages, stamp the case as almost necessarily fatal. It is scarcely necessary to si\y that many of these symptoms are indicative of the existence or threatened production of some complica- tion, upon the nature of which must depend, after all, in great measure our prognosis. The complications most apt to occur have already been considered in a previous section. Treatment. — The treatment must be regulated by the type of the case under charge. It will vary, therefore, from a mere quiet expectancy throughout, to the vigorous use of such means as moderate fever, abate nervous agitation, and allay suffering in the early stages, with the peremp- tory exhibition of stimulants!, tonics, and nutritious foods, in the period of eruption and maturation. In the varioloid of children over eight or ten years of age, during the initial fever, rest in bed, light diet, and the use of sweet spirit of nitre, in iced lemonade, often suffice. Should there be much restlessness, insom- nia, or pain, solution of citrate of potash, with small doses of laudanum or paregoric, may be given. When the eruption appears, if it be slight, and the fever disapi)ears, nothing more is necessary than to keep the diet moderate and seclude the patient in one room, for the sake of others, until the crusts have fallen. If the eruption be more copious, enough to cause a good deal of irritation and restlessness, a warm bath at night, es- pecially with some bran added to it, and the aj)plication through the day of an ointment of glycerin and cold cream, with a mild opiate at night, are all-sufficient. In the variola of un vaccinated children, the treatment must also depend on the type of the symptoms. In the initial stage, when the fever is high, the child must be confined to the breast, if it is still nursing, and, if weaned, it is to be kept upon a proper mixture of milk and water, with lime-water, and upon chicken or beef tea, for food. Cold water must be frequently of- fered to the child at all ages, and it should be allowed to take all it desires. A tepid bath morning and evening, or even three times a day, if the child does not resist, is very soothing, and tends to reduce the heat. Spongings with tepid or cool water, from time to time, according to the degree of heat, and the effects of the application, may l)e used, if the bath terrifies or fails to reduce the fever. Diaphoretics, and especially the citrate of pota.sh, with sweet spirit of nitre, and very small proportions of laudanum, should be administered in this stage. f)r the spirit of Mindererus may he given, — twenty to thirty drops, with ten dro[)s of nitre and five of paregoric, in a tablespoonful of iced water, every two hours, to children of six months to two years. For older children the doses must be enlarged. When there is, as often happens, great agitation of the nervous system, as shown by jactitation, insomnia, anri mild or active deIiriunj,some remedy should he given to control the.«e symptoms. If the citrate of potaf^h and opium fail to relieve these conditions, the best remedy is bromide of potas- sium, one to two and a half grains, with one to two drops of demJorized 804 . SMALL-POX. laudanum, at the age of one to three years, every two hours until rest is obtained, or until three or four doses have been given. After the age of four years the proportion of the bromide may be doubled. When great heat and swelling of the skin, severe headache, and signs of congestion of the lungs or brain, exist, cold applications to the head, with hot mustard foot-baths, may be used with the diaphoretics. If, in older children, the headache or pain in the loins be very severe, a few dry cups or a sinapism may be applied to the back of the neck or loins. If the bowels are not moved spontaneously, a moderate laxative ought to be used, as syrup of rhubarb or castor oil, or an enema may be ordered. Purging with large doses of cathartics must be avoided at all ages. In the eruptive stage the treatment must vary with the type of the erup- tion and the constitutional peculiarities of the patient. It may be laid down as a rule that, the more copious the eruption, the more carefully should the strength be husbanded, and the vitality supported, to enable the patient to pass through the long and exhaustive processes of matura- tion and desiccation necessary to a cure. If the eruption come out slowly and tardily, and the extremities be cool, even though the body is hot,, hot mustard foot-baths, or warm baths, with hot drinks, as milk and water, hot broths, and small quantities of brandy, ought to be employed, and are often very useful. If the eruption be discrete and moderate in amount, nothing but rest in bed, simple sustaining foods, and some local remedy to allay cutaneous irritation, as an ointment or an occasional warm bath, will be necessary until the secondary fever appears. When this arrives, the same means, in the form of diaphoretics, anodynes, and nervous sedatives, should be used as in the initial stage. In the stage of maturation the strength must be sustained by a diet adapted to each particular case. If the patient be feeble, and therefore much reduced by even a moderate eruption, he must have brandy added to his milk, or wine-whey, from time to time, increased doses of beef or chicken soup, if he can take them, and, if old enough, eggs, or egg-nog. Quinia and muriated tincture of iron should be used as in confluent cases, of which we shall speak directly. In the semi-confluent and confluent cases all must be done to sustain the strength and vitality. From an early period of the eruptive stage, alcohol, quinia, and iron, must be employed. From twenty to thirty drops of brandy, in a wineglassful of milk, may be given every two hours, and two or three tablespoonfuls of thin beef tea, every alternate two hours, at the age of two or three years. After the age of five, these quantities may be doubled. To infants, brandy, in doses of ten to twenty drops, may be given every two hours, in breast-milk, or in warm water and sugar. Quinia, in doses of half a grain, at a year old, and one grain at four and five years, with or without muriated tincture, of iron, ought to be administered every four hours. It is best to choose the four-hour interval, because of the diffi- culty there is in giving frequent doses to children. If the stomach will not retain the iron and quinia mixed together, the quinia may be used in suppository, two grains every four hours, and the tincture of iron in doses of two to five drops, according to the age, every two hours, in syrup of TREATMENT. 805 ginger, or in combination with dilute acetic acid and solution of acetate of ammonia, as proposed in the article on scarlet fever. On account of the well-known frequency of cardiac complications in such cases, digitalis may be added to the treatment if the symptoms indicate marked failure of the heart's action. The condition of the pharynx and larynx present in confluent small-pox, as described in the article on symptoms, constitutes one of the great diffi- culties of the disease. The patient sutlers so much in the act of swallowing, the respiration is so interfered with when he attempts to drink or eat, that it ends in his taking but little, and, at last, almost nothing. Here ice should be given, iced tlaxseed tea and iced brandy and water, or frozen beef tea. A solution of chlorate of potash may also be tried. Lemonade may be used, and a warm poultice to the throat is to be recommended. Still we must persevere, as small quantities are better than nothing, and we may employ nutritive injections of beef tea, of milk, or of eg'^ and milk. Jf the patient survives the stage of eruption, we must continue the tonics, stimulants, and nutritious food through the decline of the disease. During the latter period something must be done to allay the itching, burning, and irritation of the skin. If the patient is not too weak, a flaxseed or bran bath is very soothing, or we may use lime-water and sweet-oil liniment, or glycerin and cold cream ointment, applied with a large camel's-hair brush frequently. In ha^morrhagic small-pox, which is almost always fatal, we know noth- ing better to recommend than the treatment just advised for the confluent form, to which turpentine in full doses may be added, on account of both its stimulant and luemostatic properties. Treatment of Complications. — If complications occur in the course of the disease, they must be treated always with a full consideration of the pri- mary importance of the general disorder. The angina and laryngitis of confluent cases can scarcely be looked upon as complications. They be- long to the disea.se. We have already alluded to their treatment, and may refer the reader to what has been said of the same series of symptoms in scarlet fever. In pleurisy or pneumonia we can do nothing better than persevere with the measures most proper to combat fever. Pain may make it necessary to use opium in full doses. Counter-irritation is not to be thought of becau.«e of the eruption, and even cataplasms, which are so useful in ordinary pleurisy and pneumonia, are objectionable here. The treatment of the ophthalmia which so often threatens, and some- times occasions great or irreparable injury to the eye, is very important. Niemeyer says that much may be done to prevent the development of a severe eruption on the conjunctiva by the assiduous employment of cold water compresses, or, still better, by compresses moistened with a weak solution of corro-sive sublimate, one of one grain to six ounces of distilled water. When ulcerations occur upfm the cornea, they ought to be touched, if this be practicable, with solid nitrate of silver sharpened to a point, or with a fine carael's-hair pencil which has been moistened and rubbed over the nitrate of silver crystal to insure a cauistic solution. When it is im- 806 SMALL-POX. possible to apply the solid caustic or the brush, we must resort to some collyrium. This may consist of a solution of nitrate of silver, a grain to the ounce, or of one or two grains of sulphate of zinc, with twenty or thirty drops of wine of opium, dissolved in an ounce of rose-water, two or three drops of either of which may be introduced into the eye, morning and evening. An excellent collyrium is one composed of twelve grains of borate of soda, one grain of sulphate of zinc, a drachm of camphor-water, to seven drachms of distilled water. Catarrh of the intestine must be treated by the most careful attention to the diet, by emollient and anodyne injections, and by the internal ad- ministration of astringents, and small doses of opiates. When the diar- rhoea is severe, and the stools mucous and bloody, we may use with ad- vantage the nitrate of silver by enema, as recommended in the article on entero-colitis. The treatment of the convalescence is important. The same rules apply here as in other infantile and children's diseases. Ventilation and Disinfectants. — It is even more important in this disease than in others, for the physician to see to it himself that the rooms occu- pied by the patient, and the house of which they form a part, shall be well ventilated, and that so soon as the eruption becomes purulent, and its exhalations more or less fetid, proper disinfectants shall be applied. This is necessary, not only for the good of the patient, but also for the safety and comfort of the other inmates of the house. The best ventilation in winter is that procured by an open fire, or, if this cannot be had, by a stove. If the room can be warmed only by a furnace, the windows must be very carefully opened from time to time, so as to supply fresh air, and yet avoid currents flowing over the patient. In summer, of course, the windows must be open. Among the best disinfectants is Labarraque's solution. If this cannot be bad, or if more than one be desired, chloride of lime in saucers, wetted, or a mixture of equal parts of impure sulphate of iron and of chloride of lime, wetted, and placed in saucers, in the entries and passages of the house, are very efficient. Solutions of carbolic acid or permanganate of potassa, chloral um, and other disinfectants may be substituted for the above if more convenient. Before terminating our remarks upon the subject of small-pox, it will be proper to give some account of the treatment of the eruption which has been recommended and practiced, with a view to prevent the scarring and disfiguration which so often result from the ravages of the disease. Of the different means that have been employed with this view, there are two which are chiefly relied upon at present. One is to cauterize the pustules with nitrate of silver, and the other to make a mercurial application upon the part where it is desirable to cause the abortion of the eruption. The cauterization has been performed in two modes : by the application of the caustic to each pustule separately, or to masses of the eruption without puncturing the cuticle. It appears, however, that the first-named method is much the most preferable. To succeed perfectly, it is necessary to touch TREATMENT. 807 the derm forming the base of the pustule ; so that the best plan is to re- move or lift up a portion of the top of the vesicle with a lancet, and then to introduce into its interior the sharpened point of a stick of caustic. This operation is certainly successful only when performed on the first or second day of the eruption, though MM. Killiet and Ixirthez have known it to answer as late as the third and fourth, or even fifth day. The pro- cess of cauterization is productive of acute pain, but does not increase the local infiammation, according to the authors just quoted, at least when applied to a small number of the pocks. They state that when apjdied to the pustules seated upon the edges of the eyelids, it is almost incredible to behold how great is the diminution of the oedema of those parts in a single day. The conclusion of these gentlemen is, that individual cauterization of the pustules with nitrate of silver does certainly cause them, as well as the surrounding tumefaction, to abort, and prevents them from leaving cicatrices. This plan is, however, manifestly inapplicable to any but cases of the discrete form, where the vesicles are not very numerous. The other method which has been employed to cause the abortion of the pustules, and thus prevent di.-figu ration, is, as has been stated, the applica- tion of some one of th(i mercurial preparations. The effects of this treat- ment are said to be an almost certain arrest of the development of the eruption, when it is used from the first or second, or not after the third day ; the vesicles and pustules remaining small and isolated, and not as- suming, or else soon losing, the umbilicated character. When applied early, while there are as yet but few vesicles formed, it prevents the de- velopment of new ones, and diminishes the accompanying swelling and soreness. When the application is removed on the seventh or eighth day, it is found that desiccation has occurred imperfectly, the surface present- ing small soft scabs, or little whitish, soft elevations, consisting of the pseudo-membranous substance situated between the true skin and the new epidermis, the old cuticle having generally peeled ofl^ with the plaster. In some places a light rose-colored surface alone remains. In regard to the success of this treatment in preventing disfiguration, we may quote the statement of MM. Killiet and Barthez, that none of the patients upon whom they saw it tried presented any cicatrices, though sev- eral had had confluent small-pox, which pursued its usual course on the parts not covered by the application. Dr. Stewardson, of this city, made a considerable number of trials of this treatment at the 8mall-pox Hos- pital of this city in 1841-42. He gave his conclusions in the following words (Am. Jour. Med. Set., January, 1843, pp. 86-7): " From these ex- periments, it seems pretty evident that the mercurial plaster has a deeided influence upon the sraall-pox pustules, preventing more or less completely their perfect maturation, and dimini.shing the concomitant swelling and soreness, the process of desiccation being completed without the formation of thick scabs, and the resulting cicatrices le.ss marked than when tlu; |)ro- cess of suppuration was left to pursue its natural course That, by its use, pitting may be entirely prevented, or the mortality from small-pox materially les.sened, seems to me very doubtful, although had all the pre- 808 SMALL-POX. cautions above-mentioned been taken, it is not improbable that the effects would have been still more decided." The use of the mercurial application is attended with some inconvenience. In the first place it is difficult to keep it accurately applied, particularly in children, in consequence of the unpleasant sensations it occasions. In the second place, it not very unfrequently, according to MM. Rilliet and Barthez, produces an eruption of hydrargyriasis or mercurial roseola, in about eight or fourteen days after the variolous eruption, or four or ten after the application of the remedy. M. Rayer, however, states this effect to be a rare one. Dr. Stewardson says that he thinks no apprehension need be felt as to constitutional affection from the mercury, for scarcely ever were the gums even touched. One of ourselves, however, when in Paris, in 1840, saw this effect produced in a young girl at the Children's Hospital. The method of its application is different in different hands. The French generally employ the emplastrum de Vigo cum mercuric. Dr. Stewardson prefers the strong mercurial ointment, either pure or rubbed down with an equal bulk of lard, spread upon a piece of thick muslin. The muslin is to be cut into the shape of a mask, with apertures for the eyes, nose, and mouth. It is secured upon the face by means of strings attached to its margin and tied across the back of the head and neck. It it important always for the success of the measure, that the application should be kept in close contact with the skin. To insure this, he employed a separate piece of muslin for the nose, which is the part most difficult to fit. With the same view, the French authors recommend that the plaster should be cut in pieces to suit the different portions of the face, making one for the forehead, and others for the cheeks, sides and back of the nose, and upper and lower lips. Any spaces that may remain are to be covered with other portions of the plaster, and the whole secured with strips of diachylon. On account of the difficulty of applying the mercurial plaster, the following ointment was compounded by the apothecary of the Chil- dren's Hospital at Paris, and has been found to answer very well : R. — Mercurial Ointment, 24 parts. Yellow Wax, 10 parts. Black Pitch, 6 parts. — Mix. The application ought to be confined to the face, as that is the part which it is most important to save from disfiguration, and as it is better not to use it upon a larger surface than necessary, lest it might occasion the mercurial roseola, or possibly salivation. As a general rule, four or five days are sufficient, according to Guersant and Blache, to leave it in contact with the skin, in order to avoid the bad effects just referred to. The object sought in these applications being, to a great extent, to pro- tect the vesicles from contact with the atmosphere, it has been advised to paint a saturated solution of gutta percha in chloroform, over the neck and face, so soon as the papular eruption is fully out. This plan was tried in five of our own cases {loc. cit, p. 345), two of which were discrete and three confluent, and with very satisfactory results. VACCINE DISEASE. 809 To conclude this matter we will add that Niemeyer states that Skoda prefers impresses moistened with solution of corrosive sublimate (gr. ij-. iv to water .svj) to mercurial ph\ster, which induces an injurious elevation of ten»perature. He also says that Hebra rejects both mercurial plaster and solution of corrosive sublimate, a^ well as collodion, and touching the individual pocks with nitrate of silver, and that he has come to this de- cision from the observation in his wards, that the pocks do not leave cicatrices any oflener since he ha^ ceased to employ these remedies than when he used them. He (Hebra) applies only cold water compresses, which, while the skin is tense, relieves the patient, although they do not protect the skin from destruction. ARTICLE IX. VACCINE DISEASE. Definition; Synonyms; History. — The vaccine disease is an affec- tion produced by the inoculation of the virus of variola, modified by pass- ing through the system of the cow. The proofs which exist as to the truly variolous nature of the vaccine di.sease in the cow, are altogether incontestable ; so that we must regard the vaccine disease in the human subject merely as a remarkably modified form of variola. It is susceptible of propagation from individual to iudividual by inocu- lation, but is contagious in no other way, and it pos,sesses the invaluable quality of protecting, with very great, though not with absolute certainty, those through whom it has passed, against small-pox. Bivides the name given above, it is known by the titles of cow-pox, kiue-pock, vaccina, and vaccinia. Some knowledge of the nature of the vaccine disease, and of its power to protect the human constitution against small-pox, has been found to have existed in different part« of the world, but there can be no doubt that we owe to the genius and patient research of Dr. Jenner the inestimable blessing of vaccination, since it was by him that its marvellous virtue was demonstrated and pnK-laimeect some modification in the phe- nomena of the disease, to wit, when its course is interfered with by the efl^ecta of a previous vaccination, or of an attack of variola. The irregu- larities arising from these causes are such as might he anticipated, and will be described in the article on revaccination. Whenever, however, the disease fails, in any imfK)rtant r(*spect, to exhibit the perfect attributes of a well-marked pf the four (4) who died, two (2) occurred among tho.se without cica- trices, one among tho.se revaccinated after exposure, and one among those showing p) published separate and independent memoirs on this sub- ject ; and since that time the occurrence of typhoid fever in children has been frequently observed and very carefully studied. The fact that it was so long overlooked, is undoubtedly to be explained, in great part, by certain peculiarities which the disease presents in chil- dren, which caused its real nature to be mistaken, and led to the applica- tion of other names. Of these names, that of infantile remittent fever was the most frequently used, and though this term was made to include a number of other dis- eases, and although remittent fever does occur in children, there can now be no doubt that a large proportion of the cases so styled, were in reality cases of typhoid fever. Causes. — Age. — Typhoid fever has been observed during the first year of life, but is rare under the age of two years. We have however met with well-marked instances of it at the age of eighteen or twenty months. It is comparatively frequent between the ages oi three and eight years, and it attains its maximum of frequency in childhood between the ages of eight and eleven years. Sex. — The statistics of most authorities show a preponderance, more or less marked, of cases occurring in boys. In some series of cases this dis- parity has been remarkable (three to one) ; but, notwithstanding, it is probable that in a very extensive series the difference would be compara- tively trifling. Contagion: Epidemic Influence. — If typhoid fever be at all contagious it is in the slightest degree. On the other hand, it is well known that the dejecta from patients with this disease possess the power of producing it in those who are exposed to their emanations, or who drink fluiil which have been allowed to become in any way tainted by them. The noxious vapors from foul sewers, drains or cesspool.** are also frequently the cause of typhoid fever. It is moreover subject both to epidemic and endemic influences in a marked degree ; and it is owing to the varying action of 828 TYPHOID FEVER. these causes that it presents the wide variety, in type and severity, which will be described. Anatomical Appearances. — These are strictly analogous to those found in the adult. When death occurs early in the attack, the agminate ■glands of the ileum are found swollen, prominent, injected; the alteration being most marked in those nearest to the ileo-coecal valve. Later, how- ever, these glands ulcerate, the softening beginning either on the surface, and extending mor^ and more deeply, or beginning in the deeper portion of the patch, so that the superficial la3^er may be thrown off* as a slough. These ulcers thus destroy the mucous membrane, and present the sub- mucous or muscular coats for their base ; or, in some instances, the ulcera- tive process may extend through the muscular and even though the peri- toneal coats. We have known the most violent general peritonitis to be excited early in an attack of typhoid fever, in a girl 4 years of age, by the simple extrusion of inflammation, without the occurrence of perforation. According to Rilliet (loe. cit.), however, these ulcers are more slow in forming, smaller, and less numerous and deep in children than in adults ; and, indeed, he believes that in not a few instances the swelling and in- flammation of the gland may undergo resolution without the occurrence of ulceration. Too much importance must not, however, be attached to this statement, since it appears to us evident that a few cases, at least, of typhus fever are included amongst those upon which his memoir is based. The solitary glands are, in the early stage of the disease, prominent, and may be distended with a serous or more thick and yellowish secretion, so as to resemble vesicles or even pustules. Later in the attack their mucous covering is destroyed, and small, round, or oval ulcers, with everted edges, remain. These ulcers are also most numerous in the lower part of the ileum, though in some cases they are met with quite abundantly in the large intestine. The mesenteric glands are enlarged, softened, and strongly injected, the change corresponding in intensity to that of the agminate glands in the ileum, and being most marked in those glands which are nearest the ileo- coecal valve. Usually the swelling of these glands subsides without sup- puration occurring, but occasionally this ensues, and the gland is converted into an abscess with thin walls. The cicatrization of the intestinal ulcers appears usually to occur rap- idly; thus, Rilliet has seen the process completed by the thirtieth day, though this is probably sooner than it is entirely finished in the majority of cases. Ulcers of other mucous surfaces, as of the pharynx and larynx, are more rarely met with in children than in adults. The spleen is nearly always considerably enlarged and softened. The blood in severe cases is dark and uncoagulable, and the lining membrane of the heart and large vessels is stained by imbibition. In some cases quite firm coagula are met with in the cavities of the heart. Even in cases where the most violent nervous symptoms have been present, the brain rarely presents any more positive lesion than mere con- SYMPTOMS. 829 gestion of the vessels of its membranes 'and substance, with at times some subarachnoid ettusiou. Of course, in cases where death has resulted in cousequeuce of some complication, the lesions of the intercurrent disease will be found. Symptoms. — The general course of typhoid fever is much the same in children as in adults. It presents also the same wide variety in its type and degree of severity, depending upon the predominance and excessive development of some one of the elements of the disease ; and it would be easy, therefore, to divide the disease into a great number of forms, according to the prominence of each functional disturbance; but iis our object is merely to give a practi- cal description of the disease iis met with in children, we will, in consider- ing its course, give a brief sketch of an ordinary case, and then dwell in detail upon certain symptoms which require special notice, as presenting special peculiarities in childhood. In the majority of cases, the attack is preceded for some days by slight prodromes ; the child, who ordinarily may enjoy robust health, appears languid, and is easily tired, and indisposed to play ; he loses his appetite, is restless during sleep, and possibly may complain of colicky pain in the abdomen, perhaps attended with slight looseness of the bowels. After this state of vague indisposition has lasted from three or four to eight or ten days, more decided symptoms manifest themselves, and the attack may be said to fairly begin. More or less febrile action now appears ; but this is rarely continuous, and for the ensuing five or six days there are distinct and marked remis- sions, usually in the morning, but sometimes so marked and prolonged that it is only towards night that the skin becomes heated, the pulse fre- quent, and the child grows restless, while, during the day, he has merely appeared somewhat dull and languid. The loss of appetite continues, and becomes more complete, though thirst is marked ; vomiting is apt to follow eating, and is sometimes frequent and spontaneous ; the tongue presents a moist, whitish-yellow fur in the centre. The bowels either continue loose, or now become so for the first time ; the abdomen becomes somewhat large and tympanitic, and slight tenderness may be present in the righ't iliac region towards the close of the first week. The strength is rapidly lost, and the child, after the first few days sliows no desire to leave the bed. The respirations are somewhat hurried, and are aften accompanied by sonorous rales and slight dry cough. The pulse is accelerated, but rarely rises at this stage above 110. The expression grows dull and listless, unless temporarily excited during delirium, and the child takes but little notice of surrounding persons or objects. During the night there may even now In; a tendency to more marked cerebral disturbance, and the little patient grows very ri»stleae, utters sharp, shrill cries, or talks unmeaningly. About the end of the first week the characteristic eruption api>ears, first on the upper part of the abdomen, in the form of small, oval spota, scarcely, if at all, elevated above the surface, of a light rose color, disappearing on verj' slight pressure, and quite rapidly returning. 830 TYPHOID FEVER. During the second week, the symptoms become more severe. The fever is more continuous, and the temperature ranges in different cases from 102° to 105°; it may still present, however, decided morning remissions, and it is not rare for profuse warm perspiration to occur, without having any critical value whatever. The pulse becomes more frequent, 120, 140, even 160, and at the same time smaller and of less force. The respirations are also more hurried, and, when the pulmonary complication is marked, may be very rapid and shallow, and the cough frequent and annoying ; in such cases, auscultation reveals, especially over the postero-inferior part of the lungs, abundant mucous or subcrepitant rales. The vomiting ceases, and the child will usually take the liquid food offered it ; the tongue becomes more heavily furred, and may be dry and brownish in the centre, though it often remains moist and yellowish-white throughout. Thirst is apt to diminish, owing to dulness of the perceptions, but the child will frequently drink greedily of cold water if offered to it. The diarrhoea persists, how- ever, and the stools are ochre yellow and fluid ; the belly is more tympa- nitic, and may be extremely distended. The discharges, both of urine and fseces, are often involuntary, and the child does not even appear conscious of them. The urine is high-colored and scanty. The eruption continues and becomes more abundant, the spots which appeared passing away and being followed by successive crops. Sudamina are also frequently pres- ent especially when sweating occurs. The mind becomes more and more dull, though it is nearly always possible to rouse the child by speaking loudly to it ; delirium is usually present, especially in the night, and manifests itself in young children by restlessness, sharp, unmeaning cries, and a wild expression of the face, and in older ones by muttering, or even by attempts to leave the bed. Irregular muscular movements such as floccitatio and subsultus, are rarely noticed ; though at times these, and even spasmodic rigidity of the trunk or limbs, or convulsions, may be present. We have thus sketched the course of what is, perhaps, the most common form of typhoid fever in children, where the disease begins gradually, and either remains mild throughout, or assumes a more grave character during the second week. In a certain number of cases, however, the onset of the disease is far more sudden and violent, and the severity of the attack is manifested from its earliest period. In this form, the prodromes are brief, or almost entirely absent ; and there may be in older children an initial chill, or the only symptoms present are marked debility, languor, and drowsiness. During even the first two or three days, however, there is apt also to be frequent vomiting, severe headache, or marked hebetude, and high fever, which usually presents the same marked morning remissions and evening exacerbations as in the milder form. The sleep is restless and disturbed, and the child either utters sharp cries, or, if older, talks incoherently. The pulse and respiration are much accelerated, and the temperature of the surface rapidly rises, till, by the end of the first week, it may reach 103'-" or 105°. The cerebral disturbance may mask the presence of any abdominal pain ; and as it is not unusual for the bowels to be quiet for SYMPTOMS. 831 the first few clays, the case may closely simulate some acute cerebral dis- order. By the end of the first week the disease is developed in its full severity. The fever is more nearly continuous, the morning remissions being comparatively slight, and the skin remains constantly dry and hot. There is deep stupor, from which the child is roused only with much dif- ficulty, and which occasionally alternates at night with restlessness, jacti- tation, and noisy delirium. The pulse is very frequent and feeble, and the breathing accelerated, and usually accompanied with bronchial rules. The vomiting ceases, but the abdomen becomes tympanitic, and there is more or less abundant diarrho?a ; the stools are often passed quite involun- tarily, and the urine is either retained or dribbles away unconsciously. Epistaxis occurs in a large proportion of cases, and about this time the characteristic rose-colored eruption makes its appearance. During the second week, all of the symptoms become more grave, and the patient may succumb to the violence of the disease, or remain for a week or ten days plunged in profound stupor, with subsultus and marked muscular tremor ; with the lips and teeth coated with sordes, the tongue tremulous, dry, and coated with brown crusts, the abdomen tympanitic, and the stools frequent, thin, and passed involuntarily ; with the pulse running, feeble, from loO to 160 in the minute ; the respirations shallow, imperfect, and attended with subcrepitant rales, indicating passive congestion of the luDgs; with the urine retained, dark-colored, and even albuminous; and yet gradually emerge from this apparently hopeless condition to enter upon convalescence about the close of the third week. In favorable cases, between the fifteenth and twenty-first day, the grave symptoms begin to abate. The child's expression becomes more natural, and often the earliest sign of approaching convalescence will be the ap- pearance of a smile of recognition, or of pleasure at the consciousness of improvement. The fur upon the tongue becomes looser, moister, and be- gins to separate, and the appetite slowly returns ; the distension of the abdomen diminishes, and the stools are again passed consciously and vol- untarily, and gradually assume a healthy appearance. Restlessness and delirium disappear, and the sleep becomes quiet and refreshing ; the fever subsides, and the temperature falls, and again shows a marked difference between the morning and evening. The child thus passes into a state of convalescence, which, when not disturbed by complications, is quite rapid, though attended with marked emaciation, extreme debility, and feebleness of digestive power, with a tendency to intestinal disturbances. In some rare cases, at times without a.ssignable cause, at others from improper ex- posure or exertion, or indiscretions in diet, the patient suffirrs a relapse, the original symptoms reappear, and a second fully developed attack of typhoid fever, attended with marked nervous symptoms, characteristic eruption, and diarrhoea, may ensue. In ven»' severe cases, on the contrary, and especially when a fatal result 18 to follow, the condition of the patient grows more and more grave after the end of the second week, unless, as at times happens, death has occurred sooner from the violence or malignancy of the attack. The nervous symp- toms become more marked, and the child sinks into a dee[>er stupor, even 832 TYPHOID FEVER, 1 approaching true coma, or the stupor is interrupted by violent agitation, with cries or efforts to leave the bed, or by muscular twichings, picking at the bed-clothes, or even general convulsions. The pulse is very rapid and small ; the respirations hurried and noisy, and physical examination fre- quently reveals the existence of extensive bronchitis or hypostatic pneu- monia. Vomiting is rarely present, but hiccup may be frequent and dis- tressing ; the belly is enormously distended, the stools frequent, involuntary, and at times bloody. Bed-sores form on points subjected to pressure, and death ensues amid profound stupor and with signs of extreme pulmonary obstruction. At other times death occurs not so much from the extreme violence of the disease itself as from the development of some one of the complica- tions which will be mentioned hereafter. Special Symptoms. — Although, as has been seen, the general course of typhoid fever is much the same in children as in adults, there are a few symptoms which require more detailed notice, as presenting peculiarities which impress special features upon the disease as it occurs in childhood. Prodromes. — In children, as in adults, typhoid fever is nearly always preceded by a marked prodromic stage, and the passage from the state of health to the fully developed disease is usually very gradual. The dura- tion of these prodromes varies from three or four to ten days, being least in the more severe cases. Fever. — Condition of Skin. — We have already remarked that, in the early stage, there are apt to be very marked remissions in the febrile action, lasting even throughout a considerable part of the day ; the exacerbations of the fever usually occurring towards evening. West states that in some few instances two distinct remissions and exacerbations may be noticed in the course of every twenty-four hours. It is this feature which gained for the disease the name of infantile remittent fever, and caused it to be ranked formerly with the malarial diseases. Towards the middle of the second week, however, the remissions become much less marked ; the temperature, which in some cases reaches 104° or 105°, merely presenting a somevv'hat marked fall in the morning. In general terms it may be said that the law of the accession of febrile temperature in typhoid fever in children, although in general correspondence with that found in adults, presents occasional marked eruptions. Thus, in some instances, the onset is so abrupt that a temperature of 104.5° has been noted by Roger on the first day, while it w^ill be remembered as a law laid down by Wunderlich for the typhoid fever of adults, that the disease is never attended by a temperature of 104° so early as the second day. The skin is hot and dry as a general rule, but sweats are more apt to occur during the height of the disease than they are in adults ; they are not, however, of any prognostic value. Digestive Symptoms. — Among the earliest and most important symptoms are various disturbances of the digestive functions. The appetite rapidly fails, and is often lost before the attack fairly begins. Thirst is, however, marked until dulness of the mind appears, after which it also may be en- tirely absent, though the child will usually drink if cold water be offered to it. The tongue is always furred, usually being covered throughout the I SPECIAL SYMPTOMS. 833 course of the disease by a thick yellowish-whito coat, which may reniaiii moist and hiose, or, in very grave cases, become dry and brownish. Sordes are not often observed. Vomiting, which is perhaps not more frequently met with iu the early stage in children than in adults, may be very frequent and persist until far into the second week. In the majority of cise^, diar- rhiva is either present or the bowels are peculiarily sensitive to the action of laxatives. In some cases, however, and especially those where vomiting is marked, constipation of a quite obstinate fqrm is present. The conjunc- tion of these two symptoms, iu connection with the cerebral symptoms present, may cause the case to strongly resemble the first stage of tuber- culous meningitis ; the doubt may, however, be usually resolved by careful examination, as will be more fully alluded to under the head of diagnosis. The stools, when diarrhoea exists, are ochre-colored, fluid, and, on stand- ing, deposit a sediment of shreds of mucous membrane, epithelium, and partially digested food. Mucus is rarely present ; but blood, in varying amount, may be mixed with the fecal matter. "When the amount is large, it is usually due to the ulcerative process in the intestine having opened a vessel of considerable size, and then constitutes a very grave complication. In young children it is difficult to establish the existence of abdominal pain, but, when they are capable of describing their sensations, colicky pain is frequently complained of in the early stages ; and even in the youngest children, pressure in the right iliac region may often be seen to be painful. Tympany is usually present at some time during the attack, especially when there is diarrhoea. Even when the bowels are confined, however, the abdomen is never retracted. Rilliet states that, in some grave cases, he observed such great tympany that the abdominal walls were thin enough to allow the outlines of the convolutions of the intestine to be clearly seen. Enlargement of the spleen nearly always exists, but frequently to so slight a degree that it cannot be readily detected either by pal})ation or percussion, and even when considerably enlarged, it is apt to be entirely hidden by the distension of the abdomen. On the other hand, we have repeatedly found this organ so much enlarged, as to be distinctly perceptible on careful pal- pation. The wnwe presents the ordinary febrile conditions, being scanty, high- colored and of high specific gravity ; the pigment is increased, and the chlorides much diminished. The stools are, as we have already said, often involuntary during the height of grave cases, after the beginning of the second week. Until this time, however, and throughout the entire course of more mild cases, the child is conscious of the desire, and can control the passage, or even wishes to be taken from the bed for the purpose. The urine is also, though more rarely, discharged involuntarily ; in rare cases, which may ultimately recover, retention of urine is present, and is of grave impr^rt. Rilliet never observed this symptom, but we have seen it more than once, and especially in a boy aged five years, who rcfpiired catbeterizatioD for several days successively, but who finally recovered. 68 834 TYPHOID FEVER. Respiratory and Circulatory Symptoms. — Even during the first week, there is usually more or less dry cough, with sonorous and sibilant rales over the posterior part of the lungs. Indeed, in some cases, we have known the cough and signs of catarrhal inflammation to be so marked in the first days of the disease, as to cause the attack to be regarded as one of severe acute bronchitis. Later in the disease, and owing merely to the passive hypostatic congestion of the lungs, and the accumulation of mucus in the bronchial tubes, the cough is apt to grow more frequent and troublesome, the respiration is hurried and oppressed, and auscultation reveals moist and dry rales throughout both lungs. When pneumonia or bronchitis su- pervene, these symptoms of respiratory obstruction increase to a marked degree. Extreme rapidity of breathing, with alterations in its character and rhythm, are also met with, however, in cases where the pulmonary obstruction seems moderate, but where the nervous system is profoundly disturbed. The pulse is accelerated from the very first, and during the height of the disease, rises to 120, 140, or even 180, according to the age of the child. In grave cases it may become extremely small, feeble, and compressible, but scarcely ever is intermitting or irregular. The eruption of typhoid fever in children presents precisely the same appearances as in the adult ; it usually appears first on the upper part of the abdomen, and often presents several successive crops. It is, however, more frequently absent entirely, and presents even greater irregularities, as to the date of its appearance, in them than in adults. The abundance of the eruption certainly bears no relation whatever to the severity of the attack; and in a varying proportion of cases (7 in 30, Hillier), the most careful daily examination fails to detect the characteristic spots at any period of the case. The eruption makes its appearance in a large majority of cases between the sixth and twelfth days, but the first spot has been ob- served so late as the twenty-fifth day (Hillier), or the twenty-ninth (Rilliet). Sudamina are frequently present in large numbers at any time after the ninth day. It is very important to be aware that in some cases, owing to the pecu- liar state of the cutaneous circulation, a marked reddish streak will be produced if the finger be somewhat firmly drawn across the skin. This sign, which we have described under the name of " tache meningitique," in our article on tubercular meningitis, does not therefore possess the high degree of diagnostic value accorded to it by Trousseau and others, which would make it of much use in doubtful cases. Epistaxis is very rarely abundant, but is met with in a majority of cases at some period after the third day. Nervous Symptoms. — In none of the symptoms of this disease is such va- riety observed as in those furnished by the nervous system. In mild cases, consciousness is retained throughout the attack ; the ex- pression of the face is stupid and heavy ; the child is dull and disposed to doze during the day, but becomes feverish and restless towards night, and sleeps uneasily and wakes frequently. SPECIAL SYMPTOMS. 835 In more severe cases, the nervous symptoms soon become prominent. The tace assumes an almost characteristic expression ; the eyes are dull and vacant, or bright and excited during temporary delirium ; the cheeks pre- M nt a circumscribed flush; the lips are dry and parched; and the features remain almost motionless. Headache is sometimes complained of, and without doubt exists in many cases when the child is too young to call attention to it. It is especially observeil in the early part of the attack, when there may be some hebetude and deafness present, and, according to Dr. Jenuer, ceases upon the ap- pearance of delirium. This latter symptom rarely appears in marked degree before the second week, but then may become violent, the child crying out loudly, or mutter- ing incoherently, and struggling violently to leave its bed. The delirium is rarely continuous but is more marked during the night, being replaced during the day by more or less profound stupor, which, however, rarely amounts to actual coma. Subsultus and carphologia, as well as muscular rigidity, are compara- tively rarely observed in children, and only in very grave cases. Convul- sions, even of a general and violent character, are met with in a very small roportion of cases ; they may occur in the early stages of cases which sub- sequently recover, or as one of the final phenomena in fatal cases. They are, however, at whatever stage they present themselves, of very great import. In a case mentioned by West, the convulsions recurred on two successive days at the middle of the third week of the fever, and were suc- eeded by hemiplegia, which continued, though gradually diminishing, for four days. The child was unconscious even before their occurrence, and continued so for several days, though he eventually recovered. As a general rule, the course of typhoid fever is much less apt to be at- tended by any complication in children than in adults; there are, however, some which occur with considerable frequency. We have already stated that cough and signs of slight bronchitis are fretjuent in the early stage. In a considerable number of cases these symp- toms become aggravated as the case progresses, and there may be a devel- opment of general bronchitis or even pnjeumonia; more frequently, how- ever, the condition of the lungs is rather one of hypostatic congestion than of true inflammation. These complications, when present in a marked degree, protract the case and add greatly to it** danger. Pleurisy is com- paratively rare. Perforation of the ileum, from ulceration of Peyer's patches, is more rare in children than in adults; but when present gives rise to the same vraptoms, and leads to an equally rapidly fatal result. In some cases, its urence is announced by an attack of convulsions (Rilliet). We have .».( .i.jy alluded to the fact that we have known violent general |KTitonitis to be excited by extension of inflammation without the occurrence of actual perforation of the bowel. Intestinal hajraorrhage, on the other hand, is comparatively frequent ; thus Hillier observed it four times out of thirty in which the stools were 836 TYPHOID FEVER. carefully examined. It is usually of grave significance, but is at times seen in mild cases, which recover readily. Earache is not infrequently observed after the height of the disease ; in some cases it is followed by abundant purulent discharge. Inflammation of the parotid gland is much less frequent than in adults, as is also phlegmasia alba dolens, of which, however, there are instances on record. There is very little tendency to the formation of bed-sores in children, and with care in the management of the patient, they will scarcely ever occur. In some epidemics, gangrene of other parts, as of the vulva or cheek, have been observed in a few instances. Angina, and occasionally pseudo-membranous laryngitis, have also been noticed. We have seen that the urine is at times albuminous, and in these cases there is undoubtedly an intense congestion of the kidneys, which in very rare instances eventuates in Bright's disease. QEdema is not usually pres- ent, even when there is albuminuria, though Rilliet records two cases where anasarca, accompanied by albuminous urine, appeared on the fifth day, and lasted about a week. When oedema appears late in the course of the disease, it is probably to be rather attributed to a watery state of the blood and the debility of the circulation. AVe have already seen that the febrile movement in typhoid fever, in children, presents such marked remissions, as to have led many observers to apply the name infantile remittent fever to the disease. We must bear in mind, however, that it is far from being rare for a true malarial element to be present, complicating the case, and constituting it a typho-malarial fever. During the height of the disease, it is rare for any of the other eruptive fevers to make their appearance ; but during convalescence, variola, rube- ola, and scarlatina, have all been occasionally observed to appear, and run through their regular course. Tuberculosis is by some regarded as one of the most frequent of the sequelse of typhoid fever in childhood ; and in some cases, indeed, it ap- pears as though the extreme debility of constitution induced by the disease favored the development of tubercle in children with hereditary predispo- sition. In other cases it is probable that the production of tuberculosis after typhoid fever depends upon the infection of the system by the prod- ucts of cheesy metamorphosis derived from some of the mesenteric glands, which, instead of returning to their normal state, have undergone this form of degeneration. It is probable, however, that in some cases also the early stage of acute tuberculosis has been mistaken for typhoid fever, with which, as will be more clearly pointed out, it possesses some strong features of resemblance. Various disturbances of the nervous system may occur as sequelse of typhoid fever in childhood. Among these may be mentioned paralysis, either in the forms of paraplegia, or limited to a single nerve-trunk, chorea, and locomotor ataxia. Convalescence. — The convalescence is, as in adults, tedious and un- certain. The child often remains for many weeks in a condition of great DURATION — PROGNOSIS — DIAGNOSIS. S37 debility, and with such extreme uervoiis exhaustion, that liydrencephaloid symptoms may even be present. The digestive system also manifests this debility in a most marked de- gree, and it requires the greatest tact and care to encourage the child to eat, and at the same time, to regulate the diet, since the sliglitest imlis- cretiou will serve to excite serious symptoms. Not rarely death ensues many weeks after the termination of the disease itself, in a state of intense emaciation, the child being worn out by persistent diarrhiwa, which resists all change of diet and treatment. We have already alluded to the fact, that occasionally relapses have been observed, either without cause or following some trifling indiscretion, in which the symptoms of the fully developed disease have reappeared and gone through their regular course. Duration. — The duration of the fever varies according to the severity of the case. Even in the mildest forms it rarely begins to subside before the end of the second week, while much more frequently it is protracted until from the twentieth to the twenty-third day. In many cases, indeed, convalescence cannot be said to be fairly entered upon beft)re the end of the fourth week. Prognosis and Mortality. — The symptoms and conditions which in- dicate a favorable or unfavorable termination to the case are the same as ]^resent themselves in the adult, and may be readily gathered froui the fore- going description. The mortality of typhoid fever is, however, decidedly less in children than in adults, partly owing to the comparative rarity of dangerous complications, and partly to the fact that the disease is usually of a less severe type. In mild cases, death scarcely ever occurs ; and even in the more severe forms, the mortality is only from 5 to 10 per cent., under favorable hygienic circumstances. DiAGNOfiis. — We have already stated that, partly owing to the imperfect recognition of typhoid fever, and partly to the various names which were lr^<'>ely applied to this disease as occurring in children, it was formerly frequently confounded with other affections. There are, however, several disea.se8 from which it is not always easy, even with our improved knowledge of its peculiar symptoms, to distin- guish it. Thus, in some cases of gastro-enteritis, such as are not rare among chil- dren, and especially when the disease assumes a typhoid form, the resem- blance to typhoid fever is so great as to have led Uilliet and Barthez to assert that it is impossible to make a differential diagnosis. It should be borne in mind, however, that typhoid fever may often be traced to epidemic or endemic influence, and occasionally to contagion ; that it is ver}' rarely possible to assign any direct exciting cause for the attack ; and that it especially attacks children over five years of age, com- paratively rarely those between two and five years, and very rarely those under the former age. Its onset is usually more gradual ; the vomiting and diarrhoea are rarely so marked; the fever is more intense, the low* of strength greater and more rapid; while the niarketrict attention to all hygienic precautions, and a supporting, but fluid and digestible, diet. Whatever complications ensue, should of course be treated appropriately. There are, however, a few indications in regard to which it may be well to speak more in detail. When the fever is high, febrifuges, such as liq. ammoniie acetatis and sp. anheris nitrosi should be given ; to which a little syr. ipecac, may be added, if the cough be troublesome. The surface of the body should be -ponged daily or several times a day with tepid water, to which a little vinegar may be added ; or the child may be carefully lifted for a few min- utes every day or every other day into a bath of about 65° to 75°. If there is much gastric irritability in the early stage, food should be given in very small quantities, and should be of the lightest character, as milk with lime-water or weak beef extract ; counter-irritation may be em- ployed in the form of mustard-plasters to the epigastrium ; or, if there be reason to think that the stomach contains undigested, irritating food, an emetic of ipecacuanha may be given. In cases where marked symp- toms of gastro-hepatic disturbance occur at the beginning of the attack, a few small doses of calomel with bismuth, or of blue mass, followed by a very gentle laxative, will be followed by relief to these symptoms. If the bowels are constipated, very small doses of some mild laxative, as castor oil or syr. rhei aromat., should be given during the first week ; but when spontaneous diarrhcea is present, it should, unless it becomes excessive, not be interfered with. When, however, the stools exceed three or finir daily, f balk mixture, with some vegetable astringent and opium, or small doses of opium and acetate of lead, or of paregoric alone, may be administered. In ordinary' ca.ses, the nervous symptr^ms scarcely require any especial attention. When, however, they become marked, it will often suffice to apply wet cloths to the head, and to administer warm mustard foot-baths to allay the agitation. In cases where delirium becomes extreme, with great nervous agitation, the above remedies should still 1)C used, but, in addition, small dfjses of chloroform with camphor-water, or even of opium, -h<^«uld be given, and will often prcxluce the happiest effect. Dr. West -j.« aks highly in such ca-ses of the combination of opium and tartar emetic, r.r.mmended by Graves in the treatment of the head symptoms of typhus lever. It will be found, also, that chloral, in doses of five grains at three 840 TYPHOID FEVER. to five years, or of bromide of potassium, in doses of seven to ten grains at the same age, repeated according to the urgency of the symptoms and the effect produced, will often prove successful in affording relief. In regard to the occurrence of complications, we have already alluded to the remedies by which diarrhoea is to be checked if it becomes excessive. When the symptoms of pulmonary obstruction become marked, frequent counter-irritation by mustard or turpentine should be applied to the chest, and stimulating expectorants, as carbonate or muriate of ammonia, ad- ministered internally. Haemorrhage from the bowels and peritonitis from perforation or exten- sion of inflammation, must be treated exactly as in the adult, the one by astringents, either vegetable or mineral, or by ergot and moderate doses of opium ; the other by the free use of opium. Of the special remedies which are recommended in this disease, we may allude to the treatment by means of mineral acids, especially the muriatic and nitro-muriatic, which is highly praised by some authorities. Quinia is necessary in many cases as a tonic when adynamic symptoms begin to appear, and is of service in cases attended with high temperature, when given in full doses with a view of reducing the excessive heat of the body. In some cases, also, where the remittent character of the fever is marked, and where there is a suspicion that the case is complicated with a malarial element, it should be administered in full antiperiodic doses in the earliest stages. Opium is rarely necessary in the early part of the disease, unless it be required to check diarrhoea ; but when, in the latter part of the second or third week, the delirium becomes extreme, and the child sleeps but little, the night being spent in violent restless agitation, with loud screaming, opium should be fearlessly given until quiet sleep is produced. The oil of turpentine is to be administered under the same conditions which call for its use in adults. Stimulants are by no means absolutely necessary in all cases of typhoid fever in children. Excepting in the very mildest, however, it is prudent to administer them in small quantities after the middle of the second w^eek. When, however, the condition of the child calls for their more free use, as shown by the frequent feeble pulse, rapid labored breathing, dry, brownish tongue, dulness alternating with noisy delirium, and other marked nervous symptoms, they should be given to the extent of f^iij to f^vj of sherry wine, or even of brandy, to children of six years old. It will be found in these cases that even such large amounts of stimulants as the above are very well borne by children. The food should be given in small quantities, and frequently repeated. It should throughout the entire course of the disease be exclusively fluid, consisting of milk, chicken-water, or the various animal broths. It is rarely difficult to regulate the diet of children suffering with this disease, since their entire loss of appetite renders them indifferent to all food, and they will usually take whatever is offered to them. During convalescence, the utmost care must be exercised, both in TREATMENT. 841 regard to food and exercise. Solid food should be permitted very grad- ually, aud with much caution: bci^inning with the liirlitcst and most di- gestible forms, and watching the manner in which each article is digested. In those cases where the child remains a long time in a condition of extreme debility, with impaired power of digestion, the bitter tonics and iron should be given, if the stomach will tolerate them. Sea, or cold water bathing, change of residence, and the utmost attention to all hygi- enic rules, are also to be recommended. When there is any reason to dread the development of tubercular disease, this treatment must be car- ried out with the greatest assiduity ; and, if the child can digest it, cod- liver oil may be given with advantage. CLASS VI. CACHECTIC DISEASES. ARTICLE I. SCROFULA. It does not seem appropriate, in a work whose chief character is de- signed to be practical, to enter upon a full discussion of the important pathological questions connected with the subject of scrofula, particularly in regard to its relations to simple chronic inflammation on the one hand, and to tuberculosis on the other. Indeed, in some respects these questions may be said to be still in such an unsettled state that no definite position in regard to them can be assumed with confidence. We propose therefore to confine our remarks at present chiefly to a description of the most marked manifestations of scrofula as generally recognized, and to a dis- cussion of the appropriate treatment. Definition ; Characters. — The term scrofula is of very long standing. It appears to have been originally applied to a peculiar cachectic state of the system in which there is a special tendency to enlargement of the lymphatic glands. Subsequently it has been employed in so many and such varied senses as to make it difiScult in many cases to decide in which way it is meant to be understood. We ourselves would be understood to employ it much in the old sense, to indicate a peculiar constitutional con- dition in which there is a " vubierable^' or irritable state of the lymphatics, which renders them liable to become enlarged from trifling causes, and at the same time indisposed to healthy reparative action ; and which is also apt to manifest itself by various obstinate chronic inflammations of the skin, mucous or synovial membranes, or bones. Scrofula is undoubtedly closely associated with tuberculosis. It very often happens that the children of tuberculous parents are scrofulous. And again we frequently observe that patients who have suffered with some chronic scrofulous aflfection become the subjects of tuberculosis, even of the most acute miliary form. So also there is a stage, that of yellow cheesy degeneration, in which it is not possible to distinguish between products of a scrofulous and of a tuberculous character. Still, however, we do not regard these two cachexise as identical, and enough points of difference can be indicated to fully support this opinion. Tuberculosis, it is true, often follows scrofulous affections, just as it follows any other con- r scrofula: causes — symptoms. 848 dition attended with the formation of cheesy deposits, which may infect the system and give rise to acute miliary tuberculosjis. On the other liand, it is not common for tnbercuhnis subjects to devcK)p any manifestations of scrofula; and, as West points out, we frequently see whole families which display one or the other diathesis in its most intense form, and yet per- fectly uncomplicated. Scrofula, moreover, is, far more markedly than tubercuUisis, a disease of early life. The most common and characteristic of its manifestations also are very different from those of the latter dis- ease ; it affects the bones, the skin and adjacent mucous membranes, the glands, the synovial membranes in preference to the serous membranes, the lungs, the solid abdominal organs, and the alimentary and respiratory mucous membranes. These differences in the leading pathological tenden- cies of these two great cachexia?, as well as the many points of difference in the physical peculiarities of children who are liable to tuberculosis or scrofula, are clearly and forcibly pointed out by Jenner in a clinical lec- ture published in The Medical Times and Gazette, 1860, p. 259. Causes. — Scrofula is, we think, in many cases undoubtedly due to in- herited predisposition. As in the case of other cachexiie, the actual disease is not transmitted from parent to oflJspring, but merely so strong a tendency to its development that in some cases no care or favorable hygienic in- fluences will overcome it. Not only do we meet with scrofula in the children of parents who themselves have been scrofulous, but also in cases where a feeble and vitiated constitution has been inherited from parents aflTected with tuberculosis or constitutional syphilis. In other cases, it is doubtedly acquired after birth, appearing in children born to parents of sound constitution. The causes which tend to thus develop it act by im- pairing the nutrition, and include such influences as insuflicient, improper food, protracted exposure to damp, cold, and especially to vitiated atmos- pheres, attacks of certain diseases, which like measles, typhoid fever, and chronic malaria, exercise a remarkably injurious action upon nutrition. Symptoms. — Although by no means all scrofulous children present the same physical peculiarities, there are yet certain features so commonly met with in such subjects as to have led to their recognition as forming together the symptoms of a scrofulouJi diathem^. Thus, as a rule, such chil- dren are heavy and lethargic in mind, and of phlegmatic temperament, with dull expre,^«ion, and thick, opaque skin. The features are apt to be coarse, especially the lips and nose ; the lymphatic glands are perceptible to the touch ; the abdomen is apt to be full and large; and the bones arc large, with coarse, thick ends. There is nothing peculiar or pathognomonic about the special manifesta- tions of scrofula. Alnif^st all of them may also appear as simple idio- pathic affections due to some definite exciting cause, in children of entirely sound constitution. That which characterizes these same affections when they occur in what we term the scrofulous form, are the trivial causes which excite them, the inveterate obstinacy with which they persist, and their association with other analogous phenomena in the same subject. There is also in some cases a certain order of succession of the manifesta- tions of scrofula which has even led to the division of its course into 844 SCROFULA. three stages, corresponding somewhat to the classic phases of constitutional syphilis. Thus in the earliest stage, the lymphatic glands and skin are chiefly affected ; subsequently affections of the mucous membranes and cellular tissue make their appearance ; and in the final and most aggra- vated form the bones and viscera suffer. We cannot affirm, however, that this division and order of succession of the manifestations of scrofula is by any means constant or even marked in many cases. Most of these manifestations appear as chronic inflammation of the part affected. At times such inflammation seems to arise spontaneously, while more frequently some more or less trivial exciting cause can be assigned. Thus the scrofulous enlargement of any group. of glands is apt to be pre- ceded by irritation of the area whose lymphatics pass to the affected glands, as, for instance, enlargement of the cervical lymphatics follows eruptions on the scalp or behind the ears, or attacks of sore throat. Among the most frequent affections which are generally classed as scrofulous may be mentioned, without any reference to their frequency of occurrence, enlargement of the superficial lymphatic glands, cutaneous eruptions, especially of the vesicular and pustular varieties, small sub- cutaneous abscesses, chronic inflammation of the mucous membranes which are continuous with the external skin, as of the conjunctiva, the membrane of the external auditory meatus, that of the nose, and of the vulva and vagina, chronic effusions in the synovial membranes, chronic ostitis with caries. The reader is referred for more detailed accounts of these numerous local scrofulous affections, to the special works which treat of the diseases of the skin or organs of special sense, or to general treatises upon surgery. Our own purpose is of necessity limited to a discussion of the general symptoms and treatment of the scrofulous cachexia, rather than of its numberless local manifestations. In the most advanced and severe forms of scrofula, lesions of various internal viscera may be developed. Among the most frequent and clearly marked in their nature, of these, are caseous bronchitis and pneumonia, and albuminoid degeneration of the abdominal viscera, the liver, spleen, and kidneys. Bronchitis and pneumonia at times appear in forms which entitle them to be regarded as scrofulous from the first. At other times, they apparently originate as acute inflammatory affections, but which, owing to the strong scrofulous diathesis of the patient, pass into a chronic form characterized by the low grade of the morbid products developed, by the obstinate and intractable course the affections run, and by the marked tendency to the occurrence of caseous degenera- tion and destructive changes in the diseased parts. In this condition, a sudden development of miliary tuberculosis not rarely occurs, either in the adjacent portions of the diseased organ, or throughout the other parts of the system. The exact nature of the primary changes in such cases is, at the present moment, one of the most unsettled and disputed points in pathology. The reader will find a tolerably full description of the lesions and symptoms under the head of pulmonary phthisis. The exact relation of albuminoid degeneration of the viscera to scrofula is also somewhat uncertain. Although one of the most frequent of the SYMPTOMS — DIAGNOSIS. 845 unfavorable sequelte of scrofulous aflections, it cannot itself be regarded as scrofulous in nature, since it makes its appearance in connection with other cachectic states of the system. The attempt of Dickinson to asso- ciate it with the changes in the blood and tissues caused by prolonged sup- puration v^which so often occurs in scrofulous disease of the bones, joints, or glands ), has not been altogether successful. Ahliough it is undoubtedly true that in many cases where albuminoid degeneration has been devel- oped there has been previous prolonged suppuration, there are many ex- ceptions where the visceral lesions have apparently been induced directly in connection with the scrofulous or other cachexia. The occurrence of this sequel must always be anticipated with anxiety in protracted and severe cases of scrofula. Although usually involving, simultaneously or in rapid succession, the various abdominal organs, the liver, spleen, kid- Deys, and gastro-intestinal canal, it may present a marked localization, for an indefinite time, in any of these parts. When one of the above solid organs is affected with advanced albumi- noid degeneration, it is found enlarged, though still preserving its origiual shape ; the peritoneal capsule is unchanged ; and on section the tissue pre- sents a homogeneous, waxy, or lardaceous appearance, which is associated, when the section is examined by transmitted light, with abnormal trans- luceuce. The intimate nature of the change consists in an infiltration of the organ with a peculiar structureless albuminoid neoplasm or exudation. This first affects the walls of the arterioles, and later the glandular cells of the organ. When the kidneys are involved, there is usually oedema, which appears early and increases rapidly; the urine is abundant, clear, with but slight reduction in its specific gravity, contains a large amount of albumen, and deposits numerous hyaline tube-casts. Albuminoid disease of the liver and spleen usually coexists. These organs are markedly enlarged, as can readily be detected by palpation and percussion. There is usually ab- dominal dropsy, with distension of the subcutaneous veins of the abdom- inal walls; and frequently there is also albuminuria and diarrho'a from coexisting disease of the kidneys and intestine. We have much less fre- quently observed marked albuminoid disease of the gastro-intestinal canal than of the solid abdominal organs, as above described. When it occurs, the walls of the stomach or inie.ereulosis in the adult, it is in tlie young chiUi peculiarily tiiat they reach their highest importance, owing either to the absence or the dilfieulty of appreciation of many symptoms which aid greatly iu the diagnosis of phthisis in adult life. It is necessary, therefore, to examine with the greatest care the child's hereditary tendencies, its past history, and its appearance and })hysical development. Thus it is iu cases 5f inherited tuberculosis that we see its characteristic features most strongly marked, in the tall, slim frame; the firm bones, with small and yielding cartilages; the delicate diaphanous complexion ; the fine, silky hair; the active, often precocious intelligence ; the ease with which the general health is affected by slight causes, and the peculiar proneness to catch cold on the least exposure. By careful atten- tion to these and other similar points, as much, or often more valuable information can be obtained in the phthisis of children, than from the most careful investigation of the physical signs. In enumerating the symptoms, it is unnecessary to detail those which exist iu common with pulmonary phthisis in the adult, save to point out any particular in which they may diifer as seen in the young subject. The cough varies much, in accordance with the varying amount of bron- chial irritation, being at one time scarcely troublesome, or so aggravated and accompanied with such violent dyspnrea, from some intercurrent attack of bronchitis, as to threaten immediate death. It not unfrequently has a somewhat paroxysmal character from the accompanying tuberculization of the bronchial glands. One of the most marked peculiarities of the cough in the j)hthisis of children is the entire absence of expectoration, since the secretions are either retaineil in the bronchial tubes, or, if raised into the pharynx, are swallowed without any effort at expulsion. Ihrmoptijiis very rarely occurs in the early stage or during tlie progress of the di.sea.se; and when it occurs as the cause of sudden death, is due to the complication with bronchial phthisis, rather than to the rupture of a bloodvessel in a pulmonary vomica. The temperature of the lK)dy is, as a rule, higher than normal, although it pre,«ents fluctuations on different days, and even at different hours of the «ame day; at times being normal, and again rising as high as 102°, or more. The greatest elevation of the temperature is generally noticed at night, and is usually accompanied by flushing of one or both checks; but it is rare to find the colliquative night-sweats which prove so exhausting to adults. The puUe is always accelerated, and becomes very frequent as the tem- perature rises. The fippetite is capricious, the tongue furred, and the digestion imper- 856 TUBERCULOSIS. feet ; the bowels alternate from a state of constipation to diarrhoea, and the stools are unhealthy in appearance, being generally putty-like or clay- colored. Naturally, with this disturbed state of the primse vise, nutrition is seriously impaired, and the child steadily loses flesh and strength. In- deed, in very many cases, the little patient presents merely the symptoms of impaired nutrition, becomes languid and drooping, and loses appetite, strength, and flesh, for many weeks before the development of cough reveals the lungs as the seat of the disease. Physical Signs. — We have already remarked the fact that in the investi- gation of phthisis, the physical signs are of much less value in the case of children than in adults. This arises not only from peculiarities of the physical and moral organization in childhood, but also from .the mode in which the tuberculous deposit takes place. Thus, as a rule, the deposit of tubercle in the lungs of children is more generally diffused and uniform ; so that we lose to a great degree the advantages derived in adults from a comparison of the results of auscultation and percussion in one part, with those obtained in another. For the same reason, we are also deprived of those signs which, in the adult, are developed in a single point : as, for in- stance, the coarse breathing, which is of so much diagnostic importance as one of the earliest signs of the deposit of tubercle at the apex of the lungs. Another source of difl^culty and error lies in the fact already alluded to, that the bronchial glands, when enlarged by the deposit of tubercle, as so constantly happens in conjunction with the pulmonary phthisis of children, are brought into contact with the thoracic walls, and transmit many sounds with intensified force. It is thus that prolongation of the expiratory sound beneath the clavicle, and jerking respiration, lose much of the importance they have as signs of the early stage of phthisis in adults. For although, when heard in children, they should always be re- garded as probable evidence of phthisis, they have frequently been noticed in cases whose progress shows the tubercular deposit to have been, at the most, trifling. In the same way, caution must be used not to mistake the blowing sound, mixed with moist rales, which is thus transmitted from a compressed bronchial tube containing mucus, for a large tubercular vomica. The only way in which this mistake, and the consequent too unfavorable prognosis, can be avoided, is by comparing daily the results of auscultation and percussion, and noticing whether they remain exactly the same, or whether, while the dulness on percussion over the enlarged glands persists, the results of auscultation vaiy from day to day with the varying amount of compression of the bronchus and the nature of its contents. A still further source of difficulty results from the loss of all the infor- mation which is derived, in older persons, from the vocal resonance and its alterations ; although it is occasionally possible to draw reliable conclu- sions from the resonance and fremitus of the cry or cough. And again, owing to the' excitability of children, patient and prolonged observation is required, both as to the situation, degree, extent, and duration of any ine- quality of breathing, before any conclusion can be drawn from it. Finally, the extreme, resonance of the thorax in early life tends to viti- SYMPTOMS OF TUBERCULOUS PERITONITIS. 857 ate the results of percussion by preventing tlic rocoirnition of fine varia- tions of sonority, such as are readily (iotooted in more advanrod life. AVe have thus far been considering the symptoms of pulmonary phtliisis in its usual moderately acute form, but it is necessary to be aware that in some eases it deviates from this course, being at one time extn-mely rapid, and at another very chronic in its progress. In the acute cases, we often find that there has been a previous deposit of tubercle or of cnseous inflammatory exudation in difll^rent jxirts of the economy, though to so small an extent as scarcely to have interfered with nutrition or the performance of the functions, or to have attracted the least attention. In such a state of system, death may be produced in a few days or weeks by an acute development of tubercle. When this occurs in the lungs, it is not unfrequently attended by inflammation of the pulmonary parenchyma, constituting tuberculous pneumonia ; and, whatever may be the view enter- tained as to the relation between the inflammation and the tubercular de- posit, the recognition of this. latter element is of the greatest importance, from its bearing on the treatment to be adopted. In tuberculous pneumonia, in addition to the hereditary tendency and past history of the child, we rarely find the same heat of skin or vascular excitement as in pure pneumonia. The degree of oppression of the chest is also, from the beginning, out of proportion to the catarrhal or bronchial symptoms with which the case sets in. And auscultation reveals both that the amount of inflamed lung-tissue is not sufficient to account for the dysp- Dcea, and that the rales developed are of the subcrepitant and mucous varieties, rather than the true fine crepitant nlle of uncomplicated pneu- monia. In the chronic form of phthisis alluded to, the symptoms may be pro- longed during several years. They consist of progressive emaciation, chronic cough, with or without expectoration according to the age of the patient, and the physical signs of more or less advanced tubercular deposit. In favorable cases, it is not unusual for some degree of teniporary imj)rove- ment to occur in the general symptoms, and in some rare cases the child slowly regains good health, and the physical signs gradually diminish, leaving merely some dulness and feeble respiration at jH)ints where positive signs of advanced pulmonary disease previously existed. It is neeecially from hooping-cough and measles; and the slightest disturbance of either the respiratory or dige>«tive functions should receive prompt and careful treatment; nor should we be tempted to discontinue these efforts, even if pc^sitive signs of tuberculous de|Ki8it appear; for the possibility of these deposits in childhood becoming latent 862 TUBERCULOSIS. or being evacuated, and the general health re-established, should never be lost siglit of. Curative. — Little need be said of the treatment of fully developed tu- berculosis in children, since. the same indications present themselves as in adults, and call for the same remedies. The most essential points in the treatment are attention to all hygienic conditions, careful regulation of the diet, and the administration of remedies calculated to improve nutrition and primary assimilation. It is indeed impossible to overestimate the importance of maintaining the appetite and powers of digestion ; and if these show any sign of fail- ing, we should resort to some of the bitter vegetable tonics, of which, per- haps, the combination of tincture of nux vomica, gtt. ij to v, with the compound tincture of gentian, -njjxv to xxx, according to the age of the child, is most desirable. On the other hand, if we find reason to believe that any remedy we are administering disturbs the nutrition of the child, disgusts it, lessens its appetite, or rouses violent opposition at every dose, it should be instantly abandoned as producing the very effect we most desire to avoid. The child should be strongly encouraged to take nourishing food at regular intervals, and so soon as any of the articles of its diet become unattractive, other preparations of similar nature should be substituted. Milk should enter largely into the diet, and ought to be taken at least every morning and evening. Tender, finely divided meat should be eaten at the midday meal, in such quantities as the digestion will easily bear. If marked signs of debility present themselves, a few drachms of good brandy may be taken at intervals through the day, with advantage. When the stomach does not reject it, there are few remedies whose action is more beneficial than cod-liver oil, given in the dose of a tea- spoonful or even less, three times a day. In many instances, children soon become accustomed to the taste of this substance, and even grow to relish it almost as a luxury, and to take it eagerly ; in some cases, how- ever, the taste is so unpleasant that the children refuse to take it, and it is, therefore, advisable in such instances to prescribe it in the combination which we have already recommended, at least during the first few weeks of its administration. In those cases where it is impossible to administer cod-liver oil internally, very good results may often be obtained here, as well as under similar circumstances in other wasting diseases of children, by the use of the oil by inunction. Iron and its various preparations are strongly indicated, and we can generally find some of the milder forms which will be readily tolerated. In those cases where there is considerable implication of the lymphatic glands, the syrup of the iodide of iron appears especially useful, and this may be well given alternately or in conjunction with iodide of potassium. Sea-bathing is strongly recommended, especially in the tuberculization of the glandular system; or when this is not attainable, baths in which some tonic drug has been mixed may be used. In tuberculous deposit in the peritoneum or mesenteric glands, the diet RICKETS. 863 must be regulated with peculiar care; the most bland, unirritating, and digestible food being selected. If, however, despite our pi*ecautions, diar- rha?a should make its appeanmce, the various astringents in combination with opium should be given freely. The pain in the abdomen, which is frequently so severe in these forms of tuberculosis, may be relieved by the application of sinapisms, or of warm anodyne poultices, or by gentle fric- tion with a sedative liniment. When the symptoms of any intercurrent inflammation in- the diseased organ present themselves, we must limit our treatment to the application of a few cups or leeches over the part, and the administration of a less stimulating diet, with some mild febrifuge. When the peritoneum is in- volved in the tubercular deposit, and we have reason to fear an accession of inflammation of that membrane, there is urgent necessity for the use of topical depletion in moderation ; but we must, at the same time, bear in mind the cachectic nature of the disease, and refrain from the adoption of any depressing plan of treatment. ARTICLE III. RICKETS. DEFixiTioy; Syxoxyms; Frequency. — Rickets is a constitutional disease peculiar to childhood, which first manifests itself by various dis- turbances of nutrition, and later by a specific alteration in tlie bones. This disease has been known under a vast variety of names in many diflerent languages ;' almost the only terms by which it is designated by English or American authors, however, are rickets and rachitis. An idea of the vast importance and frequency of this disease may be gained from the statements of some of the recent writers upon this subject. Thus Sir W. Jenner, whose lectures upon this subject {loc. cit.) present a must original, philosophical, and lifelike description of the disease, speaks of it as " without question the most common, the most important, and in Its eflects the most fatal of the diseases which exclusively afl'«'ct children." Hillier, at the close of an excellent chapter upon rickets (loc. cit.), pre- sents a table showing the proportion borne by the number of cases of this • the total number of out-patients treiited at the Hospital f«)rSick • 1, I»ndon, from which we calculate that of riH,^)'^; children treated during thirteen years (1854-66), Dot less than 8419, or 6.5 per cent., were rachitic ; and in some years the proportion of f^urh patients rose as high as 9 per cent. The statistics furni-he^l by other Engli-h writers, a-* (J.'e (ior. cH.), Merei, and Ritchie, supp^jrt the view that in all cla.'tsei* of Englinh wjciety a notable proportion of the children are rachitic. In the same way, the For Synonymy, Me Art. RickeU In Reynoldi's 8y«t. of Med., toI. I, p. 768. 864 RTCKETS. m highest German authorities, as Ritter von Rittershain and Henoch, state that the proportion of the children treated at public institutions in that country, who are found to be rachitic, is not less than 30 per cent. Of late years, the attention of observers in this country has been more forcibly attracted to this subject, and, as a consequence, the number of cases in which the early and less prominent symptoms of rickets are now recognized is rapidly increasing. In a paper on this subject by Parry,^ which we regard as the most valuable contribution to the literature of rachitis which has been made on this side of the Atlantic, the writer states Bj that he has been " irresistibly forced to the conclusion that rachitis is scarcely less frequent in Philadelphia than it is in the large cities of Great Britain and the continent of Europe." We must add that, although, judging from our own experience, the above statement is an overestimate, the number of cases in which we meet with the early, or even the more grave symptoms of rickets, is quite large both in private practice and in connection with public institutions. The fact that during the past twelve years the mortality returns of this city contain but two deaths reported as from rickets, is of little importance, since so rarely is it assigned as a cause of death even in Great Britain, that the Registrar-General has not found it necessary to devote a column of his tables of mortality to the disease. " The secondary diseases," as Hillier says, " are recognized, such as bronchitis, collapse of the lungs, atrophy, measles, hooping-cough, or convulsions, but the primary disease, which renders these secondary diseases fatal, is ignored." We shall limit ourselves to an account of the causes, general symptoms, and treatment of the disease, with a brief description of the anatomical changes in the bones, and the deformities which result, referring the reader who desires more minute knowledge on these latter points, to any of the elaborate memoirs published on this disease.''' 1 Amer. Jour. Med. Sciences, Jan. 1872, p. 17. 2 Bibliography of Kickets. — Shaw, Med.-Chir. Trans., vols, xvii and xxvi. Guerin, Mem. sur le Kachitis, Gaz. Med. de Paris, 1839, pp. 443, 449, 481. Elsasser, Der weiche Hinterkopf, Stuttgart, 1843. Meyer, Miiller's Arch., 1849, p. 358. Kokitansky, Path. Anat. (Syd. Soc), 1850, vol. iii, p. 174. . Beylard, J:>e Rachitis, etc. (The.se de Paris), 1852. Stiebel, in Virchow's Path. u. Ther., Bd. i, p. 527. Vogel, Beitrage z. Lehre v. d. Rachitis, Erlangen, 1853; and Diseases of Chil- dren (Atner. ed., 18G9), p. 520. Kolliker, Human Histology (Syd. Soc), 1853, vol. i. p. 352. Bouvier, Lect. Clin, des Malad. Chron. de I'Appar. Locom., 1856, p. 265. Mauthner, (Estr. Ztschr. f. Kinderhlk., vol. ii, 11, 1857. Copland, Diet, of Pract. Med., 1858, vol. iii, p. 643. Friedleben, Beitr. z. Kenntniss wachs. u. rachit. Knochen, 1860. Jenner, Med. Times and Gaz., 1860. Bouchut, Mai. des Enfants, 4eme ed., Paris, 1862, p. 825. G. Ritter von Rittershain, Die Path. u. Ther. der Rachitis, Berlin, 1863. For.ster, Handb. d. Path. Anat., 2te Aufl,, 1863, Bd. ii, p. 917. Virchow, Cellular Path. (Chance's Trans., Amer. ed.), 1863, p. 476. Trousseau, Clin. MeJ., 2eme ed., 1865, t. iii, p. 453. CAUSES. 865 Causes. — Age. — Rickets is esseutially a disease of childhood, and indeed may make its appearance during early infancy. There are also a few cases on record which show that it may, although rarely, occur in the fivtus before birth. It frequently may be detected during the first six months of extra-uterine life. Gee has noticed positive bcadirg of the ribs at the third and fourth weeks, and Parry at the sixth week after birth. The age at which it ceases to be frequent foe rachitis to begin is variously estimated. We have observed a number of cases where the earliest symp- toms were detected during the second year ; and we should be inclined to :'.-- _Mi as the limits of its most frequent occurrence the second or third !!; all to the close of the second year. It grows rarer after this latter date, and many high authorities unite in saying that it never comes on atter the completion of the first dentition in a child hitherto perfectly healthy. Considerable difference of opinion exists upon the question whether rickets is hereditary or not; but there seems no evidence to show that it ever is so, in the sense, for example, in which infantile syphilis is hereditary. There can, however, be no doubt as to the great influence ex- ercised by the health of the parents upon the development of the disease. It is stated by some authors that too early marriages, or marriages be- tween relations, and chronic tuberculosis or constitutional syphilis of the father, predispose to it. These causes are, however, of doubtful power ; and certainly are iuo|K.'rative as compared with the very positive influence exercised by the condition of the mother. Thus, it is well ascertained, that whatever tends to induce debility and anicmia in the mother, as too fre- quent pregnancies or prolonged lactation, renders it probable that her next born children will be rickety. Thus, Jenner states that it is very common for the first, or the two or three first born children, to be free from any sign of rickets, and yet for every subsequent child to be rickety; which he explains by the fact, "that among the poor the parents are generally worse fefJ, worse clothed, and worse lodged, the larger the number of their children; and among the rich and pwr alike, the larger the number of children, the more has the mother's constitutional strength been taxed, and the more likely is she to have lost in general power." {Loc. dt.) In addition to the tendency derived from the mother, there are numer- ous causes acting directly upon the child, which strongly predispose to the disease. These will be found to be nearly the same as those which favor the development of tuberculosis. Thus, premature weaning, and the sub- stitution of improper fowl for the mother's milk ; or, on the other hand, the continuance of suckling long after the pro[>er period for weaning, and after the mother's milk has deteriorated in quality and become insufficient Wwl, Din. of Children (4th Amer. cd.), 18«6, p. 688. W. .Vilken, Art. RickcU in Keynold»'H Sy»t. of Med., 1868, vol. i, p. 708. Hillicr, Di» of Child. (Amer. ed.), 1H68, p. 92. S. Gt-e, St. Bnrth. Ho«p. R^p., vol. iv, 18»i«. p 69. Niemoyer, Pract Med. rAmcr. ed.), 1869, vol. ii, p. 607. .Incobi, Amer. Jour, of Ohj«t«flric«, Nov. 1870, p. 485. Parrot, Arch, de Phyn., February, IH76, p. \S4. yioijTc, London Lancet, Augu«t 26lh, 1876. 66 RICKETS. and unwholesome ; or the use of indigestible, or of poor, scanty, and innu- tritions food at any period during early childhood, are all potent causes of rickets. So, too, many of the acute and chronic diseases of children, which impair assimilation and nutrition, as entero-colitis ; and all such depressing influences as impure water, foul air, poor ventilation, small, damp, and dirty habitations, may be classed among the predisposing causes. The marked alterations and deformities of the bones, which are so char- acteristic of rickets, are not developed until after a more or less marked cachectic state of system has persisted for a time, varying from a few weeks to several months. During this initiatory stage, the most marked symptoms are connected with the digestive system. The appetite may remain good or grow capri- cious ; and the bowels are irregular, though for the most part of the time there is diarrhoea, with stools which are at first greenish and mucous, sub- sequently serous, watery, of a brownish or slate color, and horribly offen- sive. If this chronic intestinal catarrh be but slightly marked, the child may retain a good deal of its fat, though frequently there is extreme ema- ciation. The head is frequently bathed in profuse perspiration, which occurs especially during sleep, but also after any exertion, or even while the child is lying quiet. The skin of the trunk and extremities is hot and dry, and even the lightest covering seems oppressive to the little patient ; so that there is a tendency to get rid of all the bed-clothing at night. Another symptom which makes its appearance in a certain proportion of cases, but not so constantly as the digestive disturbances, local sweatings, and restlessness at night, is general soreness and tenderness of the body, with pain on movement : when this is marked, the child dreads to be moved or even touched, cries if its limbs be pressed firmly, and will lie almost motionless for hours. According to Parry {Iog. cit.), this symptom is associated with the commencing bone changes, so that it properly be- longs to the early part of the second stage. If the disease begins before the completion of primary dentition, the development of the teeth is always impeded, and they are not only cut late, but either decay or fall very early from their sockets. The urine does not present any constant alteration, but in a certain proportion of cases the amount is increased, and there is an excess of the phosphatic salts, while in other instances excess of some free acid, said to be usually lactic, has been detected. The mental condition in rickets has been vari- ously described ; some authors regarding the intelligence as precocious, owing probably to the isolation of the patient from other children, and his constant association with his elders ; while others assert that there is an actual deficiency in intellectual capacity and power. At a somewhat later period of the disease, the child acquires a peculiar staid and sedate aspect, which, when associated with the unusual breadth and squareness of the face, imparts a strange expression of age. According to lloger and Rilliet, a blowing murmur may frequently be heard over the anterior fontanelle in this disease, synchronous with the arterial pulse. As, however, this murmur is to be heard in other SYMPTOMS OF STAGE OF DEFORMITY. 807 conditions, ami is often absent in cases of rickets, it cannot be consid- eretl as a sign of any positive value. The causes which appear to in- tensify it, are the aniemic state of the blood and the patency of the anterior fontanelle; yet Hillier states that he has found it present in thir- teen, and absent in twenty-nine rickety children whose foutanelles were open. The phenomena above described, when present in tlic same case, may certainly be regarded as positively indicative of the existence of this ini- tiatory stage of rickets, but they are by no means invaria))ly all present, so that it is often impossible to determine the approach of the next stage in which the characteristic lesions and deformities of the bones make their appearance. They are not, moreover, limited to the stage of invasion, but continue, with more or less severity, for a varying time after the bone-changes have begun. The length of this stage of invasion is exceedingly irregular, and the earliest physical signs of bone-change may occur after it has lasted a few weeks, or may be deferred for several mouths after the peculiar pro- dromic symptoms have been marked. Stage of Deformibj. — After the initiatory stage has lasted for a varying time, bead-like swellings begin to be noticed at the line of junction of the ribs and costal cartilages, which is usually regarded as the earliest lesion of the bones, and of the epiphyses and shafts of the long bones of the upper and lower extremities, giving in these latter places, as at the ankles and wrists, a peculiar knobby double-jointed appearance. With this, there is such a degree of softening of the bones, that they yield readily to pressure. Early in this stage the presence of craniotabes, or " soft spots " in the 'ccipital bone, may often be detected. Indeed, in some instances this ap- pears to be the first recognizable bone lesion. If the disease reaches this stage before the child ha.s begun to walk, there may be no deformity of the lower extremities whatever ; but in cases where the little patient has already been walking about, the femora bend so that they become markedly convex forwards ; the tibiie bend in the same for- ward direction, while the knees may be bent inwards, thus giving to the legs a series of curvatures. The forward curvature of the femora may in- deed be profluced before the child walks, simply by the weight of the legs and feet, which hang pendent from the knee-jointa as the child sits in its mother'i lap or on a chair. The bones of the upper extremities also share in these deformities ; thus the humeri Ijend at the p<^>int of insertion of the deltoids, from the weight of the arms when raised by the action of these muscles; and both the hu- meri and the bones of the forearms become bent, from the pressure which the child makes on its open palms to assist itself in sitting up. The clavicles are very constantly deformed, and present a double curva- ture ; one curve being forwards and somewhat upwanis, and seated just outside of the attachment of the stemo-cleido-niastoid muscle, the other being backwards, and seated about half an inch from the acromio-clavicu- lar articulation. 868 RICKETS. By far the most important deformities, however, are those presented by the head, spine, thorax, and pelvis. The peculiarities by which the head in rickets is distinguished, are thus described by Jenner : 1st. By the length of time the anterior fontanelle remains open. In the healthy child, it closes completely before the expiration of the second year. In the rickety child, it is often widely open at that period. 2d. By thickening of the bones. This is usually most perceptible just outside the sutures, the situation of the sutures being indicated by deep furrows. 3d. By the relative length of the antero-posterior diameter of the head. 4th. By the height, squareness, and projection of the forehead. The first two of these peculiarities of the rickety head are the result of the affection of the bones ; the last two are due chiefly to disease of the cere- brum. Besides this thickening of the edges of the cranial bones, there are spots, irregularly distributed, where the bones are so thinned and softened that they yield to the pressure of the fingers ; and, indeed, in some cases the thinning is so extreme that the pericranium and dura mater come in contact. These "soft spots," which constitute the condition known as craniotabes, were first observed by Elsasser {loc. cit). The nature and mode of their production has been a matter of much discussion. By some authorities their rachitic nature has been denied, but there seems to us no valid reason for doubting their essential connection with the rachitic alterations of the bones. They are usually limited to the occipital region, but may rarely be present over the other cranial bones. They are never observable save in those parts of the bones which are de- veloped from membrane. At first, the spots affected are the seat merely of softening, with perhaps some thickening ; then thinning of the bone occurs, and subsequently the entire thickness of the occipital bone is often removed, causing perforations. These vary in number from one or two to as many as twenty-five or thirty. In order to detect them, the skull should be carefully examined by fixing the head between the hands, and then pressing carefully over the upper part of the occipital region and the pos- terior portions of the parietal bones. The diseased spots are felt to be soft and easily depressed, and " impart the sensation of an orifice in the bone, closed by parchment." It is necessary to use much caution and gentleness in making this exaoiination, since any undue pressure may produce severe nervous symptoms, even convulsions, according to Niemeyer. It is diffi- cult to account for the production of these spots, but the most probable explanation is that they are dependent upon the prolonged pressure upon the softened bone, caused by the head resting on the pillow on one side, and by the counter-pressure of the brain on the skull on the other. The curvature of the spine varies according as the child is able or un- able to walk. In the latter case, there is a posterior curvature of the spine, beginning at the first dorsal, and extending to the last lumbar vertebrae; while if the child is able to walk, this posterior curvature is limited to the dorsal region, but is combined with an anterior curvature in the lumbar region. The cervical anterior curve is increased, and consequently the face CAUSES. 869 is directed upwards, and the head falls backwards, and being unsupjioitod, owing to the muscular debility, sways loosely from sitle to side. Jenuer points out that these curvatures may readily be distinguished from angular curvature, by the fact that the weight of the legs will usually remove them if the child be held by the up}>er part of the trunk, especially if the phy- sician at the same time raises the lower limbs with one hand, and places the other on the curved spine. The thorax is subject to deformities, which in a practical sense exceed all others in importance, owing to the serious interference which they occa- sion with the action of the heart and lungs. In the first place, owing to the curvature of the spine, the ribs are llat- tened laterally, and run forwards more horizontally, so that the lateral diameter of the chest is greatly diminished, while the sternum is carried forwards, and thus the antero-posterior diameter of the thorax is increased. In addition, there is a marked groove on either side of the sternum, ex- tending from the first to the ninth or tenth ribs, along the line of junction of the ribs with their cartilages. These grooves are produced by the bend- ing of the ribs where the dorsal and lateral portions unite; from which point they pass forwards and inwards to unite with their cartilages, which curve outwards before uniting with the sternum. The curvatures and deformities which have been described before this are chiefly due to the action of muscles or the weight of dependent parts ; but the production of the last-described deformities of the thorax is attrib- uted by Jenner chiefly to the atmospheric pressure, which, during inspira- tion, causes recession of the most yielding part of the thoracic walls, /. e., the softened ribs at the line of junction with their cartilages. In conse- quence of the support which the liver, heart, and spleen furnish to the ribs corresponding to their position, the groove extends further down on the left than on the right side, but is deeper over the fifth and sixth ribs on the right than on the left side. The pelvis is frequently aflfected in rickets, and the deformities which result, on account of the great interference they cause in childbirth in the female, rank next in importance to those of the thorax. The rickety pelvis is characterized by a shortening of the antero-posterior diameter, so that the upper strait a^ssumes an oval form, or is at times heart-shajx;d. In extreme instances the sides also approximate, and give to the pelvis a tri- angular shape. It is evident that the form will be influcnceervened. When, on the other hand, the reverse of these conditions obtains, recovery may be expected, though often only after prolonged illness. Diagnosis. — It is only during the initiatory stage of rickets, that the true nature of the attack is likely to be mistaken. But during this period the disease may be confounded either with chronic enterocolitis, or with tuberculosis of the peritoneum and intestinal canal. Careful attention to the peculiar symptoms of rickets, especially the sweating of the heatl, the general soreness and tenderness of the body, and the retardation of denti- tion, will, however, lead to a correct diagnosis, even before the swelling of the sternal ends of the ribs and of the epiphysial lines of the long bones, and the projection of the sternum, remove all doubt as to the nature of the case. Morbid Anatomy. — The essential lesions in rickets consist of the changes in the bones, though there are also certain lesions of the viscera which are frequently met with. The long bones affected by rickets, in addition to the deformities already describeon the abdomen, the inner surface of the thighs, or the lower part of the thorax. In other ca.ses, the eruption assumes a papulated form, the papules being quite prominent, and usually presenting a superficial desquamation. A form of acne, attended with the appearance of indurated pustules which leave little depressed cicatrices, is not unfrequently met with ; and so, also, vesicular and pustular eruptions occur in a good many cases. The most frequent of these eruptions is unquestionably the maculated form ; while dry, scaly eruptions in particular are quite rare in infantile syphilis. In most ca.«es the specific character of the eruption is manifested by the pecu- liar coppery color of the macula, or of the inflamed base of the papule, vesicle, or pustule. In other instances the specific character of the erup- tion must be inferred from the coexistence of other raanifestations of con- stitutional syphilis. The most frequent of these, next to the cutaneous eruptions, are the 1 Clin. MM., 2^me ed , 1866, t. Hi, p. 291. « Di». of Cfiildrun Mlh Am. ed.). 1806, p. 677. » Textbook of Pract. Med (Am. Iran*.), I860, vol. ii, p. 706. 878 CONGENITAL SYPHILIS. affections of the mucous membranes. Thus, coryza, of a serious and most obstinate form, is one of the most constant symptoms met with, and presents here all the characters fully described in our article upon that subject. The nasal raucous membrane is so much swollen that breathing and nursing are seriously interfered with. There is a profuse discharge from the nostrils, either of a thin, irritating fluid, which flows over the lip and excoriates it, or of a thicker pus, which tends to concrete and form thick, discolored crusts. The obstruction to respiration, and the accumulation of secretion in the nasal cavities, gives rise to a peculiar snorting or snufiing quite characteristic of the disease. There is apt to be, at the same time, a superficial diffuse inflammation of the mucous membrane of the mouth and throat, which may extend into the larynx, causing, in conjunction with the coryza, great alteration in the cry or voice, which is hoarse, and haS been under such conditions com- pared by West to the sound of a child's penny trumpet. Despite the severity and obstinacy of the coryza, there comparatively rarely occurs any ulceration of the mucous membrane, or necrosis of the nasal bones, or of the hard palate. In a few cases, however, we have ob- served depression of the bridge of the nose in consequence of the destruc- tion of the nasal bones and perforations of the septum between the nostrils or of the hard palate, and West records a case in which there was necrosis of the hard palate in a young infant. Another very frequent symptom is the formation of rhagades or fissures at the junction of the mucous membranes and skin, as on the lips, and at the verge of the anus. These rhagades bleed upon any stretching of the parts, and by their laceration so much pain is caused that, when the mouth is affected, the child dreads to smile, talk, or suckle ; and when they are seated on the anus, defecation is attended with extreme suffering. Occa- sionally rhagades form in the skin in the flexures of the joints, and especi- ally in those of the fingers and toes. Condylomata are also frequently present, and, like the rhagades, are most frequent at the orifice of the anus and mouth, though they may also form elsewhere upon the skin, as upon the vulva, between the scrotum and thighs, in the axillae, and behind the ears. In consequence, probably, of the softening and ulceration of these growths, large, sinuous, irregular ulcers may form in such positions, ex- tending fi)r some distance into the surrounding skin. In a few cases, iritis occurs ; and so too the deeper seated tissues of the globe, as the vitreous humor, retina, or choroid, may become inflamed. Death very frequently ensues before the end of the first year, either in consequence of the severity of the coryza and the inability to nourish the little patient, or in consequence of the profound cachexia and anaemia, or the development of some of the visceral lesions, to be hereafter described. When, however, owing to judicious treatment, or the comparatively slight development of the early symptoms, the child survives, the disease fre- quently subsides about the end of the first year ; but often, after remaining latent for a variable time, reappears in the form of tertiary symptoms. According to Hutchinson, this tertiary epoch may begin at any period SYMPTOMS. 879 after the fifth year, but is commonly delayed till at or noar tlie periiul of puberty. In addition to the traces which may remain of the earlier symp- toms, such as little pits aud scai-s upon the skin, alterations in the form" of the nose from long-standing nasal obstruction, or actual disease of the nasal bones, there are several very characteristic symptoms amongst the later manifestations. Among these is a peculiar alteration of the permanent incisor teeth, first described by Mr. Jonathan Hutchinson. Although we are not altogether disposed to attach the overpowering weight which Mr. Hutchinson does to the evidence furnished by this altenition of the teeth, of the existence of inherited syjihilis, there is no doubt that it is an important sign, and we, therefore, quote in full his description of it {loc. city p. 317) : " In the;?e patients (those suffering with inherited syphilis), it is very common to find all the incisor teeth dwarfed and malformed. Sometimes the canines are afi'ected also. These teeth are narrow and rounded, and peg-like; their edges are jagged and notched. Owing to their smallness, their sides do not touch, and interspaces are left. It is, however, the upper central incisors which are the most reliable for purposes of diagnosis. "When the other teeth are affected these very rarely escape, and very often they are malformed when all the others are of fairly good shape. The characteristic malformation of the upper central incisors consists in a dwarf- ing of the tooth, which is usually both narrow aud short, and in the atroj)hy of its middle lobe. This atrophy leaves a single broad notch (vertical) in the edge of the tooth, and sometimes from this notch a shallow furrow passes upwards on both the anterior and posterior surface nearly to the gum. This notching is usually symmetrical. It may vary much in degree in different cases ; sometimes the teeth diverge, aud at others they slant towards each other. In a few rare cases, only one of the upper central incisors is malformed, the other being of natural shape and size. It is only in the permanent set that such ix'culiarities are to be observed; the first set are liable to premature decay, but are not malformed." Another valuable symptom of inherited syphilis at this stage, and one which never occurs in acquired syphilis, is a [)eculiar form of keratitis, or inflammation of the cornea, which has been termed interi» uibling ver}- much a mild scarlatinous eruption. It was seated upon the upper part of the front of the thorax, and u|>on the outer surfaces of the arms. The reti flush disappeareint of interest iu regard to this form of erythema, as it has come under our notice, has been the diagnosis between it and scarlet fever. 884 ERYTHEMA. This is to be made out only by recollecting that it has made its appearance in the course of another disease, while the child is already suffering under some kind of sickness, which is not generally the case with scarlatina ; by the less scarlet tint of the eruption, its more superficial character, and more limited extent; and lastly, by its short duration. Erythema Intertrigo. — This form of erythema was for a long time, and is still by some, known by the single name of intertrigo. It occurs on the portions of the body exposed to friction by the contact of opposite surfaces, and to irritation from the passage over, or retention upon them, of the urinary secretion or the fecal discharges. The most common seats of it are, therefore, in the folds of the skin about the neck, in the axillae, the groins, about the anus, in the cleft of the nates, and on the inside of the thighs. As it appears in the creases of the skin about the neck, or in the axillae, it may be a mere red blush lasting a few days, and then disappearing ; or, after presenting this appearance for a short time, the inflammation may become much more intense, and occasion an excoriated condition of the surfaces attended with the discharge of a serous or a sero-purulent fluid ; or, lastly, the inflammation may run into veritable ulceration, giving rise to extensive and very painful ulcers occupying the depth of the crease, presenting abrupt and jagged edges, and discharging very considerable quantities of pus. In these latter forms of the eruption it must be regarded as a true eczema, and, indeed, this form of erythema has been by some authorities transferred to the group of eczematous affections, under the name of eczema erythematosum. In one child, two months of age, of delicate constitution, and imperfectly supplied with food, we saw the last- described form of the disease occupying at the same time the groins, the axillae, and the folds of the neck. The attack lasted two weeks, and very nearly proved fatal from the violent suffering it caused. In another child, not quite a year old, who was teething, it presented these characters in the neck and axillae, while in the groins it was much less severe, the latter parts being merely excoriated. Infants attacked with severe diarrhoea, with dysentery, or entero-colitis, and especially with that form of entero-colitis which so generally accom- panies thrush, are very apt to have an erythema of the nates, genital parts, and the internal surfaces of the thighs. So common, indeed, is this occur- rence that M. Valleix regards erythema of these parts as an almost con- stant accompaniment and even precursor of thrush. For our own part we have very often met with it in cases of diarrhoea in infants, even in those of very moderate severity, but we have never seen it precede the appearance of the intestinal disorder. This form of erythema begins as a simple redness of the skin about the anus, between the buttocks, about the genital parts, and over the inside of the upper parts of the thighs. In a mild case of diarrhoea, and in a child properly cleansed after each evacuation by stool or urine, it will go no further than this : but in a severe attack of inflammatory diarrhoea, at- tended with frequent acid stools, and in a case in which proper cleanliness is not attended to, the long-continued contact of the discharges and soiled DI A GNOSIS. 885 napkins will often cause the erythema to assume very distressing features. The rednesj? extends in such instances along the legs to the feet ; small papules, more or less numerous, make their appearance upon the inHamed skin ; the^ie are converted into pustules and then into ulcerations, and if the case goes on unchecked, the ulcerations become larger, run together, and present raw, deep red, and bleeding surfaces, sometimes of consider- able size. Very often the ulcerations present a grayish plastic exudation upon their surfaces. When these conditions present themselves, the case has passed into an exudative form, and is properly to be regarded as an eczema papulosum or pustulosum. After cicatrization there remain, at the points where the ulcerations had existed, reddish and copper-colored spots, which do not disappear for a considerable length of time. This form of erythema rarely ceases entirely until the diarrluva which has occasioned it has itself been cured. Kkvthema Nodosum generally occurs in feeble and delicate children. We have never met with it under five years of age. It may develop itself upon different parts of the body, but occurs in by far the greater part of the cases on the fore part of the legs, or over the anterior edge of the tibia. We have only twice seen it elsewhere, and then it was situated upon the outer surfaces of the arms and forearms. It is preceded usually for several days by general indisposition, by lassitude, thirst, loss of appetite, and some feverish ness. It appears in the form of red spots of an oval shape, some- what elevated in the centre, and which increase gradually in size. After a short time these patches become decidedly elevated above the surround- ing surface, and in passing the hand over them they give the sensation of n(xlosities. They increase gradually in size, so as to measure from a few lines to an inch or an inch and a half long, by half an inch or an inch broad, when they present the appearance of reddish tumoi*s, somewhat painful to the touch, and having an obscure feeling of fluctuation, as though about to suppurate. This, however, they never do, but after a short time they diminish in size, their red color changes into a bluish or liviiingui.-iied by the superficial character of the eruption, the absence of swelling and of smarting and burning pain, and by the slighter severity and much shorter duration of the symj'toms in erythema. Another important feature is the peculiar, abrupt, welUlefined, and .slightly elevated margin which marks the edge of the erysipelatous rash, and which elas commonly starts tVom, and may at first view seem to be produced by these ditlerent local irritations, it is impossible to suppose that they can be anything more than the exciting agencies or causes, which bring into action a disease of which the seeds already exist in the economy. We must, therefore, in order to untlerstand the real mode of causation of erysipelas, seek for the conditions that give rise to this predisposition to the malady, without which the above-mentioned ex- citing causes would rest without effect. These conditions are either a gen- eral epidemic constitution of the air, affecting certain district.^ of country, and acting more or less upon all classes of the community, but with especial force upon the destitute and miserable ; or else a local epidemic constitution, such as that often occasioned by the unfavorable hygienic conditions of hospitals, and particularly of lying-in and foundling hospitals, or that not unfrequently determined by the same causes in the crowded and miserable habitations of the poorer classes of the inhabitants of large towns and cities. Symptoms. — Inraniile erysipelas is not generally preceded by any con- stitutional symptoms. The appearance of the eruption is usually the first sign of the disease. So soon, however, as the eruption appears, or very soon after, the child is attacked with fever, marked by frequent pulse, heat and dryness of the skin, restlessness and insomnia, and thirst. In the form of the disease which occurs in very young infantsi and in hospitals, or amongst the lower classes of the population, the eruption almost always begins upon the abdomen, and very generally at the umbilicus, whence it extends to the rest of the trunk, to the genital parts, and sometimes to the inferior extremities. Kven under the circumstances just mentioned, how- ever, the eruption sometimes commences upon the face or upon the limbs. In children over two weeks of age, and in those observed in private prac- tice, the di.sease may begin upon any part of the surface. It very often commences in the neighborhood of a vaccine pock, in a patch of erythema intertrigo, whether this l)e seated on the neck or about the jwlvis, or it may appear first upon the face, or U|)on one of the extremities, without any ap- parent exciting cause, and extend thence with greater or less rapidity to other parts of the body. The form of the disease which occurs in very young infants, and which is by far more frequent in lying-in and foundling hospitals than under any other circumstances, begins almost always, at least when of a severe type, OD the aMomen. It attacks hearty as well as more delicate children, and U generally ver}' rapid in its progress. The erysipelatous surface is at 890 ERYSIPELAS. first of a bright-red and shiuing appearance, but soon assumes a purplish hue, and as this occurs, becomes exceedingly hard to the touch, and some- what, though not very much swelled. As the case goes on, unless resolu- tion, which is a rare event, should take place, or death occur at an early period, the purple color deepens into livid, vesications occur, the cellular tissue is destroyed, and in many instances extensive gangrene takes place, so that the scrotum has been seen to " become black and slough away, leaving the testicles bare, and hanging loose by the cords." (Maunsell and Evanson.) In a case that occurred to one of ourselves in private practice, the disease began on the ninth day at the umbilicus, and involved the soft tissues of the anterior wall of the thorax and abdomen. The skin sloughed in several places, exposing the muscles ; and at one point, just below the epigastrium, perforation of the abdominal wall occurred. Death occurred on the fifteenth day of the disease. In this form of infantile erysipelas, examination after death almost always discloses severe and extensive peri- toneal inflammation, a condition which cannot fail, of course, to add greatly to the danger of the disease. But infantile erysipelas does not always exhibit these violent characters, though whenever it occurs in infants under a year old it must be regarded as a very dangerous affection. When it attacks children over two weeks or a month old, it usually starts, as has been stated, from the neighbor- hood of a vaccine pock, from the inflamed surfaces of intertrigo or those of eczeraatous or impetiginous eruptions, or it begins without evident cause, as in adults, on the face, or on some part of the extremities. It appears first in the shape of a bright-red inflammation of the skin. After a short time the erysipelatous surface becomes tense, shining, very hot, slightly swelled, and painful to the touch. Pressure causes the color to disappear, but this rapidly returns when the pressure is removed. Coiucidently with the appearance of the cutaneous redness the child is seized with fever, rest- lessness, and severe thirst. From the spot first attacked the disease ex- tends rapidly to the neighboring surfaces, from the neck and arms to the head and trunk, and from the groins or genital parts to the rest of the trunk and to the inferior extremities. When it begins upon the face, it extends to the scalp, and may thence travel over the whole surface, or it may remain limited, as it often does in adults, to the head alone. In one case that we saw, in an infant three weeks old, in which it began upon the face, it extended gradually over the whole cutaneous surface, and yet the child recovered. In another, two months old, it began upon the bridge of the nose, and from thence extended over the whole head, but did not reach the trunk or limbs. In a third case, a vaccinated arm was attacked with erysipelas on the eighth day of the vaccination. The disease extended down to the fingers, and upwards to the shoulder. From the shoulder it spread gradually over the whole trunk, and down the whole length of both lower extremities. As it was subsiding on the feet, it appeared on the arm opposite the one first attacked, and then attacked the corresponding side of the head, where it ceased. The child finally recovered after an illness of three weeks. As the peculiar inflammation spreads to the neighboring surfaces, the DIAGNOSIS. 891 parts first attacked lose their red color and swelling, and undergo a pro- cess of desquamation. In some instances, the intlamination has caused suppuration of the subcutaneous cellular tissue, so that even when the greater part of the surface first attacked has ceased to present the peculiar characters of the erysipelatous inflammation, there remain behind abscesses of greater or less extent. Thus, in one of the cases that came under our own notice, when the erysi}>elas had left the head and thorax, and was con- fined to the pelvis and inferior extremities, there were two abscesses on the scalp, and one over the right pectoral muscle, whilst all the skin be- tween the abscesses had regained its natural appearance, with the excep- tion of the desquamative process, which was going on as usual. In another, but rarer set of cases, the inflammation sometimes returns to the parts over which it has already passed. The swelling which accompanies this disease is usually of an (edematous nature, — the axlema being most marked in the hands and feet, and upon the face, whilst upon the trunk it is much less considerable. The general symptoms consist at first, as already stated, of those indi- cating a strong febrile reaction. If the case goes on favorably these symp- toms continue until the disorder terminates. But when the disease is se- vere, and especially when it ends in vesication, in extensive destruction of the cellular tissue, or in gangrene, the general symptoms are much more violent, marking thereby the gravity of the attack. The face and lips become pale, and the tongue and mouth dry. The child is in a state of constant agitation at first, and expresses its uneasiness and suflering by incessant moaning or crying, but, after a time, it becomes heavy and drowsy from exhaustion. The pulse is very frequent and feeble; diarrluea and vomiting make their appearance, and the child dies at last in a state of profound debility ; or convulsions occur towards the last, and terminate the case, as they so often do in the diseases of infancy and childhood. The duration of erysipelas in children is extremely uncertain, and de- pends very much upon its form. In that which occurs in the new-born child, or within one or two weeks after birth, it sometimes proves fatal within seven days according to Canstatt (Handbuch der Med. Klhiik, 2d ed., vol. ii, p. 26'4). M. Bouchut {Mai. des Enf. Nonv.-N(% p. 532) gives as an approximation to the ordinary duration of infantile erysipelas, be- tween four and five weeks, and states that this is also the result arrived at by M. Trousseau. In one of the ca^^es alluded to by us, in which the dis- ease extended over the whole cutaneous surface, the duration was four, while in another it was three weeks ; in the one in which the eruption was limited to the head, the duration was a week. In the seven remaining cases, the disease was limited to the nose and eyelids, or the face and scalp, and lasted from three to ten days. DiAGNOHi.**.— The diagnosis is very easy. The peculiar shade of the red color, the presence of decided though mmlerate tumefaction of the aflfected part, the severity of the general symptoms, and the character- istic erratic mode of extension from surface to surface, all assist to render the diagnosis very clear to those who have a proper amount of medical knowledge. 892 ERYSIPELAS. Prognosis. — Erysipelas is always a dangerous disease in young chil- dren. The precise degree of danger in individual cases will depend chiefly on two circumstances : first, the age of the subject ; and second, the hygi- enic conditions under which the disease occurs. It is exceedingly danger- ous in new-born infants, so much so indeed that M. Bouchut declares that they all die {loe. cit., p. 532). This is in all probability almost strictly true of the cases which occur in infants only a few days old, particularly when they take place in lying-in hospitals, or even in private practice, during the prevalence of an epidemic of puerperal fever. The disease is always very dangerous in hospitals, even in infants over two weeks old. Yet it would appear not to be so grave as represented by M. Bouchut, who thinks that very few indeed have been cured even at that age ; for, of thirty cases in infants between one day and a year old observed by Bil- lard at the Foundling's Hospital of Paris, sixteen, or only one more than half, proved fatal. Schwebel reports 54 deaths in S6 cases (Meissner, Kinderkrankheiten, 3d ed., vol. i, p. 372). In private practice, erysipelas, as it occurs in children between two weeks and a few years old, is a dangerous malady, but yet is far from being so in the same degree as in the new-born infant, and in hospitals. We have already stated that we have seen four cases in young infants ; one nine days old, in whom the disease proved fatal in fifteen days ; one three weeks old, in whom the disease lasted four weeks, and travelled over the whole cutaneous surface ; another ten weeks old, in whom also it travelled over the greater part of the cutaneous surface ; and a fourth two months old, in whom it remained limited to the head. These last three recovered. Again, we have seen seven cases of erysipelas of the face or head in children between seven months and twelve years old, and these also ended favorably. It must be recollected, however, to account for these recoveries, that they all occurred in hearty children, and under the most favorable hygienic conditions met with in private practice. To conclude, MM. Rilliet and Barthez report nine cases of erysipelas of the face in children, all of whom, with three exceptions, were over five years of age. Five of the nine cases were idiopathic; in four the disease com- plicated other aflTections. All of the spontaneous and one of the compli- cated cases recovered. The two others, both of which occurred in subjects laboring under measles attended with pneumonia, proved fatal. Treatment. — The treatment of erysipelas in new-born infants, espe- cially when the subjects of the disease are the inmates of a hospital, and when it occurs coincidently with a puerperal fever epidemic, is, as may be learned from the almost certain fatality of the disorder, exceedingly hopeless. M. Trousseau (Barrier, Traite Prat des Mai. de I'Enfance, t. ii, p. 560) has made trial unsuccessfully of emollients in every form, of fomen- tations, lotions, baths, and of ointments containing sulphate of iron. " I have tried," he says, "surrounding the whole body and limbs with blisters in the form of strips ; the erysipelas has passed over the obstacle. I have applied without success blisters upon the surfaces already invaded by the inflammation. I have obtained no advantage from mercurial ointment or from baths containing corrosive sublimate." He even tried the applica- TREATMENT. 893 tion of the actual cautery in points where the disease was beginning, but without efiect. So, too, with methodical compression. Underwood says that "upon the complaint being first noticed in the British Lying-in Hospital, various means were made use of without suc- cess ; the progress of the inflammation has seemed, indeed, to be checked for awhile by saturnine fomentations and poultices, applied on the very first appearance of the inflammation ; but it soon spread, and a gan«rreno presently came on ; or where matter has been formed, the tender infant has sunk under the discharge." He adds that he then proposed bark, to which sometimes a little confectio aromatica was added, and that from that period several cases recovered. After this, linen compresses, wrung out of camphorated spirit, were applied in the place of the saturnine solution, and proved successful in several instances in checking the inflammation. *' Nevertheless, the greater number of infants attacked with this disorder sink under its violence, and many of them in a very few days." (^Treat. on the Dis. of Children, Am. ed., by Dr. Bell, from the 9th Eng. ed., p. 103.) In a note to the above. Dr. M. Hall states that fomentations of extract of poppies diffiised in warm water, and poultices consisting of the same fluid and crumbs of bread, proved beneficial in many instances. Dewees rec- ommends the application of a blister, when the erysipelas is so situated as to allow the whole surface of inflammation and a portion of the neigh- boring healthy surface to be covered by the plaster. When this cannot be done, he prefers the use of the strong mercurial ointment, which must be applied over the whole of the eruption, and partly upon the healthy skin, and renewed as often as the part becomes dry. It is very difficult amidst the variety of advice given by different writers, and especially when we reflect upon the great mortality of the disease under ever}' kind of treatment, to determine which to select. For our own part, we should prefer the use of cooling emollient applications during the first part of the attack, whilst the skin is of a bright red color, hot, and shin- ing. When the circulation becomes languid, and the color of the erup- tion is disposed to deepen from red to purple, we should suspend the use of the emollient applications, and employ instead the lotion of camphor- ated spirit recommended by Underwood ; the camphorated tincture of soap, which we have known to be of great service in the erysipelatous in- flammations occurring in patients of broken-down constitution, and which is to be applied three or four times a day by means of a soft sponge ; or lastly, we would make trial of Kentish's ointment, a remedy found of great service by the late Dr. Charles D. Meigs, in the erysipelas of chil- dren (Xorth Ajnf>r. Mrd. and Surg. Joiirn., vol. vi, p. 77). Tliis ointment he prepared by rendering ba.«ilicon ointment soft (not fluid) with spirit of turpentine. It is rubbed upon the inflamed part with the fingers, the anointing being " repeated often enough to keep the part always very thinly covered." The internal treatment should consist in attention to the .state of the bowels, which arc to be kept soluble by the mildest lax- atives, without being purged, and in a resort to toDJc and stimulating remf-di^s upon the very first approach of symptoms indicating exhaustion. The be.-'t remedies of thi.s cla.ss are proper diet, wine whey, small quanti- 894 ERYSIPELAS. ties of brandy, and bark in connection with minute doses of carbonate of ammonia. In addition to these, the tincture of the chloride of iron, whose remark- able and almost specific influence upon the course of erysipelas in more advanced life is so well established, should be given in large doses, pro- portioned to the tender age of the patient. Thus we may give two or three drops every three hours to an infant of a month old, as in the follow- ing formula : R.— Tr. Ferri Chloridi, f^ss. Acid. Acetic Dil., f ;5ss. Liq, Ammonise Acetat., ..'... f.^j. Syr. Simp , f^^ss. Aquse, ad f^iij.— M. S. — A teaspoonful every three hours. When the inflammation has gone on to the production of subcutaneous suppuration, it becomes still more important to sustain the forces of the constitution, by giving the infant a healthy and abundant breast of milk, and by the internal use of brandy in small quantities, of bark, or better still, of quinia in combination with small doses of carbonate of ammonia. At the same time the suppurating surfaces must be well fomented, and dressed with warm poultices, and, when necessary, laid open by careful incisions, observing the precaution to cause as small a loss of blood as pos- sible. If the case occur in a hospital, or in a child placed in unfavorable hygienic conditions, let the following statement of M. Barrier (loc. cit, t. iii, p. 562) be borne in mind : " However much the life of an infant be threatened by erysipelas, if we can but persuade a wet-nurse to take charge of it, the pure air of the country is often seen to replace most advantage- ously all other therapeutical resources." As the preceding remarks have been restricted to the form of the dis- ease which occurs in infants under two weeks of age, we have now to make some observations on the cases which occur in older children. The disease is still, even at this latter age, a very dangerous one, though much less so, certainly, than in the new-born child. We have been de- terred from the use of depletion in any form by two reasons, — the fear of exhaustion, which is so apt to occur in the disease, and the apprehension lest the leech-bites or cup-marks, in the case of local depletion, might prove new foci of the erysipelatous inflammation. The only internal reme- dies necessary in the beginning, are such laxatives as may be required to keep the bowels soluble when they are bound, such as shall correct acidity or diarrhoea when either is present, and those which promote an open state of the skin, and a free discharge of the urinary secretion. For the latter purpose we know none better than the solution of the acetate of ammonia, and the sweet spirit of nitre, about twenty or thirty drops of the former, with five of the latter, in sweetened water, to be repeated every two or three hours. The tincture of the chloride of iron should also be given, in the combination before recommended, in large doses, as three to six drops. TREATMENT. 895 every three hours, at the age of one or two years. Should the attack be attended by any symptoms of prostration, or at a later period of the dis- ease, when the child begins to emaciate and grow feeble, its strength must be carefully supported by the use of proper diet, and of stimulants and tonics. The only proper diet for nursing children is, of course, breast- milk : for those who have been weaned, the diet should consist of prepara- tions of milk, light animal broths, or beef teii. The best stimulants are five or ten drops of brandy, five drops of aromatic spirit of hartshorn, or a quarter or sixth of a grain of carbonate of ammonia, in weak syrup of ginger, to be administered four or five times a day, or more frequently, when the forces of the child are greatly prostrated. The proj^er tonic is from a quarter to half a grain of extract of bark, or half a grain of quinia, in some suitable vehicle, every three or four hours. The best local treatment is, in our opinion, cooling or tepid emollient applications, as slippery elm bark, marsh-mallow, or flaxseed tea, during the first few days, whilst the reaction is marked, and the calorification of the body high. Somewhat later, when the strength begins to be reduced, and the color of the eruption to deepen, we should make use either of mercurial ointment, which is highly recommended by some, or of the Kentish's ointment, or camphorated tincture of soap, to which attention has already been called. We would here propose the trial of an ointment which we have found not only soothing and comforting to the child, but also of manifest curative efficacy in the violent cutaneous inflammation of scarlatina. It consists of one ounce of fresh cold cream, rubbed up with a drachm of glycerin. It should be smeared over the inflamed surface sev- eral times a day, and need not interfere with the use of emollient applica- tions. In scarlatina it has been most useful in reducing the burning heat of the eruption, and in softening the hai-sh and distended skin, and by these efl^ects has aided greatly in moderating the severity of the general, and especially of the nervous symptoms. In children over two or three years of age, erysipelas must be treated on the same principles as in adults, by light but nourishing diet, and rest io bed, by the internal use of laxatives occasionally, of full doses of the tincture of chloride of iron, and of febrifuges, and by the external appli- cation of emollient infusions, so long as the symptoms remain acute and the strength unreduced. But when, after a time, the fever begins to sub- side, or the child begins to show signs of debility and a tendency towards the typhoid condition, we must endeavor to maintain the life-actions in a proper degree of energy by a more nourishing and abundant diet, by the prudent administration of bark or of quinia, and even by the use of brandy and ammonia, should the strength of the patient be disposed to give wav suddenly or rapidly. Under these circumstance^, moreover, the best local application will be either the Kentish's ointment, or the cam- phorated tincture of soap. 896 ROSEOLA. ARTICLE III. ROSEOLA. Definition; Synonyms; Frequency; Forms. — Roseola is a Don-con- tagious, fugacious exanthem, characterized by rose-colored patches, of irregular size and shape, which are unaccompanied by elevations or papules, and the appearance of which is preceded and accompanied by febrile symptoms. It is often called in this country scarlet rash, and under that title sup- posed to constitute a very mild form of scarlatina. It is sometimes called also French measles, and rubeola sine catarrho. By some writers, as Duhring, roseola is included under the general term of Erythema. Roseola is of rather freqiieiit occurrence amongst children, though more rare than either measles or scarlet fever. There are three forms of the disease met with in children, roseola sestiva, roseola autumnalis, and roseola annulata. As the two former, however, present no differences of any importance, we shall describe them under one head, whilst the latter, quite unlike the other two, requires that we should describe it apart. Causes. — Roseola may occur at all ages of infancy and childhood, and at any season, but is most common in summer and autumn. It has been known to prevail as an epidemic, but has never been thought contagious. It may attack the same individual on several different occasions, one attack not preserving from repetitions. The variolous eruptions are some- times preceded by roseola, and in some children it makes its appearance on the ninth or tenth day of the vaccine disease. Of the various causes that we have known to produce it, the most frequent is certainly derange- ment of the digestive function during the first dentition. It is said also to be occasioned by sudden changes of temperature, by violent exercise, and by the use of cold drinks while the body is heated and moist with perspiration ; causes which strongly indicate that the nervous system is closely connected with its production. Symptoms. — Young children who have been suffering for a few days with disorder of the digestive function, often exhibit a slight roseolous eruption, lasting twenty-four or thirty-six hours, and then disappearing. The eruption in this mild form of the disease appears suddenly, often in the course of a single night, covering the trunk or even the whole surface with numerous patches, nearly circular in shape, or in irregular, broad, and waving lines, situated close together, and yet distinct, and of a light rose color. In another, and rather more violent form, occurring especially during dentition, the eruption appears after vomiting, fever, diarrhoea, and slight nervous symptoms, or possibly after slight convulsions, with the characters above mentioned, except that the rash is deeper in color, greater in extent, and that it lasts generally a longer time — two, three, or four days. Again, in a yet more marked form, the roseola sestiva and autum- SYMPTOMS — DIAGNOSIS. 897 nalis, the disease is preceded by certain symptoms which it is important to note. It begins with more or less chilliness, alternating with heat, with loss of strength and spirits, with headache, restlessness, sometimes mild delirium, and even, it is said, though we have never seen them, with slight convulsive phenomena. At the same time there is some iebnic reaction, marked by aecelerateii pulse, heat and dryness of the skin, thirst and loss of ap|)etite ; the digestive function is shown to be deranged by the presence either of constipation or diarrhoea. After these symptoms have continued tbr two, three, four, or even six or seven days, the eruption appears first upon the face and neck, whence it extends in twenty-four or forty-eight hours to the rest of the body. The rash resembles very closely, in some cases exactly, that of measles. It is in the form of irregularly circular and rather large patches, at first of a red, but soon changing to a deep rose color, and separated from each other by portions of healthy skin. The eruption is sometimes accompanied by itching, and sometimes by stinging pain, and the febrile symptoms generally continue, though moderated in degree, at\er the appearance of the rash ; while in other instances the fever disap- |)ears entirely from that moment. The rash last^ between one and two or three days, as a general rule, and fades away gradually until it has en- tirely disjippeared. In some cases it comes and goes alternately for a week after its first appearance. Roseola Axnulata is a curious and interesting form of the disorder, from the singular and beautiful appearance of the bright rose-colored rings which constitute the eruption. We have seen but a few examples of this variety, while we have met with a large number of cases of the other forms. It must, however, be of rare occurrence, since MM. Guersant and Blache state that they have never chanced to meet with it, though they have seen a large number of roseolous eruptions {Diet, de Med., t. xxvii, p. ij'li)). This variety of roseola appears in the form of rosy rings, or circles, whose centres retain the natural color of the skin. The favorite seats of the eruption are the abdomen, loins, buttocks, or thighs, or it may cover the greater part of the body. In one case that we saw, the eruption cov- ered the face, neck, and trunk. In another it was seated upon the face, trunk, and upper extremities. The rings are at first not more than one or two lines in diameter, but they enlarge gradually until their centres measure as much as half an inch in diameter. In some irjstanres two or three rings surround one another,'lhe skin in the intervals between them still retaining, however, its natural appearance. The disease is, when accompanied by symptom** of reaction, u.«e*n roven by long experience to be apt to occasion attacks of the disease. Of the articles last referred to, those which mout frequently produce this effect 900 URTICARIA. are crabs, the eggs of certain kinds of fisb, certain crayfish, and some kinds of smoked, dried, or salted fish. Some children are exceedingly liable to the appearance upon different parts of the body of a fe^y patches of urticaria. Very slight disturbances of the gastric functions, a very warm day, or excessive clothing, will occa- sion in such subjects an attack of the disorder, whilst in many others again, the disease is never seen under any circumstances, or only at rare and long intervals. Symptoms, — The form of the disorder most commonly met with in chil- dren, in which there is neither fever nor other marked signs of disorder of the general health, is the disease generally described under the title of lichen urticatus, but which ought, it seems to us, to be considered as one of the varieties of urticaria, under the name of urticaria papulosa. This eruption consists of large inflamed papules, which are irregular in shape, being either rounded or oblong, projecting most in the centre, and which ■ appear suddenly, without any or with only slight prodromic symptoms. The papules are of a bright red color, excepting in their projecting central portions, where they are whitish or of a very pale red tint. The eruption is accompanied with a smarting and burning pain, and with the most vio- lent and annoying itching, which the child endeavors to allay by frequent and often rude scratching, in consequence of which the summits of the papules are often torn and present litile crusts of dried blood. It is very fugacious in its character, appearing suddenly, lasting for a few hours or several days, and then disappearing entirely, or recurring again after a short time in the same or in new places. It terminates finally, after from a few days to several weeks, by resolution or by a slight furfuraceous des- quamation. The most common seats of the eruption in children are the face, about the buttocks, or upon the thighs, or upper part of the arms. This is the form of the disease we have met with in infants, and in chil- dren under two and three years of age. It is, as already stated, of very slight consequence, being merely annoying and never dangerous. In young infants it occasions sometimes much crying and irritability, which can be • explained only by the discovery of the eruption. f The urticaria febrilis is usually, but not always, preceded for a few hours or two or three days, by feverishness, and by more or less marked signs of gastric disorder, such as nausea, chilliness, headache, and languor. In other instances the fever and the rash occur at the same time. The eruption begins with a sense of itching, and with heat and burning of the skin, and soon after there appear on the shoulders, loins, inside of the arms, and about the thighs and knees, reddish and solid elevations, irreg- ular in outline, but generally roundish or oblong. The latter shape is the one the elevations most frequently assume, and it is from the resemblance which they bear in this form to the marks left by the stripes from a rod or whip-lash, that they are often called weals. The elevations project a good deal above the surrounding surface, forming knots or ridges ; their size is variable ; they have hardened edges ; they are reddish in color, except over the central and most projecting part, which is generally, and always when the swelling is considerable, whitish in its tint ; and they are sur- ) I DIAGNOSIS — PROGNOSIS — TREATMENT. 901 rouuded by a narrow areola of a bright red or scarlet color. The anunint of the eruption is very uncertain, the elevations being sometimes separated by considerable intervals of healthy skin, while in severe cases they are extremely numerous, and from their confluent character in such attacks, give to the part upon which they are seated, a nearly uniform red color, and occasion at the same time a very decided puffing aiul swelling of the skin. The eruption, when at all considerable in degree, is attended with violent itching and burning. The former is often so severe and troublesome as to 'Cca:?ion the most distressing irritation to the patient, precluding all coni- >rt or quiet. It is increased by heat, and especially by that of the bed. The patches of eruption which appear first do not continue throughout the lisease, but, after lasting from a few minutes to a few hours, fade away, \nd are replaced by new and successive crops. During the attack, the atient is usually more or less feverish, and he suffers from languor, loss 1* appetite, furred tongue, and the usual signs of gastric derangement. Phe symptoms subside gradually, so that, after a period varying from two or three days to a week, the disorder ha.s entirely disappeared, leaving behind no traces, except, in a few instances, a slight desquamation. When this form of urticaria follows the ingestion of certain articles of food, the eruption usually appears within a very few hours after the meal, being preceded and accompanied by nausea or vomiting, pain and distress in the epigastric region, giddiness, headache, and feverishness. In cases where the cause persists, and especially among children of the poorest classes, who live in squalor, or at least under any unfavorable hyirienic conditions, the disease may assume a chronic form. The indi- vi'lual weals are more persistent, and the rude scratching and absence of cleanliness aggravate the eruption and modify its character. DiAGNOJ^is. — There can be no diflBcuIty in recognizing a case of urticaria. The peculiar characters of the eruption, and especially the size, shape, and olor of the s*e are dependent rather upon the gastric diiiorder, which is the cause of the urticaria, than ujxm the latter affection itself. We have never known it to he more than troublesome and annoying. Treatmknt. — There are but two really important indications for the treatment of this disease: to atttend to the state of the digestive func- tions, and to allay, by proper means, the distressing irritation occasioned by the itching and buniing of the eruption. In the mild form of urticaria, called in the nursery, " hives," and in wi- «»ntific language, lichen urticatus, the only treatment necessary is careful •-gulation of the diet, and the use of means proper to correct any evi- ient derangement of the digestive functions. The food should be light 902 URTICARIA. and digestible, but at the same time nourishing. Milk, bread, light meats, and the plainest vegetables, form the proper diet for children over three years of age. Under that age, milk preparations, bread, and in those over a year old, light broths, ought to constitute the diet. In a large majority of such cases, no drug whatever ought to be given. The only ones likely ever to be required are occasional mild laxatives or gentle mercurials, when constipation is present, and some of the antacids, as very small quantities of magnesia or carbonate of soda, or lime-water and milk, when the stomach is acid. To allay the itching and consequent rest- lessness of the child, the patches of eruption should be well and frequently dusted with toasted rye or wheat flour, which are often very successful. Washing the eruption with salt and water, when the cuticle is not broken, is sometimes very soothing, and, when the patches are of small extent, this may be done without any impropriety. Dr. Watson speaks well of a lotion ("first recommended by Wilkinson"), composed of a drachm of carbonate of ammonia, a drachm of acetate of lead, and eight ounces of rose-water. In the urticaria febrilis the treatment must depend upon the cause of the attack. When it follows upon the eating of some unwholesome food, we must rid the stomach of the offending substance by an emetic, unless na- ture has already caused its rejection by spontaneous vomiting. When this end has been gained, it will be proper to give some kind of cathartic medicine, and the best is castor oil, as the mildest and most certain, in order to insure the discharge of the whole of the aliment which has been causing the mischief; or small doses of blue pill; or hydrargyrum cum creta, with rhubarb, where there are present any signs of hepatic derange- ment. After this the only treatment necessary will be the use of cooling and demulcent drinks, containing perhaps a little sweet spirit of nitre ; rest in bed, or at least seclusion in the house, for a few days ; and careful regulation of the diet. The latter ought to be very light during the con- tinuance of the eruption, consisting merely of milk and bread, or of some kind of gruel or plain broth ; after the cessation of the disease, it should be augmented only with due care and quite gradually. To allay the itch- ing and burning of the eruption, and the general distress of the child, the best remedy is a warm bath carefully administered. This may be repeated in six or eight hours if necessary, and between whiles the surface should be dusted with rye or wheat flour, as above recommended. ECZEMATOUS AFFECTIONS. 903 CHAPTER II. VESICLES. ARTICLE I. ECZEMATOUS AFFECTIONS. As already stated iu our introductory remarks on skin diseases, the idea of eczema is no longer restricted to a disease characterized by the forma- tion of vesicles, but embraces all the numerous affections which present redness of the skin, frequently punctated; itching, infiltration, and ex- udation on the surface, with the formation of crusts. So far, indeed, from vesicles being characteristic of it, it may be said, and especially in regard to eczema in children, that its rarest form is that which is attended solely with their formation. The elementary lesions which may be present at the beginning of the attack, are either erythema, papules, vesicles, or pus- tules, and the disease is divided accordingly into eczema erythematosum ; eczema papulosum, which embraces eczema lichenoides, and eczema pruri- gosum ; eczema vesiculosum, the typical eczema of Willan, one of the rarest of all its varieties; eczema pustulosum,or impetiginoides, which in- cludes impetigo; and eczema squamosum, which is usually of the chronic form, and resembles, in many cases, psoriasis. It is indeed called psori- asis by Dr. "Wilson, who gives the name "alphos" to that scaly disease, which is still, by most authorities, and especially by Hebra, designated as psoriasis. It not unfrequently happens, also, that the various elementary lesions enumerated above may be present at the same time on a patch of eczema- tous eruption, so that a ca.se which has begun as eczema erythematosum, or vesiculosum, may present the development of papules or pustules, or thick scabs, and thus become converted into the pustular or squamous form. This tendency for the blending of several elementary lesions in the same eruption, and especially for the conversion of the eruption into the pustular form, is ver}- markedly seen in cases of eczema of children. Eczema is also divided. acr()r<\\n'j to it,- r•()^lr^^•. duration, and staL"'. into acute and chronir. Eczema shows, moroovfr, an <-])'''iai fcii'l'MH-y in nw-.ick ccrlain parts of the surface, and present'^ various p^-culiaritics in the difTcrent loralities; in children, it frequently occurs on the scalp and face, though it extend.-* over the entire surface of the body far morr* fr< mi, ntlv in th. m tliui in adults. The special forms of eczema which will be here descnbed, are .simple 904 ECZEMATOUS AFFECTIONS. acute eczema ; eczema of the scalp, and of the face ; eczema pustulosum, or impetigo; eczema papillosum ; and chronic eczema, or eczema squamosum. Causes. — The causes of these affections are, to say the least, very ob- scure in most cases. It is probable that some peculiarities of constitution predispose to it, and particularly the lymphatic temperament, or the scrof- ulous or tubercular diathesis. Exposure to unhealthy hygienic conditions, as want of cleanliness, insufficient or improper food, and crowded or ill- ventilated habitations, also render the system more prone to the develop- ment of eczema. In those who are thus predisposed, any trifling irritation may prove sufficient to provoke the eruption. One of the most common and un- doubted of these is the influence of the process of teething, and the ma- jority of cases of eczema in children occur during either the first or the early part of the second dentition. In like manner the application of irri- tants of any kind to the skin, or the inflammatory action set up by vaccin- ation, may serve as an exciting cause. It is remarkable, also, what slight irregularities in diet, or alterations in the quality of the mother's milk, will, under such circumstances, induce an attack. Indeed, the use of arti- ficial food in infancy, by disordering the digestive function, and impairing nutrition, may be regarded as a frequent cause of the disease. Symptoms. — We have already alluded to the fact, that in the eczema of young children, as indeed is true, to a less degree, of the disease at all ages, we constantly meet with the most varied forms of eruption in. the same case ; and have the opportunity of watching the development of papules, vesicles or pustules, until a case which has begun as one of ery- thematous eczema, presents the characters of the papular, vesicular, and ultimately of the pustular form. The predominance of one or the other of these typical forms of eczema is determined by the temperament and general condition of the child, and the grade of inflammatory action present. Eczema simplex, or vesicnlosum, may occur on any part of the body, but in children is most frequent on the face and arms. The eruption appears, without any precursory symptoms, as an erythematous patch, which is red and itchy, and may present slightly raised pimples, and being rubbed and scratched, soon presents the formation of numerous, closely aggregated, exceedingly minute vesicles, containing a transparent limpid serum. After a short time the contained fluid becomes turbid and then milky, and is either absorbed, while the vesicles shrivel up and disappear by a slight desquamation, or else the fluid escapes by the rupture of the vesicles, and little thin scales follow, which are detached before long from the surface beneath. The eruption is attended with more or less itching and smarting, but does not generally give rise to constitutional symptoms. The vesicles are generally renewed by successive crops; so that, though the case may terminate in from two to three weeks, it is apt to continue for two or more months. Eczema 'papillosum. — In the same way as the above form of eczema is characterized by the formation of vesicles, there are other cases where the eruption principally consists of papules, associated with erythematous 1 ECZEMA CAPITIS. 905 patches. These papules do not reinaiu dry and without exudation as in the typical forms of lichen and strojihulus, hut soon ])resent a slij:;ht clear or turbid serous oozing, and thin scaly desquamation of the epithelium. At the same time there will usually be found, on other parts of the body, patches of more fully developed eczema. The papules in eczeni'x infantile may either be firm, small, and conical, as in lichen agrius, or softer, and more broad and flat, as in some forms of strophulus. Eczema pu.-itulosuvi or Impctigijwidc^^. — Under this head we will describe the affection usually styled impetigo, and formerly classed among the pus- tular diseases of the skin, but which |x>ssesses peculiarities which have in- duced dermatologists to transfer it to the group of eczematous affections. It may be described as a form of eczema characterized by the production of psydracious sero-pustules, containing a thin purulent fluid, which either break and discharge, or dry up and form thin amber-colored or more thick yellowish-brown crusts. The eruption usually begins as a reddened patch, studded with slightly raised pimples. As the inflammation increases, the cuticle is often raised into more or less well-defined vesicles, or the surf\ice becomes excoriated, and there is a discharge of turbid or whitish-yellow secretion ; the skin now becomes infiltrated, and numerous rather small pustules, containing a light-colored pus, form on the red swollen surface. Not unfrequently there are vesicles on the same patch, surrounding its margin. These pus- tules are usually broken by scratching or by friction against the dressings, and their contents dry up, forming amber-colored or brownish crusts. Frequently, also, blood is mingled with the discharges, and the crusts be- come dark-colored, or at times positively black. The crusts separate in a few days, the time varying according to their firmness and thickness, and leave the surface reddened, but without any permauent scar. Frequently, however, the disease passes into a chronic form ; the eruption retreats to certain seats, as the scalp, or the flexures of the joints, where the skin remains somewhat infiltrated, while the cuticle is rough, scaly, and constantly desquamates, either in the form of a fine furfuraceous exfoliation, or of scales of considerable size. There are in reality but two .specific varieties of this form ol cc/.( tna, impetigo figurata and impetigo sparsa, so named from the manner in which the pustules forming the eruption are arranged. From the greater frequency and .severity of the disease, however, as it appears upon the scalp in young children, it has become customary to descrilx; it, when seated upon that part, under a different title. flrinna rnpHU i« often met with in infants at the breast during the first dentition, and at later periods of childhood in those who are scrofulous, or who are placed in unfavorable hygienic conditions. It may be confined to a small portion of the scalp, or it may cover the head, anfl extend to the face and neck ; or again, it may be limited entirely to the latter localitiei*, when it constitutea eczema of the face. In both cases, the eruption is very apt to run into the pustular form, constituting the disease known as impetiL'o capitis. When mild in its features, it consists of an eruption of numerous small 906 ECZEMATOUS AFFECTIONS. vesicles or sero-pustules, spread over certain portioDS of the scalp, to which it may remain limited ; or it may cover the face at the same time, or it may attack alone the forehead, temples, and, perhaps, portions of the cheeks. It is attended, under these circumstances, with very slight red- ness and heat of the integument. The sero-pustules discharge their fluid contents and form thin crusts, which gradually fall off, leaving slightly reddened or excoriated surfaces, which soon disappear, or are followed by fresh crops of eruption, destined to pass through the same changes as the preceding ones. In more severe cases the disease may be confined either to the scalp or face, or it may, as stated above, exist upon both simultaneously. The eruption presents different appearances in these two situations. When seated on the scalp, it is often called by the English, milky crust or milk-crust, crusta lactea, tinea lactea, and porrigo larvalis ; and by the French, croute de lait and gourme. On the scalp, as already said, the eruption may be either partial or gen- eral. It may consist at first of disseminated minute vesicles, which break, and form thin, lamellated crusts, of a yellowish or brownish color ; or of pustules, yellowish-white in color, and of small size, seated on an inflamed base. The surface affected is at first small, but the eruption gradually ex- tends to surrounding parts. It is attended with great heat and itching ; and, as the disease advances, the scalp becomes very much inflamed, red, tense, swollen, and painful. The eruption is now more completely pustu- lar, and as the pustules open or are torn by the uncontrollable scratching, they discharge an abundant thin sero-pus, or even a thick and viscid fluid, which glues the hairs together, and hardens into uneven brownish-yellow crusts. If the scalp is not kept clean by constant washing or by emollient applications, the crusts increase rapidly in thickness by successive dis- charges of fluid from the pustular surface beneath, until at length the whole of the diseased part is covered with thick, heavy, rough, and adher- ent crusts, of a brownish or yellowish-white color, or at times of a positive black from the admixture of blood which oozes from the inflamed surface, torn by the nails of the little sufferer. When neglected, the crusts become more and more thick, and from the heat of the head and exposure to the air, they undergo partial decomposi- tion, and exhale a fetid, sickening odor, of the most disgusting kind. Among the children of the poor and destitute, lice often form in abun- dance, and add to the repulsive character of the disease. At first, the crusts are somewhat soft and moist, from the percolation through them of the fluid exuded beneath ; but as they become more abundant and thicker, their outer surface becomes dry and sometimes very friable. The secretion from the inflamed surfaces often makes its way under the crusted mass above, and, flowing down over the forehead and behind the ears, irritates the parts that were before healthy, and thus extends the disease. "When the crusts are removed by any means, the surface of the eruption is found to be red, shining, wet, and discharging an abundant purulent or sero-purulent fluid, which escapes from minute excoriated points, dotted thickly over the inflamed scalp. The scalp is at the same time tumefied, ECZEMA FACIEI. 907 tender to the touch, and abscesses may form beneath it. The lymi>hatic glands, as the occipital, submental, or cervical, are frequently enlarged, and at times suppurate. "When the disease has lasted a considerable length of time, it tends to assume a chronic form. The inflammatory action extends to ihe hair-fol- licles, and often occasions partial loss of hair over larger or smaller sur- faces. This kind of alopecia is not, however, permanent. The hair-bulbs are not destroyed, but merely inflamed, so that the hair grows again after the cure of the disease. The tissues of the scalp remain thickened, but the amount of the secretion diminishes; and the painful irritation and itching are less troublesome. Under these circumstances, the crusts are less thick and massive ; they become lighter, thinner, and are more easily detached. The epidermis is dry, uneven, and rough, and there is a con- tinual desquamation of fine furfuraceous particles, constituting a form of pityriasis capitis, or of epithelial scales of various sizes, resembling a case of psoriasis. On the fac^ {Eczema faciei), the disease usually shows itself fii-st on the forehead and cheeks, to which parts it may remain limited, or whence it may extend to the lips, chin, ears, and neck. The nose and eyelids are seldom attacked, though we have occasionally seen the upper eyelids slightly affected. The disease begins by the appearance of minute vesicles or sero-pustules on a patch of reddened and slightly swollen !«kin ; there is also excessive pruritus. When the eruption is scanty, and rather vesicular, and the de- gree of inflammation slight, the cuticle breaks, and there is a discharge of a thin, turbid, serous fluid, which dries into delicate scales, or thin lamel- lated crusts. When the accompanying inflammation is more severe, however, the eruption is more truly pustular, the pustules being numerous and rather large, and the discharge copious, so that when the formation of crusts is not interfered with by topical applications, or by the scratching of the child, large portions of the affected surface become covered witli thick yellowish, brownish, or browoish-red crusts, which present the general ap- pearance of a mass of incrustation, broken by cracks and fissures into por- tions of ven.' irregular size and shape. In the milder ca.se<, when the scales drop off, the skin may api>04ir red- dened and moist, or may seem to be covereoints on the excoriated and inflamed sur- face. Th« eruption i 1 with severe itching and «marting, to relieve which the child often tears the affected surface with the nails, t^o as fre- quently to remove the CrUSt«, "'"t,,! tlu. «i;.i 1.. i..;itl. ;ii.een productive of good effect.'*. The diet should be nutritious and strengthening, but, at the same time, light and of easy digestion. If the appetite is weak and capricious, tonic remedies, as tincture of bark,orquinia, in combination with the ferruginous preparation employed, ought to be administered. In rare cases, where the patient is of full habit, of gross development, and of florid complexion, the diet must be somewhat restricted, and a 68 914 ECZEMATOUS AFFECTIONS. moderate use of cathartic remedies, as small doses of saline laxatives, of blue pill and extract of taraxacum, or of sulphur, resorted to. Local Treatment. — In mild cases, when the patches of eruption are small, and with very little disposition to extend, and the degree of inflam- mation is slight, a cure may often be obtained with great ease by the ap- plication, twice or thrice a day, of an ointment composed of one part of ung. hydrarg. uitratis to three or four parts of simple cerate, or lard ; of weak tar ointment ; or of the beuzoated oxide of zinc ointment, as recom- mended below ; or it may even be sufficient simply to wash the eruptive patches with cool water several times a day, and to anoint them in the evening with ointment of cucumbers. When the disease is attended with much irritation, the application of compresses repeatedly wet with cold water, or with some emollient decoc- tion, as of marsh mallow root, flaxseed, sassafras » pith, or slippery-elm bark, or the use of warm bread and water poultices, are frequently of the greatest service in reducing the heat and irritation, and arresting the progress of the eruption. The compresses must be repeatedly wetted with the cool applications, to prevent the temperature of the liquid from being raised by the heat of the body. They may be retained upon the part for several hours at a time, or throughout the day, as they may be found to suit the eruption, and during the night may be substituted by a dressing of benzoated oxide of zinc ointment. When warm, moist applications, as poultices, are employed, they should always be covered with oiled silk to prevent them from drying. The application which we have used with most marked and uniform ad- vantage, and which we believe to be the one best adapted to the forms of acute eczema, is the benzoated oxide of zinc ointment,^ applied in the manner directed by Mr. Erasmus Wilson. 1 We quote from Mr. Wilson (Diseases of the Skin, 7th Amer. ed., 1868, p. 771), the precise directions for preparing this ointment: BeWs Formula. Ukguentum Oxydi Zinci, Bknzoatum. R. — Adipis preparati, ^vj. Gummi Benzoini, Pulveris, ^j. Liquefac, cum leni calore, per horas viginti quatuor, in vaso chiuso; dein cola per linteum, et adde Oxydi Zinci, Purificati, ^j. Misce bene, et per linteum exprime. If it be desired to make this ointment rather more stimulating, we may add a little alcohol, as in the following : Unguentum Oxydi Zinci, Benzoatum, cum Spiuitu Vini. R. — Ung. Oxydi Zinci, Benzoati, ^\]. Spiritus Vini rectificati, f^ij. Misce, ut fiat unguentum. f Instead of spirit of wine, spirit of camphor, distilled glycerin, liquor plumbi LOCAL TREATMENT. 016 He directs "that the ointment should be applied abundantly, and gently distributed upon the surface until every part of the eruption has a com- plete coating; the ointment should be applied night and morning, and if accidentally rubbed off, or used upon partx*: exposed to the cjr and fric- tion, it may be repeated more frequently. When once applied, the oint- ment should be considered as a permanent dressing to the inflamed skin, and never removed until the skin is healed, unless special conditions arise which render such a process necessary." To secure the permanent con- tact with the skin, he recommends that pieces of linen rag, or a small garment of linen, be kept constantly upon the parts covered with the ointment. In cases where the disease has lasted some time, and the discharge has dried, so as to form more or less thick and hard crusts, it is absolutely essential to get rid of these entirely before any of the applications to be hereafter recommended can be efficiently applied. This is especially the case in eczema capitis, when masses of scabs have been allowed to collect and mat the hair together. The removal of these crusts is best effected by the use of thick, moist, and soft poultices, which, when applied to the head, should be inclosed in a fine linen rag, in order to prevent the matter of which the poultice may be composed from adhering to the hairs. Over the outside of the poultice should always be })laced an oiled silk covering, to preserve it moist and soft. The poultice may be made of almost any unirritating material usually employed for such purposes. One of the best is that made of stale bread and water, with the addition of a little washed lard or hot almond-oil to keep it soft. The water is preferable to milk, as the latter often sours soon after being applied. Another excel- lent poultice is one made of ground slippery-elm bark, mixed with a little flaxseed or Indian meal, to give it a slightly greater consistence, t^ach poultice may be allowed to remain on the part for three or four hours. After the crusts have been entirely removed, and the inflammatory con- dition diminished by means of the emollient applications above recom- mended, the latter may be dispensed with entirely, or during the greater part of the day ;-or they may be used only during sleep, at which time they are usually best submitted to by the child. At this j-tage of the dis- ease it becomes proper to make use of diflTerent lotions and ointments intended to modify the action of the diseased skin. The number of local remedies recommended in the books for eczema in its various forms is, however, so enormous, that we shall refer only to those which we have ourselves made trial of and found useful, or which come from such sources as entitle them to our attention. The choice between the use of lotions or ointments must depend very much upon trials made in each particular case, since it will be found that some are irritated by all, even the mildest ointments, and Ixar lot ions ooly, while in other instances exactly the opposite occurs. Amongst the lotions, the most soothing aod beneficial are a weak solu- diaceUti!!, Peruvian balMitn, or the juniper Ur nintmont, tniiy he combinftl with the benzoated oinlmeot of oxide of sine, in the tame proportion as above, one drachm to the ounce. 916 ECZEMATOUS AFFECTIONS. tion of borax containing morphia ; weak lead-water ; a sulphuro-alkaline lotion, as the following : B — Potass. Carbonat., . ^ss. Sulph. Sublimat., . . . . . . • 3J. Aquae Fluvial., f^viij. Ft. Sol. Or weak solutions of bichloride of mercury, gr. ss. to f^j, as Van Swieten's liquor : R. — Hydrarg. Chloridi Corros., gr. xviij. Alcohol, f^iij. Aquae Destillat., fjxxix. Ft. Sol. These lotions may be applied on pledgets of lint wetted with them, or, if such prolonged applications prove irritating, they may be used by merely washing the part with them for a quarter of an hour each time. We have ourselves usually found that ointments afford more relief in such cases, and the one which we think the most appropriate, is the oint- ment of the benzoated oxide of zinc, rubbed down with a little alcohol. Among the other ointments highly recommended, are those containing oxide of lead or calamine, or citrine ointment diluted with two or three parts of simple cerate. When the eruption is confined to a rather small surface and is not very acute and rapid in its progress, or when the activity of the inflammation has been somewhat subdued, more powerful local remedies may be em- ployed. Among these may be mentioned a saturated solution of borax in dilute acetic acid ; stronger solutions of corrosive sublimate ; solutions of nitrate of silver, of from 2 to 10 grains to the ounce ; or such ointments as the citrine, either pure or mixed with an equal amount of lard or sim- ple cerate ; or, ointments containing protiodide of mercury : R. — Hydrarg. Protiod., # gr- s:ij. Camphorse, ........ gr. v. Axungise, ........ ^j. — M. Apply twice daily. Or, calomel : R.— Hydrarg. Chlor. Mitis, 9j. Camphorse, gr. v. Glycerinse, ........ i'5j. Ungt. Aquae Rosae, f^j. — M. Tar ointment, or either of the zinc ointments, may also be used. After the activity of the inflammation has been diminished by treatment or by time, and the disease tends to pass into a chronic form, it becomes necessary to make use of more stimulating applications than those just named. The best of these remedies are those which contain alkaline sub- stances, tarry substances, or mercury. LOCAL TREATMENT. 917 The remedy from which we have obtained the most beneficial effects in 6uch cases, is the spin'tu^t saponafu,, p. l-}i;, recom- mends in ca.se3 of localized eczema, with much infiltration of the skin, the use of an ointment or lotion containing cau.stic pota>t>8a in addition to tar. The amount of pota^^h must be carefully regulated by the suscepti- bility of the skin, a.** much irritation may follow if too large a proportion be u.<^. The forms of mercury best adapted to thi« stage are the nitrate, the protiodide, and the mild chloride, which may be combined with lard iu 918 ^^^W HERPES. a larger proportion than that recommended for an earlier stage of the disease. In cases of eczema tarsi, attended with infiltration of the eyelids, McCall Anderson recommends that the eyelashes should be extracted, the eyelids everted and a solution of caustic potash grs. v or x to f^ j applied and quickly washed off by a large brush. Care should be observed in case the edges of the eyelids are adherent in the morning, not to separate them rudely, but to moisten them with tepid water or milk and water, so as to soften the crusts. Afterwards an application of citrine ointment, diluted with about two parts of lard, should be made along the edges of the lids night and morning. ARTICLE II. HERPES. Definition; Varieties; Frequency. — Herpes is a non-contagious cutaneous disease, characterized by an eruption of vesicles assembled in groups on inflamed surfaces, of irregular size and shape, which are sepa- rated from each other by perfectly healthy portions of skin. The disease is usually acute in its course, seldom lasting more than two or three weeks, but it is not, as a general rule, accompanied by any severe constitutional symptoms. The separate vesicles composing the eruption last about ten days, and then disappear by the absorption of their contents, by the dry- ing up of the contained fluid without rupture of the vesicles, or by the rupture of the vesicles, the escape of the fluid, and the formation of thin, brownish, or yellowish scabs. There are several different varieties of herpes, which have been well divided by Mr. Wilson into two groups, the phlydeiioid and circinate. The phlyctenoid group is characterized by the irregularity of form exhibited by the eruption, and includes the variety called herpes phlyctenodes, and the local forms, called according to their seat, labialis, nasajis, palpebralis, auricularis, prseputialis, and pudendalis; whilst the circinate group is char- acterized by the arrangement of the vesicles in circles, and includes the herpes zoster and iris. Of these different varieties we shall describe, as of importance in children, only the phlyctenodes, zoster, and iris. Herpes circinatus, formerly included in this group, will be found described in the article on tinea. Herpes is quite a frequent disease in children, though one rarely of any considerable importance. Causes. — The causes of herpes are often obscure and uncertain, and in many cases entirely inappreciable. The disease is most common in per- sons who possess a delicate and irritable skin. The most frequent and most clearly ascertained cause is some disturbance of the digestive func- tions, and when there exist, in connection with this condition, irritations SYMPTOMS OF HERPES PULYCTENODES. 919 or inflammations of the respiratory mucous membrane, it is especially apt to be developed. Herpes phlyctenodes often follows exposure to a hot eun, while herpes labialis is frecjueutly caused by exposure to a cold wind, especially when this occurs immediately after leavinir a heated room. The latter variety also frequently accompanies coryza, angina, auH stomatitis, and appears often as a critical eruption in the course, and particularly at the termination, of fevers, catarrhs, and visceral inflammations. The usual excitinu causes of the disease are irrcijularities in diet, expos- ure of the body while in a heated state to cold and damp, local irritants, malarial disease, and bilious disorders of all kinds. The cause of herpes zoster is peculiar. The eruption appears, in nearly if not quite all cases, to be dejx^ndent upon a morbidly irritable state of some nerve-trunk ; which may be the result of simple or rheumatic in- flammation, of pressure, of mechanical irritation, etc. Herpes Phlyctenodes. — This variety of herpes, unlike the other forms of the disease, may appear upon any part of the cutaneous surface, and does not assume a determinate shape. It may appear, indeee- corae, in the course of a day or two, turbid or lactescent. The red color of the eruptive patch generally extends a short distance beyond the ves- icles: the integument between the different patches retain.*, however, in all cases, its healthy color and character. A sense of smarting and itch- ing accompanies, as well as prece' turbid, and they begin to shrink. About the seventh or ei;.'lith day, they are usually transformed, by the drying up of their contents, into thin, brownish crusts, which fall off* by des(|uarnatiMn about the tenth or twelfth day. There &\m remains, for a few days after the disappearance of the eruption, some redness of the surface, which subsides little by little. This variety of herpes is never accompanied by couMtitutional fymptoma 920 HERPES. • of any severity. A very slight febrile reaction, some languor, loss of ap- petite, and thirst, are the only ones worthy of note. Herpes Labialis. — This is the most frequent of all the varieties of the disease. It is, as its name implies, a disease of the lips. Usually it is seated upon the line of junction of the mucous membrane with the in- tegument ; but it may affect either the former or latter alone. Though generally confined strictly to the lips, the eruption, in some instances, ex- tends to the cheeks, chin, or alse of the nose. The disease begins generally with redness, heat, smarting, and painful tension of the portion of the lip upon which the eruption is about to ap- pear. After a few hours, or a day, vesicles begin to show themselves upon the inflamed spot, and there is then observed a red, swollen, and shining point, upon which is seated a group of vesicles. The tumefaction and redness commonly extend some distance beyond the vesicles. The latter develop themselves rapidly, until five or six small, rounded vesicles, filled with a transparent fluid, are seen. The vesicles remain solitary, or several may unite together to form one of considerable size. After the complete development of the eruption, the burning pain which existed at first com- monly subsides. The contents of the vesicles soon become turbid and lac- tescent, and are converted, by the third or fourth day, from a serous into a sero-purulent fluid, at which time, also, the accompanying redness and swelling have, in great measure, disappeared. Soon after this, brownish crusts are formed by the drying up of the fluid of the vesicles, and these drop off* usually about the seventh or eighth day. A slight redness re- mains for a short time at the point of eruption, and then disappears entirely. Herpes Zoster. — This variety of herpes is known also by the names of Zona and Shingles. It is of much less frequent occurrence, in this city, in children, than either the herpes labialis or circinatus. We have seen but few examples of it in children, though Rilliet and Barthez state that they met with this form and the herpes labialis more frequently than any other. The name of the disease, herpes zoster, the latter word signifying a gir- dle or belt, is derived from the fact that, when it attacks the trunk the eruption appears in the form of a half zone, surrounding half the body. The most frequent seat of zona is the base of the thorax, the disease extending usually, in the form of a cincture, from the mesial line in front to the same point behind. It may, however, be developed either above or below the part just named, and, under these circumstances, is apt to extend towards or down the arm, or towards the thigh and down the leg. Still more rarely, it has been observed upon the neck, face, or scrotum. It will be found to nearly always follow the course of some nerve tract; and is usually confined to one side of the body. The zone formed by the eruption is not composed of a continuous line of vesicles, but is made up of distinct patches of eruption, all following the same general direction, but divided from each other by portions of healthy integument. The eruptive patches may be very closely approximated, or they may be sepa- rated by considerable spaces of skin untouched by the disease. HERPES CIRCINATUS — HERPES IRIS. 921 The disease is acute in its character, lasting, as a general rule, from one to three or four weeks. Shingles appear first, after some previous smarting and burning in the -kin, and neuralgic pains which may have lasted one or two days, in the form of irregular patches of a vivid red color, more or less widely sepa- rated from each other, and developed, one after the otlicr, until one-half the body is girdled by the eruption. In some instances, the disease ap- pears simultaneously at the two extremities of the zone, and is terminated by the gradual formation of successive patches between these two points. Soon after the appearance of the inflamed patches, numerous small, white projections can be seen, by careful examination, upon the red surfaces; these increase rapidly in size, and are soon converted into distinct, trans- parent vesicles. The vesicles augment in size, and arrive, in the course of three or four days, at their fullest development, when they arc about as large as small or large peas, or, in some few instances, much larger. At this stage of the eruption, the red surface upon which each group of vesi- cles is seated extends a slight distance beyond the patch, thus forming a kind of areola. After pursuing the course just described during four or five days, each group of vesicles begins to subside. The redness of the inflamed patch diminishes; the vesicles shrink, and become shrivelled; their contents, which were transparent at first, become opaque, and finally they dry up and form small, dark-brown scabs, which fall ofl^ about the tenth or twelfth day, leaving behind reddish spots, which disappear little by little. The constitutional symptoms of herpes zoster consist usually of slight feverishness, languor, and the signs of gastro-intestinal irritation. The local symptoms are pungent and burning pain at the beginning of the eruption, and more or less severe tension, and sometimes acute pain, in the part upon which the disease is seated, which latter lasts, in some instances, throughout the course of the disorder, or even for some considerable time after it has disappeared. This neuralgic pain which appears to be de- pendent on the implication of a nerve-trunk varies much in intensity, being at times slight, and at others very intense. Herpes Circinatt^. — This variety of herpos has been caller! also ring herpes, herpetic ringworm, and vesicular ringworm ; it will be found de- scribed under the name tinea circinata in the article on parasitic diseases of the skin. Herpf>? Iris. — This is a very rare variety of herpes, and one that we have met with in children in Init two instances, although according to Duhring (op. ci7., p. 228) it is comparatively frequent in children and young people. It begins with small red spot«, which are soon surrounded by four or five rings of diflferent shades of redness. About the second day of tha eruption, the central red spots present in their centres one or more vesicles, and on the third and fourth days, vesicles of very minute size generallv appear on the outer concentric rings. After two or three days, the fluid contained in the central group of vesicles, which was transparent at first, becomes turbid, and alK)ut the fifth or sixth of the eruption, it is absorbed, and the disease terminates by a slight desquamation. The 922 HERPES. vesicles formed on the outer ring undergo the same changes as those de- scribed as occurring on the central ones. In some instances, the vesicles open, and their contents escaping, form small, thin, and brownish scales, which fall off in ten or twelve days. Herpes iris may attack any part of the body, but is most frequently de- veloped upon the face, hands, fingers, and neck. According to some dermatologists, as McCall Anderson, herpes iris is a parasitic disease and merely a form of tinea versicolor. This view how- ever does not appear to us to be correct. Diagnosis. — The diagnosis of herpes is seldom attended with any difli- culty. The small size of the vesicles, their globular shape, their number, their aggregation upon distinct patches of inflamed integument, and the slight degree of constitutional disturbance attendant upon the disease, all render the eruption unlike any other cutaneous affection, and therefore easy of recognition. Herpes phlyctenodes might possibly be confounded by an incompetent observer with pemphigus. The recollection that the eruption in pemphigus consists of distinct bullae, much larger, of course, than the vesicles of herpes, while that of herpes phlyctenodes consists of numerous vesicles, much smaller than the bullae of pemphigus, and closely dotted over isolated red patches, will always serve to distinguish the two affections. It might be mistaken also for eczema, when the vesicles of the latter are disposed, as sometimes, though rarely, happens, in groups. The distinction may be made, however, by attention to the facts that the eczematous vesicles are redder, less elevated, scarcely transparent, and that, though arranged in groups, they are confluent, whilst in herpes they are always distinct. Herpes labialis is not likely to be mistaken for any other eruption. Herpes zoster may always be distinguished by the peculiar belted form assumed by the eruption, by the arrangement of the eruption in the course of some nerve-tract, and by the neuralgic pains which attend it. There is but one disease with which herpes iris is likely to be con- founded, — roseola annulata. The entire absence of vesicles in the latter aflfection w^ill ahvays, however, enable us to make the distinction. Prognosis. — The prognosis of herpes is always favorable. It is never in itself a dangerous disease, though the variety called zona often causes much suffering, and is moreover usually the expression of a considerable disturbance of the general health. Treatment. — The different varieties of herpes seldom require more than the mildest treatment. In all, attention should be paid to the gen- eral health. The diet must be regulated according to the state of the digestive function. When constipation is present, especially if there be some febrile reaction at the same time, gentle laxatives ought to be ad- ministered, such as sulphur, magnesia, syrup of rhubarb and magnesia, or castor oil. If the skin be sallow, the tongue heavily coated, the breath foul, and the stools scanty and light-colored, or very offensive, small doses of blue pill in combination with rhubarb, or followed by rhubarb and magnesia, would be the most appropriate remedy. Excessive or fre- quently-repeated doses of any purgative ought to be avoided, as the de- SCABIES. 023 bility and gastro-intostinal irritation that so often follow such practice, are more injurious than the original disease. The local treatment of herpes is important, and is, indeed, in many cases, all that is necessary. Her[H?s phlyctenodes requires nothing more than mucilaginous lotions, an occasional warm bath, or the frequent moistening of the eruption with a liniment made of equal parts of lime-water and sweet-oil. Herpes labialis, if it demand local treatment at all, may be relieved by the use of any mild lip-salve ; a very ^ood ointment is one composed of equal parts of (Joulard's cerate and simple cerate, with a few drops of glycerin. ^Ir. Wilson recommends the following ointment: R. — Unguenl. Flor. Sanibuci, ^^j. Liq. Plumbi, f^j.— M. During the early stage of herpes zoster, the local treatment should be such as will tend to allay inflammation and relieve pain. These effects may be obtained by applying compresses moistened with some kind of mucilage, such as barley-water, or decoction of flaxseed or slippery-elm bark, or with simple cold water, or with weak lead-water and laudanum. When the eruption is followed by excoriations or ulcerations, and the pain is severe, the latter may be allayed by the use of an ointment consisting of equal parts of Goulard's cerate and lard, either alone, or containing two or three grains of opium, or half a drachm of the watery extract of opium. Underwood recommends, when the discharge has subsided, and the scabs have formed and become adherent, that they should be anointed twice daily with the uug. hydrarg. ammoniat. It is, however, necessary to also employ some internal treatment to relieve the neuralgic pains, which arc so prominent a symptom. For this purpose, opium must frequently be em- ployed. We have also found that the combination of iron, quinia, arscni- ous acid and belladonna has aff'orded marked relief in some cases. Phos- phide of zinc has been highly recommended by Ashburton Thompson in doses of one-third of a grain for an adult. The employment of a galvanic current, applied along the tract of the affected nerve has proved very bene- ficial. Herpes iris seldom requires any treatment. If any be determined on, it should consist of alkaline lotions, or of water rendered .slightly a-stringent by the addition of alum, or sulphate of zinc. ARTICLE III. Al;ll>. I>i.F iM I !•>> ; .-^^<.^^^i-. \ r.i.'r >>" » — Scabios i« a contagious erup- tion of the skin, characterized by the formation of papules, vesicle?, or pustules ; the vesicles being pointed, generally discrete, and usually pre- 924 SCABIES. seuting small red lines, of one or several lines in length, running off from them. The eruption is attended with severe itching, and is caused partly by the presence in the skin of a small insect, called the acarus scabiei, and partly by the scratching which the intolerable itching provokes. Causes. — Itch is a contagious malady, and is in all probability caused only by contact, either immediately with some person laboring under the disease, or with articles of clothing worn by an infected individual. It is much more frequently met with amongst the poor and destitute, whose habits are uncleanly, who live closely packed together in small and inconvenient houses, and in whom, therefore, the means of communication are more abundant, than amongst the easy classes of society, whose habits, and, consequently, liability to contact, are the opposite of those just named. It is, however, comparatively rare in the United States, and particularly in this city: thus Duhriug met with but 12 cases out of 2472 consecutive cases of skin disease. The disease usually appears in children in from four to five days after the exposure to contagion. In healthy, sanguine children, it often shows itself w.ithin a shorter time — after two days — while in those who are feeble and weakly, the period of incubation may be even longer than four or five days. Symptoms. — The first symptoms of itch appear in the part to which the cause, a contagious contact, may have been applied. In infants at the breast, it is usually first developed on the hips and thighs, as it is those parts that are most constantly in contact with the nurses who carry the child, and from whom young children generally receive the infection. In older children, the disease commonly appears first on the wrists and be- tween the fingers, and extends thence more or less quickly to the flexures of the elbows, and to the axillae and abdomen. It rarely or never attacks the face in adults ; but in children, even this part is not, according to M. Richard, exempt. (Trait. Prat des Mai. des Enfants, p. 590.) The disease is always attended with severe itching, which, in infants, causes uneasiness and fretfulness, and, in older children, violent scratching. The itching is increased by the heat of the bed-coverings, and is, therefore, most troublesome at night. The eruption appears in the form of more or less numerous vesicles, which are small, discrete, acuminated, and trans- parent at the top. The vesicles are at first of a faint rose color, and they contain a viscid transparent serum. Their number is variable, being sometimes very abundant, and at others sparse. They either open spon- taneously, or are soon broken by the fingers or clothes, and are followed by small, thin, slightl}^ adherent scabs. In some instances the action of the nails causes slight effusions of blood, which dry into small bloody scabs, like those of prurigo, thus embarrassing to a certain extent, the diagnosis of the disease. Sometimes, particularly when the inflammation attendant upon the eruption, or that caused by scratching, is marked, there are, inter- mingled with the psoric vesicles, pustules of impetigo, or perhaps papules of lichen, which tend, like the sanguine crusts just alluded to, to render the diagnosis difl^cult. Indeed it is not strictly correct to define scabies, i DIAGNOSIS. 925 as was formerly done, as a vesicular affection, since the eruption is papular in a very large proix>rtion of cases. When a recent vehicle is carefully examined, there may generally ho observed running oti' from it, in a straight, curved, or zigzag direction, a whitish or reddish line, like that produced hy the scratch of a pin. This line marks the course of the fecundated female of the acarus scabiei in its burrowings under the epidermis, and is called the cuniculus, or burrow. It varies in length from one or two, to five or six lines. At the point where it terminates opi>osite to the vesicle, there is usually to be seen a small rounded projection, deej>er in color than the rest of the euniculus, beneath which lies the insect. The acarus can often be f«)und at this spot, and re- moved, by carefully introducing horizontally under the epidermis tiie point of a small needle, and by manipulating so as to take ofl' a small layer of the epidermis. The insect clings to the point of the needle, and can then be extracted from its lodgment. The number and extent of the vesicles vary greatly in ditlerent subjects. In some they are confined to limited surfaces, while in others, and partic- ularly in robust, sanguine children, and in those who are neglected and imperfectly cleansed, they extend to many different parts, or over the greater part of the body. Itch occasions in children much irritability and suffering, and when neglected may injure seriously the general health, and cause emaciation and debility. The acarus scabiei is an arachnoid insect, varying, according to Mr. Wilson's measurements, between tIt and A of an inch in length, and between 3^3 and i\ of an inch in breadth. It is of a whitish and shin- ing color, when examined with the naked eye, of a globular form, and is provided with eight legs, four anterior and four posterior. A most accu- rate and minute account of the structure of the insect is given by Mr. Wilsi- 5^''ij- — M. TREATMENT. 927 the skin before a fire, morning: aiul ovoniiifr, for two days. The cliiKl -hould he kept in a flannel gown, and in bed, during this treatment. On ilie morning of the third day, the skin may be waslied clean with soap and water, or by immersion in a warm bath. This plan rarely fails to efleet a cure. Should it happen, however, to fail, the treatment mujt be re- peated. Before the application of this or any of the other ointments, the -Lirface should be well scrubbed with soap and hoi water, so as to cleanse and soften the skin. It also increases the effect of the sulphur, to conjoin with it some alka- line substance, as in the various sulpho-alkaline ointments and lotions, of which the following are among the best: Unq. Sulpuuris cum Potassa (Wilson). R. — Sulphuris Sublimati, ..... Potassa? Carbonatis, Unguenti Benzoati, ...... Olei Anthemidis Esscntialis, .... Uelmerich's Formula. B- — Sulphuris Sublimati, ..... Potassie Carbonatis, ...... Adipis Preparati, VLemingkx's Forymda. R. — Calcis Vivi, ,^ij. Sulphuris Sublimati, ...... ^^iv. Aqua Fontwnae, ^o^^- Boil in an iron vessel, and stir with a wooden gpatula to a perfect union. These are all quoted in the proportions directed for adult,s, which are much too active to be applied to the delicate skin of children ; they should therefore be diluted one-half at least. Anderson recommends the use of oil of cade or tar, comljiiicd with the sulpho-alkaline ointments. As the use of the sulphur ointment is sometimes objected to in j)rivate families, on account of its disagreeable odor, various substitutes have been recommended. Mr. Wilson states that he found camphor di.ssolved in oil, in the proportion of one drachm to the ounce, answer every purpo.se of • radicating the di.sease ; and Dr. Coley (Prac. Treat, on I)'n^. of C/ilidren, Phil, ed., 101 J speaks highly of an ointment compo.'^cd of a drachm of iodide of pota.ssium to an ounce and a half of lard, of which a little is to be applied all over the body, except the head aud face, every night. OintmeDts containing carbolic acid or petroleum are also used with good effect. The use of stavcsacre and hellebore has lately been revivec«en broken down by unwholesome hygienic influence**, it may ansumc a danger- ous character, and the prognoois should, therefore, always l>e guarded under such circumstances. 69 930 RUPIA. Treatment. — Simple acute pemphigus requires, as a general rule, no other treatment than attention to diet, and regulation of the digestive function. When constipation is present, this should be overcome by means of simple enemata, or by the use of some mild laxative, as manna, spiced syrup of rhubarb, or very small doses of castor oil. If the dis- charges be too frequent, they should be restrained by the use of opium in doses proportioned to the age of the child. In young infants, it will often be found that the gastro-intestinal secretions are of an acid and irritating character. This condition may be treated with small doses of paregoric or laudanum, combined with lime or magnesia-water, or with soda. The diet must be managed according to the state of health of the child. For an infant, a good breast of milk is, of course, the best treatment in the world. For older children, the diet ought to be light and unirritating, but, at the same time, nourishing and strengthening. The local treatment should consist, in the early stage, of an occasional warm bath. When the bullae have fully formed, they ought to be punc- tured, and the fluid gently pressed out, care being taken not to remove the cuticle, as this forms the best possible dressing for the inflamed integu- ment. When the bullae are followed by excoriations, these may be dressed with an ointment consisting of equal parts of Goulard's cerate and simple cerate, made a little soft by the addition of glycerin, or with carrot or elder-flower ointment, or with Turner's cerate. Much relief may also be gained from the use of water dressings by means of cloths. When the child shows signs of debility during the progress of the dis- ease, and also when the eruption tends to assume a chronic course, the treatment ought to be tonic and invigorating. It should consist in the use of a nutritious diet, and in the exhibition of tonics, as Huxham's tincture of bark, in small doses, quinia, arsenic, cod-liver oil, or in the use of wine-whey, or small quantities of brandy. AKTICLE II. RUPIA. Definition ; Varieties. — Rupia is an eruptive disease, characterized in its early stage by distinct, somewhat flattened bullae, of more or less considerable size, containing at first a serous, and then a purulent or blackish fluid : at a later period the disease exhibits very thick scabs, and still later, ulcerations. There are three varieties of this eruption : rupia simplex, rupia prom- inens, and rupia escharotica. The latter variety was formerly described under the title of pemphigus infantilis, and pemphigus gangrenosus, and is known in Ireland under the different names of white blisters, eating hive, and burnt holes. It is the most important variety of the disease in young children. CAUSES — SYMPTOMS — RUPIA ESCHAROTICA. OHl Causes. — Rupia is most apt to occur in weakly, badly nourisliod, ami scrofulous children, and seems to depend, therefore, upon that state of de- bility and exhaustion of the general health, which results from exposure to unfavorable hygienic conditions, which follows exhausting diseases, or which exists as a consequence of some hereditary taint. Symptoms. — Bupia simplex begins almost always on the inferior ex- tremities, or more rarely on the trunk or arms, without previous inflam- mation, in the form of small, flattened bulla; of about three or four lines in diameter. The bullie contain at first a serous and transparent fluid, which soon becomes thicker, and is converted into pus. At an early period they shrink and become wrinkled, their contained Huid hardens and is converted into rough, brownish scabs, which are always thicker at the centre than on the edges, and which leave beneath, after their fall, superficial ulcerations. These ulcerations either soon cicatrize and disap- j)ear, or are covered by fresh scabs. After the fall of the final scabs, there yet remain, for some time longer, dark-brown or livid spots, which gradu- ally fade and disappear. Jhipia promiueus exhibits the same general characters as the preceding variety, but with more marked and peculiar features. The eruption com- mences witk a circumscribed inflammation of the skin, on which inflamed spot soon appears a bullie filled with yellowish serum, or sometimes with a blackish fluid, which rapidly hardens into a brownish or blackish wrinkled crust. The crust is surrounded by an erythematous areola, formed by the extension of the cutaneous inflammation beyond the cir- cumference of the scab. Upon this areola a fresh elevation of the cuticle, by purulent deposit, often takes place, which, by its desiccation, adds to the size of the crust. This successive increase at the margin of the scab enlarges it in breadth, and, at the same time, raises the height of its cen- tre, so as to give it a peculiar and characteristic ap})earance, and causes it to resemble very closely the shell of a limpet or oyster. The scabs thus formeen8, remain open, presenting a foul surface of a livid red color, which thickened edges. The ulcers are difficult to heal, and, after cicatrization, leave livid or purplish stains, which often remain for months. The number of bulla is usually small, there being generally one at ita height, and one or two about to apixjar, or on the decline. Rupia Escharotica. — This variety of rupia, formerly described aa belonging to the class pemphigus, and then calle*! pemphigus infantilis and gangrenosus, differs in some respects from the other varieties of ruj)ia, and particularly in the absence of the thirk and projecting rrustJ*, wliich characterize rupia simplex and prominens. It occurs chiefly amongst cachectic children, appearing usually in the period between birth and the first dentition. It is seate.iiiiM>.»i the disease to which children are subject, edhyma vulyare, or arntiim, and ecthyma inf untile. CAtsErj. — The most frequent causes of ecthyma arc the application of 934 ECTHYMA. irritating substances to the skin, such as croton oil and tartar emetic ointment, and the presence of other eruptions upon the skin, particularly small-pox, measles, scarlet fever, herpes, or scabies. The causes just Darned give rise to the variety called ecthyma vulgare, which, it may be well to state in this place, is of an acute character, and has therefore been called by some writers ecthyma acutum. The other variety of the disease, ecthyma infantile, is a chronic affection, and occurs almost always in feeble, badly nourished, and cachectic children, and in those whose health has been injured and broken down by exhausting diseases, and particularly by disorders of the gastro-intestinal apparatus. Symptoms. — Ecthyma vulgare occurs most frequently on the extremities and neck, and more rarely on the trunk of the body. It appears in the form of small, red, and circumscribed spots, projecting above the surface of the skin, hard to the touch, and accompanied by smarting and often severe pain, and by soreness on pressure. The centre of the spots is soon elevated into a pustule, filled with a purulent fluid. The size of the pus- tules varies, but is usually about that of half a pea. Each pustule is generally surrounded by a hard base of a bright red color, constituting an areola, while, in some instances, the whole of the red elevation is covered by the pustular formation. The pustule remains unchanged usually for three or four days, and more rarely for a week, and is then converted, by the drying up of the effused fluid, into a thinnish brown scab, which drops off after a few days, and leaves a congested purple spot that remains for some time longer. In other instances, the pustule breaks and leaves a small ulceration which terminates with a slight cicatrix. The eruption is commonly successive, and is seldom accompanied by any febrile reaction. Ecthyma infantile is much more frequently met with than the other variety of the disease, and occurs in a single, or oftener in successive eruptions, in feeble, badly nourished, and cachectic children. It appears on the neck, shoulders, arms, and chest, and especially upon the lower extremities. It is often connected with some chronic disorder of the diges- tive or respiratory apparatus, and is developed during the state of debility and exhaustion to which children are reduced by those affections. The pustules of ecthyma infantile are of variable size, some being small, and others as large or larger than a sixpence. They are circular in form, and surrounded by an areola of a red or purplish tint ; the fluid which they contain is generally not very thick, and is of a dark and sanguinolent ap- pearance ; they terminate by the formation of a dark and adherent crust, by absorption of the contained fluid and a kind of desquamation, or by a bloody excoriation, or true ulceration, which are followed by a deep stain upon the skin or a true cicatrix. Diagnosis. — Ecthyma is more likely to be confounded with rupia than with any other disease. The pustular character of ecthyma from the very beginning, will, however, almost always enable us to distinguish it from the broad and distended bullae of rupia, filled with seropurulent fluid ; and the difference between the two becomes still more marked, when we recollect the hard and inflamed bases on which the pustules of ecthyma rest, and the shapeless crusts and superficial excoriations of that disease, I PROGNOSIS — TREATMENT. 935 instead of the projecting, rugous, and imbricated scabs, and dee]> ulcer- ations of rupia. Ecthyma is not at all likely to be mistaken for the small and numerous pustules of impetii^o, or the umbilicated ones of small-pox. Prognosis. — Ecthyma is never a dangerous disease in its of many of them. The hlofxl dries and forms so many .'•mall black crusts crowning the summitfl of the papules, a peculiarity which constitutes one of the most di.^tinctive features of the disease. The papules terminate by absorption or by a slight desquamation. After the disease has lasted some time, the skin acr|uire8, partiv from the constant and violent scratching, a peculiar thickened and harsh character, which \a most marked on the lower extremities. The duration of the eruption is very uncertain. In acute ca-es, when properly treated, it may end in a few weeks, though it often, and indeed more generally, la-sts for several months or years, or even through life. DiArjxosis. — The only di-^jases with which prurigo is likely to be con- founded are strophulus or lichen. It may be distinguished, however, gen- 940 SQUAMA. erally with ease, by the facts that the papules of prurigo are larger, less numerous, and more extended, than those of strophulus or lichen ; that in the latter diseases the papules are never crowned by the small black crusts of prurigo, and they are never attended with the same violent itching as the former. From pruritus, it is to be distinguished by the absence in the former af- fection of papules, as well as of thickening and roughness of the skin. The regions affected in pruritus are also quite different from those most frequently involved in prurigo. Prognosis. — Prurigo is never perhaps a dangerous disease, though usu- ally a very troublesome one from the severe irritation which attends it, from its not unfrequently obstinate resistance to treatment, and its disposi- tion to relapse. According to Duhring, it is perhaps curable in children, but scarcely so when it has lasted until adult life. Treatment. — The internal treatment of prurigo in children should con- sist in the use of sulphur, given alone or in combination with magnesia, of demulcent drinks, of mild laxatives when there is constipation, and of such remedies as may be rendered necessary by any disordered state of the di- gestive function. The diet must be carefully regulated. It ought to be nourishing and sustaining, but at the same time light and easy of diges- tion. In obstinate cases, recourse must be had to the administration of arsenic, cod-liver oil, iron, and other powerful nutrient and alterative remedies. In addition to the internal treatment, simple warm-water baths, or emollient baths of flaxseed, bran, slippery-elm, or marsh-mallow, should be made use of in the early stage of the disorder. At a later period, alkaline baths, containing from three to eight ounces of carbonate of potash to each bath, according to the age, are recommended by Cazenave and Schedel. To allay the cutaneous irritation, mild ointments are often found useful. Billard employed with success, in a child six months old, inunctions with the oil of sweet almonds. Soaps or lotions, containing juniper tar or car- bolic acid, are excellent anti-pruriginous applications ; and relief will fre- quently be obtained from the application of a dilute solution of chlorin- ated soda. When the case is obstinate, resisting emollient and alkaline baths, sulphurous baths must be made use of. CHAPTER YI. SQUAM-E. The various forms of scaly disease, psoriasis, pityriasis, and ichthyosis, are so much more rare in children, and therefore so much less important practically, than the various eruptions we have thus far considered, that we deem it unnecessary, in a work limited in extent like this, to attempt a detailed account of them. We shall make merely a few observations on TREATMENT. 041 each, referring the reader, should he desire further information, to the special treatises upon diseases of the skin. Psoriasis is, in our experience, a very rare disease in chihhcu, though we have met with a few cases of it. It is met with in two forms, the psorians diffusa and guttata, of which the former is said to uc the more frequent. Pi^oriasis diffum appears in the form of patches of rather large, but very- variable size, of irrcgular shajx^, and covered with thin scales of dried epi- dermis, which are constantly falling off and being renewed. When the scjiles are removed, the surface of the eruptive patch is seen to be of a dull red color, somewhat rough, and raised above the surrounding skin. In severe cases, as the disease occasionally occurs in young children, the skin presents numerous chaps and fissures, and is often excoriated more or less by the dress, or by the neighboring surfaces. From the excoriations is sometimes poured out an unhealthy secretion, which hardens and forms scabs. Psoriasis guttata appears in small, reddish, and rounded elevations, more elevated at the centre than the circumference, and of different sizes ; from that of the head of a pin, as mentioned by Billard, to that of a large pea, as seen by ourselves, and which become covered very soon after their ap- pearance with fine, minute and whitish scales. A third variety, psoriasis inveterata, a severe, obstinate, and inveterate disease, as met with in adults, is very rare, if not unknown, in cliihh'cn. Treatment. — In recent cases, psoriasis is to be treated with simple warm-water or emollient baths, and with mild liniments or ointments, such as oil of sweet almonds, glycerin alone, or glycerin mixed with cold cream or simple cerate. In more chronic cases, the local treatment is the only one which promises any certain success. The particular mode of local treatment which we have found most successful is that recommended by Hebra, a short account of which will be found in our remarks on the treat- ment of chronic eczema. The carbolic acid soap, dilute citrine ointment, or weak solutions of caustic potash when there is much infiltration of the skin, are all service- able applications in the chronic form of the disease. In all cases the digestive function must be carefully attended to, any disorder that it may present being removed as rapidly and effectually as possible by the proper remedies. In cases where the eruption persists despite the use of local applications and attention to the digestive functions, the child should Ik* placed upon the use of the ferro-arsenical mixture. Pityriasis is a slight scaly disease, which may attack the head only, or extend to other parts of the bo*h, furfuracoous wales, which form a thin or thicker covering for the scalp, in propd., p. 614), that the structures found in these cases, are due to a peculiar "granular" degeneration of the normal elements of the part, owing to whiili they lose their power of developing into healthy epithelial structures, but retain their power of proliferation, appears to us opposed to all sound reason and accu- rate observation. In addition, however, to the evidence furnished by the chemical and microscopical examination of the growths in question, their fungous na- ture is shown by the facts that they can be cultivated after removal from the body, and that the diseases with which they are associated are conta- gious and can be commuuicateti by inoculation to healthy j^ersons, or even to some of the lower animals. hi searching for these growths, the scrapings from the surface of the diseiised spot, or the hairs which traverse it, may be taken for examina- tion ; but before subjecting them to microscopic study, they should be treated with dilute acetic acid to render them more translucent, and sub- sequently with a little sulphuric ether to remove the fatty granules which often obscure the fungus. The structures which the fungi affect are the hairs with their follicles, and the epidermis. The special alterations which the hairs undergo will be detailed under the head of the ditlerent diseases ; the fungus gains entrance to the folli- cle, penetrates the bulb of the hair, insinuates itself between its longi- tudinal fibres, thus splitting it up and rendering it brittle. In the epi- dermis the fungus is said at first usually to ap|>ear beneath the superficial layer, until, by its development, it causes such irritation as leads to the exfoliation of this layer, when it reaches the surface and then multiplies rapidly. The objection which has been based upon this fact, that the growth can- not be a parasitic one, does not seem to us of much force, since it is ea.**y to account for the introduction of such extremely minute biKlies as the spores of these fungi beneath the superficial layer of tho cuticle. Admitting then the presence of these parasitic growths, a more interest- ing question arises in regard to the relation which exists between them and the diseases with which they are associated ; whether, that is, they are es- sential to, and actually the causes of the respective di.<(eases, or are merely accidental, and are present only l>ecau»c they find a suitable nidus for de- velopment in the diseased skin. Opinions are at variance upon this (pies- tion, but there are at least two considerations which render it probable that the fungi are essential rather than accidental pnKluctionj*. The fin»t of these is, that they are prcj*ent in the early stages of the diM.'ase, U-fore any considerable inflammatory change has occurred, and that in pnijnirtion as suppuration ensues they diminish in abundance. And, secondly, that, 944 PARASITIC SKIN DISEASES. as already stated, they are capable of transmission to perfectly healthy persons by inoculation. There can, however, be no doubt that the development of the fungus, under ordinary circumstances, is greatly favored by the constitutional con- dition of the patient and the state of the cutaneous surface. Thus it is especially in children of a delicate or strumous constitution, that these various diseases are most frequently met with ; and when, in addition, personal filthiness with inattention to properly combing and cleansing the hair, and changing the clothing, are combined, the spores find the most favorable conditions possible for their rapid development. There remains the further question, upon which authorities are still di- vided, whether there are various fungi concerned in the production of these diseases, or whether the apparently different species are merely different stages of a single fungus. For the sake of greater ease of reference and comparison, we will here give a brief description of their characteristic appearances. Fungus of Tinea Favosa. — In the earliest stage of development of the favus crust, it is still covered by the superficial layer of epidermis ; but later, when this is ruptured, it presents an envelope of a sulphur-yellow color, which on microscopic examination shows a homogeneous or finely granular substance. The interior, of a pale white color, is the true favus matter, and consists of the sporules, thalli, and mycelia of a fungus named the achorion Schoenleinii, in honor of Schoenlein, who first fully de- scribed it. The sporules are of a rounded, or more frequently of an oval form, and have well-marked edges, and a homogeneous and slightly opalescent in- terior. Their average diameter is about uoV^th of an inch. Many of these sporules are seen to be grouped together, while some are more elongated and present a contraction in the middle; others are nearly triangular in form, with rounded angles ; others, yet more elongated, are marked with several contortions. Some sporules, completely formed, seem to have a double envelopment membrane, and others present in their in- teriors something like a nucleus. There are also present numerous diaphragmated tubes, formed by the development and confluence of the sporules, which are either simple or present ramifying branches. These tubes vary in diameter from loVoth to Tshoth of an inch, and are either empty or have granular contents. Amongst the sporules and mycelia, especially towards the circumference of the cups, may be seen a considerable number of molecular granules, which are probably imperfectly developed sporules. Fungus of Tinea Tricophytina. — The next parasite, the tricophyton, is that which produces tinea tonsurans, tinea circinata, and tinea sycosis. The microscopic characteristics of this parasite, as first described by Malrasten, in 1845, and since confirmed by numerous observers, are very numerous rounded or oval sporules, about ToVuth of an inch in diameter, which. are isolated or united together into chains, and a comparatively small number of mycelial threads. Again, the parasite, which by many observers is believed to cause tinea FUNGUS OF FAVUS. 045 versicolor, is the micrOsporo7i furfur, discovered by Eichstiidt, iu 1846. This fuugus presents numerous rounded spores, and long tubes. The spores are about 3^0*0 o^^^ '"^*^^ '" diameter, and are tVeiiuently collected to- gether in large clusters, like bunches of grapes (Anderson). Some of the tubes observed are simple, and others jointed. In regard to the parasitic nature of alopecia areata, there is great doubt, and even so warm a supporter of the fungous origin of the other diseases we have mentioned as Dr. Anderson, does not allow it. Numerous observations have been made which go to show the exist- ence of a very wide range of variation as regards form in these fungi ; and have led some observers to assert not only the identity of the^e particular forms, but indeed to refer all varieties of epiphytic fungi to some one cen- tral type. The evidence upon which this view rests, mainly drawn from the results obtained from germination of the various fungi, and from the study of their transitional forms, cannot at present be considered conclusive ; and further investigation of the question is demanded. It is, however, thought by some high authorities, that no doubt can be entertained in regard to the identity at least of the parasites which produce the various forms of tinea, including the achorion of favus, the microsporon furfur of tinea versicolor, and the tricophytou of the various varieties of ringworm. The most complete exposition of the arguments upon which this view is based, will be found in Dr. Tilbury Fox's admirable treatise on skin diseases of parasitic origin (London, 18G3;. On the other hand, some eminent dtermatologists believe that the fungi which produce these diseases, are essentially distinct. The arguments upon which they base this opinion may be briefly expressed as follows, in the language of Dr. Anderson (loc. cit, p. 170). That in all cases of successful inoculation with the achorion, tricophytou, and microsporon furfur, the same parasitic disease has been j)roduced as that from which the parasite was taken. That of the innumerable cases occurring in the human subject, illustrative of the contagious nature of favus, tinea tonsurans, and tinea versicolor, there is no authentic case in which one of these diseases gave rise to one of the others. That the difference in the appearance of the eruptions, when fully de- veloped, is so very striking as to lead to the belief that they are produced by separate parasites. That there is no authentic record of the transition of one of these dis- eases into one of the others. That the raicrosa>pic differences between the throf ^M-.r; .r. ir, many. cases 8ufl[icient to base a correct diagnosis upon. That of the numerous instances* on record of the traii.-ini.%-»i(»n of tinea favosa, and tinea tricophytina, from the lower animals by contagion or inoculation, favus has always given rise to favus, and tinea tricophytina to tinea tricophytina. We regard then the parasitic nature of these affections as undoubted, but more extended observation is Deoeasary before the relations of their respective fungi can be determined. 60 946 TINEA FAVOSA OR FAVUS. ARTICLE I. TINEA FAVOSA OR FAVUS. Favus is a parasitic disease of the scalp, long confounded by different writers with other and very dissimilar affections of that part. In conse- quence of this confusion it has received a great variety of names, of which the most generally known are porrigo and tinea. In adopting the above title, we follow the example of Erasmus Wilson and other recent author- ities, amongst the English, and of MM. Rilliet and Barthez, Gibert and Rayer, amongst the French. Definition ; Synonyms ; Varieties ; Frequency. — Favus is a spe- cific contagious eruption of the scalp, characterized by inflammation of the hair-follicles dependent upon the presence of a peculiar fungus, the achorion Schoenleinii. It is distinguished at first by small yellow pustules, countersunk in the skin ; these are soon converted into yellow cuplike crusts, which adhere often for a very long period. It usually causes per- manent loss of hair at the affected part. The disease is described by most of the former English writers under the title of porrigo, but as several other eruptions have been included under the same name, we think it best to follow the example of Mr. E. Wilson, and call it favus. By MM. Biett and Cazenave it is designated, after Willan, porrigo favosa and porrigo scutulata. MM. Rayer and Gibert, as above mentioned, give it the name of favus. There are two varieties of favus, the favus dispersus, the porrigo favosa of most writers, and the favus confertus, the porrigo scutulata of many observers. The disease is much less frequent than eczema of the scalp, but is nevertheless constantly met with amongst the crowded populations of Europe. In this country it is more rare, and amongst the middle and upper classes, at least of this city, is almost unknown, since we have never met with a case of it in our own private practice, though we have occasionally seen it in the hospitals here. Causes. — The only well-ascertained exciting cause of favus is generally thought to be contagion, a quality of the disease acknowledged by most observers, though denied by Mr. E. Wilson, who considers its cause a debility of nutritive vitality, allied with struma. It may be propagated ,by direct contact of the diseased with a healthy skin, or by means of combs, brushes, or other articles of the toilet ; and it is also probable that the spores may be carried by the atmosphere so as to communicate it by infection. It has been frequently propagated by direct inoculation, — by Remak, Bennett, Hebra, Bazin, Gruby, Kobner, etc. Favus is also said to be met with in the lower animals, and especially amongst mice and cats ; and cases are on record which render it highly probable that it may be communicated from them to the human subject. It occurs at all seasons, attacks either sex indifferently, and is met with I SYMPTOMS. 947 at all ages, but is especially frequent in. children and young people, ami, indeed, when met with in adult-j, is usually found to have comnienct^l in early life, and to have j^rjiistetl for years. Certain conditions act as pre- disposing catises in its production, and may alone, perhaps, give rise to its development. These conditions are unhealthy hygienic intivences, as unwholesome and insufficient food, poverty, tilth, and the living in low, damp, and ill-ventilated dwellings. It is met with most frequently in persons of feeble, lymphatic, and especially in those of scrofulous consti- tution, though, be it remarked, it occui*s also in persons of strong and vigorous health. Among those who believe in its truly parasitic nature, there are some, as Devergie, who believe that it may be spontaneously generated, the parasite originating in the body of the affected person. One of the facts upon which the theory is based is the asserted occasional cure of the dis- ease by internal remedies, but we believe that these can only relieve it by fortifying the system, and so removing the conditions which favored the development of the parasite. Symptoms. — Favis Disi»ersvs, or PoRRUiO Favosa. — This variety begins with very small pustules of a peculiar straw-yellow color, which exhibit from the first the special character of not being raised at all above the level of the skin. Directly after their formation, the yellowish matter which they contain begins to concrete, and there can be i)erccived tVom this early period a central depression in the crusts, which becomes more marked as these augment in size, so that at the end of five or six days it is perfectly evident. Each pustule, and of course each crust is, as a gen- eral rule, traversed by a hair. The favous crust is a very remarkable feature of the disease, and is in itself a pathognomonic symptom. As it increases in size, which it does gradually until it reaches in some instances a diameter of half an inch, the central depression above spoken of he- comes more and more distinct, and the crust a.ssumes, from this circum- stance, the shape of a cup with an inverted edge. Their structure is made up of a series of concentric layers, or layers or rings, compactly arranged one upon the other. This cuplike form with the concentric arrangement of lavers, the peculiar straw-yellow color, and the fact that each crust is usually pierced by a hair, are the distingui.>*hing characters of the di.«ease. The pustules are usually i.solated at first, though they may be arranged in groups of irregular size. When numerous, the cruj*ts, by their gradual enlargement, touch at their edges, and blend into larger or smaller patches of irregular shajx;, but still presenting many little depressions corrcsjwnd- ing to the first-formed pustules. In rare cases, the diK-ase is so extensive as to form a kind of mask covering the whole scalp. When the di.«ease is not interfered with by treatment, the cruets rf main adherent for a long time, — for months or even years ; they become al.-o paler in color than they were at first, and so dry and pulverulent, as to break very readily when rubbed or touched. They U'come, moreover, thicker and more ma-ssive, and lose their first regular cuplike form, from the disappearance of their depressions, and from the irregular and uneven shape given to their edges and surfaces, by the breaking which they 948 TINEA FAVOSA OR FAVUS. undergo. When the case runs on in this way, the head exhales a most unpleasant odor, which has been compared to that of mice or the urine of a cat ; McCall Anderson has, however, noticed a very similar odor in cases of eczema irapetiginoides of the scalp. In some instances, where the disease is grossly neglected amongst the very poor, pediculi form in abun- dance amidst the crusts, and add to the disgusting appearance of the dis- order. When the crusts have been removed by any means, the surface of the Bcalp is seen to be red, moist, and to present slight erosions or even ulcer- ations. The crusts are reproduced only by the eruption of new pustules. An invariable and unfortunate sequel to the favous disease is a more or less extensive loss of the hair. The hairs become loose from a very early period of the disease, and can be pulled out with great ease. As the case goes on they fall out, and the scalp is left smooth, shining, uneven, and deprived of hair. On these spots the hair seldom grows again, and if it does, it comes out thin, woolly, and with every appearance of weakness and unhealthfulness. Though the usual and favorite seat of favus is the scalp, it is met with occasionally on the forehead, temples, chin, and eyebrows, and, in still rarer instances, on the shoulders, elbows, forearms, on the upper and outer parts of the legs and thighs, on the scrotum, and even on the nails. The nails are also liable to be invaded, probably in consequence of the parasite gaining entrance during the act of scratching. The affected nails become thickened, yellowish and opaque, and brittle. Even in such cases, how- ever, it has frequently existed first on the scalp, and extended thence to the other parts, though it may sometimes begin upon the trunk or limbs in consequence of a direct application to them of the contagious element. Favus Confertus, or Porrigo Scutulata. — In this variety of favus the pustules are arranged so as to form circles or rings upon the forehead or scalp, instead of being dispersed irregularly over the scalp, as in the preceding variety. The disease begins with red, circular patches, attended with a good deal of itching, upon which, after a short time, appear small yellow pustules, that seem to be sunken in the skin. The pustules are more numerous on the circumference than at the centre of the red patch or disk ; or the latter increases in size by the extension of the disease to the follicles just beyond its outer edge. The pustules are exactly like those of favus dispersus, except that their yellow color is of a lighter tint. They desiccate very rapidly, and form crusts which are very thin at first, never very thick, and of an irregular shape. When the disks are very numerous, either originally, or by propagation of the disease from part to part, they meet at their borders, blend together, and give to the scalp the appearance of an extensive and irregular crust, presenting at its circumference curved lines, marking the segments of circles of which the whole is composed. The crust has sometimes covered the whole scalp, excepting merely a small border at its circumference, where may still exist some scanty remains of the hair. When the crusts are removed, the surface beneath is found to be red and tumid, according to Wilson, and to present numerous yellow points. I DIAGNOSIS. 049 Cazenave and Schedel state that when the crusts fall, they leave exposed a large, imeveu, furturaeeous patch, upi>5. — This disease is easily distinguished fmm other eruptions of the scalp. The appearances it presents when fully (loveK>]>cd, are utterly unlike those of favus or eczema i?n pet igi nodes capitis. In favus, the pecu- liar cup-shaped crusts and the presence of the spores of the achorion, are sufficient to prevent mistakes; while in eczema, the eruption is «jero-pustu- lar, with the formation of yellowish or brownish yellow crusts ; the patches are not circular, the hairs are healthy, the itchinor is extreme, and finally the disease is not contagious; in all of which particulars it differs entirely from the eruption of ringworm. Pityriasis capitis does not occur in circular })atches, but affects the whole scalp ; it is not parasitic nor contagious, and does not lead to so much al- teration of the hairs. Occasionally tinea tonsurans, cither from ilie irritation of scratching, or some other cause, may be associated with eczema impetiginodes, which to a great extent obscures the former disease, though a careful search will usually detect some of the characteristic broken stumps of hairs, loaded with the parasitic growth. PRCKiNOSi?. — Ringworm of the scalp is entirely devoid of danger, but is an exceedingly troublesome disease, as it is apt to spread to other chil- dren, and is often very difficult of cure. Its duration is very indefinite, and it not rarely leads to patches of permanent baldness. Tinea circinata, as we have already said, fretpiently occurs in con- nection with tinea tonsurans, appearing on the neck or face ; though it occurs also as an independent disease on any part of the body, and in pa- tients of every age. It begins as a little rose-colored, slightly elevated spot, which soon be- comes the seat of slight furfuraceous desquamation ; and extends circum- ferentially, healing in the centre, until it forms a large slightly elevated erythematous ring, inclosing a portion of sound skin. In other cases, minute vesicles form on the reddened inflamed ring. They follow the usual course of development, being at first transparent, then turbid, and finally drying into small thin scales. The size of the patch varies greatly, being in some instances small, not larger than a shilling, and in others presenting a diameter of two or three inches. When small, the redness covers the whole of the patch, but is much fainter in the centre than at the circumference; when large, the centre regains the natural color of the skin. Usually the ring is exactly circular, but at times it assumes an oval shape. If any hairs have been growing on the afltcted spot, they become brittle and changed, as before described. There are usually several such circles present, and in some cases they are formed in great numbers. The only symptoms accompanying the eruption are slight pricking, smarting, and itching in the part. Occasionally the parasitic growth invades the nails, which then become opaque, whitish, thickened and brittle. DiAr;NOSiH. — There are but few diseases with which there is any danger of confounding tinea circinata. It is distinpii.-hed from erj'thema circina- tum bv ti>.. irr^ater elevation of the marginal ring, by the presence of the 956 TINEA. parasite, and by its contagious nature ; and the two last peculiarities serve to distinguish it from psoriasis circinata. According to McCall Anderson, and some other dermatologists, herpes iris is merely a form of this affection. Treatment. — The cases of tinea tonsurans that have come under our charge, have proved in many instances very rebellious to treatment. Strict attention should always be paid to cleanliness and hygienic rules ; and, if the disease be associated with any impairment of the constitution, cod-liver oil, iron, in the form of the syrup of the iodide in syrup of sarsa- parilla, arsenic, and bitter tonics, should be administered. The local treatment is, however, the most essential. Where the disease occurs on a part covered with hair, epilation is advised by some authori- ties, and it would in all probability facilitate and hasten the cure. Among the local applications which have proved most useful to us have been sulphuro-alkaline lotions, composed of 5j of subcarbonate of potash and 5ij of sulphur, to a pint of water, applied by washing with a sponge several times a day ; strong solutions of sulphite of soda ; and an ointment consisting of 5j of muriate of ammonia, mixed in an ounce of sulphur ointment, applied first at night by inunction, and after a time on rags. Alkaline remedies have also been much used by other observers, who recommend washing the scalp every morning with a lotion composed of gr. XXX or xl of carbonate of potassa or borax to a pint of water, and ap- plying in the evening an ointment containing ^'} of tannic acid to ^j of lard. Much more stimulating applications are, however, highly recommended, and often prove very serviceable. Thus Mr. Wilson advises a single ap- plication of the acetum cantharidis, or the stronger acetic acid; and Devergie recommends a solution of nitrate of silver, 5j to f^j of water. Various mercurial applications are also advised, as solutions of corrosive sublimate, the citrine ointment, or the following, recommended by Jenner : R. — Hydrargyri Ammonio-Chloridi, . . . gr. xx. Ung. Sulphuris, ^iv. Tarry applications may also be employed in obstinate cases, in the form of lotions, ointments, or soaps, containing tar, or oil of cade. Nayler speaks highly of a plan used by Mr. Coster, who saturates the part with the following mixture : R. — lodini, ^^^ij. 01. Picis, ffj. This solution is to be rubbed in firmly with a piece of sponge on the end of a piece of wood or whalebone. It is allowed to dry on the part, and left until the cuticle and the black crust separate at the end of a week or ten days. In cases where many patches are present over the body, it is advisable to employ mercurial or sulphur vapor baths. It must not, however, be forgotten that these varieties of tinea are among CASES. 957 the most obstinate disorders to which children are subject. The most faithful trial may be made with the remedies recommended above, for a long time, without success, and it is often necessary to persevere in their use for months; conjoining the treatment with a change of diet, and, when possible, with a change of residence, before the affection will be entirely and permanently cured. Cases. — The following cases may be taken as types of the aggravated form of tinea, after it has persisted a long time and become complicated "with secondary eruptions of eczema or pityriasis. It will be noticed that in the following records, all of the patients are stated to have been mark- edly scrofulous ; but this circumstauce must not have too much importance attached to it, since in the Home where these cases occurred, almost every one of the children presented unquestionable marks of the strumous dia- thesis. There can be no doubt, however, that tins condition of constitu- tion strongly favored the development of the disease, rendered it more severe and obstinate, and also favored the occurrence of the secondary in- flammatory eruptions. George T., aet. five, scrofulous, admitted to the Home in \SC>i, with bloedini; piles. Tinea tonsurans appeared two months after admission, and persisted with various fluctuations for eighteen months, when it became com}ilicated with eczema impetiginodes. Applications of tar and corrosive sublimate have been chiefly re- lied on. Nov. 3Qtb, 1866. Scalp covered with grayish-yellow crusts, one-fourth inch thick, in places running together or forming isolated lumps. A f«^w spots of tinea circinata on face and neck. The scalp is reddish, and, there is very little dis- charge from it. The hairs are sparse and broken. The cervical glands are much enlarged on both sides. On removing the crusts and examining the base, numerous exudation corpuscles and some spores of tricophyton were found; the epithelium not very granular. Poulticed to remove the crusts. Ordered iodide of iron and potassium inter- nally. December 4lh. Scalp quite clean from crusts, but remains reddish, with here and there bald patches. Numerous spores of tricophyton found in the hairs and among the epidermic cells. Solution of sod» sulphis (5J to Oss. water), applied morning and evening, and kept on during the whole time by means of folds of linen saturated in the solution, and covered with an oil-silk cap. December 16th. Much improved. Scalp cleaner, and less red. Some flat, thin, whitish scales over surface. Hairs more free from tricophyton, but numerous spores can still be seen by scraping moist surface beneath the thin crusts. Treatment continued, with ultiitiate success. William L., let 5; herediUry tendency to tuberculosis; scrofulous; cervical glands enlarged on both sides; admitted in 1865, and has had tinea ever since, many forms of treatment having been tried, but none with more than tcmpornry ■access. November 30tb, 1866. The scalp it reddened and wax-like from infiltration, with patches of baldness. In places where the eruption ii oldest it is covered with whitish scales ; elsewhere, there are i»cattered or confluent grayish-yellow or yellow cru.*ts. Discharge of pale, thin, fetid pus. On examining the surface beneath the crust*, numerous pus-cells and spores of tricophyton, often aggregated Ujgf-ther, arc found. The hairs have lof«t their normaf appearance entirely, are bent, and where they emerge fi*pm the scalp, the 958 ALOPECIA AREATA. shaft is swollen, with bulging outline. The shafts are covered with spores of tri- cophyton, and their longitudinal fibres separated by collections of the fungus. •Some of the -bulbs remain healthy, others are broken and apparently converted into masses of fungous spores. Ordered poultices to remove crusts ; iodide of iron and potassium internally. Decemher 4th. Scalp clean, with exception of minute white scales; shows bald glazed patches, with light, short, thin hairs. Ordered same application of sul- phite of soda as used in previous case. December loth. Immensely improved ; the large bald patches still covered with minute shining white scales, but few tricophj'ta to be seen. Charles L., £et. 4, admitted in May, 1866; hereditary tendency to tuberculosis; cervical glands slightly enlarged. Tinea soon appeared on the face and scalp, and in early part of November, thin flat grayish-yellow crusts formed over vertex, the rest of the scalp being covered with minute whitish scales. I^ovember 30th, 1866. Ordered poultices to remove crusts; iodide of iron and potassium internally. December 4th. Scalp comparatively clean. Patches of baldness, especially over parietal protuberances, with straggling, short, light-colored hairs. Abundant spores of tricophyton found. The hair-shafts much involved, collections of the parasite existing between the longitudinal fibres. The bulbs are also diseased, and seem to have become afl:ected just below the exit of the hair ; the bulb first becom- ing swollen at this point and then its sheath having become destroyed, so that the fungus forms a bed surrounding the shaft. Ordered same application of solution of sulphite of soda. December 16th. Yery much improved ; scalp smooth and clean, excepting above the ears, where there is on each side a collection of thin yellowish crusts. The hairs passing through these had numerous pus-cells adherent to their shafts, but the hair- bulbs seemed healthy, and no spores of tricophyton could be found on any of them. ARTICLE III. ALOPECIA AREATA. This affection, which is also known by the names of area and tinea decalvaus, is characterized by the loss of hair in circumscribed patches of round or oval shape. It is by no means a rare disease, and is much more common in children than in adults ; thus of 42 cases cited by Hutch- inson, 28 were under fifteen, 14 above that age. Cause. — There is still much doubt as to the essential cause and nature of alopecia areata, although it appears to us that the view which attributes it to a perversion or suspension of innervation is the correct one. Gruby is said to have discovered in 1843 a fungus in it, which has been called the microsporon Audouini, and some dermatologists of high au- thority accept the view of its parasitic nature. It cannot, however, be said to be demonstrated, since the parasite is very rarely found ; so that Andei*son, who has made numerous microscopic examinations, has never succeeded in detecting it. SYMPTOMS — DIAGNOSIS — PROGNOSIS — TREATMENT. 959 "Wilson, Duhring, and many others, consider it as due to suspended in- nervation, as a kind of paresis. The disease appears to be, at least in some instances, propagated by contagion ; though it certainly possesses this property to a much less degree than either of the forms of ringworm. Symptoms. — The disease is limited to the scalp in children ; thougli in adults it may attack any hairy part. In some cases, the first intimation of the existence of the disease is the sudden discovery of a bald spot, but in others, though less frequently, there is slight itching, with redness and branny desquamation of the affected spot^. The bull)s of the haii-s then atrophy, and become tapering instead of being rounded and club-shaped ; the hairs themselves become dry, lustre- less, and brittle, with a fibrous fracture, and rapidly fall out, leaving bald patches. These patches vary in size from one-half inch to an inch or even more in diameter, and there may be but a single one present, or they may be numerous, in whicl> case they often coalesce, forming large patches of irregular shape ; when the patches are single they usually assume a round or oval form. The denuded portion of scalp is peculiar in appearance, being very white and polished, and thinner than the surrounding healthy scalp; the sensi- bility of the ati'ected surface is also frequently impaired. Diagnosis. — There can be no difficulty in recognizing the fully devel- oped disease, excepting in the comparatively rare cases when it is combined with other skin diseases, as eczema or pityriasis. Pro<^;nosis. — The only danger attendant upon alopecia areata is that of deformity, which is, in some cases, very great, depending of course upon the extent of the disease and the stage at which it is brought under treat- ment. If the patches are small, the scalp not materially atrophied, and the orifices of the hair-follicles still visible on the bald patches, there is good reason to hope that steady persistence in treatment will effect a cure. In the majority of instances, it may be said that recovery occurs after a length of time varying from .several weeks to several months. Treatment. — Those who regard this as a parasitic affection, advise the ablation of the hairs immediately surrounding the patch, and the applica- tion of s<»me of the stimulating parasiticide- •■....<.i,hu ended in ')'<• 'irflrl.. CD tinea. The majority of authors, however, content tht ninrlves with th» ajiplica- tion merely of such stimulating lotions and ointments as will incrca.^c the nutrition of the affected gpot«, and favor the renewed growth of hair. Among the ointments which are most highly recommended are those con- taining the red io. Hillier recommends, as the treatment he has found most useful, the ap- plication at long intervals of acetum cautharidis to the bald patches ; paint- ing them every other day with tincture of ir»diiie, washing the head twice a wct^k with soap and cold water, and applying a wash (consisting of one 960 SCLEREMA. piDt of rum, one ounce of tinct. cantharidis, one-half ounce of spirit, am- monise aroraat., and ten ounces of water) to the parts of the head which are not bald, twice a week. The effect of this local treatment will be much increased by the internal administration of arsenic and iron. Alcohol, carbolic acid, ammonia, and capsicum have also all been highly- recommended as local applications in the treatment of this affection; they should of course be employed in a sufficiently dilute form. SECTION 11. AETICLE I. SCLEREMA. Definition; Synonyms; Cause; Frequency. — This peculiar affec- tion, characterized by induration of the skin and subcutaneous tissue, with or without oedema, has been described by numerous writers, almost each one of whom has given a distinct name and theory for the disease. Among these names the most appropriate are sclerema, scleriasis, sclero- derma, induration of the cellular tissue, or chorionitis. It is an affection not altogether peculiar to infants, though it is rare to find it well developed after the first few months of life. There are, how- ever, a sufficient number of cases in adults on record to establish the fact of its occasional occurrence at all ages. It must be a very rare disease in this country, even among infants, and especially in private practice, as we have met with but three well-marked cases in adults, and but one instance occurring in childhood, which was the case in which imperfect induration of the skin was developed in connection with atelectasis pul- monum, to which allusion is made in our article upon the latter affection. In the large foundling hospitals in Europe, however, where so many causes exist to depress the vitality of the infants, it is of very frequent occurrence. Under such circumstances, moreover, it generally develops itself within the first twelve or fourteen days after birth. The most varied causes were formerly assigned for this disease, before the researches of Bailly and Legend re appeared to point out sclerema as one of the results of imperfect expansion of the lungs. As we have already remarked, it is seldom observed among the children of the upper classes of society, so that all those conditions which depress the strength of the child, as insufficient or unhealthy nourishment, imperfect clothing, cold, especially when associated with moisture, may be considered as the predis- posing causes of sclerema. The inffuence of dampness and cold in develop- ing this affection is shown by the fact, deduced from numerous statistics, that twice as many children are attacked during the cold and wet months of SYMPTOMS. 9()1 the year as at other times, although there are cases recorded as occurring iu the hottest months. Authors still ditler in regard to the relation hetween atelectasis and sclerema. We^t' accepts the results of the researches of Bailly and Le- gendre, and considers it a result of the imperfect expansion of the lungs. Bouchut,- on the other hand, regards the changes found in the lungs as the result rather than the cause of the induration of the skin. Letourneau' agrees with West in regarding sclerema as a condition depending primarily on congenital weakness, imperfect expansion of the lungs and defective hiematosis. According to his view it is a slow asphyxia, the hodv becominir irraduallv cooled down and the child remainin Diseases of Children (8d Amer ed.), p. 288. • Di»eii»e« of Infancy ^Bird's tron« ). • Letourneau, Sclerema and (Edema. Pari*, 1858 (Can»Ut. Jalirb., iv, 460). 61 962 SCLEREMA. attended with great emaciation, as we find in Elsasser's ^ cases, where the average loss of weight was three-fourths of a pound, the extremes being six ounces and two pounds. The respirations are imperfect, and, after a short time, cough makes its appearance and continues throughout the case, indicating the occurrence of either pneumonia or collapse of the lungs, which are by far the most frequent complications, even if the state of atelectasis be not regarded as an efficient cause of sclerema. The disease, however, is not always so general and severe as above described ; occasionally it occurs in limited portions of the body, and without any very alarming symptoms. In later life the disease is more frequently thus limited to small portions of the body ; the symptoms follow a more chronic course, and are somewhat amenable to treatment. Eilliet and Barthez ^ describe an acute and chronic form, and mention the following symptoms as distinguishing the disease in the adult : the severe epigastric pain associated with violent palpitations, the less acute progress of the case, and the more frequent implication of the serous membranes. In one well-marked case, occurring at the age of thirty-five years, which one of us had the opportunity of observing during its entire course, these symptoms were very prominent. Peognosis. — In infants, when the induration is at all general, the dis- ease almost invariably terminates fatally in from two to six days. Under favorable circumstances, however, and when the induration is limited, reso- lution may occur, and the case terminate favorably ; though it requires from fifteen days to a month to effect the cure. The fatal result is either caused by the gradual exhaustion of the vital powers, or by the supervention of one of the complications already men- tioned, by far the most usual of which are lesions of the lungs. In later life, when the disease tends to recovery, a long time may be consumed before the induration completely disappears. Eilliet and Bar- thez report a case, occurring in a girl aged eleven years, which lasted two years, although it was at no time very general or accompanied by very severe symptoms. Of 53 cases reported by Elsasser, all but 4 proved fatal, either from the sclerema itself, or from some incidental disease. Diagnosis. — The absence of any lesion of the internal organs, together with the perfectly characteristic appearances of the induration, render an error of diagnosis almost impossible. Anatomical Appearances. — The induration of the surface persists after death, and on incising the part, a turbid fluid, resembling that of anasarca, often flows out. The subcutaneous tissue is also indurated, and the fat is found in the form of solid granules. This layer, which varies from one-half a line to three lines in thickness, is sometimes followed by a gelatinous one. The fluid which is contained in the meshes of the tissues has been sub- jected to analysis by several observers, but with conflicting results : Chev- ' Sclerema, Arch. Gen., N. S., t. i, 1853, p. 531. 2 Qp. cit, t. ii, p. 106. ANATOMICAL APPEARANCES. 063 real and Breschet reporting that it contained a plastic matter, spontane- ously coagulable on contact with the air, which they were inclined to re- gard as characteristic of the disejise ; wliilst Billard, on repeating this observation with tliiid derived from an ordinary case of anasarca, found it to possess the same property. This subject, therefore, of much importance in regard to the pathology of sclerema, requires to be more fully investi- gated. Different observers are not agreed as to the condition of the coriuni and subcutaneous tissue. In sclerema adultorum the essential element in the changes of the skin appears to consist in a morbid increase of the connective tissue, associated with a marked development of lymphoid cells, by multi- plication of the cells in the perivascular sheaths of the minute bloodves- sels of the derm and subcutaneous tissue. This condition was pointed out by Rasmussen (translated in Ediu. Med. Journ., vol. xiii, part i, pp. 200 and 318^, and accords with our own investigations. In sclerema in chil- dren, Jenks* and Loschner" have observed marked increase in the connec- tive tissue of the corium ; but this condition has not been found by other observers. The indurated tissue is traversed by numerous vessels, permeable, and for the most part gorged with dark blood. Bouchut believes that the cutaneous capillaries are in great measure obliterated in the indurated parts, and that the oedema which occasionally coexists with sclerema is due to this obliteration ; founding his opinion upon an unsuccessful at- tempt to inject the skin of a limb affected with sclerema, although the injecting fluid freely entered all the deeper tissues. The observatibns of Elsiis^ser, however, render this view doubtful, since in 49 cases, he failed to find this condition. Apart from these morbid changes in the skin and subcutaneous tissue, there is no lesion characteristic of sclerema. In a large number of cases, however, the lungs present some abnormal condition. According to Bou- chut, they are often gorged with blood, and here and there contain patches of lobar pneumonia: condition.-^ wliich he rcLMrds rather as the result than the cause of sclerema. Elsasser found lobular pneumonia pre.-rnt in a tenth of his cases; and in a third of them, portions of the lungs were impermeable to air. We have already stated that Wext, following the researches of Bailly and Le- geodre on atelectasis, believes that sclerema is one of the results of this persistence of the foetal condition of the lung, not differing in it« essential nature from cedema following pulmonary obstruction. The occurrence of undoubted cases of sclerema in the adult, and the frequent absence of atelectasis in well-marked cases of sclerema in infants, appear, however, to render this view untenable. The entire venous system and the cavities of the heart are distended with dark fluid blwd ; but the heart presents no constant condition to which could be attributed the production of the disease. The janndicc » Amer. Journ. of Obflclnc*, M«y, 1871, p 129. « Pragor, Vicrleljahr*cbrifl, 1868. 964 SCLEREMA. which has been mentioned as occasionally existing, is not found to be as- sociated with any abnormal condition of the liver, excepting congestion. Eutero-colitis is a rather frequent complication of sclerema, and has been regarded as influencing its development ; but this view has long since been abandoned. Elsiisser found intestinal lesions and hypersemia of the ab- dominal viscera quite commonly; and in eight of his cases, peritonitis was present. Treatment. — The preventive treatment of sclerema consists in attention to all the hygienic conditions of the young infant. The curative treatment implies the removal of all the causes, and the application of remedies calculated to restore the force of the circulation, and the function of the skin. Warmth stands foremost as a curative measure, and recourse may be had to warm baths or hot vapor-baths, and to frictions with hot oil ; hot sand or bran-bags may be applied to the sur- face, and the temperature of the room should be Carefully regulated. The child should be nourished with breast-milk ; and stimulants, such as wine-whey, should be freely given. Cordial and aromatic draughts are also recommended, which may be formed of any of the diffusible stimu- lants. As there is reason to believe that some relation exists between sclerema and atelectasis pulmonum,we should, in addition, resort to all those means especially adapted to remove this condition, for a full account of which the reader may refer to the article on collapse of the lungs. The same plan of treatment is advisable in cases in adult life. By 'these means we may hope to arrest, and even cure this strange affec- tion, when it has not involved any considerable portion of the surface. CLASS VIII. WORMS IX THE ALIMENTARY CANAL. GENERAL REMARKS. There are five different species of worms found in the alimentary canal. These are the Ascaris lumhricoides, or round-worm ; Ascaris vermicularis, thread-worm, seat-worm, or, as it is popuhirly calle«l, ascarid&s ; Tricoceph- alus dispar, or lonp^ thread-worm ; Taenia solium, and Tivnia mediocanellata, the most common varieties of tape-worm ; and the Bothriocephalus latus, taenia lata, or broad tape-worm. We shall give a short description of each of the intestinal entozoa, in order that they may be readily distinguished, but will treat of the causes, symptoms, and treatment only of the first two. inasmuch as the ticnias very rarely exist during infancy or childhood, and the tricocephalus is much less fre ri-o to symptoms of the same kind as the former. Description. — The Ascaris lumhricoides, or, as it is commonly called, lumhricoides, lumbricus, or round-worm, is shaped not unlike the common earth-worm, having a cylindrical body, which is attenuated towards either extremity, but particularly the anterior. It varies in length generally between six and twelve inches, and is usually about two or three lines in thickness. The young worm, about an inch and a half long, is rarely met with. The head of the animal is at the smallest extremity, and may be distinguishes! by a circular depressioD, around which may be seen three tubercles. When recently voided, the worms are somewhat transparent, so that the viscera may sometimes be .seen through the ])ariotos. The in- tegument is marked by circular fibres, and by four line^ extending at equal distances from the head to the tail, the former of which indicate the course of the muscles, while the latter indicate that of the vessels and nerves. The color of the worm is whitish, yellowish, or more or le.«s deep rosy in tint, according to the nature of the aliment they contain ; they are, as already stated, somewhat transparent when first voided. The alimentary canal, which may be distinguished by it* brownish color, terminates by a transverse ofiening or anus, .situated on the inferior surface of the animal, just in front of its posterior extremity. The two sexes are in different individuals. The male may Ik* known by its tail, which is shortly curved, while that of the female is straighten aod thicker. The genitals of the male consist of a double penis, which may sometimes be seen to protnide just in front of the caudal extremity ; thoee 966 WORMS. of tlie female may be distinguished by the vulva, seated at a constricted point of the body, about a third of the distance from the head to the tail. The male is smaller and much less abundant than the female. The Ascaris or Oxyuris vermicularis, thread- worm, seat-worm, or maw- worm, is the smallest of the intestinal worms, and is generally distinguished in popular language by the title of ascarides. The sexes are in separate individuals. The male is generally about two lines in length ; its body is elastic, of a whitish color, very slender, and looks not unlike a piece of cotton thread, whence one of its names was derived. The female is larger than the male, reaching a length of four or five lines. The anterior part of the body is of the same shape in both sexes. It is obtuse, and surrounded by a trans- parent membrane, through which may be seen a straight tube, forming a kind of bladder, which is the oesophagus, and which terminates in a glob- ular stomach. The head is provided with three tubercles, as in the lum- bricoides. The intestinal tube in the male continues the whole length of the body, which becomes somewhat thicker towards the end, and is arranged into a spiral shape at the tail. The body of the female is shaped like that of the male as far back as the stomach, and increases in size in the first third of its length, after which it diminishes, and becomes so small at the end as to be seen with difficulty by the naked eye. The Tricocephahis dispar, or long thread-w^orm, is generally about an inch and a half or two inches long, and consists, as it were, of tw^o portions, of which the anterior, constituting about two-thirds of the length, is exceed- ingly slender, scarcely thicker than a horse-hair, while the posterior third swells out suddenly so as to become much thicker and larger. The sexes are in different individuals. The worm is provided with an alimentary canal, which, commencing at an orbicular mouth placed in the small ex- tremity, runs through the animal to the anus, placed at the caudal ex- tremity. The male is smaller than the female, and is, usually, found con- voluted. This worm is met with chiefly in the coecum and colon, particu- larly the former. It usually exists in very small numbers, and sometimes but a single one is found. The symptoms which it occasions are the same as those produced by the lumbricoides. The Taenia solium, common or long tape-worm, as well as the Taenia lata, are of rare occurrence in children. Of 206 cases observed by M. Wavruch, only 22 occurred in subjects under fifteen years of age, and of them the youngest was three years and a half old (Bib. du Med. Prat, t. v, p. 626). These worms have, however, been met with at an earlier age, but as they are rare, we deem it unnecessary to do more than describe their appearance, in order that the reader may be able to distinguish between them and the varieties which generally exist in children, the Ascaris lumbricoides and vermicularis. For a full account of the symptoms produced by the two varieties of the taenia, and their treatment, the reader is referred to any of the standard works on the practice of medicine. The Tcenia solium is usually of a whitish color, flat in form, and varying in length from five to ten feet, its ordinary, length, to twenty feet, or even more. It is uneven in shape, being thick and broader behind, and meas- DESCRIPTION — FREQUENCY. 0G7 uring three or four lines at its widest part, while it tapers gradually towards the anterior extremity, where it becomes slender and thread- like. The head is globose and very minute, being about 3'otli inch in di- ameter. It has a projecting papilla in the centre, furnished with a double circle of booklets. There are also four projecting suctorial c^isks placed at equal distances around the head. The neck is delicate and tliread-like, but on microscopic examination presents transverse wrinkling at a short distance from the head, and soon merges into the distinctly jointed boidly in length tlian in breadth. The largest joints measure about one-fourtliof an inch wide by half an inch long. Each joint contains both male and female sexual apparatus, opening by a common ajx^rture on the side. The Tivnia wietf/oca/jc/Za/a was formerly confounded with the ticnia solium. It attains however a greater length, its joints are longer and broader, and its head is about three times as thick. The four suckers are present, but there is no central projecting papilla, nor any booklets. The Bothriocephalus latw^y Ttcnia lata, or broad f; remarks: "When wc consider how universally worms are found in all young animals, and how fretpiently they exist in the human bwly, without producing di.<)ea.se of any kind, it is natural to conclude that they serve some useful and necessary purf>r>sc8 in the animal economy." M. Guersant says {Did. dc Med., t. xxx, GG9) : 968 WORMS. ** It has always been the custom to assign to entozoa much too important an influence upon the diseases of childhood. In proportion as this part of pathology is perfected, it becomes evident that the greater number of chil- dren dying after having discharged worms, or even while having them still, are aflTected with acute or chronic diseases, which leave after death incontestable traces of their effects, and which are of themselves neces- sarily fatal." M. Barrier {Mai. de VEnf., t. ii, p. 100) quotes M. Trousseau as making the following remarks : " For sixteen years we have not met with a single child who has presented any verminous symptoms; never or almost never does a child born and reared in Paris discharge worms, while just the contrary is true as to the provinces Young children, to be sure, are sometimes met with in our hospitals, who discharge worms, but they are those who have been born in the country, and have lived in the capital only for a short time." Dr. Condie {Dis. of Child., 2d ed., p. 226), remarks : " Worms are a very common occurrence in the intestines of children, and may unquestionably, under certain circumstances, become a cause of severe irritation ; but much less frequently than is generally supposed." We believe we may conclude, therefore, that though these parasites are of very common occurrence, and productive of grave disorders in some countries, they are rarely met with in quantities sufficient to do serious injury to the health, in other places, as for instance Paris, and probably in this country, or at least in the northern parts of it. That intestinal worms do, however, not unfrequently in some countries, and occasionally in all, produce dangerous and even fatal disturbances of the health, cannot be doubted after careful perusal of the evidence brought forward by different authorities. M. Guersant, amongst others, remarks {loe. cit.f p. 670) : " It is nevertheless incontestable, that the development of these animals in the gastro-intestinal and abdominal cavities does some- times give rise to very varied morbid phenomena, which are in some in- stances grave enough to cause death." Nevertheless, we are disposed to believe, as stated above, that fatal or even dangerous results from the existence of these parasites are of rare occurrence in this city, and prob- ably throughout our Northern States. Dr. Dewees, however, mentions several cases in which they produced alarming symptoms, and one in par- ticular (Dis. of Child., p. 492), in which the subject, a child twenty months old, was extremely emaciated, and whose abdomen was " enormously dis- tended, and semi-transparent," who recovered rapidly after ninety-six lumbricoides, from six to ten inches long each, had been expelled under the use of pink-root in infusion. ASCARIS LUMBRICOIDKS. 969 ARTICLE I. ASCARIS LUMBRICX)IDES. The de^'icnption of this worm has already been given at page 065. Causes. — Under this head we shall not pretend to consider the question of the origin of worms, but only the causes which predispose to tlicir pro- duction, or favor their growth. Age ha^ no doubt a considerable influence upon the predisposition to lurabricoides. According to M. Guersant (loc. ci7., p. 685), infants at the breast under six months of age are very rarely affected with them. In- stances occasionally occur, but are altogether exceptions to the general rule. Above six months of age, they begin to be met with, but still very rarely, so that scarcely one or two will be found in several hundred chil- dren of a very early age; while from three to ten years of age they will be observed in about a twentieth, or in some seasons perhaps in a larger proportion. M. Valleix states that he has never met with them in new- born children. Dr. Dewees says {loc. cj*f., p. 481), that he has never seen worms in children under ten months old ; and in only two instances at that age. We do not rei'ollect ourselves ever to have seen them in subjects younger than eighteen months, and very rarely in those under three or four years. There can be little doubt that the disposition to worms is hereditnnj in some families. It is generally believed that the species under consideration is more common in girU than boys; that it is most common in children of Ipnphafic and scrofulous constitutions ; and that a too exclusively vegetable or milk diff, and an abuse of fruih, strongly predispose to their production. The habitatiou of a cold and damp, or warm and damp climate, and the seasons of summer and autumn, are sujiposod by many also to favor their production and growth. It is a general belief, and we should suppose from personal experience, a well-founded one, that a feeble and disordered state of the digestive finution from any cause, often acts as a predisf^siug cause of worms, and particularly of lumbricoides. Seats. — The small intestine is, in a ven.' large majority of the cases, the seat of the ascaris lumbricoidei*. They are met with, however, in other part* of the digestive tube, particularly the stomach and large inte.**tine, and more rarely in the ed on the opening of the abscess. The number of a>*caridcs is exceedingly variable; there may be only two or three, ten or twenty, or sevfral hundred. Whf-n very numerous, they are apt to be rolled or twisted into kii<»t-< or baIN, wliirh have been seen aa 970 ASCARIS LUMBRICOIDES. large as the fist, so as to block up completely the canal of the intestine. In a case cited by Rilliet and Barthez, from M. Daquin, the duodenum was so filled with worms as to be distended, and to have acquired a con- siderably larger size than natural, while at the same time it was hard and elastic. The jejunum, ileum, and caecum were filled, so that it seemed as though the worms must have been pushed in by force. They were found also, but in smaller quantity, in the colon. Dr. Condie {loc. cit, p. 230) states that he has known one hundred and twenty lumbricoides to be voided in a single day by a child five years old. It ought, however, to be remarked, that the instances in which such large numbers are met with are altogether exceptional, especially in our Northern States. We have never ourselves known more than six, eight, or ten to be expelled within a few days' time, and very generally there have not been more than three, four, or five. Anatomical Lesions. — When the number of lumbricoides is small, the mucous membrane has been found in a state of perfect health, while, on the contrary, when they are numerous, and especially when collected together into knots, the membrane has presented a fine injection like that which exists in erythematous enteritis; in some very rare instances on record, in which the quantity of worms has been very great, the mucous membrane has been found deeply injected, thickened, granulated, and, in a small proportion of cases, softened, and even eroded. Not unfrequently the intestine presents all the characters of well-marked enteritis, or entero- colitis, though the number of worms may be very small. In such cases, it is reasonable to suppose that the inflammatory affection has been an acci- dental complication of the verminous disorder. Much discussion has arisen in regard to the manner in y^hich. perforation of the intestine, as an accompaniment of worms, takes place. It is neces- sary to suppose, in subjects in whom worms are found in the peritoneal cavity, or in abscesses formed in the abdominal parietes, that perforation of the bowel has taken place, and yet in some instances no trace of the opening is left, no inflammation of the serous membrane is met with, nor has there been any escape of the contents of the digestive canal into the abdominal cavity. In others, however, and much the most numerous cases, it is evident from the anatomical appearances, that the perforation has taken place in consequence of previous ulceration of the coats of the bowel, and that the worms have escaped with the other contents of the intestine. It is in regard to the former class, therefore, that discussion has principally taken place ; some asserting that the parasite itself makes the opening, by an active process, while others deny the possibility of this occurrence, and maintain a previous ulceration or softening in all cases. Amongst those who advocate the possibility of perforation independent of previous change in the intestinal coats by disease, are MM. Mondiere and Charcelay, the former of whom has examined the subject with a great deal of care, quoted by Rilliet and Barthez ; Rilliet and Barthez themselves ; the authors of the Biblioth. du Med. Prat, and M. Guersant ; while amongst those opposed to this opinion may be cited, MM. Cruveilhier, Barrier, Dr. Arthur Farre, who greatly doubts the possibility of the accident, and Dr. Condie. We confess ourselves inclined to believe, from facts stated by different authors, ANATOMICAL LESIONS — SYMPTOMS. 971 and from the history of two cases which occurred to M. Guersant in 1841, at the Children's Hospital of Paris {loc. cit., p. 680), that worms may in some instances cause a perforation independently of previous disease of the coats of the intestine. In one of these, two lumbrici were found engaged in an opening in the appendix vermiformis, half the bodies of the animals being in the appendix and half in the peritoneal sac ; while in the other, an opening of the same kind as in the previous case was found in the ap- pendix, and though the three worms which were found lying in the abdom- inal cavity might have escaped through an ulcerated perforation of the colon, it is not the less true that the opening in the appendix presented the same characters exactly as in the first case, in which the animals were, as the author remarks, " taken in the act." In both instances, the perfora- tion of the appendix was at the extremity of that canal, and in the form of a narrow opening of a conical shape; the membranes were smooth, thinned, and the edges of the orifice sloped off from within outwards; no trace of anterior ulceration was perceptible. On the other hand, we have met with a fatal case of intestinal perforation, dependent on extensive ul- ceration of the bowel, in which a lumbricoid worm was found lying loosely half-way out through the opening. In this case it was evident that the presence of the worm was purely accidental. In regard to the verminous abscesses already refered to, w^e shall make but few remarks, referring the reader to more extensive treatises for fuller information. These abscesses have been, in very rare instances, met with in the pharynx and nasal passages, but much more frequently they exist in the abdomen. The latter may be of two kinds, stercoraceous and no7i- stercoraceous. In the former, the abscess, which forms upon some por- tion of the walls of the abdomen, gives issue not only to the worm or worms, and pus, but also to fecal and even alimentary substances, and leaves behind a fistula connecting with the cavity of the intestine, which may cicatrize after a short time, or remain open during life. In the other form of abscess, the opening through the coats of the intestine has been closed immediately after the passage of the worm, so that the abscess gives issue only to the animal and pus, after which it heals up without giving rise to a fistula. The verminous abscesses are said to be found generally about the in- guinal and umbilical regions; to occur most frequently between the ages of seven and fourteen years, and not to be, as a general rule, very danger- ous to life. Symptoms Indicative of the Presence of Worms.— We believe it is almost universally acknowledged by later writers, that there is no single symptom, nor group of symptoms, other than the expulsion of the worms, and their detection, which indicate with certainty their existence in the digestive tube. This is the expressed opinion, amongst others, of MM. Guersant, Rilliet and Barthez, Barrier, Valleix, and Drs. Eberle and Condie, and it is also the opinion Avhich we have ourselves been led to form from our experience amongst children. Another point worthy of remark is, that even though one or several worms may have been expelled, it is not always fair to conclude that the 972 ASCARTS LUMBRICOIDES. symptoms under which the child labors, are the result of the presence of others of these animals, as there may be no more in the bowels, or they may be so few in number as not to produce injurious effects ; while, on the contrary, various disorders of the digestive tube, as chronic indigestion, simple diarrhoea, and inflammatory diseases of the gastro-intestinal mucous membrane, may and do exist simultaneously with, and yet independently of, the presence of these parasites. The symptoms generally enumerated as indicative of the presence of worms are the following. The child presents various signs of disturbed health. The stomach is more or less deranged, as shown by furred tongue, eructations, variable appetite, which is sometimes diminished, and some- times increased, thirst, acid or heavy breath, and nausea. The abdomen may be enlarged or retracted, generally the former, and is often more or less hard and painful to the touch ; the condition of the bowels varies in different cases, as they are spmetimes costive, and sometimes affected with diarrhoea. According to M. Guersant, the stools often contain glairy sub- stances, and are sometimes streaked with blood and of a yellowish-green color; the patient often suffers from colics, which may be either dull or acute, though more generally the latter, and which are generally felt at the umbilical region. Children affected with lumbricoides are said to pre- sent a peculiar physiognomy ; the face is usually paler than natural, and sometimes has a leaden tint ; the eyes are surrounded by bluish rings, and have at the same time a dull and languid expression ; the inferior eyelids are often swelled and puffy ; the sclerotic coat of the eye assumes a bilious tint; the nostrils are said to be sometimes swelled, and the child com- plains much of irritation and itching of those parts, and is constantly picking at them with the fingers. In some instances epistaxis takes place. The child is generally pale and thin, indolent and languid, or irritable and unhappy. The sleep is almost always disturbed. This indeed is, it seems to us, one of the most important signs both of worms and of chronic functional disorders of the stomach and bowels. The nights are almost always restless, the patient either waking often to drink, or waking in fright and alarm from dreams, or else constantly tossing and turning in sleep, moaning, or grinding the teeth. Other symptoms mentioned by different observers, and by some very much depended upon, are acceleration with irregularity of the pulse, and dilatation, especially unequal dilatation, of the pupils. We might cite also strabismus, and occasionally cough. In children in whom the number of lumbricoides is very large, the con- stitution suffers to a dangerous degree. The symptoms above enumerated are very marked, and at the same time the child is very pale or sallow, emaciated, weak, and without appetite ; the abdomen is hard and tumid ; the nervous symptoms are severe, and some of the symptoms which we shall describe presently, under the head of disorders occasioned by worms, are also observed. It should be remarked, however, again, that all or any of the symptoms just described may exist independently of the presence of worms, the only certain sign of which is their expulsion from the patient. I I I mechanical' EFFECTS. 973 Morbid Effects occasioned by Worms. — MM. Rilliet and Barthez divide the accidents or effects produced by the existence of lumbricoides into two groups : those which result from the mechanical influence of the entozoa, as their accumulation or displacement ; and those which appear to be the consequences of a purely sympathetic action on the different systems of the body, and particularly the nervous system. Mechanical Effects. — Under this head are included perforation and hsemorrhage of the intestine, enteritis, abscesses, and the symptoms deter- mined by the displacement or migration of the worms into the ductus communis choledochus, the liver, or the air-passages. Of perforation and abscesses, we have already treated under the head of anatomical lesions. Haemorrhage is a very rare event, but it occurred in one instance cited by MM. Rilliet and Barthez, and Guersant, from M. Charcelay, in consequence of the rupture of an arteriole in a small rounded ulceration in the duodenum, apparently occasioned by the pres- ence of a large number of lumbrici. Enteritis, as an effect of the pres- ence of worms, has also been referred to under the head of the anatomical lesions. In many instances it is, no doubt, a mere accidental complica- tion, in no way connected w^ith the presence of entozoa ; probably this is true of a large majority of the cases. When, however, the number of the parasites is very great, and particularly when they are collected into large or firm knots and bundles, they may, no doubt, occasion, by their mechanical irritation, inflammation, thickening, softening, and even destruction of the mucous tissue, as in cases cited by M. Guersant, from MM. Bretonneau and Charcelay, and in one which occurred to himself. It should be remarked, however, that the cases on record in which ulcera- tions evidently depended upon the presence of worms, are, so to speak, infinitely few in comparison with those in which no such alteration ex- isted, or in which it was evidently independent of any influence exerted by the worms. Effects caused by the Displacement or Migration of Worms. — Lumbricoides have been found, as we have already seen, in the walls of the abdomen, giving rise to abscesses. They have been discovered, also, in the vermiform appendix, in the ductus communis choledochus, in the gall-bladder, in the hepatic ducts in the substance of the liver, forming abscesses, and in the pancreatic canal. The symptoms occasioned by the latter class of cases are very obscure. In one instance, M. Guersant sup- posed that an attack of convulsions depended upon the presence of worms in the common duct. More numerous examples are on record, in w^hich violent dyspnoea and cough, and fatal asphyxia, have occurred in consequence of the pressure of lumbricoides which had passed into the oesophagus, or from their in- troduction into the larynx, trachea, or bronchia. The symptoms occa- sioned by these accidents are a sudden attack of dyspnoea, anxiety, agita- tion, threatened suffocation, dry, spasmodic cough, acute painful cries, pain in the larynx or trachea, and, unless relief be obtained in a few hours, death. This kind of attack may depend on the rising of a worm or bundle of worms into the oesophagus, causing pressure on the larynx 974 A«SCARIS LUMBRICOIDES. and trachea, as in the case reported by M. Tonnelle, in which the symp- toms disappeared after the expulsion of a large number of worms; or else it may be due to reflex spasm of the oesophagus or larynx dependent upon the irritation transmitted from the intestine which is excited by the pres- ence of these parasites. One of us has met with an instance of this kind. It occurred in a boy fifteen years old, presenting every mark of strong and vigorous health, but who, for three or four weeks before we were consulted in regard to him, had been subject to sudden and apparently causeless at- tacks of sujBTocation, which seized him without the least warning. When the attack came on, he would for some instants cease to breathe, or breathe with much difficulty. He always seemed to suffer from the greatest anx- iety ; the countenance became altered and distressed ; he was unable to speak, but made signs for water, and when able to swallow a mouthful, which was always exceedingly difficult, was at once relieved. His mother told us that he always appeared to be in the greatest distress, so that, on several occasions, she feared for his life. Striking him violently on the back, which she, when present, always did, sometimes relieved him, but generally the difficulty continued until he could swallow a little fluid of some kind. These attacks were unattended at the time by cough, nor was there the least sign of disorder of the respiratory system in the intervals between them. Suspecting that the difficulty must depend on the rising of a worm or worms into the oesophagus, or upon sympathetic irritation from the presence of these parasites in the stomach, and learning that he had been troubled with worms some years previously, we gave him wormseed oil, which caused the expulsion of a few large lumbricoides, after which he had no return of the symptoms. The attacks of dyspnoea may depend also, as already stated, on the introduction of worms into the air-passages. Under these circumstances death is very apt to be the result. In one instance, however, reported by M. Arronsshon, after the difficulty had lasted two hours, the patient, a little girl eight years old, after violent efforts at coughing, threw up a living lumbricus. We have next to consider the sympathetie effects, and particularly the nervous symptoms, occasioned by worms. We may include amongst the nervous symptoms produced by worms the headache, languor, irritability, restless and disturbed sleep, and grinding of the teeth, so frequently ob- served. These, however, are of but slight importance in comparison with certain other disorders of the nervous system, which do undoubtedly occur sometimes, though we should suppose very rarely, in proportion to the whole number of subjects affected with the parasites. The disorders to which we allude are partial or general convulsions, chorea, hysteria, and catalepsy, which are the most frequent, though, as so often stated already, extremely rare in comparison with the number of cases in which the presence of the worms produces no such effects. Other disorders cited by the authors of the Bib. du Med. Prat, with cases to prove their reality, are insanity, paralysis, coma, palpitations, strabismus, cough, hypersesthesia of the skin, amaurosis, and aphonia. DIAGNOSIS — PROGNOSIS. 975 Diagnosis. — It has already been stated that there are no certain signs of the presence of worms in an individual except their expulsion. The symptoms which have seemed to us most strongly to indicate their presence are, a chronic disordered state of the digestive apparatus, producing irreg- ular apjjetite, which is sometimes good and at others bad ; slight emacia- tion ; paleness or unhealthy tint of the complexion ; languid expression of the face ; some irritability of the temper, or a want of the gayety and ac- tivity of disposition natural to childhood ; picking at the nose; often some tumidity of the abdomen, which may be at the same time either hard or merely tympanitic ; and, what seems to us more important than any that we have named, very restless and broken sleep at night, with frequent grinding of the teeth. M. Valleix remarks that, in a case presenting nervous symptoms simu- lating disease of the brain, we may suspect the existence of worms, if we learn upon inquiry that symptoms of marked intestinal disorder, the various signs cited above as indicative of the presence of worms, and different de- rangements of digestion, had preceded for some time the appearance of the nervous symptoms ; chiefly for the reason that, in most diseases of the brain, the digestive tube is, at the invasion, in a state of integrity, with the excep- tion of sympathetic vomiting. If we can learn, upon inquiry, that the child has discharged worms on some previous occasion, the probability of the dependence of the symptoms upon them becomes still stronger. It is sometimes difficult to determine positively whether certain sub- stances discharged at stool are fragments of worms, or whether they are portions of imperfectly digested aliment, or foreign bodies. The things which most resemble lumbricoides, are the remains of tendons, ligaments, vessels, fibres of plants, etc. To make the distinction with certainty, the doubtful substance ought to be placed in water, so that it may be thoroughly cleansed, after which it must be carefully examined as to its structure, ar- rangement, consistence, etc., with the eye, and with the microscope, if necessary. M. Guersant has suggested a very easy method of ascertaining whether the substance be animal or vegetable, which is to subject it to heat, after it has been carefully washed, when the odor will at once inform us of its real nature. Prognosis. — It is no doubt a very rare event, at least in the northern parts of our country, for life to be endangered by the presence of worms. We have never, ourselves, met with an instance in which the general health was more than moderately disturbed by this cause. That vermin- ous affections are sometimes, however, dangerous to life in this city, is shown by three cases related by Dr. Dewees, in which very severe and threatening symptoms were instantly relieved upon the expulsion of lum- brici after the exhibition of vermifuges. Worms become dangerous to life when they migrate from their original seat to neighboring and important organs, particularly the air-passages and liver. The prognosis is unfavorable also when they accumulate in very large numbers, and give rise to the different nervous symptoms above described. 976 ASCARIS LUMBRICOIDES. Treatment. — Before commeDcing our remarks upon the particular remedies employed for the destruction and expulsion of worms from the alimentary canal, we would call the attention of the reader to the fact that most of the recognized anthelmintics are more or less irritating to the gastro-intestinal mucous membrane, and some of them to the nervous system also, producing, in . overdoses, severe and even dangerous nervous symptoms. It is evident, therefore, that remedies of this class ought not to be exhibited unless they are manifestly called for, and not at all when symptoms of severe gastro-intestinal irritation, and particularly of inflam- mation, are present, unless there be the very strongest reasons for supposing that those symptoms depend upon accumulations of worms. We are quite sure that we have, in a considerable number of instances, met with children whose digestive organs had been injured, and in whom slight functional derangement had been converted into severe indigestion, and even inflam- matory disorder, by the too frequent or long-continued use, or the adminis- tration in excessive quantities, of different vermifuges, and of various quack nostrums, which are sold to an amazing extent in this city, and all over the country. As the diagnosis of worms is always doubtful, it is best never to risk the administration of any of the irritating vermifuges, unless convinced, by the previous expulsion of worms,, that they are almost certainly present ; and, indeed, we ourselves rarely give any other remedy than small quantities of the wormseed oil in slight, and especially in doubtful cases, unless this has already been tried and failed. From our own experience, we believe that this remedy is all-sufficient in a large majority of the cases that occur in this city ; as these are almost always of a mild character, and, as it not only produces the expulsion of the parasites when they exist, but also acts bene- ficially upon the forms of digestive irritation which simulate so closely the symptoms produced by worms. We are persuaded, indeed, that of all the cases that have come under our notice, in which it seemed probable that worms might be present, none were expelled in nearly half, and yet the signs of disturbed health have passed away under the use of the remedy. The oil of wormseed may be given in doses of four drops to children of two years of age, and of six or ten to those above that age, three times a day for three days, to be followed on the morning of the fourth day by a moderately active, but not irritating cathartic dose, the best of which is castor oil or syrup of rhubarb. The objection to the remedy is its nauseous taste and smell ; these, however, may be partially disguised by making it into a mixture with yolk of egg, powdered gum, and syrup of ginger. Some children take it very well dropped, upon a lump of white sugar, while others take it best mixed with common brown sugar. If one course of the oil, as it is called, fail to relieve the symptoms, another should be ad- ministered. It ought to be recollected that, when given in large doses, the wormseed oil is irritating to the digestive mucous membrane, and pro- duces dangerous nervous symptoms. We know of one case, in which a girl six or seven years of age was made exceedingly ill and suffered for years afterwards, from the effects of a teaspoonful of the oil given by mis- TREATMENT. 977 take. The following is a very good formula for the administration of this remedy : R. — 01. Chenopodii, gtt. Ix vel f^j. P. G. Acaciae, . . . . . . • ^ij- Syrup. Simp., f^j. Aq. Cinnamom., f^ij. — M. Give a dessertspoonful three times a day, for three days, and repeat after several days. The wormseed may be given also in powder, in the dose of from twenty to forty grains. The remedies most frequently employed in this country besides the wormseed, are pink-root or spigelia, oil of turpentine, calomel, and the bristles of cowhage. We believe that the pinJc-root is more depended upon amongst us than any other single remedy. It is given either in substance or infusion. The dose of the powder is from ten to twenty grains for a child three or four years old, to be repeated every morning and evening for several days, and followed by an active cathartic. The powder is seldom used, however, as the drug is almost always given in infusion. The best and safest mode of administering it is in combination with cathartic substances. Thus, half an ounce each of pink-root and senna may be infused for a few hours in a pint of boiling water, and a tablespoonful given two or three times a day to children two or three years old, for three, four, or five days, when it should be suspended for a time, and resumed, if necessary. A prepara- tion much used in this city under the title of worm-tea, and which we have ourselves given with very good success, consists of the spigelia mixed with senna, manna, and savine, in different proportions, made into an in- fusion and sweetened with brown sugar. Dr. G. B. Wood (Pract. of 3Ied., vol. i, p. 626) recommends the following formula: R. — Sennae, Spigol SfOllJ Magnesiae Sulphat., Mannge, . Foeniculi, Aquie Fervent , aa ^ss. . Eh . Oj. These are to be macerated for two hours in a covered vessel, and a table- spoonful given to a child two years old once or twice a day, or every other day, so as to procure two or three evacuations in the twenty-four hours. The remedy is continued for a few days, or for one or two weeks, if neces- sary, and if it do not debilitate the child. The fluid extract of spigelia and senna has been introduced as a more convenient and acceptable mode of administering this vermifuge with a cathartic. The dose for a child is from thirty minims to a teaspoonful, according to the age. The spirit of turpentine is highly recommended as an efficient remedy for worms by several authorities, and particularly by Dr. Joseph Klapp and Dr. Condie, of this city. Dr. Condie states that it is the article from 62 978 ASCARIS LUMBRICOIDES. which he has derived the most decidedly beneficial effects, and remarks that it may be given when there exists considerable irritation of the ali- mentary canal, or even subacute inflammation, without any fear of its in- creasing either. He gives the rectified spirit in sweetened milk, in mo- lasses, or in the following mixture : Mucil. G. Acacise, • . f|y. Sacch.Alb., . 3x. Spir. JEther. Nitr., . • f3"J. 01. Terebinth., ...... . . f^iij. Magnes. Calcinat., . . Bj- Aquae Mentha©, . . f5J.-M Of this mixture a dessertspoonful is given every three hours. We have used the spirit of turpentine but seldom, on account of its ex- tremely disagreeable taste, having always succeeded perfectly well with the wormseed oil, or with infusion of pink-root with cathartics. Calomel also is highly thought of by many persons as a vermifuge, and, no doubt, when used in combination with or followed by cathartics, or given in full purgative doses, it is very effectual. We can only repeat what we have already said on several occasions, that it is a remedy which, from the powerful influence it exerts upon the constitution, ought not to be given except when really called for ; and, as we can almost always suc- ceed in curing verminous affections by milder drugs, we see no occasion for resorting to this, except in rare cases. When used it is given alone in considerable doses, and followed by some cathartic, or in combination with rhubarb and jalap, or jalap, or scammony. The bristles or down of cowhage are also used by some practitioners, no doubt sometimes with success. We have never used them, and can give no opinion, therefore, from personal experience, as to their eflficacy. They are administered by making them into an electuary with honey, syrup, or molasses, a teaspoonful of which is given every morning for three days, and then followed by an active cathartic. The following electuary, recommended by Bremser, is very much em- ployed in Europe, and is highly spoken of by Dr. Eberle : H- — Semin. Santoniese (semen-contra of the French writers), Semin. Tanaceti rude contus., . . . . aa ^ss Valerian, pulv., Jalapse pulv., . Potass. Sulphat., Oxynnel. Scillse, SJss.-ij. q. s.— ut ft. Electuarium. A teaspoonful of this is given morning and evening for three or four days, when the dejections generally become more copious and liquid. If it do not produce this effect, B-remser advises that the dose be increased. Dr. Eberle gave it for six or seven days, and says it does far less good when it produces frequent and watery evacuations, than when it causes only three or four consistent stools a day. This preparation has a very dis- TREATMENT. 979 agreeable taste, and children sometimes refuse to take it on that account. When this is the case it may be made into pills. MM. Rilliet and Barthez recommend the following syrup, which was i3roposed and highly thought of by M. Cruveilhier : R. — FoUicul. Sennae, Rhei, Semin. Santonic, Artem. Abrotan., Helminthocort., Tanaceti, Artemis. PoDtic, . . . aa gj. To be infused in half a pint of cold water, strained, and made into a syrup with sugar, of which a tablespoonful is to be given every morning for three days. Of late years, santonin, the active principle derived from the European wormseed, has been much employed, and with very good success. The remedy may be given in doses of from gr. ij to gr. v, combined or followed by a dose of castor oil or senna. It is also prepared in the form of sugar- coated dragees, which renders it quite acceptable to children. The empyreumatlc oil of Chabert is also highly spoken of by some European authorities. It is made by mixing one part of the empvreu- matic oil or fetid spirit of hartshorn, with three parts of spirit of turpen- tine, and allowing them to digest for four days. The mixture is then put into a glass retort and distilled in a sand-bath until three-fourths of the whole have passed over into the receiver. The product should be kept in small and tightly-closed vials. The dose is about fifteen or twenty drops three or four times a day, for children between two and seven years old. This is recommended highly by Bremser and other authorities. The great objection to it is its exceedingly nauseous taste. Dr. Eberle speaks in very favorable terms of a strong decoction of helminthocorfon or Corsican moss, which he has found "not only valuable as a vermifuge, but particularly so as a corrective of that deranged and debilitated condition of the ali- mentary canal favoring the production of worms." An ounce of helmin- thocorton, with a drachm of valerian, are to be boiled in a pint of water down to a gill, and a teaspoonful of the decoction given morning, noon, and evening. It is particularly beneficial in cases attended with the usual symptoms of worms, connected with want of appetite and mucous diarrhoea, and arising from debility of the digestive organs, and a vitiated condition of the intestinal secretions. Kameela, the reddish-brown powder which clothes the capsules of the Rottlera tinctoria, has been of late highly recommended, not only in cases of tjfinia, but of ascaris lumbricoides. The dose for children is about gr. V, repeated till it has acted on the bowels. In all cases of deranged health supposed, either from the nature of the symptoms, or proved by the previous expulsion of worms, to depend on the presence of these animals in the alimentary canal, it is. exceedingly impor- tant to attend to the hygienic treatment of the child, and in some instances to administer tonic^s and stimulants. In not a few cases that have come under our own notice, in which many of the symptoms supposed to indicate the presence of worms have been extremely well marked, we have succeeded in removing them all without a resort to any vermifuge, by the treatment proper for the chronic indigestion or dyspepsia of children. The method 980 ASCARIS LUMBRICOIDES. of treatment to be employed in such cases has already been laid down in the article on indigestion, to which the reader is referred for full informa- tion. It should consist chiefly in strict attention to exercise and diet, and in the use of tonics, as quinia and iron, and small quantities of fine port wine. Whenever any complication exists in connection with worms, the treat- ment must be modified according to its nature. If it consist in inflamma- tion of any part of the digestive tube, the inflammation ought to be at- tended to first, and the verminous disorder for the time neglected. If the inflammation be very slight, or if the symptoms indicate only severe irri- tation rather than positive inflammatory action, we may exhibit the milder and least injurious vermifuges, as very small doses of wormseed oil, which we have never known to do harm, the decoction of helminthocorton and valerian, recommended by Dr. Eberle, or, according to Dr. Condie, the spirit of turpentine. If the verminous afl^ection coexist with any of the acute local inflammations of the thorax, the former ought to be, as a gen- eral rule, neglected, until the latter has been relieved by appropriate treat- ment. In doubtful cases, in which it is impossible to ascertain with cer- tainty whether the symptoms depend on worms, or upon a simple dyspeptic condition of the digestive organs, it is most prudent to give only the sim- plest and least irritating vermifuges, to regulate the hygienic conditions of the patient, and afterwards to resort to tonics, if necessary. Various writers, and particularly M. Guersant, advise that we should fori^id, in verminous cases, the use of relaxing food, especially of milk preparations, fruits, and of fatty and farinaceous substances ; and that, after the expulsion of the worms, we should direct a tonic and strengthening regimen. The diet should consist of boiled and roasted meats, of wine, and of bitters. The author just quoted, states that a change of food alone will often suffice to procure the expulsion of worms. He says {Did. de Med., t. XXX, p. 689), " I have met with children who had been tormented with ascarides lumbricoides while residing in the country and living upon milk and fruits, and who, upon being brought to the city, and put upon the use of broths and soups, passed considerable quantities of worms, and after that got entirely rid of them." Occasionally our opinion is asked with reference to worms of other va- rieties, which are reported to have been passed from the rectum of children. Thus, tapering elongated pieces of coagulated casein may be mistaken for worms. So, too, we have seen a specimen, submitted to us by Dr. Bussey, of Buena Vista, Texas, and said to have been passed by a boy there, of male Gordicus aquaticus, or horse-hair worm. This is a nematoid worm, of chestnut-brown color, a foot in length, a little more than one-half line in breadth, with a bifid caudal extremity. It grows in stagnant water, and thus may readily have been swallowed and passed per anum. ASCARIS VERMICULARIS. 981 ARTICLE II. ASCARIS VERMICULARIS. The description of this worm has already been given at page 966. Seat. — The ascaris vermicularis is found almost exclusively in the large intestine, and in a large majority of the cases is confined to the rectum. It is said to have been found in the vagina in the female, having no doubt passed from the rectum into that canal. The causes which determine the presence of this worm are not at all understood. Symptoms. — The characteristic, and often the only symptom indicative of their presence, is violent itching about the anus, which is sometimes almost insupportable, and which is generally most troublesome and most apt to occur at night when the child is in bed. In consequence of this, the sleep is much disturbed, and the child grows peevish and irritable, and may suffer considerable impairment of general health. In some instances they give rise to acute and violent pain in the region of the anus, and sometimes to tenesmus and mucous or bloody stools. When the last- named severe symptoms exist, the worms may occasion dangerous nervous disorders, and even give rise to general convulsions. The worms not un- frequently escape from the rectum and are found upon the bed-clothes, or upon the clothes which the child has worn through the day. Sometimes they are discharged in considerable numbers, and are found, in that case, either mixed with the faeces, or with mucus, or collected into balls or knots. The diagnosis of the seat-worm, like that of the lumbricoides, cannot be regarded as positive, unless some have been expelled, or unless they can be seen by examination of the rectum. This can generally be done when they are present in any number, by pressing the nates apart so as to open the anus and bring the folds of the mucous coat of the bowel into view. The only other symptom which indicates their presence with any certainty, is the existence of severe itching about the anus, not to be ex- plained upon any more reasonable supposition. , Prognosis. — These worms do not, as a general rule, produce the same disturbances of the general health as lumbricoides, and in not a few in- stances are entirely innocuous, with the exception of the pain^ an-d incon- venience they occasion. They are, however, exceedingly troublesome, because of the difficulty of removing them entirely by any treatment. No matter how many are discharged, some almost always remain concealed in the folds of the mucous membrane, and as they are propagated with great rapidity, the same train of symptoms is very apt to return soon after they may have been seemingly dislodged. Treatment. — It has been found by long experience that the common vermifuges, given by the mouth, exert much less influence in causing the expulsion of these worms than of the lumbricoides. For this reason 982 ASCARIS VERMICULARIS. enemata are generally resorted to in the treatment, instead of remedies given by the mouth. Dr. Dewees, however, recommends the elixir pro- prietatis (tinct. aloes et myrrhse), in small and often-repeated doses, con- tinued for some time, and followed by enemata of lime-water, camphor, or aloes. He gave twenty drops of the elixir three times a day, in a little sweetened milk, to children from two to four years old, and thirty drops to those between five and seven years. The plan we have generally resorted to has been to give small doses of the wormseed oil, as directed in the article on lumbricoides, and to direct, an injection of from four to six grains of powdered aloes, suspended in a gill of warm milk, for children four years old, to be repeated once in three, four or five days, according to the necessity of the case. Lime-water by injection is recommended by several different authorities. It may be given of its ordinary strength, or mixed with an equal quantity of warm milk, or flaxseed mucilage. Other enemata recommended are spirit of turpentine in milk, a teaspoonful of the former to a gill of the latter ; decoction of helminthocorton ; an injection made by infusing two drachms of fresh garlic-cloves in three ounces and a half of boiling water, and adding to the infusion, after it has been poured off, a scruple of assa- foetida rubbed up with the yolk of an egg ; a solution of from six to twelve grains of sulphuret of potassium in half a pint of water ; injections of sweet oil, or of lard beaten up with water until it becomes fluid, and even of cold water. The three last-mentioned substances have the advantage of calming the itching and irritation of the rectum almost immediately. Enemata of a solution of nitrate of silver, in the proportion of two to four grains to the ounce of water, have been recommended by Schultz (Deutsche Klinik, quoted in Med. Times and Gaz., 1858), who asserts that two, or at most three, of these injections suffice to effect a cure. Again, it has been recommended to pass a bougie smeared with mercurial ointment into the rectum. We should much prefer a method of using this ointment which succeeded in the hands of M. Cruveilhier in a very severe case. This was to place a little of the ointment on the auus, by which course the patient was entirely relieved after a few days. In a very obstinate case in an adult, we succeeded in entirely destroying the worms by the daily use of suppositories, made unusually long, and impregnated with carbolic acid. M. Valleix states that he has obtained the same results by causing the anus to be anointed with the following preparation, a small quantity of which was introduced at the same time into the inferior extremity of the intestine : R.— Hydrarg. Chlor. Mitis, .... ^iv. Axung., ^vj. — M. Dr. Wood states that a dose of sulphur taken every morning before breakfast has been found very useful. The diet and general health ought always to be strictly inquired after, and attended to by the physician. For information upon these points the reader is referred to the remarks upon hygienic treatment in the last article. INDEX. Abdomen, examination of, and signs from, 45, 46 condition of in enterocolitis, 398 in cholera infantum, 425 in tuberculous peritonitis, 850 in tuberculosis of mesenteric glands, 852 in variola, 789 in typhoid fever, 83n, 833 in cases of worms, 972 Abscess of leg, simulating rheumatism, 32 of lung following pneumonia, 164 bronchial, in bronchitis, 194 retropharyngeal, 351 iliac, in disease of coecum and appendix, 447, 451 following erysipelas, 891 Absorbents in enterocolitis, 405 Acarus scabiei, description of, 923 Achorion Schoenleinii, the fungus of favus, 944 Acids in local treatment of gangrene of the mouth, 314 carbolic, in gangrene of the mouth, 314 in diphtheria, 679 in scabies, 927 in favus, 952 muriatic, in gangrene of the mouth, 314. in diphtheria, 679 in typhoid fever, 840 sulphuric, in chronic entero-colitis, 414 -^gophony in pleurisy, 229 Affusion, cold, in scarlatina, 748 warm, in mild cases of scarlatina, 746 Air, as injection in intussusception, 469 Albuminoid degeneration of viscera in scrof- ula, 845 Albuminuria, in pneumonia, 174 in diphtheria, 671 during desquamation in scarlatina, 713 in scarlatinous dropsy, 730 in variola, 794 in typhoid fever, 831 in scrofula, 845 Alkalies in membranous croup, 102 in thrush, 340 in rheumatism, 648 local use of in diphtheria, 680 in skin diseases, 952, 956, 960 Alopecia Areata. article on, 958 frequency of, 958 fungous nature of, doubtful, 943, 959 contagion as cause of, 958 symptoms of, 959 condition of hairs in, 959 baldness following, 959 Alopecia areata, diagnosis of, 959 prognosis in, 959 treatment of, 959 Alum, as an emetic in true croup, 99 in hooping-cough, 268 Amaurosis, after diphtheria, 675 Anesthetics. use of during tracheotomy, 119 in eclampsia, 548 in tetanus, 582 Analysis of cow's milk, 330 of human milk, 338 of fluid in hydrocephalus, 523 of bones in rickets, 872 of fluid in sclerema, 962 Anatomical Lesions. in coryza, 52 in simple spasmodic laryngitis, 69 in pseudo-membranous laryngitis, 88 in congenital atelectasis, 130 in collapse of the lung, 141 in pneumonia, 156 in bronchitis, 193 in emphysema, 213 in pleurisy, 227 in pneumothorax, 248 in hooping cough, 258 in cyanosis, 276 in acute pericarditis, 285 endocarditis, 287 in chronic valvular diseases, 288 in gangrene of the mouth, 305 in thrush, 317 in chronic enlargement of tonsils, 344 in simple pharyngitis, 347 in simple diarrhoea, 366 in gastritis, 375 in entero-colitis, 387 in cholera infantum, 420 in dysentery, 437 in diseases of coecum and appendix, 446 in intussusception, 457 in tubercular meningitis, 475 in simple meningitis, 504 in cerebral haemorrhage, 515 in chronic hydrocephalus, 522 in eclampsia, 540 in laryngismus, 553 in tetanus nascentium, 578 in chorea, 588 in atrophic infantile paralysis, 617 in progressive paralysis, with apparent hypertrophy of muscles, 637 in diphtheria, 656 in mumps, 686 in rickets, 871 984 INDEX. Anatomical lesions in albuminoid degenera- tion of viscera, 844 in bronchial phthisis, 849 in pulmonary phthisis, 849 in tuberculous peritonitis, 850 in tuberculosis of mesenteric glands, 851 in congenital syphilis, 880 in scarlatinous dropsy, 730 in scarlatina, 736 in measles, 778 in typhoid fever, 828 in sclerema, 962 in ascaris lumbricoides, 970 Anderson McCall. on parasitic skin diseases, 945 Angina ; spe Pharyngitis and Tonsillitis. in diphtheria, 662 in scarlatina, 721, 758 Antimony in catarrhal croup, 80 in pseudo-membranous laryngitis, 99 in pneumonia, 183 in capillary bronchitis, 208 excessive action of, in children, 183, 208 in pleurisy, 237 Antiseptic remedies in scarlatina, 764 Antispasmodics in eclampsia, 547 in laryngismus stridulus, 563 in tetanus, 583 in chorea, 602 Aphtha ; see Follicular Stomatitis. fatty nature of deposit in, 298 Apoplexy ; see. Cerebral haemorrhage, 513 Apparatus, mechanical, in infantile paralysis, 624 Appendix C(eci. catarrhal inflammation of, 449 perforative ulceration of, 451 article on diseases of coecum and appen- dix, 441, 455 age as cause, 443 sex as cause, 444 intestinal concretions as cause, 444 anatomical lesions of, 446 cases of, 447 symptoms of, 449 duration of, 451 prognosis in, 452 diagnosis of, 452 treatment of, 453 Arsenic in chorea, 603 in scrofula, 847 in eezematous affections, 912 Artificial food for children, 331 as cause of indigestion, 354 Ascaris Lumbricoides. article on, 969. 979 description of, 965 synonyms of, 965 early age as cause of, 969 disposition to, hereditary, 969 seat of. 969 number of, 969 anatomical lesions in, 970 condition of mucous membrane in, 970 perforation of intestine by, 970 haemorrhage from bowel in, 970 verminous abscesses in, 971 no diagnostic symptoms of, 971 Ascaris lumbricoides, digestive disturbances caused by, 972 restlessness caused by, 974 peculiar physiognomy, caused by, 972 mechanical effects of, 973 effects caused by displacement or migra- tion of, 973 dyspnoea and cough caused by, 974 nervous symptoms caused by, 974 diagnosis of 975 prognosis in, 975 treatment of, 976 caution in use of vermifuges, 976 wormseed oil in cases of, 976 pinkroot in cases of, 977 turpentine in cases of, 977 calomel in cases of, 978 santonin in cases of, 979 kameela in cases of, 979 general treatment in cases of, 979 treatment of complications in cases of,980 diet in cases of, 980 Ascaris Vermicularis. article on, 981 description of. 966 synonyms of, 966 seat of, 981 causes of, 981 symptoms of, 981 diagnosis of, 981 prognosis in, 981 treatment of, 981 enemata in treatment of, 981 ointments in treatment of, 982 Assafoetida in chorea, 602 Astringents in entero-colitis, 412 local use of, in diphtheria, 679 Ataxia, locomotor, after diphtheria, 677 Atelectasis puimonum, and collapse of the lung, 130, 152 peculiarity of respiration in, 40, 132 forms of, 130 congenital, anatomical appearances in, 130 congenital, causes, 131 symptoms of, 132 in early weeks of life, symptoms of {see Collapse), 133 diagnosis of, 136 prognosis in, 136 treatment of, 137, 150 effects of position in, 137 post-natal (see Collapse of lung), 139 as cause of sclerema, 960 Atmospheric pressure as cause of deformities in rickets, 869 Atrophy, muscular {see Infantile paralysis), 609 Auscultation. of heart, 36 of lungs, 41, 42, 43 best position of child in, 42 in true croup, negative results of, 96, 112 in pneumonia, 175 in bronchitis, 201 in pleurisy. 228, 2.34 of heart in chorea, 589 in bronchial phthisis, 854 in pulmonary phthisis, 856 of head in rickets, 866 INDEX. 985 Barthez. results of expectant treatment in pneu- monia, 181 Baths. in treatment of cholera infantum, 435 in treatment of skin diseases, 923, 937 rold, as prophylactic in catarrhal' croup, 83 in treatment of chorea, 605 in griive c.ises of scarlatina, 746 hot, in treatment of scarlatinous dropsy, 762 in treatment of tetanus, 583 ■tvurm, in treatment of catarrhal croup, 79, 81 in eclampsia, 546 in tetanus, 585 in mild cases of scarlatina, 746 in rubeola, 785 in variola, 804 Becquerel, pulse in children, 34 Belladonna in catarrhal croup, 81 in hooping-cough, 270 in tetanus, 583 in infnntile panilysis, 623 as a prophylnctic in scarlatina, 749 Benedict, case of laryngismus stridulus, 565 Bennett J. Hughes, restorative treatment of pneumonia, 183 on bleeding in treatment of pneumo- nia, 183 Berg, fungous nature of thrush, 320 Billard, pulse in children, 33 Bird, Golding, alum in hooping-cough, 268 Bismuth, subnitrate of, in entero-colitis, 406 Blebs (.wBullEe), 128 Bleeding in severe spasmodic simple laryn gitis, 180 in pseudo-membranous laryngitis, 97 in pneumonia, 183 in bronchitis," 207 in pleurisy, 237 in hooping cough, 265 in gastritis, 379 in typhlitis. 454 in intussusception. 468 in tubercular meningitis, 494 in simple meningitis, 508 in eclampsia, 545 in tetanus, 582 in atrophic infantile paralysis, 622 in dropsy following scarlatina, 748 in rubeola. 783 Blisters, mode of using in children, 186 in pneumonia, 186 in pleurisy, 239 Blood, condition of, in scarlatina, 737 in measles, 778 in variola, 798 in typhoid fever, 828 Bloodvessels of skin in sclerema, 963 Bloody stools in intussuception, 467 Bones, alterations of, in ricttets. 867 disease of, in congenital syphilis, 879 Bothriocephalus latus, 967 Bouchut, pulse in children, 34 expectoration in pneumonia, 171 stools in entero-colitis, 394 Brain, condition of, in tubercular meningitis, 477 in simple meningitis, 504 I Brain, congestion of {see Cerebral congestion), 510 condition of, in cerebral haemorrhage, 515 in tetanus, 578 in chorea, 540 in congenital syphilis, 880 in scarlatina, 736 in typhoid fever, 828 Bretonneau, on nasal diphtheria, 655 Bronthia. dilatation of. in capillary bronchitis, 194 in chronic bronchitis, 201 physical signs of, 204 Bronchial abscess, in bronchitis, 194 glands, tuberculosis of, 849, 853 phthisis {see Tuberculosis of bronchial glands). Bronchitis, connection of, with atelectasis, 141 in typhoid fever, 835 in hooping-cough, 260 in measles. 774 in scrofula, 844 frequency and mortality of, 137-150 effect of temperature and season upon I mortality of, 191 1 article on, 190 definition of, 190 I synonyms of, 190 I forms'of, 191 I predisposing causes of. age, sex, season, I insufficient clothing, 191 i exciting causes, 191 I anatomical alterations in, 193 ; in acute ordinary form, 193 i in capillary form. 193 dilatation of bronchia in, 194 bronchial abscess in, 194 condition of lung tissue in, 195 lesions in chronic form. 196 symptoms of simple acute form, 196 aggravation of symptoms at night, 196 duration of simple acute form, 197 danger of collapse of lung in, 198 symptoms of capillary form, 198 duration of capillary form. 200 symptoms and course of chronic form, 200 physical signs in, 201 cough in, 202 sputa in capillary form of, 202 peculiar cough in capillary form, 202 respiration and pulse in, 202 temperature in, 202 expression in, 203 urine in, 203 diagnosis of, 203 peculiarity of dyspnoea in, 204 prognosis in, 205 treatment of. 205 importance of confinement to bed, 205 bleeding in, 207 emetics in, 208 antimony in the capillary form, 208 ipecacuanha in, 209 external applications, cups in, 208 use of stimulants in, 210 use of quinia in, 210 treatment of chronic form, 211 Bullae, chapter on, 928 Cachectic Diseases, 842 986 INDEX. Calomel (see Mercury), use in spasmodic croup, 79 in membranous croup, 100 use in diarrhoea, 403 cholera infantum, 436 tubercular raeningiti?, 499 simple meningitis, 509 chronic hydrocephalus, 529 eczematous affections, 913 as a vermifuge, 978 Cannabis Indica in tetanus, 583 Canula for Tracheotomy. details of size and form, 116 Capillary bronchitis (see Bronchitis), 193 Carbolic Acid; see Acid. Carpo-pedal spasms, 569 in laryngismus stridulus, 558 Cases, Illustrative. of chronic coryza, 59 of pseudo-membranous laryngitis, 124 of collapse of the lung, 14 7 of cerebral pneumonia, 174 of general emphysema, 216 of chronic emphysema, 221 of pneumothorax, 250 of chronic pleurisy, 246 of cyanosis, 278, 283 of cardiac disease, 292 of perforation of appendix coeci, 447 of tubercular meningitis, 479 apparent recovery from, 491, 501 of cerebral haemorrhage, 518 of laryngismus stridulus, 564-567 of contraction with rigidity, 571 of atrophic infantile paralysis, 613 of progressive muscular sclerosis, 632 of heart-clot in diphtheria, 673 of paralysis following diphtheria, 675 of mode of invasion of scarlatina, 714, 718 of grave form of scarlatina, 723 of croup in, 727 of convulsions in, 742 of use of cold lotions in, 751-754 of Ui-e of ice in angina of, 759 of convulsions in measles, 768 of fatal serous effusion in, 777 fatiil, of measles, 780 illustrative of protective power of vacci- nation, 814 of tinea, 957 Catarrh of stomach and intestines (see Indi- gestion), 353 of stomach, 375 in measles, 767 Cauterization of variolous pock to prevent pitting, 806 in treatment of diphtheria, 678 Cavities, tuberculous, 850 Cerebral Congestion, article on, 510-513 symptoms of, 511 duration of. 512 treatment of, 512 Cerebral disease in congenital syphilis, 880 Cerebral form of pneumonia, 176 Cerebral haemorrhage, article on, 513—521 definition and frequency, 513 forms of, cerebral and meningeal, 513 causes of, 514 Cerebral haemorrhage, anatomical lesions of, 515 of the meningeal form, 515 transformation of the clot in, and forma- tion of pseudo-cyst, 516 symptoms of cerebral form, 517 case of, 518 meningeal form, 518 chronic hydrocephalus following menin- geal form, 519 duration of, 519 diagnosis of cerebral form, 520 meningeal form, 520 prognosis in, 520 treatment of, 520 depletion in, 520 cold and counter-irritation in, 521 treatment of paralysis following, 521 chronic hydrocephalus following, 521 Cerebral synlptoms, in pneumonia, 173 in cholera infantum, 426 in intussusception, 464 in tubercular meningitis, 480, 484 in simple meningitis, 505 in cerebral congestion, 511 in cerebral haemorrhage, 517 in chronic hydrocephalus, 526 in laryngismus stridulus, 557 in contraction with rigidity, 569 in chorea, 594 absence of in atrophic infantile paralysis, 611 in mumps, 688 in scarlatina, 715 in measles, 776, 786 in variola, 794 in typhoid fever, 829, 831, 835. 839 caused by worms, 974, 981 Chambers, T. K., on poultices in pneumonia, 187 on calomel in diarrhoea, 404 Chemical characters of false membr.anes, 658 Chenopodium, oil of, in treatment of worms, 976, 982 Chicken pox ; see Varicella. Chloral in tetanus, 580 Chloroform in eclampsia, 548 in laryngismus, 664 Cholera Infantum, article on, 416-436 general remarks on, 416 definition and synonyms of, 416 frequency of, 416 causes of, 417 great heat as a cause of, 417 improper diet as a cause of, 418 hygienic conditions favorable to, 419 anatomical appearances and pathology of, 420 symptoms of, 424 character of stools in, 425 of vomiting in, 425 course and duration of, 426 diagnosis of, 427 prognosis in, 427 prophylactic treatment in, 428 treatment of stage of evacuation, 429 of stage of collapse, 431 Cholera infantum, treatment of, importance of free supply of water in, 432 mistura indica in, 433 importance of rest in, 433 treatment of stage of reaction, 434 INDEX. 987 Cholera infnntum, importance of attending to state of gums in, 435 use of baths in, 435 use of calomel in, 436 Chorea, article on, 584-609 definition and synonyms of, 584 frequency of, 584. 599 early age as predisposing cause of, 584 other predisposing causes of, 584 rheumatism as cause of, 586 feur and other exciting causes of, 588 anatomical lesions in, 588 lesions of heart in, 589 brain in, 590 spinal cord in, 591 microscopical changes in spinal cord in, 591 portions of body affected in, 591 prodromic symptoms of, 592 symptoms of invasion of, 592 of the confirmed disease, 592 respiratory muscles and heart at times affected*. 593 paralysis of sphincters in, 594 loss of voluntary power in, 593, 611 general symptoms in, 594 condition of urine in, 594 cardiac murmurs in, 594 course of, 594 effects of acute intercurrent disease upon, 595 duration of, 595 frequency of relapses, 595 nature of, 595 probable seat of lesion in, 596 alterations of blood as cause of, 597 reflex irritation as cause of, 597 embolism as cause of, 287, 598 mode of action of rheumatism as caus of, 599 prognosis in, 599 statistics of mortality in, 600 diagnosis of, 599 unfavorable symptoms in, 600 duration of, 600 treatment of, 601 use of purgatives in, 601 antispasmodics in, 602 cimicifuga in. 602 arsenic in, 603 strychnia in, 604 conium in, 604 stimuli in, 605 baths in, 605 gymnastic exercises in. 606 Bouchut on treatment of, 604 hygienic treatment of, 608 Chronic bronchitis, 200 pleurisy, 233 Cimicifuga racemosa in chorea, 602 Circulatory organs, diseases of. 276 Clark, J. L., state of spinal cord in tetanus 579 in chorea. 591 Clinical examination of children. 17 Club-foot in infantile paralysis, 625 Cod-liver oil in habitual indigestion, 362 in rickets, 875 in tuberculosis, 862 Cod-liver oil in congenital syphilis, 881 in eczematous affections, 913 Coecum and appendix coeci, article on diseases of, 441-445 {Sae also Typhlitis, Perityphlitis, and Ap- pendix.) synonyms and definition of, 441 seat and character of, 442 causes of, 443 intestinal concretions and f-^reign bodies as causes of, 444 anatomical lesions in, 446 illustrative cases of, 447 symptoms of, 449 duration of. 451 prognosis in, 452 diagnosis of 452 treatment of, 453 typhlitis, 449 perforation of coecum, 450 perforative ulceration of appendix, 451 perityphlitis. 451 Coecum, symptoms of fecal distension of, 449 perforative ulceration of, 451 inflammation of {see Typhlitis). Cold, as cause of dropsy after scarlatina, 729 applications in tubercular meningitis, 497 in simple meningitis, 509 in eclampsia, 546 in laryngismus stridulus, 564 in tetanus, 583 in scarlatina, 748 Collapse op Lung. in bronchitis, 195, 197, 202 in hooping-cough, 259 in rickets, 872 article on, 130-152 in early weeks of life, symptoms of, 133 cyanofis in. 134 cases of, 134, 135 diagnosis of, 136 prognosis in, 136 treatment of, 137 of post-natal atelectasis, 139-152 general remarks on the pathology of, 139- 144 identity of lobular pneumonia with, 141 anatomical lesions in, 141 congestion of lung accompanying, 142 differences between condition of lung in, and in pneumonia, 142 portions of lung affected in, 143 causes of, and explanation of mode of pro- duction, 144 symptoms of, 146 •diagnosis of, 149 prognosis in, 150 treatment of, 150 use of emetics in, 151 treatment of, when combined with bron- chitis, 151 Coloration of skin, significance ofchanges of, 22 in infants, 30 of face in pneumonia, 172 in tubercular meningitis, 483 Colostrum corpuscles, 339 Compression of head in hydrocephalus, 530 Concretions, intestinal, 444 Condensed milk, 333 analysis of, 323 adul'teration of, 337 Condylomata in congenital syphilis, 878 Congenital Syphilis : see Syphilis. 988 INDEX. Congestion of the brain (see Cerebral Conges- tion), 510 Congestion of the lungs, not inflammatory, 158 in bronchitis, 195 in typhoid fever, 835 Conium in tetanus, 583 in chorea, 604 Constipation, as cause of diseases of the coe- cura, 444 in intussusception, 462 in tubercular meningitis, 481 Constitutional diseases, 645 Contagion of hooping-cough, 255 of diphtheria, 653 of mumps, 685 of scarlatina, 705 of rubeola, 765 of small-pox, 788 of varicella, 824 of typhoid fever, 827 of favus, 946 of tinea, 953 of alopecia areata. 959 Contraction, with rigidity, article on, 567-577 a rare affection, 567 definition of, 567 causes of, 568 nature of, one of the forms of eclamp- sia, 568 symptoms of, 568 carpo-pedal spasms in, 569 diagnosis of, from symptomatic con- traction, 570 prognosis in. 570 treatment of, 570 case by Dr. J. F. Meigs, 571 Contracture ; see Contraction. Convulsions, General, or Eclampsia, article on, 532-550 general remarks on ; forms of, 532 definition, synonyms, frequency, 532 predisposing causes of, 533 most frequent before age of seven years, 533 nervous temperament as a predispos- ing cause of, 533 hereditary nature of, 534 exciting causes of, 535 frequency of different forms of, 535 prodromic symptoms of, 536 symptoms of the attack, 537 partial, varieties of, 538 general, duration of, 538 nature of, 539 M. Hall's views on spasm of the lar- ynx, 539 centric and eccentric causes of, 541 no lesion as yet detected in, 541 diagnosis of from epilepsy, 541 the form of convulsion, 542 prognosis in, 543 treatment of, 544 importance of discovering cause of attack, 545, 549 treatment of attack, 545 bleeding in, 545 emetics in, 546 antispasmodics and opium in, 547, 548 chloroform in, 548 internal definition of, 558 Convulsions, internal, symptoms of paroxysm, 559 degree of laryngismus present, 559 incomplete, or holding-breath spells, 559 rarely dangerous, 560 in pneumonia, 174 in hooping-cough, 258 in tubercular meningitis, 483 in simple meningitis, 505 in meningeal apoplexy, 518 in scarlatina, 717, 742 uraeraic, in scarlatina, 733 in initial stage of measles, 767 in later stages of measles, 777, 781, 785 in typhoid fever, 832, 835 in worms, 974, 981 Corson, cold affusions in scarlatina, 750 Coryza, definition, synonyms, forms, fre- quency, 51 causes of, 51 anatomical lesions in, 52 symptoms of mild form, 52 of severe form, 53 epistaxis in, 54 duration of, 54 prognosis in, 54 in the course of other diseases, 54 chronic, symptoms and duration of, 55 treatment of acute, 56 local, of acute, 56 of chronic, 57 case of chronic, 59 in congenital syphilis, 878 in scarlatina. 722 Cough, in simple laryngitis, 62 violent in chronic laryngitis, 63 in true croup, 92 in pneumonia, 170 in pleurisy, 231 in hooping-cough, 255-257 in spasmodic simple laryngitis, 70, 72 in bronchial phthisis, 853 in pulmonary phthisis, 855 in measles, 769, 774 in typhoid fever, 835 Countenance, alterations of, 21 Counter irritation in tubercular meningitis, 496 in simple meningitis, 509 in chorea, 606 in pulmonary complications of measles, 785 Country residence, importance of in summer, 399, 429 in tuberculosis, 861 Cowhage as a vermifuge, 978 Cow-Pox ; see Vaccine Disease. Cracked-pot sound in bronchial phthisis, 854 Cream, proportion of in cow's milk, and mode of determining, 326 in human milk, 338 Croup, diphtheritic, 663 relations of to pseudo-membranous laryn- gitis, 83, 663 false, spasmodic, or catarrhal (see Spas- modic simple laryngitis), 67 true or membranous {see Pseudo-mem- branous laryngitis), 83 secondary, in scarlatina, 726 tracheotomy in, 103 Crust, vaccine, characters of, 819 INDEX. 989 Crusta lactea (see Eczema capitis), 905 Cry, characters of the, 24 peculiar in meningitis, 482 alterations of in simple laryngitis, 62 peculiar in sclerema, 961 Crystalli ; see Varicella. Currie, cold affusions in scarlatina, 748 Cutaneous diseases, 882 not transmitted by vaccination, 817 Cutaneous diphtheria, 665 surface, signs from, 22. 30 Cyanosis, in collapse of the lung, 134 article on, 276-284 definition of, 276 anatomical appearances in, 276 illustrated cases of, 279, 283 theories of mode of production of, 280 symptoms of, 280 date of appearance of lividity, 281 modes of death in, 282 duration of life in, 282 treatment of the form due to atelectasis, 283 of paroxysms of dyspnoea, 283 hygienic treatment, 283 eflfect of position on. 284 neonatorum-, Prof. Meigs on treatment of, 137 Cynanche Parotidea ; sef Mumps. Cynanche maligna {see Diphtheria). 651 tonsillaris {see Tonsillitis), 342 Cyst, pseudo-, in arachnoid, in meningeal ap- oplexy, 516 Deafness after diphtheria, 676 Decubitis of children, 28 in different diseases, 29 in tubercular meningitis, 486 Deformities in rickets, 867 Deglutition, diflBculty of in bronchial phthisis, 853 in retropharyngeal abscess, 352 in scarlatina, 721 Dentition as cause of entro colitis, 386 of cholera infantum, 4l9 of eclampsia, 535 of laryngismus stridulus, 532 of infantile paralysis, 611 impeded in rickets, 866 Desiccation in variola, 793 Desnos and Huchard on cardiac complications in variola, 795, 799 Desquamation in scarlatina, 712 in measles, 770 in small-pox, 793 in erysipelas, 891 Development, degree of as aid in diagnosis, 27 Diagnosis in children, difiBculties of, 18 general method of, 19 of simple laryngitis v?ithout spa?m, 64 of spasmodic simple laryngitis from true croup, 74 from laryngismus stridulus, 560 of pseudo- membranous laryngitis, 95 of catarrhal from true croup, 74, 95 of idiopathic, from diphtheritic croup, 89, 96 of atelectasis from pneumonia, and pleu- risy, 149 of collapse of the lung, 149 Diagnosis of pneumonia from bronchitis, pleu- risy, etc., 175-177 of cerebral pneumonia from cerebral dis- ease, 176 of bronchitis from pneumonia, 203 from hooping-cough, 203 of emphysema, 222 of pleurisy from pneumonia, 235 in early stage from one of the exan- themata, 236 of pneumothorax, 253 of hooping-cough from acute laryngitis, 262 from tuberculosis of the bronchial glands, 262 of aphthae from ulcero-membranous stomatitis, 298 of ulcerative stomatitis from gangrene of the mouth, 309 of thrush, 323 of tonsillitis. 343 of simple pharyngitis. 349 of retropharyngeal abscess, 352 of indigestion, 357 of simple diarrhoea, 369 of gastritis, 378 of enterocolitis, 398 of cholera-infantum, 427 of dysentery, 438 of diseases of coecum and appendix, 452 of intussusception. 465 of tubercular meningitis, 487 of simple meningitis, 507 of cerebral hasmorrhage, 520 of chronic hydrocephalus, 527 of eclampsia, 541 of laryngismus stridulus, 560 of contraction with rigidity, 570 of tetanus nascentium, 581 of chorea, 599 of atrophic infantile paralysis, 621 of facial paralysis, 626 of progressive muscular sclerosis, 635 of acute rheumatism, 647 of diphtheria, 670 of malarial fever, 691 of mumps, 688 of rickets, 871 of tuberculosis, 859 of tuberculous peritonitis, 860 of tuberculosis of mesenteric glands, 860 of congenital syphilis, 880 of scarlatina, 838 of rubeola, 740 of variola, 799 of vaccine disease, 813 of varicella, 826 of typhoid fever, 836 of scrofula, 845 of erythema fugax, 883 of erythema, 885 of erysipelas, 891 of roseola, 897 of urticaria, 901 of eczeiuatous affections, 910 of herpes, 922 of scabies, 925 of pemphigu-s 929. 932 of rupia, 932, 934 of ecthyma, 934 of strophulus, 937 of lichen, 938 of prurigo, 939 990 Diagnosis of favus, 949 of tinea tonsurans, 955 of tinea circinata, 965 of alopecia areata, 959 of sclerema, 962 of ascaris lumbricoides, vermicularis, 981 INDEX. 975 Diaphoretics; seeFonuvhJE. hot bath as, in scarlatinous dropsy, 762 Diarrhoea in thrush, 322 simple or catarrhal, article on, 364-373 nature of, 364 causes of, 364 improper diet as a cause, 365 anatomical lesions in, 366 symptoms of, 367 course of, 369 diagnosis of, 369 prognosis in, 369 treatment of, 370 of chronic form, 372 inflammatory {see Entero-colitis), 380 in rickets, 866 in tuberculous peritonitis, 858 in tuberculosis of mesenteric glands, 860 in scarlatina, 735 in measles, 770, 785 in variola, 806 in typhoid fever, 829, 833, 839 Diday^, on infjintile syphilis, 877 Diet {see also Food), in pneumonia, 189 after tracheotomy, 123 in chronic bronchitis, 212 in pleurisy, 237 in thrush, 325 after premature weaning, 325-331 in indigestion, 361 improper, as cause of indigestion, 354 as en use of diarrhoea, 364 proper in diarrhoea, 370 in gastritis, 379 in acute entero-colitis. 401 in chronic entero-colitis, 409 improper, as cause of cholera infantum, 418 suitable for children, 329, 428 in tubercular meningitis, 500 in laryngismus stridulus, 561 in diphtheria. 683 in rickets, 874 in tuberculosis, 862 in congenital syi.bilis, 881 in scarlatina, 746, 763 in rubeola. 782 in variola, 804 in typhoid fever, 840 in scrofula, 846 in erysipelas, 895 as cause of urticaria, 899 in urticaria, 902 in rupia, 932 in ecthyma, 935 in ascaris vermicularis, 980 Digestive organs, diseases of, 296 disturbances in early stage of rickets. 866 in tuberculous peritonitis, 858 in tuberculosis of mesenteric glands. 859 in variola, 794 in typhoid fever, 829, 830, 832 in erythema intertrigo, 884, 887 caused by worms, 972 Digitalis in scarlatinous dropsy, 763 Dilatation of bronchia, 194 Diphtheria, article on, 651-684 definition and synonyms of, 651 history of, 651 statistics of frequency of, 652, 654 epidemic, contagious, and infectious na- ture of, 652 influence of season upon, 655 table showing monthly mortality of, 654 influence of age upon, less than in croup, 655 nature of; a constitutional disease, 655 pathological anatomy of, 656-661 development of false membranes, 656 color and consistence of false mem- branes, 657 microscopic anatomy of false mem- branes, 658 chemical characters of false membranes, 658 condition of mucous membrane in, 858 lesions in croup following, 659 seat of exudation in, 659 exudation on skin in, 660 condition of submaxillary glands in, 660 fatty degeneration of heart in, 660 condition of kidneys in, 661 lesions in secondary form, 661 forms of, 661 symptoms of, 662 condition of throat in, 662 difficulty in deglutition not constant, 663 danger of exudation extending to larynx, 663 symptoms of croup in, 664 nasal variety of, 665 cuta.iieo^cs symptoms of, 665 invasion often insidious, 666 general symptoms of mild form, 666 of severe form, 667 urine in, 668 eruption in, 668 course in fatal cases. 668 malignant symptoms in, 669 duration of, 669 prognosis in, 669 diagnosis of, 670 from scarlatina, 670 albuminuria in, 671 heart-clot in, 672 Richardson's account of symptoms of, 673 Robinson on, 674 cases of 673 endocarditis in, 674 paralysis following, 674 order of muscles affected in, 676 motion and sensation both aflFected, 676 result usually favorable, 676 explanation of, 677 locomotor ataxia following, 677 treatment of, 678-684 local applications to throat in. 678 solvents for the false membranes, 679 use of gargles in, 680 local use of ice in, 681 external applications in, 681 injections in nasal form of, 681 general treatment of. 681 emetics and purgatives in, 683 necessity for supporting remedies, 682 I INDEX. 991 Diphtheria, stimulants in, 683 diet in, 684 necessity for absolute rest, 684 treatment of the paralysis after, 684 of heart clots, 684 Diuretics {ste Formulae), in scarlatinous dropsy, 762 Dress, suitable for children, 82, 400, 429 Drinks, manner of taking as a diagnostic sign, 48 Dropsy, after scarlatina (see article on scar- latin;!), 728-785 treatment of, 760-763 after measles, 776 Duchenne, on progressive paralysis, 630 Dysentery, article on, 436-441 definition of, 436 causes of, 437 anatomical lesions in, 437 symptoms of, 437 diagnosis of, 438 prognosis in, 438 treatment of, 438 Earache, violent crying in, 25 Eclampsia {see Convulsions), 532 Ecthyma, article on, 933-935 definition, synonyms, varieties, 933 causes of, 933 diagnosis of, from rupia, 932, 934 prognosis in, 935 general treatment of, 935 local treatment of, 935 vulgure. symptoms of, 934 infantile. symptoms of, 934 Eczematous affections, article on, 903-918 definition of. 903 elementary lesions in, 903 eruption frequently mixed in, 903 seats of eruption in, 903 forms of. 903 causes of, 904 diagnosis, 910, 926 prognosis in, 911 no danger in curing quickly, 911 principles of treatment of, 911 general treatment in, 911 attention to digestive symptoms in, 912 use of arsenic in, 912 of cod-liver oil in, 913 of iron in, 913 of calomel in. 913 local treatment of, 914, 918 cool and emollient applications in. 914 benzoated oxide of zinc ointment in, 914 mode of removing crusts in, 915 lotions in. 915 ointments in. 916 spiritus saponatus kalinus of Hebra in, 917 solutions of potash in, 918 tarry applications in, 917 use of soaps in. 917 mercurial applications in, 917 eczema simplex. symptoms of, 904 diagnosis of from scabies, 626, 910 from sudamina, 910 eczema pnpiilosiun. symptoms of, 904 Eczematous affections. eczema piistulosum, or imptigijioides, symptoms of. 905 diagnosis from favus, 910 prognosis in, 911 eczema capitis. symptoms of, 905 condition of scalp in, 906 chronic form of. 907 mode of removing crusts in, 915 eczema faciei. symptoms of, 907 eczem.a larva le. general symptoms in, 908 duration of, 908 eczema grannlatuin. symptoms of, 909 eczema, tarsi. symptoms of, 909 treatment of, 918 impetigo fig urata, 909 spursa, 909 eczema chrouicum. common to all varieties, 910 symptoms of, 910 seats of, 910 duration of, 910 general treatment of. 912 local treatment of, 916 Electrical batteries, 623 Electricity in chorea, 606 in infantile paralysis. 616, 623 in facial paralysis, 627 in progressive paralysis, 631, 639 in diphtheritic paralysis, 684 Electro-muscular contractility in infantile palsy. 613, 616 in facial palsy, 627 in progressive palsy, 631 Embolism in endocarditis as cause of chorea, 287, 597 Emetics in catarrhal croup. 78, 80 in membranous croup, 98 in collapse of the lung, 151 in bronchitis, 207 in hooping-cough, 267 in eclampsia, 546 in diphtlleria, 683 Emphysema, time and cause of existence, 213 anatomical appearances, 213 vesicular. 213 interlobular, 213 causing pneumothorax, 215 case of, 215 causes of age, previous disease, etc., 216 mecha.-ism of production, 216 symptoms, rational, 218 physical signs, 220 case of, 221 diagnosis of, 222 prognosis in, 222 treatment of, 223 association with pneumonia, 161 Empyema, symptoms and course of {see Pleu- risy), *233 paracentesis in, 242 Empyreumatic oil of Chabert, as a vermifuge, 979 Endocarditis, in diphtheria, 674 in scarl itina, 736 acute. 286 symptoms of, 286 prognosis in, 287 992 INDEX. Endocarditis, acute, anatomical appearances in, 287 embolism in, in connection with chorea, 287 treatment of, 287 Enemata, astringent, in chronic entero-coli- tis, 413 in dysentery, 440 in disease of coecum. 454 of air and fluids in intussusception, 468 in echimpsia, 547 in diphtheria, 683 in treatment of worms, 981 Enteritis in measles, 776 in variola, 793, 806 Entero-colitis, article on, 380-416 definition of, 380 frequency of, 380 improper food and intense heat as causes of, 381 table of mortality in. 382 analogies to camp diarrhoea, 385, 390 dentition and weaning as causes of, 386 anatomical lesions in, 387 seat of disease in. 387 condition of intestinal follicles in, 389 lesions in chronic form, 390 microscopic changes in intestines, 391 condition of stomach in, 392 of liver in, 392 of mesenteric and mesocolic glands in, 392 pathology of, 392 symptoms of in acute form, 393 condition of stools in acute form. 394 of abdomen in acute form, 395 vomiting in acute form, 396 erythema of buttocks in acute form, 396 duration of acute form, 397 symptoms of chronic form. 397 course and duration of chronic form, 397 diagnosis of, 398 prognosis in, 398 treatment of acute form, 398-409 prophylactic, 398 necessity for change of residence, 399 importance of exercise in open air, 400 diet in, 401 therapeutical treatment of, 401 cold water in treatment of, 402 use of calomel in, 403 use of opium in, 404 use of astringents and absorbents in, 405 of tonics and stimulants in, 407 remedies for vomiting in, 4ii8 treatment of chronic form, 409-416 diet in chronic form, 410 creasote in, 409, 414 use of raw meat in chronic form, 410 nitrate of silver in, 412 astringent enemata in, 413 sulphuric acid in, 414 tonics and stimulants in, 415 Epidemic nature of diphtheria, 652 of mump?, 686 of scarlatina, 706 of rubeola, 764 of variola, 787 of varicella, 824 of typhoid fever, 827 of roseola, 896 Epilation in favus, 951 in tinea, 956 Epistaxis in coryza, 55 in measles, 769 in bronchial phthisis, 853 in typhoid fever, 834 Ergot, in infantile paralysis, 623 Eruption in diphtheria, 668 in mild cases of scarlatina, 710 in grave cases of scarlatina, 719, 722 in measles, 769 in malignant measles, 773 in variola, 790 in varioloid, 797 in varicella, 825 in typhoid fever, 829, 831, 834 in erythma fugax, 883 intertrigo. 884 nodosum, 885 in erysipel'S, 890 in roseola, 896, 897 in urticaria, 899, 90a in eczematous affections, 904, 910 in herpes, 918, 922 in scabies. 924 in pemphigus, 928 in rupia, 931, 932 in ecthyma, 934, 935 in strophulus, 936 in lichen, 938 in prurigo, 939 in psoriasis, 941 in pityriasis, 941 in ichthyosis, 942 in favus", 947, 948 in tinea. 954. 955 Eruptive fevers, 701 Erysipeliis, article on, 888-895 definition and forms of, 888 frequency of, 888 causes of, 888 following vaccination, 889 epidemic and endemic nature of. 889 starting-point of eruption, 889 symptoms of, 889 characters in very young infants, 890 sloughing of skin in, 890 characters of in older children, 890 desquamation in. 891 abscesses following, 891 febrile symptoms in, 891 typhoid ."yraptoms in, 891 duration of, 891 diagnosis of, 891 prognosis in, 892 treatment of in young infants, 892 local applications in, 893 tr. ferri.'chl. in. 894 treatment of in older children, 894 stimulants and tonics in, 895 local applications in, 895 Erythma about anus in thrush, 322 of buttocks in entero-colitis, 396, 884 article on, 883-888 definition and forms, 883 fugax. symptoms of, 883 diagnosis of from scarlatina, 884 from erysipelas, 885 from roseola, 886 intertrigo. seat of eruption, 884 character of eruption, 884 ulceration in, 884 INDEX 993 Erythema intertrigo, form of occurring in con- nection with diarrhoea, 884 prognosis in, 886 treatment of, 886 local applications in, 886 attention to digestive derangement in, 887 nodosayii. symptoms of, 885 diagnosis of from phlegmonous erysipelas. 886 prognosis in, 886 treatment of, 887 tonics and stimulants in, 887 local appliciitions in, 888 Essay, introductory, 17 Essential convulsions {fee Convulsions). Essera (s^e Urticaria), 899 Examination, clinical, in children, 17 difficulties of, 17, 18, 19 of abdomen, 45 of the heart, 35, 36 of mouth and fauces, 47 of the pulse. 33, 34, 35 Exercise in open air, importance of, 400 Expectoration, nummular, in measles, 770 in true croup, 93 in pneumonia. 171 Expiratory respiration in bronchitis, 202 External applications {see Local applications). Facial paralysis (5.«e Paralysis). Facies {see- Physiognomy). False membrane, in croup, characters of, 88 in secondary croup, 89 extent of and frequency with which bronchia are invaded, 88 action of chemical reagents upon, 679 in capillary bronchitis, 193 in diphtheria, 656 in scarlatina, 720 Fauces, examination of, 47, 48 in membranous croup, 89 in simple pharyngitis, 348 in diphtheria, 659 in scarlatimt, 712, 720 in measles, 768 Pavus. article on. 946-952 definition and synonyms, 946 varieties and frequency of, 946 Fecal accumulation as cause of eclampsia, 549 Fevers, eruptive, 693 scarlet {see Scarlatina), 702 in variola, subsides on appearance of eruption. 792 secondary in variola, 792 typhoid, 827 febrile action in, 832 Finlayson, normal temperature in children, 38 Follicles of intestine in entero-oolitis. 389. 391 Fomites as means of transmitting scarlatina, 706 variola, 789 Food, artificial, 325, 339 gelatin, for infants, 332 Merei's for infants, 332 improper, as eau>e of indigestion, 354 of diarrhoea, 365 of entero-colitis, 381 of laryngismus stridulus, 552 Foot-baths, in treatment of diseases, 186, 207, 784 Formulary of receipts recommended. Alteratives. Formula for mixture of iodide of potassium and bichloride of mercury, 496 for iodide of potassium and compound decoction of sarsaparilhi, 847 for iodide of potnssium, syrup of iodide of iron, and syrup of ginger, 847 Antacids avd alkalies ; lax"tives. Formula for mixture of soda, rhubarb, and paregoric. 341 of magnesia and tr. thebacic, 341 of sulphate of magnesia and rhubarb, 371 of sulphate of magnesia and lauda- num. 371 of soda, blue mass, and paregoric,402 of crabs' eyes, 406 for neutral mixture, 409 of acetate and bicarb, potash and opium, 649 Antiseptic. Formula for mixture of chlorinated lime, 304 Ai'thrlmintics. description ofthe fungus which causes, 944 Formula for mixture of ol. chenopodii, 977 contagion as cause of, 946 occurs in lower animals, 946 other causes of, 947 symptoms of, 947 nature of. 949 diagnosis of, 949 prognosis in, 950 general treatment of, 950 local treatment of, 950 mode of removing crusts in, 950 epilation in, 951 parasiticides in, 951 dispersiis. eruption in. 947 course of, 947 condition of hairs in, 947 baldness following, 948 seats of the eruption, 948 conftrtus. 948 eruption in, 948 Fecal accumulation in coecum, symptoms of, 449 diagnosis of, 466 of spigelia, magnesia, and manna, 977 of ol. terebinth, and magnesia, 978 of santonin, etc., 978 A ntispasjnodics. Formula for pills of belladonna, opium, and valerian, 266 for mixture of belladonna and opium, 266 Astritigejits. Formula for mixture of alum and honey of roses, 297, 342 of sulphate of copper and cinchona, 303 of sulphate of copper and quinia, 351 for aromatic syrup of galls, 406 of morph. sulph., and dil. sulph. acid, 409 of soda, krameria, and opium, 912 of nitrate of silver. 413 solution of nitrate of silver, 413 of pernitrate of iron and nitric acid, 414 63 994: INDEX. Formula of aromatic opium and krameria, 414 of acetate of lead and acetic acid, 431 Pfhrif ages and diiiretics [see also Alkalies). Formula for mixture of citrate of potash, ipecac, and paregoric, 80 of ipecac, opium, sp. aether, nitrosi, 206 of morphia, liq ammon. acet., 2!1 of iodide of potassium and sarsaparilla, 238 of squill and digitalis, 239 of carbonate of potash, antimony, and opium, 66 senega and opium, 66 of acetate of potash, digitalis, and squill, 763 of bitart. of potash, juniper, and sp. aetheris nitrosi, 762 , of powders of sulphurated aniimony and Dover's powder, 80, 184 of opium, ipecac, and nitrate of pot- ash, 247 Foods. Formula for gelatin-food for children, 332 for Merei's food for children, 333 for preparation of raw meat, 410 Laxatives (sf-e also Antacids). Formula for mixture of sulphate of soda, sen- na, and laudanum, 454 for pill of opium and colocynth, 454 of blue pill, castor oil, and aromatic syrup of rhubarb, 572 Local applications. Formula for lotion of carbonate of potash and sulphur, 916 of lime and sulphur, 927 of bichloride of mercury, 916 of soft soap and alcohol (Hebra'ssp. saponatus kalinu?), 917 for ointment of elder flowers, 923 of glycerin and ung. aq. ros , 747 for benzoated oxide of zinc ointment (Bell's formula), 914 for mercurial ointment to prevent pitting in variola, 808 for ointment of nitrate of mercury and belladonna, 58 of protiodide of mercury, 916 of calomel and camphor, 916 . of ammon chl. of mercury with sul- phur, 956 of tar and vin. opii, 917 of tar and iodine, 956 of sulphur and carbonate of potash (Wilson), 927 of sulphur and carb. potash (Hel- merich). 927 Nervous sedativfs. Formula for mixture of antimony, valerian, and paregoric, 67 of antimony, \ aleiian, and laudanum, 188 Nervous stim u la. ?/ ts . Formula for mit^tura indica, 433 Specific remedies. Formula for mixture of carbonate of potash in hooping-cough, 268 of alum and conium in hooping- cough, 269 of alum in hooping-cough, 269 and belladonna in hooping- cough, 270 Tallies. Fotmula for mixture of cod-liver oil, 363 of nux vomica and gentian, 373 Formula of tr. ferri chl , acetic acid, and sp. Mindereri, 415, 495, 758 of quinia, morphia, and sulph. acid, 649 of quinia and dil. sulph. acid, 210 of elix. cinchona and curacoa, 210 of arsenic and bitter wine ofiron, 912 Forster. temperature in new-born children, 37 Fox, Wilson, on softening of stomach, 377 on use of cold in treatment of hyper- pyrexia, 750 French measles {see Roseola), 896 Frequency of diseases {see Statistics). Fuller, statistics of tracheotomy, 104 Fungi in skin diseases {see Parasites). Fungous origin of measles, 766 Gairdner, collapse of the lung, 139 lesions in bronchitis, 195 difference between dyspnoea of pneumonia and bronchitis, 204 Galls, aromatic syrup of, 406 Gangrene, of mouth (s^e Gangrenous stoma- titis), 309 of pharynx in diphtheria, 659 in scarlatina, 721 of skin in erysipelas, 891 Gargles in diphtheria, 680 Gastritis, article on, 374-379 frequency and nature of, 374 causes of, 374 anatomical lesions in, 375 softening of stomach in, 376 symptoms of, 377 diagnosis of, 378 prognosis in, 378 treatment of, 378 Gastromalacia {see Softening of stomach). Gastrotomy in intussusception, 470 General diseases, introductory remarks upon, 645 Gerhard, G. S , on chorea, 585 Gestures, significance of, 28 Glands, bronchial, tuberculosis of, 849, 853 cervical, in scarlatina, 722 intestinal, in scarlatina, 737 in typhoid fever, 828 mesenteric, tuberculosis of, 851, 858 parotid, in mumps {see Mumps). in scarlatina, 722 submaxillary in diphtheria, 660, 662 • enlarged in some cases of mumps, 687 enlarged in scarlatina, 721 Glottis, spasm of. in eclampsia, 540 {fee Laryngismus stridulus), 550 Golis, on treatment of hydrocephalus, 529 Gregory, cold aff'usions in scarlatina, 749 Guersant, mortality of true croup, 88 Guinier, statistics of paracentesis, 242 Gum {see Strophulus), 936 Gummy tumors in congenital syphilis, 880 Gums, importance of lancing in cholera in- fantum, 435 in laryngismus, 561 Gutta percha. solution of, to prevent pitting in variola. 808 Gymnastic exercises in chorea, 606 in infantile paralysis, 624 Haemoptysis in pulmonary phthisis, 855 1 INDEX. 995 Hair, in favus, 948. 949 in tinea,, 954, 955 • in alopecia areata, 958 Hull, Marshiill, on spasm of glottis in eclamp- sia, 539 on nature of laryngismus, 556 Hammond, electrical condition of muscles in infantile paralysis, 616 Harley, John, on connection of scarlet and enteric fevers, 737 Harris, R. P., on hereditary nature of eclamp- sia, 535 Head, peculiarities of, in hydrocephalus, 525 in rickets, 868 soft spots on, in rickets, 867 Heart, physical examination of, 35, 36 sounds of, 35 diseases of, article on, 284-295 (see Pericarditis and Endocarditis-) causes of, 284 chronic valvular diseases of, 288 causes of, 288 anatomical appearances in, 288 symptoms of aortic disease, 289 prognosis in, 290 symptoms of mitral obstruction, 290 prognosis in, 291 symptoms of mitral regurgitation, 291 prognosis in, 291 compensation for, efifeeted by grow- ing heart, 292 tendency to improve by time, 292 treatment of, 292 illustrative cases of, 292 in chorea, 589 irregular action of, in chorea, 594 fatty degeneration of, in diphtheria, 660 inflammation of endocardium in diph- theria, 674 inflammation of membranes of, in scar- latina, 736 Heart-clot in diphtheria, 672, 684 in scarlatina, 738 Heat, intense, as cause of entero-colitis, 383 Heat of surface (t^ee Temperature). Hebra, on treatment of eczema, 917 Helminthocorton as a vermifuge, 979 Hemiplegia in chorea, 594 in cerebral haemorrhage, 518 cerebral, diagnosis of, from facial paraly- sis, 627 Hgemorrhage during paroxysms of hooping- cough, 256 intestinal, in intussusception, etc., 466 in typhoid fever, 835, 840 Herpes, article on, 918-923 definition of, 918 varieties of, 918 frequency of, 918 causes of, 918 diagnosis of, 922 prognosis in, 922 general treatment of, 922 local treatment of, 923 phlyctef/odes. seat of eruption in, 919 symptoms nf, 919 diagnosis of from pemphigus, 922 treatment of, 922 lab /'alls . seat of eruption in, 920 symptoms of, 920 local applications in, 923 Herpes zoster, definition of, 920 seats of, 920 character of eruption, 921 course and duration of, 921 general symptoms in, 921 pain in, 921 diagnosis of, 922 local applications in, 923 circinatus (««e Tinea eir-ein{d;a), 955 iris. symptoms of, 921 seat of, 922 parasitic nature of, 922 diagnosis of from roseola annwlata, 922 treatment of, 922 Hewitt, Grailly, on collapse of the lung in hooping-cough, 259 Hives (-see Urticaria), 8D9 Hillier, indications for bleeding in pneumo- nia, 181 on pathology of infantile paralysis, 617 albuminuria in diphtheria, 672 Holding-breath spells {htberia, 83, 84 frequency of faucial deposit in, 85,89 frequency of, 86 mortality from, 86 predisposing causes of, 87 exciting causes of, 87 second attacks of, 88 anatomical lesions in, 88 extent and characters of false mem- branes, 88 mucous membrane rarely ulcerated, 90 symptoms of, 91 of irjitial stage, 91 characters of voice and cough, 91, 92 of respiration, 92 explanation of recession of base of chest in, 93 ' Laryngitis, expectoration and rejection of false membrane in. 93 negative results of auscultation in, 93, 112 mode of recovery in, 94 duration of, 95 diagnosis of. 95 pseudo-niembra7ious, importance of examination of throat in, 96 prognosis in. 96 treatment of, 96 bloodletting in, 97 emetics in, 98 antimony in, 99 mercury in. 100 alkalies in. 101 opium in, 101 local treatment in, 101 inhalations in. 102 hygienic treatment, 103 summary of the treatment of, 103 tracheotomy {see under that head), 103 spasmodic, siviple, 67-83 synonyms of, 68 forms of, 68 causes of, 68 anatomical lesions in, 69 symptoms of, 70 duration of, 72 nature of, 73 diagnosis of from true croup, 74 from laryngismus stridulus, 560 peculiarities of voice in, 75 prognosis in, 77 treatment of the mild form of, 78 of the severe form of, 80 hygienic treatment of, 81 prophylactic treatment of, 82 style of dress suitable in, 82 simple, without spasm, 61 definition and frequency of, 61 causes of, 61 anatomical lesions in, 61 symptoms and course of, 62 duration of, 64 diagnosis of, 64 prognosis in, 65 treatment of, 65 Larynx, general remarks on diseases of, 59 Legendre and Bailly, researches on collapse of lung, 139 Lichen, article on, 937, 938 strophulus {see Strophulus), 936 tropicus, the variety usually met with, 938 frequency of, 938 cause of, 938 symptoms of, 938 duration of, 938 diagnosis of, 938 of from scabies, 926 prognosis in, 938 treatment of. 938 vrticatus {see Urticaria), 900 Liebig. food for infants, 338 Liver, state of in entero-colitis, 392 in rickets, 872 in congenital syphilis, 879 Lobular pneumonia, in reality collapse of lung, 139 Local applications in chronic coryza, 58 in membranous croup, 101 in pneumonia, 186 INDEX. Local applications in bronchitis, 208 in pleurisy, 2H9 in hooping-cough, 271 in aphtha?. 299 in ulcero-membranous stomatitis, 203 in gangrene of the mouth, 311 in thrush, 341 in diseases of ceecum and appendix, 455 of cold in tubercular meningitis, 497 of cold in simple meningitis, 508 in eclampsin, 546, 548 in chorea, 605 in rheumatism, 650 in diphtheria, 678 in mumps, 688 in congenital syphilis. 881 to throat in scarlatina, 746, 758 external in scarlatina, 746 in erysipelas, 892, 895 in eczema, 914 in herpes, 923 in scabies, 926 in pemphigus, 930 in rupia, 933 in ecthyma, 935 in strophulus, 937 in lichen, 938 in prurigo, 940 in psoriasis, 941 in pityriasis, 942 in ichthyosis, 942 in favus, 950 in tinea. 956 in erythema intertrigo, 886 in alopecia areata, 959 Locomotor ataxia following diphtheria, 677 Lotions (5ffi Formulae) . of water in scarlatina, 948, 951 in treatment of eczema, 914 Lumbricus {see Ascaris lumbricoides). Lungs, auscultation of, 41, 42, 43 general remarks on diseases of. 129 collapse and imperfect expansion of, 130- 152 inflpnimation of, 153 abscess of, following pneumonia, 158 congestion of, non-inflammatory, 159 condition of in pleurisy, carnification, 228 collapse of, in rickets, 872 tuberculosis of, 849, 855 percussion of, 43. 44, 45 condition of, in congenital syphilis, 880 in typhoid fever, 829, 830, 834 in sclerema, 963 Magnesia, hyposulphite of. in scarlatina, 756 Malarial fever, 689 causes, frequency of. 689 symptoms of acute, 689 features of paroxysm imperfectly de- veloped, 690 of chronic, 691 enlargement of spleen in, 691 neuralgia rare in, 691 diagnosis of, 691 prognosis in, 691 treatment of, 692 quinia in, 692 iron and arsenic in, 692 Marsh. F. H., on tracheotomy in croup, 115 Maturative fever in variola, 792, 804 Maw-worm (see Ascaris vermicularis). Measles {see Rubeola), 764 French {see Roseola). Meigs, Charles D., treatment of coryza, 56 use of alum as an emetic, 99 on proper position of body in atelectasis and cyanosis, 137, 284 Meigs, Charles D., treatment of paroxysm of laryngismus, 564 Meigs, J. F., case of contraction with rigidity, 571 heart-clot in diphtheria, 673 Membrane, false {see False membrane). Meningeal apoplexy {see Cerebral haemor- rhage), 513 Meningitis, simulated by cerebral form of pneumonia, 173 epidemic cerebro-spinal, article on, 693 anatomical lesions of, 695 case of, 696 paralysis following, 698 eruptions in, 699 treatment of, 701 simple, article on, 503-510 definition, synonyms, frequency, 503 causes of, 503 anatomical lesions in, 504 symptoms of convulsive form, 505 of phrenitic form, 506 course and duration of, 507 diagnosis of.from congestion of brain, 507 differential diagnosis of, 507 from tubercular form, 488 prognosis in, 508 treatment of, 508 bleeding in, 508 calomel in, 509 cold and counter-irritation in, 509 tuberc7dar, article on, 473-507 definition, synonyms, and frequency, 473 predisposing causes of, 474 exciting causes of, 475 pathology of, 475 anatomical lesions in, 475 microscopical changes in, 476 division into stages, 479 mode of invasion, 480 symptoms of first stage, 481 hydrencephalic cry, 482 condition of mind in, 482 use of ophthalmoscope in, 483 convulsions in, 483 circulation in. 484 •symptoms of second stage, 484 tache meningitique, 485 nervous symptoms in, 485 decubitus in, 485 pulse in, 485 respiration in, 486 temperature in, 487 diagnosis of, from simple meningitis, 487 from typhoid fever, 489 cases simulating, 490 prognosis in, 490 cases of recovery from, 491 case of apparent recovery from, 491 prognosis not absolutely hopeless, 493 uncertainty of date of death in, 494 treatment of. 494 bleeding not to be used, 494 iodine and iodide of potassium in, 495 INDEX, 999 Meningitis, counter irritation in, 497 cold applications in, 497 calomel and mercury in, 497 prophylaxis in, 498 narcotics in, 499 diet in, 500 importance of country residence, 501 illustrative case, 501 Mental condition in rickets, 866 MercurinI ointment to prevent pitting in vari- ola. 808 in congenital syphilis, 881 applications in eczema, 917 in favus, 952 in tinea, 956 Mercury (<(?e Calomel). in membranous croup, 100 in pneumonia, 184 in pleurisy, 288 in entero-colitis, 403 in diseases of coecum and appendix, 454 in tubercular meningitis, 497 in simple meningitis, 509 in chronic hydrocephalus, 529 in scrofula, 847 in congenital syphilis, 881 Mesenteric glands, tuberculosis of, 851, 858 Metastasis in mumps, 687 Microscopic examination of milk, 339 of false membranes in diphtheria, 658 changes in tubercular meningitis, 475 in spinal cord in tetanus, 579 in chorea, 591 in infantile paralysis, 618 in muscle in infantile paralysis, 616 in progressive paralysis, 638 in kidneys in scarlatinous dropsy, 730 Microsporon furfur, 945 Miliary tubercles, 475 Milk {see also Food and Diet). properties of, and mode of examining cow's milk, 326 mode of preserving, 328 proper dilution of, for infants, 328 quantity of, for infants, 329 preparation of, 331 human, analysis of, 338 microscopic examination of, 339 mode of examining, and properties of, 339 substitutes for, 325-331 Milk-crust {see Eczema capitis), 905 Morbilli {see Rubeola), 764 Mortality (.vee Statistics). Mouth, examination of, 47 mode of examining, 47 diseases of {see Stomatitis), 296 Mucous membrane, condition in entero-colitis, 389 of fauces in diphtheria. 658 affections of, in congenital syphilis, 878 of fauces, in scarlatina, 720 gastro-intestinal. in scarlatina, 736 eruption on, in small-pox, 791 condition of, in small-pox. 798 in cases of ascaris lumbricoides, 970 Muguet {see Thrush). Mumps, article on, 685-689 definition, synonyms, and frequency of, 685 causes of, 685 Mumps, anatomical appearances in, 686 symptoms of, 686 characters of swelling in, 686 salivary secretion in, 687 general symptoms in. 687 tendency to metastasis in, 687 prognosis always favorable in, 688 course and duration of, 688 usually terminates by resolution, 688 suppuration of parotid in, 688 diagnosis of, 688 treatment of, 688 danger of febrile sequelae in, 689 Muriate of ammonia {xfe Ammonia). Muriatic acid {s^e Acid). Murmur, cardiac, in chorea, 590, 594 cerebral, in rickets, 866 Muscle, condition of, in atrophic infantile paralysis, 616 in progressive paralysis. 638 Muscular sclerosis, progressive (56e Paralysis), 628 Nasal variety of diphtheria. 665 Nature of spasmodic laryngitis, 73 of pseudo-membranous laryngitis and diphtheria, 83 of collapse of the lung, 139 of pneumonia. 153 of emphysema, 213 of pneumothorax. 248 of hooping-cough, 264 of cyanosis, 280 of aphthae, 388 of thrush. 317, 323 of tonsillitis, 344 of simple diarrhoea, 364 of gastritis, 374 of entero-colitis, 393 of cholera infantum, 420 of diseases of coecum and appendix, 441. 442, 446 of cerebral congestion, 510 of chronic hydrocephalus, 522 of eclampsia, 539 of laryngismus stridulus, 553 of contraction with rigidity, 568 of chorea. 595 of atrophic infantile paralysis, 616 of progressive muscular sclerosis, 637 of diphtheria, 655 of mumps, 685 of rickets, 873 of scarlatina, 705 of rubeola, 764 of variola, 788 of varicella, 824 of typhoid fever, 828 of erysipelas, 889 of herpes iris, 921 of scabies, 924 of prurigo, 939 of parasitic skin diseases, 943 of favus, 949 of alopecia areata. 958 Nephritis, after scarlatina, 728-735 Nervous system, general remarks on diseases of 472 symptoms [see Cerebral symptoms). Nettle-rash {see Urticaria), 899 Neurosis, evidence in favor of hooping- cough being a, 263 1000 INDEX. Neurosis, evidence of laryngismus stridulus being ii, 552 infantile paralysis not a, 618 Niemeyer, indications for bleeding in pneu- monia, 183 on lesions in catarrh of stomach, 376 Night terror, 639 case? of, 640 pathology of, 642 causes of, 643 treatment of, 643 Obstruction of the intestines {see Intussus- ception), 456 Occipital bone, depression of, as cause of teta- nus, 576 (Edema of face in bronchial phthisis. 853 of neck in scarlatina, 722 in varioh., 792 in typhoid fever, 836 in erysipelas, 891 in sclerema, 96 I Ogle, J. W., on chorea, 585 Oidium albicans {see Thrush), 315 Oi7itmeiits {see Local applications). in treatment of seat-worms, 982 Omentum, tuberculosis of, 851 Ophthalmia, in variola, 805 Ophthalmoscope in tubercular meningitis, 483 Opisthotonos in tetanus nascentium, 580 Opium in catarrhal croup, 79, 81 in membranous croup, 101 in pneumonia, doses, and mode of admin- istering, 188 in pleurisy, 237 in thrush, 341 in entero-colitis, 404 in cholera infantum, 431 in dysentery, 439 in diseases of coecum and appendix, 455 in eclampsia, 548 in rheumatism, 649 in variola, 804 in typhoid fever, 840 Otorrhoea, in scarlatina, 722, 735 Ova of acarus scabiei, 925 Oxyuris vermicularis {see Ascaris vermicu- laris), 966 Packing, cold, in scarlatina, 755 Pain, modes of expressing, 22 in pneumonia, seats and peculiarities of, 162, 171 in pleurisy, seats and peculiarities of, 230 abdominal, in intussusception, 463 in tuberculous peritonitis. 858 in variola, 789 Palpation of thorax in pleurisy, 230 Pancoast, J., on tracheotomy in croup, 108, 117 Papules, chapter on, 936 in small-pox, 790 Paracentesis, in pleurisy {see Pleurisy), 239- 247 thoracis, 245 case of, 246 in hydrocephalus, 530 Paralysis, in tubercular meningitis, 485 in cerebral hsemorrhage, 518, 521 in chorea, 594 in diphtheria, 574 after scarlatina, 736 Paralysis, atropine infantile, article on, 609- 626 history of and authors on, 609 synonyms of, 611 causes of, 611 forms of and muscles affected in, 612, 613 mode of attack, 612 reaches its maximum suddenly, 613 condition of paralyzed muscles in, 613 illustrative case of, 613 at times temporary, 614 at other times, followed by atrophy, 614 temperature lowered in palsied parts, 614 subsequent deformities in, 614 duration of, 615 prognosis in, 616 electrical condition of muscles as aid in prognosis, 616 microscopic examination of muscles in, 617 anatomical lesions in and nature of, 617 cannot be considered reflex, 617 primary condition usually one of spinal congestion, 618 sclerosis of cord in a later stage, 619 other lesions of cord occasionally met with, 620 diagnosis of from other forms of pa- ralysis, 621 from progressive muscular atro- phy, 622 occasionally simulates eoxalgia, 622 use of local treatment to spine in, 622 ergot, belladonna, and iodide of po- tassium in acute stage, 623 iron and strychnia in later stage, 623 use of electricity in, directions for choice of current, 623 mechanical contrivances in treat- ment of, 624 tenotomy to relieve deformity, 625 necessity of pursuing treatment for years, 626 facial, article on, 626, 627 causes of, 626 symptoms of. 626 diagnosis of from cerebral hemi- plegia, 626 prognosis in, 627 treatment of, 627 progressive, with apparent hypertrophy of the muscles {see Progressive muscular sclerosis), 628-639 Parasite of thrush {see Oidium albicans). of favus {spe Achorion Schoenleinii), 944 of tinea tricophytina {see Tricophyton), 944 of tinea versicolor {see Microsporon), 945 of alopecia areata, 945 Parasitic skin diseases, 942-964 general remarks on, 942 varieties of. 942 nature of, 943 mode of detecting fungus in, 943 relation between fungus and the erup- tion, 943 description of achorion Schoenleinii {spe Favus also), 944 INDEX. 1001 Parasitic skin diseases, description of trico- phyton (see Tinea also), 944 description of raicrosporon furfur (see Alopecia areata), 945 relation of the various fungi in, 945 Parasiticides, 952 Parotid gland, condition of in mumps, 686 suppuration of in mumps, 687 Parotitis (set" Mumps). in typhoid fever, 836 Paroxysm of hooping-cough, peculiarities of, 255 treatment of, 274 of laryngismus stridulus, svmptoms of, 557 treatment of, 564 of eclampsia, symptoms of, 537 treatment of, 545 in tetanus, 580 in diphtheritic croup, 664 Parrot, on thrush, 317, 320 Pathology of catarrhal pneumonia, 158 Pelvis, alterations of in rickets, 869 Pemphigus infantilis (see Rupia escharotica). Pemphigus, in congenital syphilis, 877, 928 article on, 928-930 definition and synonyms of. 928 forms and frequency of, 928 causes of, 928 symptoms of, 928 duration of, 929 diagnoi^is of, 929 prognosis in, 929 general treatment of, 930 local treatment of, 930 Pepper, Prof., case of laryngismus stridulus, 566 incotitinence of urine in chorea, 594 Pericarditis, acute, symptoms and difficulty of detection of, 285 prognosis in, 285 anatomical appearances in, 286 treatment of, 286 chronic, 286 Percussion of heart, 35 of lungs, mode of performing,etc.,43,44,45 in pneumonia. 163, 170 in pleurisy, 229 in bronchial phthisis, 854 in pulmonary phthisis, 857 Perforation of coecum, 450 of appendix coeei, 451 of intestine in typhoid fever, 835, 840 from ascaris lumbricoides, 970 Peritoneum, tuberculosis of (see Tuberculo- sis), 850, 857 Peritonitis, from perforation of ccecum and appendix. 447 tuberculous (sef Tuberculosis), 850, 857 in scarlatina, 736 Perityphlitis, in art. on dis. of coecum and appendix, 441-455 definition, 442 iliac abscess in, 443 anatomical appearances in, 446 symptoms of, 451 Perspiration, tendency to profuse, in rickets, 866 Pertussis (sre Hooping-cough), 254 Pharyngitis, simple, 346-351 definition and frequency, 346 causes of, 346 lesions in, 347 Pharyngitis, symptoms of, 347 diagnosis of, 349 prognosis in, 350 treatment of, 350 Phlyzacia (see Ecthyma), 933 Phthisis (.«ee Tuberculosis). Physical signs (see Auscultation and Percus- sion). Physiognomy in diseases, 21 in pneumonia, 162 in pleurisy, 231 in tetanus, 580 in cases of worms, 972 Pinkroot as a vermifuge. 977 Pitting in variola (see under Variola), 793 in varioloid, 797 treatment to prevent, 806 Pityriasis, symptoms of, 941 treatment of, 942 Pleurisy, article on. 226-247 chronic physical signs of. 234 definition, frequency, and forms, 226 predisposing causes of, 226 exciting causes of, 227 anatomical lesions in. 227 symptoms of .-icute form, 228 physical signs from auscultation, 228 percussion, 229 inspection, 230 palpation, 230 rational sympto us, pain, cough, respira- tion, pulse, 230 urine in, 233 symptoms of chronic form, 233 of empyema, 234 diagnosis of, 235 obscurity in early stage from violence of constitutional symptoms, 236 prognosis and mortality in, 236, 237 treatment of, 237-247 bloodletting in. 237 antimony in, 237 mercury in. 238 diuretics and purgatives in, 239 external remedies in. 239 paracentesis, 239-247 indications for, 240 objections to, 246 Trousseau's rule in regard to, 241 indicated in empyema, 242 success greater in children, 242 rules to guide in advising, 243 mode of performing, 243 after treatment, 244 use of medicated injections through canula, 245 illustrative case of chronic form, 246 Pleuro-pneumooia. physical signs in, 230 mortality in. 237 Pneumonia, lobular, in reality collapse of the lung, 139 croupous, 168 catarrhal, dififerential diagnosis of, 178 prognosis of, 179 differences between condition of lung in, and in collapse, 141 in hooping-cough, 261 in measles, 774 article on, 153-190 definition and synonyms of. 153 frequency and mortaliry of. 153 forms and classification, 153, 154 hbular, identity of with collapse, 139, 154 1002 INDEX. Pneumonia, predisposing causes, 154 nge at which most frequent, 155 table showing influence of season, 156 relation of mortality from, to the tem- perature, J 56 exciting causes of, 156 anatomical lesions of, 156 of lobular form, 157 of partial form. 158 abscess of lung following, 158 difference between condition of lung in, and in non-inflammatory congestion, 159 inflation of lung impossible in, 159 usually unilateral, 159 portion of lung involved in, 160 apex quite frequently the seat of, 160 not so frequently attended by bronchitis as formerly thought, 160 association with pleurisy, 161 with emphysema, 161 general course of, in young children, 161 in children over two years old. 165 varieties of mode of onset, simulating other affections, 165 unfavorable symptoms and modes of death, 167 general course of the partial form, 168 duration of, 169 physical signs of, 170 cough in, 170 expectoration in, 171 thoracic pain in. 162, 171 state of respiration in, 162, 172 physiognomy in, 172 grade of fever in, 163, 173 rate of pulse in, 163, 166, 173 nervous symptoms, convulsions, 173 appetite, vomiting, diarrhoea in, 174 thirst in, 174 urine, albuminuria in, 174 chlorides in, 175 diagnosis from bronchitis, 175 from pleurisy, 175 of catarrhal form, 175 of cerebral form, 176 during teething, 177 from t.vphoid fever, 836 prognosis of, 178 treatment of, 179-190 question of bloodletting in treatment of, 183 indications for bleeding in, 182 use of antimony in, 183 calomel in, 184 salines in, 184 muriate of ammonia in, 185 quinia in, 185 ipecacuanha in. 185 purgatives in, 186 external apfilications in, 186 tonics and stimulants in, 187 diet in, 187 use of opium in, 187 general management of, 189 diet in, 189 importance of administration of water in, 189 confinement to bed, 189 change of position in, 190 scrofulou?, 844 relations of to tuberculosis of the lungs, 848, 857 Pneumonia in typhoid fever, 835 Pneumothorax, from rupture of abscess of the lung, 158 article on, 248 nature of, 248 anatomical appearances in, 248 case of, 250 causes of. 250 phthisis, pneumonia, gangrene, and emphysema, 251 symptoms of, 251 course of, 252 prognosis in, 252 diagnosis of, 253 treatment of, 253 Pock, anatomy of variolous, 799 of vaccine, 810 Pompholyx (sfe Pemphigus), 928 Porrigo {see Tinea), 953 Porrigo larvalis {sf-e Eczema capitis), 905 granulata (s^e Eczema granulatum), 908 favosa {see Favus), 947 scutulata {see Favus), 948 Position recommended in atelectasis, 142 Post-pharyngeal abscess {see Retropharyn- geal), 351 Potash, carbonate of, in hooping-cough. 268 and acetate of, in rheumatism, 649 chlorate of, in ulcerative stomatitis, 203 in diphtheria, 682 in scarlatina, 745, 758 caustic solutions of, in eczema, 916 Potassium, iodide of, in pleurisy, 238 in chronic valvular disease of the heart, 294 in tubercular meningitis, 495 in chronic hydrocephalus, 530 in infantile paralysis, 623 in rheumatism, 648 in scrofula, 847 in congenital syphilis, 881 sulphuret of, baths of, in chorea, 606 Poultices in pneumonia, 186 in bronchitis, 208 in eczema, 915 in favus, 950 Prickly- heat {see Lichen tropicus), 937 Prognosis in simple laryngitis without spasm, 65 in spasmodic simple laryngitis, 77 in pseudo-membranous laryngitis, 96 in atelectasis pulraonum, 136 in collapse of the lung, 150 in pneumonia, 178 in bronchitis, 205 in emphysema. 222 in pleurisy, 236 in pneumothorax, 252 in hooping-cough, 263 in acute pericarditis, 285 in acute endocarditis, 288 in chronic valvular disease of the heart, 290, 291, 292 in aphthse, 299 in ulcerative stomatitis, 302 in gangrene of the mouth, 311 in thrush. 324 in tonsillitis, 343 in chronic enlargement of tonsils, 345 in simple pharyngitis, 350 in retropharyngeal abscess, 353 in indigestion, 358 INDEX. 1003 Prognosis in simple diarrhoea, 369 in gastritis, 378 in entero-colitis, 398 in cholera infantum, 427 in dysentery, 438 in diseases of coecum and appendix, 452 in intussusception, 465 in tubercular meningitis, 490 in simple meningitis, 508 in cerebral haemorrhage, 520 in chronic hydrocephalus, 528 in eclampsia, 543 in laryngismus stridulus, 560 in contraction with rigidity, 570 in tetanus, 581 in chorea, 599 in atrophic infiintile paralysis, 616 in facial paralysis, 626 in progressive muscular sclerosis, 635 in acute rheumatism, 647 in diphtheria, 669 in diphtheritic paralysis, 676 in mumps, 688 in malarial fever, 691 in rickets, 870 in tuberculosis, 860 in congenital syphilis, 880 in scarlatinous dropsy, 735 in scarlatina, 740 in rubeola, 780 in variola, 802 in varioloid, 802 in varicella, 826 in typhoid fever, 836 in scrofula, 845 in erythema, 886 in erysipelas, 892 in roseola, 898 in urticaria, 901 in eczematous affections, 911 in herpes, 922 in scabies, 926 in pemphigus, 929 in rupia, 932 in ecthyma, 935 in strophulus, 937 in lichen, 938 in prurigo, 940 infovus, 950 in tinea, 955 in alopecia areata, 959 in sclerema, 962 in ascaris lumbricoides, 975 in ascaris vermicularis, 981 Progressive muscular sclerosis, article on, 628-639 definition of, 628 history and synonyms of, 628 causes of, 628 symptoms of, 630 peculiar gait in, 629 condition of muscles in, 630 produces club-foot, 631 electrical condition of muscles in, 631 appearance of skin in, 631 temperature in, 631 cause of, 632 mental condition in, 635 duration variable, 635 termination fatal, by affection of re- spiratory muscles, 635 diagnosis of, 635 anatomical appearances in, 636 Progressive muscular sclerosis, treatment of, 639 Prurigo, article on, 939 definition of, 939 frequency of, 939 causes of, 939 symptoms of, 939 duration of, 939 diagnosis of. from strophulus or lichen, 939 from scabies, 926 prognosis in, 940 treatment of, 940 Pseudo-hypertrophic muscular paralysis {scp- Progressive muscular sclerosis), 628-639 Pseudo-membranous angina {see Diphtheria), 651 in true croup, 88 laryngitis {see Laryngitis). Psoriasis, diffusa, symptoms of, 941 gnttnta, symptoms of, 941 treatment of, 941 Pulmonary resonance, characters of, in chil- dren, 44 tuberculosis. 848, 857 Pulse, in children, 33, 34, 35 rate of, at different ages, 33, 34 intermittence or irregularity of, 35 irritability of, 35 to be examined during sleep, 33 peculiarities of, in tubercular meningitis, 484, 486 in mild cases of scarlatina, 711 in grave cases of scarlatina, 717 in variola, 792 in typhoid fever, 834 Purgatives {see Formulae) in pleurisy, 239 in diseases of coecum, 454 in intussusception, 468 in eclampsia, 546 in chorea, 601 in rheumatism, 649 in scarlatina, 745, 762 in scarlatinous dropsy, 762 in rubeola, 983 in variola, 804 in eczema, 912 in worms, 976 Pustules in variola, 791 chapter on, 933 Quinia in pneumonia, 187 in bronchitis, 210 in entero-colitis, 407 in tetanus, 583 in rheumatism, 649 in diphtheria, 682 in malarial fever, 692 in variola, 804 in typhoid fever, 840 Quinsy (se^ Tonsillitis), 342 Rachitis {see Rickets). Radeliffe, J. N., electrical condition of mus- cles in infantile paralysis, 616 Rashes, 883 Raw meat, use of, in entero colitis, 410 Reaction of cow's and human milk, 316, 339 Recession of base of chest in inspiration, 40 Rees, Gr. A , recession of base of chest in in- spiration, 41 respiration in collapse of the lung, 133 1004 INDEX. Reflex irritability exaggerated in early stage of pleurisy, 286 Relapses of chorea, 595 of acute rheumatism, 646 of typhoid fever, 881 Remittent Fever (see Typhoid fever). Residence, change of, in laryngismus stridu- lus. 564 in unhealthy localities, influence of, 398 change of, in treatment of entero-eolitis, 399 in country, importance of, 399 Resonance, pulmonary, character in children, 44 Respirations, general characters of, in chil- dren. 38, 39, 40, 41, 43 rate of, 39 expiratory, 40 diagnostic signs from. 41 peculiar in atelectasis and croup, reces- .sion of base of thorax, 41, 93, 133 puerile, 44 alteration of, in simple laryngitis, 62 in catarrhal croup, 76 in true croup, 92 in pneumonia. 162, 173 in bronchitis, 203 in pleurisy, 231 in bronchial phthisis, 853 in typhoid fever, 829, 830. 834 in sclerema, 962 Respiratory muscles affected in some cases of chorea, 593 organs, diseases of, 51 sounds, 43 Rest, importance of, in cholera infantum, 433 in bed, importance of, in rheumatism, 650 Retropharyngeal abscess, 351 definition, causes, symptoms of, 351, 352 diagnosis, prognosis, treatment of,352, 353 Return-cry, alteration of, 27 Revaccination. 821 Rhagades in congenital syphilis, 878 Rheumatism as a cause of heart disease, 285 of chorea, 586 in scarlatina, 736, 760 acute, article on, 645-650 symptoms of. 645 temperature in, 646 condition of joints in, 646 local symptoms often comparatively slight. 646 duration and tendency to relapses. 646 causes of, 647 influence of sex not yet determined, 647 chorea as complication of, 587 heart disease as complication of, 284 prognosis in. 647 diagnosis difficult when local symp- toms are slight, 647 treatment of, 648 alkalies in, 648 iron and quinia in, 649 opium in. 649 local applications in, 650 importance of strict rest in bed, 650 diet in, 650 treatment of complications, 650 Richardson, B. W., heart-clot in diphtheria, 673 Rickets, article on, 863-875 Rickets, frequency of, in England and Amer- ica, 863 bibliography of, 864 causes of, 865 symptoms of initiatory stage, 866 digestive disturbances in, 866 general soreness of body in. 866 tendency to profuse perspiration in, 866 dentition impeded in, 866 urine in, 866 mental condition in, 866 cerebral blowing murmur in, 866 stage of deformity, 867 alterations of long bones in, 867 of head in, 868 of spine in, 868 of thorax in, 869 of thorax due to atmospheric pres- sure, 869 of pelvis in, 869 general symptoms in later stage, 869 in favorable cases. 870 secondary diseases causing death in, 870 prognosis and duration in, 870 diagnosis of, 871 morbid anatomy of bones in, 871 collapse of lung in, 872 condition of viscera in, 872 pathology of, 873 treatment of, 874 importance of proper diet in, 874 cod-liver oil in. 875 means of avoiding deformities, 875 Rilliet and Barthez, size of heart by percus- sion, 36 diagnosis between true and false croup, 74 atelectasis and collapse of the lung, 140 state of vessels in gangrene of the mouth, 306 diagnosis of gangrene of the mouth from ulcero-membranous stoma- titis, 309 lesions in diarrhoea, 366 on pathology of cholera infantum, 422 diagnosis of simple from tubercular meningitis, 487 diagnosis of simple meningitis from congestion of the brain, 507 diagnosis of symptomatic from essen- tial contraction, 570 on convulsions in scarlatina, 742 cold aff'usion in scarlatina, 749 Ringworm (s^e Tinea), 953 Robinson, on heart-clot in diphtheria, 674 Roger, pulse in children, 33 respiration in children, 39 and Barth, auscultation in croup, 94 Rokitansky, on changes in spinal cord in teta- nus, 579 Rosalia, or rubeola notha, 740 Rosoola. epidemic, or rubeola notha, 740 article on, 896-899 definition and synonyms, 896 frequency of, 896 forms of, 896 causes : occasionally epidemic, 896 symptoms of; eruption, 896 duration of, 897 annulata. symptoms of, 897 diagnosis of, from scarlatina, 897 INDEX. 1005 Roseola annnlnta. diagnosis from rubeola, 897 from herpes iris, 921 prognosis in, 898 treatment of. 899 Round-worm (sie Ascaris lumbricoides), 965 Rubeola, article on, 764-787 definition of. 764 forms of, 764 frequency of, 702, 764 epidemic nature of, 764 contagiousness of, 765 period of incubation of, 765 influence of age on frequency of, 765 straw-fungus as cause of, 766 mode of invasion of regular form of, 766 fever in initial stage of. 766 catarrhal symptoms in initial stage of, 767 marked drowsiness in initial stage of, 767 convulsions in initial stage of, 768 red papules on palate in initial stage of, 768 duration of initial stage of, 768 date of appearance of eruption in, 769 characters of eruption in, 769 symptoms during eruption in, 769 duration of eruption in, 770 urine during eruption in, 770 symptoms of stage of decline of, 770 desquamation in, 770 temperature in, 771 irregularities of prodromic stage in, 771 of eruption, 771 petechial character of eruption without any malignant symptoms, 772 form of, without eruption, 772 notha or sine cu tar r ho, a form of roseola, 772 malignant form of, 773 eruption in, 773 complications and sequelae of, 773-778 bronchitis and pneumonia in, 774 effect of upon eruption, 774 prognosis in bronchitis and pneumonia in, 775 laryngitis in, 775 enteritis in, 776 frequency of, 776 causes of, 776 symptoms of, 776 fatal cerebral symptoms in, 776 cases of, 776 serous effusions in, 777 tendency of, to develop tuberculosis, 778 coexisting with variola, scarlatina, or erysipelas, 778 anatomical lesions in, 778 diagnosis of, 779 from roseola, 779, 898 from variola, 779 from typhus, 779 prognosis in, 780 causes of death in, 780 hygienic treatment of, 781 diet in, 782 laxatives and febrifuges in, 782 depletion in, 783 treatment of malignant form of, 784 of pulmonary complications in, 784 counter-irritation in pulmonary compli- cations in, 785 treatment of diarrhoea in, 786 of laryngitis in, 786 of cerebral symptoms in, 786 ' Rupia, article on, 930-933 definition of, 930 varieties of. 930 causes of, 931 symptoms of, 931 diagnosis of, from pemphigus, 932 from ecthyma, 932 prognosis in, 932 general treatment of. 932 local treatment of, 933 siinplex. symptoms of, 931 •pro mine as. symptoms of, 931 eschar utica. symptoms of, 931 Salines, in treatment of membranous croup, 101 of pneumonia. 185 Salisbury, on straw fungus as cause of mea- sles, 766 Salivary secretion in mumps. 687 Santonin as a vermifuge, 979 Scabies, article on, 923-928 definition of, 923 caused by acarus scabiei, 924 seat of eruption in, 924 local symptoms in. 924 character of eruption in, 924 cuniculi in, 924 mode of detecting acarus, 925 general symptoms of. 925 description of the acarus, 925 diagnosis of, by finding acarus or its ova, 925 from eczema simplex, 910, 926 from prurigo. 926 from lichen, 926 prognosis in, 926 treatment of, 926 applications of sulphur in (.'e Herpes zoster), 920 Sims, Marion, on cause of tetanus nascentium, 676 Silver, nitrate of, in chronic entero-colitis, 413 in dysentery, 440 local application of in diphtheria, 678 in diphtheritic paralysis, 684 local use of in scarlatinous angina, 759 to prevent pitting in variola, 806 enema of, in worms, 982 Skin, diseases of, general remarks on, 882 examination of, 30, 31, 32 color of, in infants, 30, 31 in different diseases, 31 exudation on, in diphtheria, 659, 660 in congenital syphilis, 876 in scarlatina (« C CC * C C<^ < <^ c c < cccc C_ CC_ c r. c -c. * c c c ■ c :. cc c. c: cc < C cc < C cc < ^ c c < C cc < c c ( < c << ^. ■ C:,C C < ' CcCC' C c ( c CCJ. ^ c c < C C ' cc < C C c c C. 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